Havenwood Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bemidji, Minnesota.
- Location
- 1633 Delton Avenue Nw, Bemidji, Minnesota 56601
- CMS Provider Number
- 245397
- Inspections on file
- 40
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Havenwood Care Center during CMS and state inspections, most recent first.
Failure to provide ordered restorative exercise programs for multiple residents. Residents with dementia, impaired mobility, paraplegia, fractures, and limited ROM had FMPs for ROM, strengthening, standing, and ambulation, but restorative logs showed few completed sessions, missed ambulation, and documented refusals. Staff said restorative aides were often pulled to the floor, nursing staff handled ambulation, and documentation did not always reflect whether residents were offered the exercises.
Dietary staff failed to wear a hairnet while serving meals from the Walnut Unit kitchenette. An aide was observed leaning over steam table food containers and setting up resident plates without a hair restraint, then later delivering food and clearing tables before realizing she was not wearing one. The DM stated hairnets are required whenever serving food, and facility policy required hair restraints to prevent hair from contacting exposed food.
Insufficient staffing led to missed restorative exercise services for multiple residents with OT/PT discharge plans for ROM, strengthening, ambulation, and functional maintenance. Restorative aides were repeatedly pulled to the floor to work as NAs because of call-ins and short staffing, leaving many residents without ordered FMPs or exercise sessions, including one resident with no documented restorative exercises during the review period and others receiving services only a few times despite frequent opportunities.
Failure to Follow Missing Property Reporting Process: A resident with severe cognitive impairment and extensive ADL assistance needs had a wedding ring go missing, but staff did not complete the facility’s missing item report or document the concern in the medical record. The family reported the loss to multiple staff members and later to police, while interviews showed several staff were unaware of the issue; the DON later stated the ring had been found in laundry and kept in the safe without the missing-item process being completed.
Care plans were not updated to reflect ordered FMPs for two residents receiving restorative exercise programs, including goals and staff interventions tied to strengthening, transfers, standing, and ambulation. One resident had severe cognitive impairment and could not ambulate, while another was cognitively intact but required substantial to maximal assistance with bed mobility and transfers. The facility also did not include EBP details in another resident’s care plan despite staff stating gown and gloves were used for direct care with a g-tube.
Failure to Reposition a Resident at Risk for Pressure Injury: A resident with severe cognitive impairment, dementia, edema, restlessness, and agitation was care planned for turning and repositioning every 2-3 hours after being identified as moderate risk for pressure injury. During observation, the resident spent extended time in a wheelchair in the hallway and activity area, was not offered repositioning at multiple points, and staff passed by without addressing it. Interviews showed staff used inconsistent methods to track repositioning times, and the DON and other staff stated the resident should have been repositioned within the care-planned timeframe.
A resident with intact cognition and diagnoses including a right femur fracture and diabetes received enoxaparin injections ordered for DVT prevention after hip arthroplasty. The MAR listed a calculated end date based on the dispensed quantity, but an RN did not contact the PCP to verify the stop date and no verbal order to stop the med was obtained. The DON stated the end date for enoxaparin should be verified with the provider, and the consulting pharmacist noted that no refills does not always mean the med should be discontinued.
A resident with swallowing precautions and a cardiac diet was observed eating lunch in bed at less than 90 degrees, without staff present, and with a sandwich that was not clearly cut into bite-size pieces as ordered. Staff interviews showed confusion about whether the positioning and food-preparation instructions were official orders, and the resident’s chart contained mixed directions about meal setup and swallow precautions.
A resident with severe cognitive impairment and dependence for toileting was not offered toileting within his care-planned timeframe, was moved through the facility without being toileted, and was later found with a urine-saturated brief. Staff gave inconsistent accounts of toileting times and tracking methods. Another resident with severe cognitive impairment and total ADL dependence was supposed to be shaved daily, but on two observed days he remained visibly unshaven despite staff confirming the daily shaving expectation.
Failure to use required PPE during direct resident care. Staff provided catheter care for a resident with an indwelling Foley catheter and assisted with repositioning a resident with a G-tube while wearing gloves but not gowns, despite EBP guidance and care plan directions for gown and glove use during high-contact care. The DON stated staff should wear gown and gloves for direct care involving indwelling tubes and catheters.
A resident with dementia, dysphagia, severe cognitive impairment, and poor coordination, care-planned to need supervision, cueing, and a covered mug with cooled coffee, sustained first- and second-degree burns after spilling hot coffee that had been brewed and served at high temperatures in an activity kitchen. Staff interviews showed inconsistent practices for identifying which residents required lids or cooled liquids, lack of awareness of the resident’s specific cup requirements, and no formal policy or assessment tool for safe hot liquid service, despite prior coffee-spill incidents involving the same resident.
A nurse administered 20 units of rapid-acting insulin instead of the prescribed long-acting insulin to a resident with diabetes after becoming distracted during medication preparation. The error led to a hypoglycemic reaction requiring emergency treatment, and review found that medication administration protocols and verification steps were not followed.
Staff left a medication cart unlocked and unattended in a hallway with medications and a resident's information exposed, while also failing to ensure that a resident's Baclofen medication was labeled accurately and administered according to current orders. The medication bottle label did not match the provider's order, lacked the required direction change sticker, and contained half pills, leading to repeated medication errors.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents as required.
A resident with multiple medical conditions required significant assistance and was reported by family to have received poor care, including inadequate food and fluid intake. The family described the situation as neglect and had the resident transferred to the hospital, where dehydration and vomiting were noted. Despite the family's explicit allegation of neglect, facility staff did not report the incident to the state agency, citing their belief that neglect had not occurred.
Three residents with significant mobility impairments and fall risks were not consistently assisted with transfer belts as required by their care plans, resulting in falls and injuries. Staff failed to follow care instructions, such as keeping bed remotes out of reach and using two-person assistance, and admitted to not always using transfer belts due to inconvenience or unavailability. Observations and interviews confirmed these lapses, and facility policy required the use of transfer belts for safe transfers.
The facility failed to maintain comfortable water temperatures on the Maple Lane unit, affecting two residents directly and potentially impacting all 13 residents on the unit. A resident with severe cognitive impairment had to be taken to another wing for showers due to the lack of hot water, while another resident reported lukewarm water in their sink. The maintenance director acknowledged the issue, noting that a new hot water heater had not resolved the problem, and lacked a consistent monitoring process. Staff reported the issue multiple times, but the maintenance logbook did not reflect these requests, indicating a breakdown in communication and documentation.
A resident with moderate cognitive impairment and non-Alzheimer's dementia was found to be living in a room with a floor covered in a sticky, black substance, posing a safety hazard. Despite regular cleaning, the issue persisted, and the maintenance director attributed it to glue from the tiles. The infection preventionist and administrator acknowledged the problem, but no plan was in place to replace the flooring, and a maintenance policy was not provided.
A resident with severe cognitive impairment and multiple diagnoses experienced an 11.13% weight loss over 180 days, which was not accurately coded on the MDS as a significant weight loss. The registered dietician's report failed to identify the 180-day weight, leading to the oversight. Facility staff, including the MDS coordinator and director of nursing, acknowledged the coding error, emphasizing the importance of accurate coding for reimbursement and care planning.
A facility failed to develop a baseline care plan for a newly admitted resident within 48 hours, as required. The resident, admitted with a foley catheter and a history of falls, did not have a care plan to guide staff in addressing his needs. The DON confirmed the absence of the plan, which is against the facility's policy.
A facility failed to implement enhanced barrier precautions for a resident with a surgical wound, leading to a deficiency. The care plan did not address the need for PPE, and a nurse was observed changing the resident's dressing without wearing a gown, despite signs of potential infection. The omission of EBP in the care plan and lack of PPE use were not addressed.
A resident experienced significant weight loss, dropping from 125 lbs to 110 lbs over three months, without the care plan being updated to reflect the registered dietician's recommendations for high-calorie, high-protein shakes and weekly monitoring. The facility's policy required care plans to be reviewed and updated as needed, but this was not done, leading to a deficiency in care planning.
A resident at high risk for falls, with moderate cognitive impairment and a history of seizures, was left unattended in an elevated bed, contrary to their care plan. The bed was left approximately 3.5 feet high after a transfer, and staff did not immediately lower it, increasing the risk of falls.
The facility failed to prevent significant weight loss in two residents due to inadequate assessment and intervention. One resident lost 25.7 pounds over six months, while another lost 15 pounds over three months. Staff did not consistently assist or encourage eating, and there were discrepancies in documenting meal intakes and weights. The care plans lacked necessary interventions, and facility policies on weighing and documentation were not followed.
A facility failed to maintain a complete medical record for a resident with multiple diagnoses, including epilepsy and diabetes. The Physician Order Report was incomplete, with only two of four pages available and several medication orders illegible due to faded printing. Interviews revealed that the medical records staff missed checking the document's legibility and completeness, contrary to the facility's policy requiring physician's progress notes to be stamped and signed at each visit.
The facility failed to ensure timely physician visits for two residents, one with intact cognition and multiple diagnoses, and another with severe cognitive impairment and dementia. The residents did not receive routine visits every 60 days as required, with gaps of 165 days and 76 days between visits, respectively. The facility's policy was not followed, leading to missed appointments.
A facility failed to comprehensively assess and implement interventions for a resident with dementia, leading to repeated episodes of distress and agitation. The resident exhibited behaviors such as yelling and aggression, but the care plan lacked specific interventions, and staff often resorted to administering PRN Zyprexa without attempting non-pharmacological interventions. Interviews revealed a lack of understanding of the resident's triggers and the absence of individualized interventions, contributing to ongoing distress for the resident.
A resident with mild cognitive impairment was incorrectly administered loperamide on a scheduled basis instead of as needed for loose stools. The medication was transcribed from standing orders incorrectly, leading to multiple refusals by the resident, who stated it was unnecessary after initial doses. Staff interviews confirmed the error, and the medication was discontinued after the director of nursing contacted the resident's primary provider.
A facility failed to act on a consulting pharmacist's recommendations regarding a resident's medication regimen, which included Eliquis and Diltiazem, posing a higher bleeding risk. Despite recommendations to reassess the risks, there was no documented response from the physician, and the resident continued receiving the medication. The DON acknowledged the lack of response and mentioned issues with the process of handling recommendations.
A facility failed to conduct a face-to-face provider evaluation for a resident's continued use of PRN Zyprexa, despite multiple administrations for behavior issues and agitation. The resident's medical records lacked documentation of the physician's rationale and duration for the PRN medication, contrary to the facility's policy requiring re-evaluation every 14 days.
The facility failed to implement enhanced barrier precautions (EBP) for two residents, one with a catheter and another with a surgical wound. Staff did not wear gowns during high-contact care activities, contrary to CDC guidelines. The care plans did not adequately address EBP needs, and there was a lack of PPE carts and signage. This resulted in non-compliance with infection prevention protocols.
A resident with dementia and other health issues experienced increased lethargy and was not eating or taking medications. Despite family concerns and staff observations of the resident's decline, the facility delayed notifying the physician and organizing a care conference. The resident was eventually sent to the hospital with severe dehydration and other complications.
A resident with dementia and other health issues experienced increased sleepiness and missed medications, leading to a decline in health. Despite family concerns and visible deterioration, the facility delayed action, resulting in a hospital transfer where severe dehydration and other conditions were diagnosed. Staff interviews revealed a lack of communication and assessment, violating facility policy.
A facility failed to assess a wedge cushion as a potential restraint for a resident with severe cognitive impairment and a history of falls. The resident experienced an unwitnessed fall with injuries when the wedge cushion and fall mat were not in place. Staff and family indicated the wedge was used to prevent falls, but the facility did not evaluate it as a restraint, contrary to their policy.
The facility failed to provide nutrient and calorie substantive snacks and allowed a 15-hour gap between dinner and breakfast without offering a substantial snack. Residents reported the removal of the snack cart, and staff confirmed that snacks were only available upon request. The administrator acknowledged the issue, which could affect residents' nutritional status.
A resident reported inappropriate touching by a staff member, but the facility failed to investigate or report the allegation. Despite the resident's care plan identifying her as a vulnerable adult, no action was taken to address the issue, and the staff member did not receive remedial training.
The facility failed to verify the registration of a nurse aide before allowing them to work directly with residents after the four-month training period. The nurse aide had taken the skills test but did not take the knowledge test due to a communication misunderstanding. The facility did not adhere to its abuse prevention/prohibition program, which required screening through the State of Minnesota Department of Human Services and the Minnesota Nursing Assistant Registry prior to employment.
A resident reported inappropriate touching by a male nursing assistant during peri-care, but the facility failed to investigate or report the allegation to the State Agency or police. Staff were aware of the complaint but did not follow through with necessary actions, and the nursing assistant received no remedial training.
A resident with severe cognitive impairment and multiple diagnoses was observed self-administering a nebulizer treatment without proper assessment or supervision. The care plan did not address nebulizer treatments, and the facility's policy requiring an interdisciplinary team assessment and a written order for self-administration was not followed.
The facility failed to clarify conflicting directives for a resident's emergency care and treatment. The resident's EMR had inconsistent information regarding her code status, leading to confusion among staff. Despite the resident's clear communication of her wishes, the facility did not promptly update and clarify her code status, resulting in a failure to honor her advanced directives accurately.
The facility failed to notify the long-term care ombudsman of resident transfers for hospitalization. A resident with multiple diagnoses, including dementia and hemiplegia, was transferred to the hospital twice without notification to the ombudsman. An email from the ombudsman confirmed no communications had been received since April 2021. A social worker stated notifications were only made if the hospitalization or discharge was contested. A policy on notifying the ombudsman was requested but not provided.
The facility failed to provide a written bed hold notice to a resident or their representative during two hospitalizations. Despite the resident signing a bed hold form upon admission, the medical record lacked evidence of written notification for either hospitalization, contrary to facility policy.
A resident with severe cognitive impairment and incontinence was not repositioned or checked for incontinence for almost four hours, contrary to her care plan. Staff interactions and observations confirmed the failure to adhere to the care plan directives, leading to a deficiency in care.
The facility failed to ensure timely changes of nebulizer and tubing for a resident with severe cognitive impairment and multiple diagnoses, including asthma. The care plan and physician's orders did not address respiratory care, and there was no documentation of nebulizer and tubing changes, contrary to the facility's policy on Quality of Care.
The facility failed to administer medications according to physician orders for two residents, resulting in a seven percent medication error rate. One resident received a nebulizer treatment without supervision, and another was given medication at an incorrect time due to scheduling conflicts.
The facility failed to label medications with an opened-on date and did not dispose of expired medications properly. An inspection revealed a bottle of Flonase and an albuterol sulfate inhaler without opened-on dates in the North medication cart. The TMA admitted to irregular checks for expired medications, and the ADON confirmed that pharmacy audits were conducted every three months. Guidelines for safe storage and disposal of medications were not followed.
Failure to Provide Ordered Restorative Exercise Programs
Penalty
Summary
The facility failed to provide ordered restorative exercise programs for 6 of 6 residents reviewed for restorative exercise services. The report identified that residents with functional maintenance programs (FMPs) were not consistently receiving the exercises and mobility activities that had been ordered after discharge from therapy, and the restorative logs showed very limited completion of the programs over the review period. The facility’s own policy stated that residents with limited ROM or mobility would receive appropriate treatment and services to increase or maintain ROM and mobility, and that a trained nursing assistant would complete restorative care and document the time provided. For one resident, the record showed severe cognitive impairment, inability to ambulate, osteoporosis, Alzheimer’s disease, weakness, and a history of fractures. Therapy orders and restorative instructions directed upper and lower extremity exercises, standing, and transfer-related activities, but the restorative logs documented only one completed exercise session and three refusals over the review period. When the resident was observed with therapy staff, she became visibly weak and shaky toward the end of the exercises. For another resident with intact cognition, paraplegia, chronic pain, and impaired ROM to both lower extremities, the restorative plan called for upper and lower extremity ROM and stretching, but the logs showed only five exercise sessions and one refusal during the review period. A third resident with severe cognitive impairment and non-ambulatory status had a restorative plan to maintain lower extremity ROM and strength, including NuStep, seated exercises, and standing with a walker, yet the log showed only three completed sessions and three refusals out of 105 opportunities. Another resident with dementia, repeated falls, dizziness, and osteoarthritis had orders for daily PT and OT FMP exercises, but the restorative logs showed no completed restorative exercises and three refusals during the review period. A resident with dementia and diabetes had a restorative plan for passive ROM, stretching, and assistance with movement, but received restorative exercises only twice during the review period. One additional resident with a walking program as part of FMP received only two exercise sessions and no ambulation services during the period reviewed. Staff interviews indicated that restorative aides were frequently pulled to the floor for resident care, that nursing assistants were expected to provide ambulation, and that documentation did not always reflect refusals or whether residents had been offered the exercises.
Dietary aide served meals without a hair restraint
Penalty
Summary
The facility failed to ensure dietary staff served meals while wearing a hair covering on 1 of 2 units, Walnut Unit. During an observation on 4/28/26 at 12:06 p.m., dietary aide (DA)-A was serving meals from the Walnut Grove kitchenette and leaned over the steam table food containers while setting up individual resident plates for the noon meal. DA-A was not wearing a hairnet at that time. At 12:15 p.m., DA-A left the kitchenette to deliver food to a resident and then began cleaning off tables where residents had finished eating. During an interview on 4/28/26 at 12:20 p.m., DA-A stated hairnets were required whenever in the kitchen and/or while serving food, then realized she was not wearing one and said, "I don't have one on? Oh no, I thought I had one on." DA-A left the Walnut Grove kitchenette, went into the main kitchen, and returned wearing a hair net. During an interview on 4/29/26 at 3:17 p.m., the dietary manager stated staff should always wear a hairnet, especially while serving food, to ensure hair does not get into the food and to prevent illness and for palatability. The facility policy on Employee Sanitary Practices stated all food and nutrition services employees will wear hair restraints to prevent hair from contacting exposed food.
Insufficient staffing caused missed restorative exercise services
Penalty
Summary
The facility failed to provide sufficient staffing to carry out restorative exercise services for residents enrolled in restorative nursing and functional maintenance programs. The report states that 6 of 6 reviewed residents (R14, R20, R32, R40, R53, and R66) did not receive their ordered exercise programs as scheduled, and that the issue had the potential to affect all 38 residents who had exercise programs. The deficiency was tied to staffing shortages and restorative aides being pulled from restorative duties to work on the nursing floor. R20, R53, R40, R14, R66, and R32 each had restorative care plans with specific exercise or range-of-motion interventions ordered after discharge from OT and/or PT. The documentation reviewed showed that these residents received the ordered services inconsistently or not at all during the review period. For example, R40 had no restorative exercises documented during the 15-week period reviewed, R14 received exercises 3 times out of 105 opportunities, R66 received exercises twice during 15 opportunities, R20 received exercises once and refused three times, R53 received exercises five times and refused once, and R32 received FMP exercises twice with no ambulation services documented. The restorative program logs showed multiple weeks in which very few residents received services, including weeks with 0 residents served. During interviews, the restorative aide stated she was frequently pulled to the floor to work as a NA, could not get through the resident list, and that many residents did not receive FMP services because of short staffing and call-ins. The DON stated there were two part-time restorative aides, but for about 6 months the facility had only one part-time restorative aide, and that it was not acceptable to keep pulling restorative aides to the floor because they could not get to all residents in a week and residents went without their FMP.
Failure to Follow Missing Property Reporting Process
Penalty
Summary
The facility failed to ensure a report of missing personal property was followed up on for a resident with severe cognitive impairment. The resident’s quarterly MDS identified dementia, edema, restlessness, and agitation, and showed the resident required extensive assistance with dressing, bathing, personal hygiene, toileting, and footwear. The resident’s family member reported that the resident’s wedding ring went missing a few months earlier and said the concern had been reported to nursing assistants, cart nurses, an RN unit manager, and the prior DON, but the family was told only that no staff had seen the ring. After the ring had been missing for a week, the family member reported it to police and stated no further information had been provided. Staff interviews showed multiple employees were unaware of the missing ring, and the resident’s medical record did not identify the ring as missing. The facility’s Missing Items Report required staff to complete the form immediately, notify the unit manager, search likely locations, contact the family if the item was not found, and treat the item as misappropriated and report it to law enforcement and the state agency if the family was unaware of its location. The DON later stated the ring had actually been found in laundry in December 2025 and kept in the safe until the family began asking about it, but no missing item report had been completed.
Care plans lacked ordered FMPs and EBP details
Penalty
Summary
The facility failed to complete and revise care plans to include ordered functional maintenance programs (FMPs) with goals and interventions for two residents who were receiving restorative exercises. R20’s annual MDS identified severe cognitive impairment, need for moderate assistance with ADLs, and inability to ambulate. Her diagnoses included osteoporosis, Alzheimer’s disease, anxiety, weakness, and a history of hand and hip fractures. Although physician orders and restorative program documentation showed OT and PT discharge to restorative services with specific upper- and lower-extremity exercises, standing, and transfer-related activities, R20’s care plan dated 3/16/26 only addressed decreased physical mobility and fall potential related to a left hip fracture and did not include an FMP with goals or staff interventions. R32’s quarterly MDS identified cognitive intactness, substantial to maximal assistance with bed mobility and transfers, and no walking. Her diagnosis included a left knee joint replacement. Physician orders and restorative care documentation showed an FMP beginning 11/19/25 that included seated exercises, strengthening activities, stretching, and assisted standing and ambulation up to 100 feet with a walker and gait belt after PT discharge. However, R32’s care plan last reviewed on 3/13/26 addressed decreased physical mobility and fall potential related to recent left knee replacement, but it did not include any documentation of the FMP, goals, or interventions related to ambulation or restorative exercise. The facility also failed to include enhanced barrier precautions (EBP) in R66’s care plan. R66’s quarterly MDS identified extensive assistance needed for all ADLs and diagnoses including colostomy, diabetes, and Alzheimer’s disease. The care plan dated 8/27/21 addressed risk for altered nutrition due to a gastrostomy tube and tube feedings, but it did not identify what PPE staff should wear during care. Staff interviews stated that gown and gloves were worn for direct care for residents with indwelling tubes, including tube feedings, and the DON stated staff were instructed to wear a gown and gloves when providing direct cares for residents with indwelling tubes, but this was not reflected in R66’s care plan.
Failure to Reposition a Resident at Risk for Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to ensure timely repositioning for a resident who was identified as having severe cognitive impairment, dependence on staff for repositioning, and diagnoses including dementia, edema, restlessness, and agitation. The resident’s Braden Scale dated 2/13/26 identified moderate risk for pressure injury, and the care plan revised 4/29/26 directed staff to assist with turning and repositioning every 2-3 hours. During observation on 4/29/26, the resident was seen in a wheelchair in the hallway, eating breakfast late, moving himself along the handrail, sitting in the hallway and doorway, and later participating in an activity while remaining in the wheelchair. Staff passed by the resident at multiple points, including the DON, but the resident was not offered repositioning during those observed periods. RN-C assisted the resident to his room, applied topical pain medication to his knees, and asked if he wanted to lie down, but repositioning was not offered at that time. The resident’s call light remained on for a period while he was in the hallway and activity area. Interviews showed staff did not have a consistent method for tracking when the resident had last been repositioned. RN-C, TMA-B, NA-G, LPN-A, RN-A, the DON, and the assistant administrator gave differing accounts of expected timing and documentation practices. TMA-B stated staff tracked repositioning differently and that some staff wrote times down while others did not, and RN-C stated there was no expectation of how staff tracked times. The facility policy Skin Care, reviewed 6/2023, stated staff would ensure proper identification of residents at risk for skin breakdown, prevention of pressure ulcers, and individualized care plans to address resident-specific needs.
Failure to Verify Stop Date for Temporary Anticoagulant Order
Penalty
Summary
The facility failed to ensure that a stop date for a temporary medication was confirmed by the primary care provider for one resident reviewed for medication management. The resident had intact cognition on the five-day MDS and diagnoses including diabetes, fracture of the right femur, altered mental status, calculus of the kidney, hydronephrosis, and metabolic encephalopathy. The resident received injectable medication for all seven days of the observation period and also received anticoagulant medication, and a complete drug regimen review noted no potentially clinically significant medication issues. The resident’s transfer orders included enoxaparin 40 mg/0.4 ml subcutaneous nightly for prevention of deep vein thrombosis related to total right hip arthroplasty, with a listed quantity of 13.6 ml and no refills. The MAR showed enoxaparin with a start/end date of 4/15/26 to 5/18/26 and special instructions calculating 34 total doses from the quantity dispensed. Nursing staff administered the medication as ordered, but during interviews an LPN stated the pharmacy had filled the medication in prefilled single-use syringes, and an RN stated she calculated the end date from the quantity rather than contacting the medical provider. The RN stated she had not contacted the resident’s primary care provider to verify the stop date and no verbal order had been obtained to stop the medication. The consulting pharmacist stated that if a medication required an end date, either the pharmacist or nursing would obtain it from the provider, and the DON stated staff would be expected to reach out to the provider to verify the end date because no refills did not always mean the medication should be discontinued.
Food Not Prepared or Served per Resident Swallowing Needs
Penalty
Summary
The facility failed to ensure food was prepared and served in a form designed to meet one resident’s individual needs. The resident had speech therapy recommendations for safe swallowing precautions, including being seated at 90 degrees for all oral intake, receiving one-to-one assistance to use small bites and sips, eating at a slow rate, alternating bites and sips, and being fed only when alert. The resident’s MDS identified intact cognition and set-up assistance with eating, and the care plan directed staff to assist with meal set-up and to keep the resident as upright as possible when eating in bed, with encouragement to sit in a wheelchair for meals. Physician orders also included a cardiac diet with instructions to cut food into small bite-size pieces and to maintain the 90-degree positioning and other swallow precautions. During observation, the resident was eating lunch in bed with the head of the bed raised to about 75 degrees rather than 90 degrees. The lunch tray was on a bedside table, and the resident was eating a half-submarine sandwich with large pieces of lettuce and tomato while no staff were present in the room. Staff interviews showed confusion about the resident’s orders: one TMA stated she was not aware the food had to be cut into bite-size pieces, a NA said the care plan identified cut-up food but did not direct staff to ensure a 90-degree position, and a dietary aide stated dietary staff were supposed to cut up ordered foods but was not sure whether the sandwich had been cut. A RN stated the special instructions were not an official order and were additional notes left on the chart after the resident returned from the hospital.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living for dependent residents, including toileting for one resident and grooming for another. One resident had severe cognitive impairment, dementia, edema, restlessness, agitation, and was dependent on staff for toileting. His assessment and care plan directed staff to offer toileting every 2 to 3 hours and as needed, check his brief every 2 to 3 hours, and provide assistance with brief changes and perineal care. During continuous observation, he was not offered toileting after breakfast, was moved between areas of the facility, and remained without toileting for an extended period despite staff awareness that he needed assistance. The resident was observed from the morning through late morning while staff passed him, redirected him to activities, and delayed toileting. Nursing staff and aides gave inconsistent accounts of when he had last been toileted and how toileting times were tracked. One RN stated she asked staff to toilet him around mid-morning, but he was not toileted until later, when he was already in bed and his brief was found saturated with urine. Staff interviews indicated there was no consistent expectation for tracking toileting times, and some staff relied on memory while others used care sheets. The DON stated the resident should have been toileted immediately after breakfast or within the care-planned timeframe, and staff should always offer him the commode even when incontinent. A second resident had severe cognitive impairment and required maximum to total assistance with ADLs. His care plan directed staff to comb his hair, brush his teeth, and shave him, and his resident care sheet specifically directed daily shaving at family request. On two consecutive observations, he had visible grey whiskers scattered over his chin, cheeks, neck, and below his nose and remained unshaven. Staff interviews confirmed he was supposed to be shaved daily, but they were unsure why it had not been done on those days. The DON stated she would have expected staff to shave him as care planned or document why it could not be completed.
Failure to Use Required PPE During Direct Resident Care
Penalty
Summary
The facility failed to ensure staff wore the appropriate PPE during direct care for residents on enhanced barrier precautions. R25’s MDS identified an indwelling Foley catheter and dependence on staff for ADLs, including catheter care, and the care plan identified infection risk related to the catheter with staff to wear gown and gloves during care. During observation, a NA emptied R25’s catheter drainage bag into a urine graduate and toilet while wearing gloves but not a gown. During interview, the NA stated he had worn gloves but not a gown and acknowledged he should have worn a gown because of the risk of splashing urine and spreading bacteria. R66’s MDS identified extensive assistance needs and diagnoses including colostomy, diabetes, and Alzheimer’s disease, and the resident had a G-tube. During observation, an RN administered medication through the G-tube while a NA entered the room wearing gloves but not a gown and assisted with repositioning the resident in bed, including moving the resident up in bed and adjusting pillows. The RN stated the NA should have worn a gown and gloves while assisting with direct care because of the resident’s G-tube. The NA stated she usually wears a gown for residents with tubes but forgot to put one on during the care.
Burn Injury from Hot Coffee Due to Lack of System for Safe Hot Liquid Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to hot liquids, resulting in a resident sustaining burns from spilled coffee. The resident had diagnoses including dementia, aspiration pneumonia, dysphagia, and insomnia, and a quarterly MDS identified severe cognitive impairment with a need for setup or cleanup assistance for eating. The care plan documented a self-care deficit related to dementia, poor coordination, and weakness, and indicated the resident was independent with eating but required supervision and cueing at times. The nursing assistant care guide specified that the resident should receive coffee only in a covered mug with cooled coffee and no styrofoam cups. Despite these documented needs and instructions, the resident experienced multiple coffee-related incidents. Progress notes showed that on one earlier occasion the resident spilled coffee on his left foot, causing a burn with minimal redness. Later, the resident again spilled coffee while drinking in his room, resulting in a large reddened area on the left side of his body, including the forearm and abdomen, with peeling skin and subsequent documentation of first- and second-degree burns. Staff noted that the resident would not allow them to touch the affected areas and that pain medication and cold packs were required, with ongoing monitoring and treatment ordered by the NP and physician. Surveyor interviews and observations revealed systemic gaps in how hot beverages were prepared and served. Coffee for early-morning service was brewed in the activity kitchen while the main kitchen was closed, and the dietary manager measured coffee in a cup at 170°F. Staff practices for determining which residents required lids or cooled liquids were inconsistent; some CNAs relied on asking the charge nurse, some believed this should be in the care plan, and one CNA who served the resident on the day of the burn was unaware of the requirement for a specific handled cup with lid and had not seen the care sheet indicating no styrofoam cups. The DON acknowledged there was no policy on safe serving temperatures for hot liquids and no assessment tool to determine which residents were safe to receive hot liquids, while CNAs reported informal methods such as adding cold water or ice and noted that several residents with dementia drank coffee without being identified as needing cooled beverages.
Insulin Administration Error Due to Distraction and Protocol Lapses
Penalty
Summary
A medication administration error occurred when a nurse administered 20 units of Novolog, a rapid-acting insulin, instead of the physician-ordered 20 units of Lantus, a long-acting insulin, to a resident with diabetes. The resident's care plan and physician orders specified the use of Lantus at bedtime and Novolog only per sliding scale or with meals, depending on blood sugar readings and meal intake. On the evening of the incident, the nurse became distracted by questions from other residents and staff while preparing the insulin at the medication cart, leading to the selection and administration of the wrong insulin type and dose. The error was discovered after the insulin was administered, and the nurse realized the mistake upon returning to the medication cart. The resident's blood sugar was monitored, and the nurse contacted the DON and the on-call provider. The resident was subsequently sent to the emergency room for evaluation and treatment. Medical records indicate the resident experienced a hypoglycemic reaction and required administration of dextrose, glucagon, and glucose tablets. The resident remained neurologically intact and was monitored until blood sugar levels stabilized before being discharged back to the facility. Interviews with staff and review of facility policies revealed that the nurse did not follow the rights of medication administration, was distracted during medication preparation, and failed to verify the medication against the EMAR and physician orders. The root cause analysis identified distraction, lack of communication between nurses, and failure to adhere to established medication administration protocols as contributing factors to the incident. The resident, who had a history of diabetes and was cognitively intact, received the incorrect insulin due to these lapses.
Failure to Secure Medications and Ensure Accurate Medication Labeling
Penalty
Summary
Facility staff failed to ensure that medications and resident information were secured at all times. During an observation, a medication cart was left unattended and unlocked in a hallway, with the computer screen displaying a resident's identifying information. On top of the cart, there was a cup containing a clear liquid and a medication cup with three white pills. No staff were present in the hallway, and a resident in a wheelchair passed by the unattended cart. The trained medication assistant (TMA) later returned to the cart after assisting with a resident transfer, confirming that the cart and computer screen had been left unsecured with medications exposed. Additionally, the facility did not ensure that medication labeling was clear and unaltered. A resident with multiple sclerosis had a provider order for Baclofen with specific dosing instructions, but the medication bottle label did not match the current order. The label on the bottle was outdated and had handwritten instructions to refer to the electronic medication administration record (EMAR), but there was no required orange sticker indicating a direction change. The TMA was unaware that incorrect doses had been administered over several days due to the mismatched label and lack of clear instructions. The TMA also found half pills in the bottle, which should not have been present, indicating ongoing medication administration errors. The director of nursing confirmed that the Baclofen dose had been changed, but staff continued to use a bottle with an incorrect label after running out of the correctly dosed medication. The facility's policy required that medication labels be neat, legible, and only changed by the pharmacy, but this was not followed. The failure to secure medications and resident information, as well as the lack of proper medication labeling and administration, resulted in multiple medication errors for the resident.
Deficiency in Menu Planning and Nutritional Compliance
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met as outlined in their care plans. These deficiencies were observed through review of menu documentation and dietary records, which showed lapses in menu preparation, review, and adherence to residents' individualized nutritional requirements.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency for a resident who was admitted with diagnoses including atrial fibrillation, adult failure to thrive, and hypertension. The resident required assistance with repositioning, toileting, and wheelchair mobility. According to progress notes, the resident's family expressed concerns about poor care, specifically that the resident was not eating or drinking adequately and was refusing medications. The family insisted the resident be sent to the emergency department, and upon arrival at the hospital, the resident was found to be dehydrated and vomiting. The family explicitly described the care as neglect to facility staff. Despite these allegations and the facility's own policy requiring reporting of neglect allegations within specified timeframes, interviews with staff revealed that the allegation was not reported to the state agency. The social services designee and licensed social worker both acknowledged the family's claims but stated the facility did not believe neglect had occurred and therefore did not report the incident. The administrator confirmed that the allegation was not reported, as she was not aware of the concerns until after the family had already removed the resident from the facility.
Failure to Use Transfer Belts and Maintain Hazard-Free Environment Leads to Resident Falls
Penalty
Summary
The facility failed to provide a hazard-free environment and did not utilize required assistance devices, such as transfer belts, as outlined in resident care plans for three of four residents reviewed for falls. One resident with a history of falls, left scapula fracture, and moderate dementia required substantial to maximal assistance for transfers and was care planned for transfer belt use. Despite this, the resident was assisted without a transfer belt and subsequently fell, resulting in visible injuries to the face and head. The resident confirmed that the transfer belt was not used during the incident. Another resident with severe cognitive impairment and a history of fractures was identified as a fall risk and required two-person assistance with a transfer belt. Staff failed to follow the care plan by leaving the bed remote within the resident's reach, which allowed the resident to raise the bed and fall. Observations confirmed the remote was accessible, and staff interviews revealed a lack of awareness regarding the ability to lock the bed remote, contrary to care plan instructions. A third resident with hemiplegia and recent stroke was also care planned for transfer with a belt and two-person assistance. However, staff were observed ambulating the resident without a transfer belt, and the staff member admitted to not using the belt because it was bothersome and unavailable. Interviews with nursing and therapy staff confirmed that the transfer belt was required for safe transfers, and the facility's policy mandated its use for both single and double assist transfers. Family members also reported inconsistent use of transfer belts and adherence to care plans by staff.
Failure to Maintain Adequate Water Temperatures on Maple Lane Unit
Penalty
Summary
The facility failed to maintain a system ensuring comfortable water temperatures for residents on the Maple Lane unit, affecting two residents directly and potentially impacting all 13 residents on the unit. Resident 22, with severe cognitive impairment, was dependent on staff for personal care and had to be taken to another wing for showers due to the lack of hot water. Resident 45, with moderate cognitive impairment, reported that the water in their sink was lukewarm at best, necessitating showers on another wing. Interviews with family members and residents highlighted the inconvenience and discomfort caused by the cold water issue. The maintenance director acknowledged the problem, noting that a new hot water heater installed in November 2024 had not resolved the issue. Water temperatures were recorded between 93 to 98 degrees, below the expected maximum of 115 degrees. The maintenance director admitted to only testing water temperatures when complaints were received and lacked a consistent monitoring process. Staff reported the issue multiple times, but the maintenance logbook did not reflect these requests, indicating a breakdown in communication and documentation. The director of nursing and the administrator were aware of the ongoing issues, which were discussed in quality assurance meetings, but the problem persisted, with no policy on water temperature management provided.
Failure to Maintain Safe Flooring Environment
Penalty
Summary
The facility failed to maintain a safe environment for a resident with moderate cognitive impairment and non-Alzheimer's dementia, as evidenced by the condition of the flooring in the resident's room. Observations revealed a black, sticky substance built up on the seams between the flooring tiles, covering approximately 50% of the floor. This substance adhered to shoes when walked upon, indicating a potential safety hazard. Interviews with housekeeping staff revealed that the room was cleaned about three times a week, but the sticky substance persisted and was difficult to remove. The maintenance director acknowledged the issue, attributing it to glue from the tiles, and noted that the floor had been replaced within the past year. Despite attempts to address the problem by scraping and rewaxing the floor, the issue recurred within a week. The infection preventionist confirmed the floor's condition, stating it was sticky and could not be cleaned thoroughly. The administrator acknowledged the situation as unacceptable and recognized the need for the floor to be replaced. However, there was no current plan in place to replace the flooring, and a policy for maintenance of flooring was requested but not provided. This lack of action and planning contributed to the deficiency in maintaining a safe and clean environment for the resident.
Failure to Accurately Code Significant Weight Loss on MDS
Penalty
Summary
The facility failed to accurately code a significant weight loss on the Minimum Data Set (MDS) for a resident with severe cognitive impairment and multiple diagnoses, including diabetes, hemiplegia, hemiparesis, chronic kidney disease, dysphasia, and aphasia. The resident's weight decreased from 172.5 pounds to 153.3 pounds over 180 days, representing an 11.13% weight loss, which should have triggered a significant weight loss alert on the MDS. However, the registered dietician's initial report did not identify the 180-day weight, leading to the resident not being flagged for significant weight loss. Interviews with facility staff, including the registered dietician, MDS coordinator, director of nursing, and administrator, revealed that the coding error was acknowledged, and the resident's quarterly MDS was incorrectly coded. The MDS coordinator stated that accurate coding is crucial as it affects reimbursement, quality reports, and the implementation of appropriate interventions. The facility's policy requires assessments to be completed by qualified staff and coded accurately to develop person-centered care plans, which was not adhered to in this case.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident, identified as R211, within the required 48-hour timeframe. R211 was admitted to the facility after being hospitalized for acute blood loss anemia and acute knee pain due to gout. Upon admission, R211 had a foley catheter in place, which was to remain until a scheduled urology appointment, and required assistance with ambulation due to a history of falls at home. Despite these needs, the facility did not create a baseline care plan to guide staff in providing appropriate care for R211. During an interview, the Director of Nursing (DON) confirmed the absence of a baseline care plan for R211, acknowledging that it was the facility's practice to complete such plans within 48 hours of admission. The facility's policy mandates that the baseline care plan should include initial goals, physician and dietary orders, therapy services, and instructions for effective, person-centered care. The lack of a baseline care plan meant that staff were not formally informed of R211's care needs, including the management of the foley catheter, enhanced barrier precautions, and assistance with activities of daily living and mobility.
Failure to Implement Enhanced Barrier Precautions for Surgical Wound Care
Penalty
Summary
The facility failed to identify and implement enhanced barrier precautions (EBP) for a resident with a surgical wound, leading to a deficiency. The resident, who was cognitively intact, had been admitted with a surgical wound requiring care. The care plan, revised after the resident's admission, included monitoring for signs of infection and assistance with daily activities but did not address the need for EBP. During observations, it was noted that there was no personal protective equipment (PPE) cart near the resident's room, nor were there signs instructing staff to wear PPE during dressing changes. A registered nurse (RN) was observed changing the resident's dressing without wearing a gown, despite noticing signs that the wound might be getting infected. The RN admitted to not wearing PPE during wound care, based on instructions from the infection preventionist, and acknowledged the risk of spreading bacteria. The facility's care plan policy required updates as needed, but the omission of EBP in the resident's care plan and the lack of PPE use during wound care were not addressed, contributing to the deficiency.
Failure to Update Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to revise and update a comprehensive care plan for a resident who experienced significant weight loss. The resident, who was cognitively intact and required set-up assistance for eating, was not on a physician-prescribed weight-loss regimen. Despite recommendations from a registered dietician (RD) to offer high-calorie, high-protein shakes and monitor weekly weights and intake, the care plan did not reflect these individualized interventions. The resident's care plan, dated several months prior, only included general interventions such as offering a regular diet and snacks, without addressing the specific needs identified by the RD. The resident's weight had decreased from 125 lbs to 110 lbs over a three-month period, indicating a significant weight loss. The RD had completed a significant change assessment and discussed a plan to increase the resident's weight, but the care plan was not updated to include these recommendations. The facility's policy required care plans to be reviewed every 90 days and updated as needed, but this was not adhered to in this case. Interviews with the RD and the facility administrator confirmed the expectation for accurate assessments and care planning to prevent weight loss, which was not met for this resident.
Failure to Maintain Bed in Low Position for High-Risk Resident
Penalty
Summary
The facility failed to ensure a bed was kept in the low position to prevent falls for a resident identified as high risk for falls. The resident, who had moderate cognitive impairment and a history of unspecified convulsions, required substantial assistance for mobility and was unable to ambulate. The care plan for the resident included specific fall interventions such as a low bed and floor mats. However, during an observation, the resident was left unattended in an elevated bed position by the nursing staff, which was not in line with the care plan interventions. The incident was observed when a registered nurse and a nursing assistant transferred the resident into bed using a mechanical lift, leaving the bed approximately 3.5 feet high. The bed remained elevated and out of staff view while the nursing assistant attended to the resident's roommate and left the room to gather supplies. The bed was eventually lowered after incontinence care was provided. Interviews with staff, including the director of nursing and the administrator, confirmed that the resident should not have been left unattended in an elevated bed due to the risk of falls, especially considering the resident's history of seizures.
Failure to Prevent Weight Loss in Residents
Penalty
Summary
The facility failed to adequately assess and implement interventions to prevent weight loss for two residents, leading to significant deficiencies in their nutritional care. One resident, who had severe cognitive impairment and multiple medical conditions, experienced a weight loss of 25.7 pounds or 14.89% over six months. Despite the resident's fluctuating weights and inconsistent meal intakes, the registered dietician did not recognize the significant weight loss, and the care plan did not include necessary interventions to stabilize or prevent further weight loss. Observations revealed that staff did not consistently assist or encourage the resident to eat, and there were discrepancies in documenting meal intakes and weights. Another resident, who was cognitively intact, experienced a weight loss of 15 pounds over three months. The resident was identified as malnourished, with a nutritional risk score indicating significant weight loss and a BMI less than 19. Although the registered dietician recommended high-calorie, high-protein shakes and other interventions, the care plan failed to include these individualized interventions. Observations showed that the resident's meal intake was not accurately documented, and the facility's policy on weighing residents was not consistently followed. Interviews with staff, including the registered dietician, nurses, and nursing assistants, highlighted a lack of consistent monitoring and documentation of weights and meal intakes. The facility's policies on weighing residents and documenting meal intakes were not adhered to, contributing to the failure to recognize and address the significant weight loss in both residents. The director of nursing and other staff acknowledged the deficiencies and the need for improved monitoring and intervention strategies.
Incomplete Medical Record for Resident
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, identified as R7, during routine visits. R7's medical history includes epilepsy, diabetes, pain, autistic disorder, fibromyalgia, and chronic kidney disease. The Physician Order Report for R7, covering the period from October 7, 2024, to January 7, 2025, was incomplete. Although the report was supposed to contain four pages, only two pages were available, and of the 12 medication orders listed, only nine were legible due to faded and incomplete printing. Additionally, the order for a non-pharmaceutical intervention for pain was illegible, and pages three and four of the report were missing. Interviews with the medical records staff member and the director of nursing revealed that the full four-page Physician Order Report could not be located. The medical records staff member admitted to missing the check for legibility and completeness after scanning the documents into the resident's medical records. The facility's policy requires that the physician's progress notes be stamped and signed at each visit, confirming the review of the plan of care, medications, treatments, and all other orders. However, this policy was not adhered to in R7's case, leading to the deficiency.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that long-term residents received routine physician visits every 60 days as required, affecting two residents. Resident R7, who had intact cognition and multiple diagnoses including epilepsy and diabetes, did not have documented physician visits for 165 days between July 26, 2024, and January 8, 2025. The medical record staff noted that visits were scheduled but not completed or billed, and the primary physician had stopped rounding at the facility, leading to missed appointments. R7 eventually changed to a different primary physician and was seen in January. Resident R39, who had severe cognitive impairment and dementia, was not seen by a physician within the required timeframe on two occasions. The resident was seen on August 21, 2024, but not again until November 5, 2024, which was 76 days later, and then again on January 15, 2025, which was 71 days later. The medical record staff, who was new to the role, acknowledged the oversight in scheduling and counting days, resulting in the delay. The facility's policy required residents to be seen by a physician every 60 days, with a 10-day grace period, but this was not adhered to in these cases.
Failure to Address Dementia-Related Behaviors in Resident
Penalty
Summary
The facility failed to comprehensively assess and implement interventions for a resident diagnosed with dementia, leading to repeated episodes of distress and agitation. The resident, who had a severe cognitive impairment and was on antipsychotic medication, exhibited behaviors such as yelling, hallucinations, and aggression towards staff. Despite these behaviors, the resident's care plan lacked specific interventions to address these issues, and staff did not consistently attempt non-pharmacological interventions before administering medication. Observations and interviews revealed that the resident frequently yelled out, especially at night, and had difficulty being consoled. Staff often resorted to administering PRN Zyprexa without documented attempts of non-pharmacological interventions. The resident's care plan directed staff to reorient and validate as needed, but it did not provide specific strategies to manage the resident's behaviors effectively. Interviews with staff indicated a lack of understanding of the resident's triggers and the absence of individualized interventions in the care plan. The facility's failure to provide a comprehensive assessment and implement effective interventions for the resident's dementia-related behaviors resulted in ongoing distress for the resident. Staff interviews highlighted the need for a more resident-centered care plan with specific interventions to prevent or calm the resident's behaviors. The absence of a facility policy regarding dementia care further contributed to the deficiency, as staff were left without clear guidelines to manage the resident's condition effectively.
Medication Transcription Error Leads to Improper Administration
Penalty
Summary
The facility failed to ensure that as-needed medication from facility standing orders was transcribed and administered correctly for a resident experiencing loose stools. The resident, who had mild cognitive impairment and was continent of bowel and bladder, was prescribed loperamide, an antidiarrheal medication, to be administered four times daily for diarrhea. However, the medication was intended to be given only after each loose stool, not exceeding 8 mg in a 24-hour period. The medication was incorrectly scheduled for regular administration times, leading to multiple instances where the resident refused the medication, stating it was unnecessary after initial doses resolved her symptoms. Interviews with staff revealed that the loperamide order was transcribed from standing orders incorrectly, as it should have been recorded as a PRN medication rather than scheduled doses. The director of nursing confirmed that the medication should not have been scheduled and that the resident's primary provider was contacted to discontinue the medication. The facility's policy required notifying the provider if a resident experienced four or more loose stools in a 24-hour period, which was not adhered to in this case. The transcription error led to medication errors each time the medication was administered at scheduled times.
Failure to Act on Pharmacist's Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations were acted upon, addressed, and documented in the medical record for a resident reviewed for unnecessary medication use. The resident, who had intact cognition and diagnoses including paroxysmal atrial fibrillation, heart disease, and secondary hypertension, was on a medication regimen that included Eliquis, aspirin, and Diltiazem. The consulting pharmacist identified an irregularity in the medication regimen, noting that the concomitant use of Diltiazem with oral anticoagulants like Eliquis was associated with a higher bleeding risk. The pharmacist recommended reassessing the risks versus benefits of using Diltiazem, but there was no recorded response from the physician to either accept or reject the recommendation. The deficiency was further highlighted when the consulting pharmacist renewed the recommendation in a subsequent review, again noting the lack of response from the physician. Despite the recommendation being made in both August and October, the resident continued to receive the medication without any documented action or response from the physician. The Director of Nursing (DON) acknowledged the absence of the provider's response and mentioned that the physician sometimes took the recommendation forms back to the clinic for further review without returning them. The facility's policy required that recommendations be acted upon and documented, but this was not adhered to in this case.
Failure to Provide Face-to-Face Evaluation for PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a face-to-face provider evaluation for the continued use of a PRN psychotropic medication for a resident with severe cognitive impairment and a diagnosis of dementia. The resident was prescribed Zyprexa (olanzapine) 2.5 mg to be taken as needed for behaviors, with the order stating it was acceptable to continue until the next face-to-face visit. However, the resident's medical records from January 22 to February 12 did not include documentation from the physician regarding the rationale and duration of need for the PRN antipsychotic medication. The resident received the PRN medication multiple times in January and February for various reasons, including behavior issues and agitation. Interviews with the Director of Nursing and the administrator revealed that PRN antipsychotic medications should be re-evaluated by the physician every 14 days with documented rationale and duration for use. The facility's policy required a face-to-face assessment by the prescribing provider 14 days after initiating a new PRN psychotropic medication, which was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents, one with a catheter and another with a surgical wound. The Centers for Disease Control and Prevention (CDC) guidelines require the use of personal protective equipment (PPE), including gowns and gloves, during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). However, the facility did not adhere to these guidelines for a resident with an indwelling Foley catheter and another resident receiving surgical wound care. For the resident with the Foley catheter, the care plan indicated the need for EBP due to the catheter. Despite this, staff members, including a nursing assistant and a registered nurse, failed to wear gowns during catheter care and toileting activities. The facility's infection preventionist and director of nursing confirmed that EBP was required for residents with catheters, but staff did not consistently follow this protocol, as evidenced by the lack of PPE carts and signage indicating EBP requirements. Similarly, for the resident with a surgical wound, the care plan did not address the need for EBP, and staff did not wear gowns during dressing changes. Observations revealed that a registered nurse assessed and changed the resident's dressing without wearing a gown, despite the presence of a fluid-filled blister and signs of potential infection. The facility's policy required EBP for residents with wounds, but staff were not informed or did not adhere to these requirements, leading to a failure in implementing necessary precautions.
Failure to Notify Physician of Resident's Decline
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who was experiencing increased sleepiness, not eating, and not taking medications. The resident, who had a history of dementia with behavioral disturbance, depression, hypertensive kidney disease, and other conditions, was observed by family and staff to be more lethargic and not consuming food or medications. Despite these observations, the facility did not promptly inform the physician or take immediate action to address the resident's declining condition. The resident's family member expressed concerns about the resident's medication and condition, noting that the resident was not eating and was difficult to understand. The family member visited the facility multiple times, observing the resident in a deteriorated state, and communicated these concerns to the staff. However, the facility delayed in organizing a care conference and did not notify the physician until the resident's condition had significantly worsened, leading to an unscheduled hospital discharge. Interviews with facility staff, including a trained medication aide, registered nurse, and the director of nursing, revealed that the resident's decline had been noted but not adequately addressed. The staff had observed changes in the resident's behavior and condition, yet failed to follow the facility's policy of notifying the physician and family in a timely manner. The director of nursing acknowledged that the staff should have updated the provider upon identifying the change in the resident's condition.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify and assess a change in condition for a resident who exhibited increased sleepiness, missed medications, and irregular eating and drinking habits. The resident, diagnosed with dementia, depression, and other health issues, was noted to have severe cognitive impairment and required assistance with mobility and nutrition. Despite these needs, the facility did not adequately respond to the resident's deteriorating condition, which included lethargy and refusal to eat or drink, until the family member insisted on a hospital transfer. The resident's family member expressed concerns about the resident's medication, Zyprexa, and its effects, noting that the resident was not communicating or eating as usual. Despite these concerns and the resident's visible decline, the facility delayed action, opting to schedule a care conference instead of immediate intervention. The family member's insistence led to the resident's transfer to the hospital, where severe dehydration, hypernatremia, and a urinary tract infection were diagnosed. Interviews with facility staff revealed a lack of communication and assessment regarding the resident's condition. The Director of Nursing and the administrator acknowledged the failure to update the provider or conduct an assessment following the change in condition. The facility's policy required notification and evaluation of changes in resident status, which was not followed in this case, leading to the deficiency.
Failure to Assess Wedge Cushion as Potential Restraint
Penalty
Summary
The facility failed to assess the use of a wedge cushion as a potential restraint for a resident with severe cognitive impairment. The resident had a history of multiple falls and was identified as restless and impulsive. The care plan included the use of a wedge cushion to prevent falls, but the facility did not evaluate whether the wedge cushion functioned as a restraint. The resident experienced an unwitnessed fall, resulting in injuries, when the wedge cushion and fall mat were not in place. Interviews with staff and family revealed that the wedge cushion was used to keep the resident positioned in bed and prevent falls. However, the facility's nurse consultant admitted that the resident had not been assessed for a potential restraint, and the type of wedge being used was unfamiliar to her. The facility's policy on physical restraints required an assessment to determine the need and risk/benefit relationship before using a restraint, which was not conducted in this case.
Failure to Provide Substantive Snacks and Prevent Long Gaps Between Meals
Penalty
Summary
The facility failed to ensure nutrient and/or calorie substantive snacks were offered and readily available for three residents who voiced concerns at a resident council meeting. These residents reported that the snack cart, which used to be available, was no longer in use. Interviews with nursing assistants confirmed that the snack cart was no longer available, and residents had to request snacks if they wanted them. The certified dietary manager confirmed that dinner was served at 5 p.m. and breakfast at 8 a.m., resulting in a 15-hour gap between meals without offering a substantial snack in the evening. The administrator acknowledged that the hours between meals were too many and that the snack offerings did not meet the requirements for a substantial snack, which is important for maintaining residents' consistent weights and preventing weight loss. The facility's decision to remove the snack carts was based on concerns about safety and infection control, as noted in the Havenwood Resident Council Meeting Minutes. The dietary staff would lock the snack carts in the kitchenettes after meal service, and residents had to ask staff to get them snacks or drinks. This change led to residents not having access to snacks between meals, particularly in the evening, which could affect their nutritional status. The facility's policy stated that there should not be more than 14 hours between meal services unless a substantial bedtime snack is offered, but this policy was not being followed, leading to the deficiency identified in the report.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure allegations of abuse were investigated for a resident who reported inappropriate touching by a staff member. The resident, who had diagnoses including anxiety, depression, bipolar disorder, and secondary Parkinsonism, reported the incident to staff but no investigation was conducted. The resident's care plan identified her as a vulnerable adult and encouraged family involvement in care conferences. Despite this, the allegation was not reported to the State Agency or the police department, and the staff member involved did not receive any remedial training on performing cares after the incident. Interviews with various staff members revealed that the resident had expressed discomfort with the care provided by the nursing assistant and did not want him to provide further care. However, the facility did not follow its policy on abuse prevention and investigation, which required a thorough and objective investigation of all allegations. The failure to investigate and report the allegation, as well as the lack of remedial training for the staff member involved, constituted a deficiency in the facility's handling of the situation.
Failure to Verify Nurse Aide Registration
Penalty
Summary
The facility failed to verify the registration of a nurse aide (NA-A) before allowing them to work directly with residents after the four-month training period. NA-A was hired on 10/23/23 and placed on investigatory suspension on 4/1/24. A review of NA-A's personnel file showed no verification of nursing assistant certification. A search of the nursing assistant registry confirmed that NA-A was not currently registered. During an interview, the administrator revealed that NA-A had taken the skills test on 12/22/23 but did not take the knowledge test due to a communication misunderstanding between the testing site and the facility. The facility's abuse prevention/prohibition program required screening of all applicants through the State of Minnesota Department of Human Services and the Minnesota Nursing Assistant Registry prior to employment, which was not adhered to in this case.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were reported for a resident who had diagnoses including anxiety, depression, bipolar disorder, and secondary Parkinsonism. The resident, who was cognitively intact, reported that a male nursing assistant had touched her inappropriately during peri-care, making her uncomfortable. This incident was reported to staff, but no further investigation or reporting to the State Agency or police department occurred. The resident's care plan identified her as a vulnerable adult, but the facility did not follow through with the necessary actions to address her concerns properly. Interviews with staff revealed that the assistant director of nursing and a social worker were aware of the resident's complaint but did not investigate further because the resident stated it wasn't abuse. The nursing assistant involved was not given any remedial training, and there was no documentation of any education or training in his personnel file following the allegation. The facility's policy required prompt reporting of any suspected abuse, but this was not adhered to in this case.
Failure to Assess Resident for Self-Administration of Nebulizer Treatment
Penalty
Summary
The facility failed to ensure nursing staff observed medication administration for a resident who was not assessed to be able to self-administer a nebulizer treatment. The resident, who had severe cognitive impairment and multiple diagnoses including aphasia, asthma, anxiety, depression, and morbid obesity, was observed self-administering a nebulizer treatment without proper assessment or supervision. The resident's care plan did not address nebulizer treatments, and there was no assessment for self-administration of medications. During an observation, a trained medication aide prepared the resident's nebulizer and left the resident alone with the call light within reach, returning only after the treatment was completed. The medication aide was unaware if the resident had been assessed for self-administration. The corporate registered nurse confirmed that the resident had not been assessed for self-administration of medications. The facility's policy required an interdisciplinary team assessment and a written order for self-administration, which had not been followed in this case.
Failure to Clarify Conflicting Advanced Directives
Penalty
Summary
The facility failed to ensure conflicting directives for emergency care and treatment were clarified for a resident (R28) who had advanced directives. R28's electronic medical record (EMR) identified her as do not resuscitate (DNR) on her face sheet, while another document in her EMR indicated she wanted full code status, meaning all available reasonable technology should be used in the event of cardiac respiratory arrest. Despite R28's cognitive intactness and her clear communication that she wanted full code status, the facility's records were inconsistent, leading to confusion among staff about her true wishes in an emergency situation. Interviews with staff revealed that the conflicting information was not promptly addressed. An LPN verified the discrepancy between the face sheet and the scanned document, and a social worker confirmed that the code status should have been updated and clarified during care conferences. Observations showed that the code status information on the clipboard next to the automated external defibrillator (AED) was outdated, listing R28 as DNR. The facility's policy required regular audits to ensure accurate communication of residents' code status, but these audits were not effectively implemented, resulting in the failure to honor R28's wishes accurately.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure the long-term care ombudsman was notified of resident transfers for one of two residents reviewed for hospitalization. The resident, identified as R26, had diagnoses including dementia, hemiplegia, seizure disorder, and depression, and was cognitively intact. The resident's progress notes indicated hospital transfers on two occasions, but the medical record lacked evidence of notification to the state ombudsman's office. An email from the ombudsman confirmed no communications regarding hospitalizations had been received since April 2021. During an interview, a social worker stated the facility only notified the ombudsman's office if the hospitalization or discharge was contested. A policy on notifying the ombudsman's office was requested but not provided.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative during two separate hospitalizations. The resident, who had diagnoses including dementia, hemiplegia, seizure disorder, and depression, was cognitively intact according to the quarterly Minimum Data Set (MDS). The resident's progress notes indicated hospital transfers on two occasions, but the medical record lacked evidence of written notification for either hospitalization. Interviews with facility staff revealed that residents typically sign a bed hold form upon admission, which includes language about holding the bed without charge for up to 18 consecutive days. However, the facility's policy and resident handbook both require written notification at the time of transfer or discharge. The social worker confirmed the importance of this notification to inform residents or their families about potential charges and to determine if they want their bed held.
Failure to Reposition and Check Incontinent Resident
Penalty
Summary
The facility failed to ensure timely repositioning and incontinence care for a resident (R30) who was at risk for pressure ulcers. R30, who had severe cognitive impairment, morbid obesity, and was always incontinent of bowel and bladder, was observed from 8:15 a.m. to 11:54 a.m. without being repositioned or checked for incontinence as per her care plan. Despite multiple interactions with staff and visitors, R30 remained seated in her wheelchair for almost four hours without being repositioned or checked for incontinence, which was against the care plan directives of repositioning and checking every two to three hours. During the observation period, staff failed to offer or perform necessary care actions, such as checking and changing R30's brief or repositioning her, even when prompted by visitors. Interviews with staff confirmed that R30 had not been repositioned or checked for incontinence as required. The facility's Skin Care policy emphasized the importance of individualized care plans to address pressure relief and incontinence, which was not adhered to in this case, leading to a deficiency in care for R30.
Failure to Change Nebulizer and Tubing in a Timely Manner
Penalty
Summary
The facility failed to ensure that the nebulizer and tubing for a resident were changed in a timely manner. The resident, who had diagnoses including aphasia, asthma, anxiety, depression, and morbid obesity, was identified as severely cognitively impaired and receiving oxygen therapy. The resident's care plan did not address respiratory care or nebulizer treatments, and the physician's orders did not include instructions for the care and changing of the nebulizer and tubing. The medical record also lacked documentation for nebulizer and tubing changes. During an observation, the resident's nebulizer setup was found on the bedside table with undated tubing. Interviews with a trained medication aide and a nurse consultant revealed that the nebulizer setup should be rinsed after each use and the tubing should be changed regularly to prevent infection. However, there was no documentation of these changes in the medication administration record. The facility's policy on Quality of Care emphasized the importance of providing respiratory care consistent with professional standards, but this was not followed in the resident's case.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for two residents. Resident R30, who has severe cognitive impairment and multiple diagnoses including asthma and morbid obesity, was observed receiving a nebulizer treatment without supervision. The trained medication aide (TMA) left R30 alone during the treatment, despite R30 not being assessed for self-administration of medications. This action was contrary to the facility's policy and the TMA's training, which required supervision during nebulizer treatments. Resident R39, diagnosed with end-stage renal failure and undergoing hemodialysis, was given calcium acetate at a time not aligned with her meal schedule, contrary to physician orders. The TMA administering the medication acknowledged the error but cited scheduling conflicts with R39's dialysis times. The assistant director of nursing confirmed that the medication should be given as directed with meals. These actions resulted in a medication error rate of seven percent, exceeding the acceptable threshold of five percent.
Failure to Label and Dispose of Medications Properly
Penalty
Summary
The facility failed to ensure medications with a shortened expiration period were labeled with an opened-on date and failed to ensure expired medications were disposed of properly. This was observed during an inspection of the North medication cart, which contained a bottle of Flonase for a resident without an opened-on date and with a manufacturer expiration date of 2/2024. Additionally, an albuterol sulfate inhaler for another resident was found without an opened-on date and with a dose-meter reading of 202. The trained medication aid (TMA) admitted to checking for expired medications only every couple of weeks or whenever time allowed, rather than on a regular basis. The assistant director of nursing (ADON) stated that the pharmacy consultant conducted medication cart audits every three months and that it was expected not to have expired medications in the cart. The ADON also emphasized the importance of dating medications when opened to ensure their effectiveness. A document from Thrifty Pharmacy outlined that medications should be stored safely and securely, and outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures. However, these guidelines were not followed, leading to the observed deficiencies.
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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