Kittson Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Hallock, Minnesota.
- Location
- 1010 South Birch Ave, Hallock, Minnesota 56728
- CMS Provider Number
- 245247
- Inspections on file
- 22
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kittson Healthcare during CMS and state inspections, most recent first.
A resident with blindness and multiple comorbidities, identified as a fall risk and care planned for contact guard assist, was ambulating with a cane and staff supervision when she lost balance and fell, resulting in a left arm fracture. Staff did not use a gait belt or maintain close proximity as required by the care plan, and interviews confirmed confusion about assistance levels. The facility's policy did not explicitly require gait belt use for all transfers or ambulation, contributing to the incident.
A resident identified as DNR in facility records and who verbally confirmed their DNR preference did not have a signed advanced directive in their medical record. The DON confirmed the required documentation was missing and could not provide the facility's policy on advanced directives.
A resident who was independent with bed mobility and transfers was observed using half bed rails, but the facility did not complete a comprehensive assessment or obtain informed consent for their use. Staff interviews confirmed that no assessment was performed, as the rails were considered adaptive equipment rather than restraints, despite facility policy requiring documentation and assessment.
A resident with diabetes did not receive insulin according to manufacturer instructions when an LPN failed to prime the insulin pen with 2 units before administration. The LPN attached a new needle but did not perform the required priming step, contrary to facility policy and manufacturer guidelines. This was confirmed through observation, staff interviews, and review of the facility's insulin administration policy.
The facility did not provide the latest CDC education on vaccine risks and benefits or offer the most recent pneumococcal vaccines to several residents. Documentation was lacking regarding whether residents received required vaccine information or were offered the newer PCV20 or PCV21 vaccines, and staff interviews confirmed there was no process to re-evaluate vaccination status outside of annual reviews.
The facility did not include the daily resident census on the nurse staffing posting, despite displaying other required staffing information. The census was omitted on nearly all reviewed days, and staff confirmed they were not trained or instructed to include it. The census was only recorded in a non-public area, making it inaccessible to residents and visitors.
The facility failed to implement timely transmission-based precautions and confirmatory testing for COVID-19 for residents displaying symptoms, as per CDC guidelines. Additionally, enhanced barrier precautions were not used for a resident with an indwelling catheter. The facility's infection control log lacked details on test types and isolation measures, and staff were not instructed on proper PPE use for catheter care.
The facility failed to ensure unlicensed personnel did not administer injectable medications, violating state requirements, and omitted medications during medication pass for several residents. A CCMA administered insulin injections, which should have been done by licensed professionals. Additionally, medications were not administered as ordered, with some remaining in the medication cart despite being signed off. The DON acknowledged these as medication errors and was attempting to improve medication tracking.
The facility failed to date opened prescription eye drops, risking the use of expired products for three residents. During a review, it was found that the open vials of latanoprost on a medication cart lacked recorded open dates. The RN acknowledged that staff often forget to date medications, and the DON confirmed that not all staff were following the policy. The facility's policy required discarding latanoprost 42 days after opening, but without open dates, compliance was not possible.
A facility failed to implement antibiotic stewardship protocols for a resident with a UTI. The infection control log did not specify the organism identified in urine cultures, and the resident's medical record lacked evidence of culture results to ensure the correct antibiotic was prescribed. Staff interviews revealed gaps in processes, including lack of orientation for an RN and inadequate documentation of culture results. The facility's Antibiotic Stewardship Policy was not followed in this case.
A resident with severe cognitive impairment was left exposed in their room, visible from the hallway, due to staff inaction. Despite multiple staff members passing by, the resident remained uncovered for several minutes. The facility's policy emphasizes maintaining resident dignity and privacy, which was not upheld in this instance.
A resident with severe cognitive impairment was improperly restrained in a recliner by a nursing assistant to prevent wandering. The resident's wheelchair was moved out of reach, restricting self-transfer, which violated the facility's restraint-free policy. Video evidence and staff interviews confirmed the incident, revealing a misunderstanding of restraint use among staff.
The facility failed to report an incident where a resident with cognitive impairment was handled roughly and restrained by a nursing assistant. Additionally, an injury of unknown origin on another resident was not reported, despite being in a suspicious location. The facility's policy requires immediate reporting of such incidents, but these were not reported to the appropriate authorities.
A facility failed to investigate allegations of rough treatment and the use of a recliner as a restraint for a resident with severe cognitive impairment. Additionally, the facility did not report or investigate an injury of unknown origin for another resident, violating its own policies on abuse and injury investigation.
A resident with severe cognitive impairment and bladder cancer experienced a skin tear on the scrotum, which the facility failed to properly assess and address. Despite being at risk for pressure ulcers and frequently incontinent, the resident's care plan was not updated, and staff were unaware of the injury. Observations showed improper handling during transfers, and interviews revealed a lack of communication and follow-through in wound care, leading to inadequate interventions and oversight of the resident's condition.
A resident with severe cognitive impairment and hemiplegia was at risk for pressure ulcers, yet the facility failed to consistently implement prescribed interventions. Observations showed the resident wearing fuzzy slippers instead of heel protectors, and their heels were not properly offloaded. Staff interviews confirmed the care plan was not followed, and a policy on pressure ulcer care was not provided.
A nursing assistant improperly transferred a resident with severe cognitive impairment, using a recliner as a restraint and failing to use a gait belt, leading to unsafe conditions. Additionally, another resident with severe cognitive impairment was not adequately supervised, resulting in aimless wandering and potential safety risks. Staff failed to intervene appropriately in both cases, highlighting deficiencies in the facility's transfer and supervision practices.
A resident with dementia became agitated and aggressive when a nursing assistant attempted to remove a banana from his wheelchair, contrary to his care plan directives. The incident, captured on video, showed the assistant's approach escalated the situation, leading to physical aggression from the resident. The facility lacked a policy on dementia care.
A resident with multiple diagnoses, including cancer and Parkinson's disease, did not have a physician-prescribed Tramadol taper order implemented, leading to continued urinary retention issues. Despite a pharmacy consultant's recommendation and the physician's signed order, the medication dosage was not reduced due to communication and system issues within the facility.
Failure to Use Gait Belt During Ambulation Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to use a transfer (gait) belt during ambulation for a resident identified as being at risk for falls. The resident, who was blind and had diagnoses including type 2 diabetes and hypertension, required partial to moderate assistance for walking and was care planned for contact guard assist (CGA) or stand by assist (SBA) with one staff for all mobility. Documentation and care plans indicated that a gait belt was to be used during ambulation, particularly when walking to dine. On the day of the incident, the resident was ambulating in a hallway with a cane and a nursing assistant providing SBA. The resident lost balance and fell, landing on her left side and sustaining a left arm fracture. Multiple staff interviews and a review of surveillance video confirmed that the resident was not wearing a gait belt and the nursing assistant was not in close proximity at the time of the fall, contrary to care plan directives and facility expectations. Staff interviews revealed confusion regarding the meaning of CGA and SBA, and it was acknowledged that a gait belt should have been used for safety. The facility's fall prevention policy outlined universal fall precautions and the need for individualized care plans for residents at risk of falls, but did not specifically direct staff to use a gait belt with all transfers or ambulation. The lack of adherence to the care plan and failure to use a gait belt directly contributed to the resident's fall and subsequent injury.
Failure to Maintain Signed Advanced Directive for DNR Status
Penalty
Summary
The facility failed to ensure that a signed copy of an advanced directive, specifically indicating whether to perform cardiopulmonary resuscitation (CPR) or to implement a do not resuscitate (DNR) order, was present in the medical record for one resident. Documentation including the resident's face sheet, care plan, and admission checklist identified the resident as DNR, and the resident verbally confirmed their wish for DNR status during an interview. However, the medical record did not contain a signed advanced directive by the resident or their representative and the provider. The DON confirmed that the process required a signed provider order and advanced directive upon admission, and that the resident was not listed as wanting CPR, but was unable to locate the required signed document. Additionally, a policy related to advanced directives was requested but not provided.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident with attached bed rails was comprehensively assessed for their use. The resident in question had no cognitive impairment and was independent with bed mobility and transfers, according to the quarterly Minimum Data Set (MDS), which also indicated that bed rails were not used. However, observations on two separate occasions showed that the resident had half bed rails up and locked on both sides of the upper half of the bed. The resident reported using the rails to reposition and assist with getting out of bed, and stated that the rails did not restrain movement. A review of the resident's medical record revealed a lack of assessment regarding entrapment risk, risk versus benefits, informed consent, bed dimensions in relation to the resident's height and weight, and documentation of alternatives attempted or contraindicated before installation. Interviews with facility staff, including the MDS coordinator and the DON, confirmed that no assessment was performed because the bed rails were considered adaptive equipment for mobility and transfers, not restraints. The facility's policy required documentation and assessment for bed rail use, but this was not completed in this case.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to administer insulin according to the manufacturer's instructions for a resident with diabetes. The resident, who was cognitively intact and had a diagnosis of diabetes, was prescribed Lantus and Novolog insulin at specific times throughout the day. During an observation of medication administration, the LPN prepared the Novolog insulin pen by attaching a new sterile needle but did not prime the pen with 2 units of insulin before administering the dose, as required by the manufacturer's instructions. The LPN stated she had been instructed that priming was only necessary on the initial use and had never primed the pen before subsequent injections. Further review revealed that the facility's policy, as well as the manufacturer's instructions for the insulin pen, required priming with 2 units before each injection to ensure accurate dosing. Another nurse confirmed that she always primed the pen by wasting 2 units before drawing up the prescribed dose. The director of nursing also stated that staff are instructed to always prime insulin pens prior to administration. The failure to follow these procedures resulted in the resident not receiving insulin in accordance with the manufacturer's instructions.
Failure to Provide Updated Pneumococcal Vaccine Education and Offer New Vaccines
Penalty
Summary
The facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the risks and benefits of vaccinations and did not offer the most recent pneumococcal vaccines to three out of five residents reviewed for immunizations. Specifically, the medical records for these residents did not document whether they received the Vaccine Information Statements (VIS) or education about the risks and benefits of the pneumococcal vaccine. Additionally, there was no documentation indicating that these residents were offered or had accepted or declined the newer pneumococcal vaccines (PCV20 or PCV21), despite having received earlier versions of the vaccine in previous years. Interviews with nursing staff and the Director of Nursing revealed that while vaccination status is reviewed upon admission and annually during care conferences, there was no established process to re-evaluate current residents' pneumococcal vaccination status outside of these times. The facility's standing orders and policies referenced the use of older pneumococcal vaccines and did not address the newer recommendations. As a result, the facility did not ensure that current residents were consistently offered the most up-to-date pneumococcal vaccines or provided with the latest CDC educational materials as required.
Failure to Post Daily Resident Census on Nurse Staffing Information
Penalty
Summary
The facility failed to include the daily resident census on the nurse staffing posting, as required. Observations on multiple days showed that the nurse staff posting, displayed across from the nurse's station, included the date, shift hours, and the number of RNs, LPNs, and NAs with their total and actual hours worked, but consistently omitted the daily census. Review of postings from over a month revealed that the census was missing on 37 out of 38 days. Interviews with the health unit coordinator (HUC) and the director of nursing (DON) confirmed that neither had been documenting the census on the posting, as the HUC was not trained to do so and the DON had not enforced this requirement. The census was only recorded on a white board in the nurse's area, which was not visible to residents or visitors. No nurse staff posting policy was provided upon request.
Inadequate Infection Control and Precautions in LTC Facility
Penalty
Summary
The facility failed to implement timely transmission-based precautions and testing for COVID-19 according to CDC guidelines for four residents who were displaying COVID-19 symptoms. These residents exhibited symptoms such as cough, shortness of breath, and fever, yet were not placed in isolation after initial negative antigen tests. The facility's infection control log did not specify the type of COVID-19 test used, whether confirmatory tests were conducted, or if isolation was implemented. The Director of Nursing (DON) confirmed that symptomatic residents were not placed in isolation, as the facility did not want to isolate residents based on initial negative antigen tests. Additionally, the facility failed to implement enhanced barrier precautions for a resident with an indwelling catheter. The care plan for this resident did not include instructions for using personal protective equipment (PPE) during catheter care. A nursing assistant was observed performing catheter care without wearing a gown, and the DON admitted that staff had not been instructed on enhanced barrier precautions related to catheter care. The facility's policy on catheter care did not provide specific guidance on PPE use. The facility's policies and procedures were not aligned with CDC guidelines, which recommend confirmatory testing following a negative antigen test for symptomatic individuals and the use of enhanced barrier precautions for residents with indwelling medical devices. The DON and staff were unaware of these guidelines, leading to inadequate infection prevention and control measures for both COVID-19 and catheter care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that unlicensed personnel did not administer injectable medications, which is inconsistent with state requirements. This deficiency was identified for four residents who received insulin injections. The certified clinical medical assistant (CCMA) administered insulin to these residents, despite state statutes requiring that injectable medications be administered only by licensed professionals such as physicians, physician's assistants, registered nurses, nurse practitioners, or licensed practical nurses. The CCMA believed that administering injections was within her scope of practice, as she was supervised by a registered nurse who was available in the building. Additionally, the facility failed to ensure medications were administered as ordered for three residents whose medications were omitted during medication pass. For instance, one resident's levothyroxine tablets were found in the medication cart, indicating they were not administered as signed off by the licensed practical nurse. Another resident's medication card was missing a tablet without any documentation of wastage, and a third resident's medication was not administered despite being signed off by the CCMA. These omissions were identified during observations of the medication cart and interviews with nursing staff. The facility's director of nursing acknowledged that extra or missing medications from resident medication cards constituted medication errors. The facility was aware of the issues with medication administration and was attempting to improve tracking of resident medications. The director of nursing had implemented a policy for nurses to initial and date each bubble on the medication cards when administering medications, but inconsistencies remained. The facility's policy on medication pass delivery emphasized the importance of following the six rights of medication administration, yet these standards were not consistently met.
Failure to Date Opened Eye Drops Leads to Potential Expired Medication Use
Penalty
Summary
The facility failed to ensure that prescription eye drops were dated when opened, which could lead to the administration of expired products. During an observation of the medication carts, it was found that the open vials of latanoprost for three residents did not have the date of opening recorded. This oversight was noted on one of the two medication carts reviewed. The registered nurse (RN-A) acknowledged that staff often forget to date the medications when opened, and was unsure when the eye drops had been opened, suggesting that new vials should be ordered. The director of nursing (DON) confirmed that the expectation was for staff to record open dates on medication bottles, but acknowledged that not all staff were complying with this policy. The facility had a significant number of new staff members, and efforts were being made to ensure they were properly trained. The facility's policy stated that latanoprost eye drops should be discarded 42 days after opening, and the manufacturer's guidelines indicated that once opened, the drops could be stored at room temperature for six weeks. However, the lack of recorded open dates on the medication vials meant that these guidelines could not be followed accurately.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic stewardship protocols for a resident identified as R4, who was taking an antibiotic for a urinary tract infection (UTI). The Nursing Home Infection Control Log, updated in April 2022, identified three residents diagnosed with UTIs in May 2024, including R4. However, the log did not specify the organism identified in the urine cultures. R4's medical record lacked evidence of the urine culture results to ensure the correct antibiotic was prescribed, and the facility was unable to provide a copy of these results. R4, who had a history of bladder cancer and chronic kidney disease, experienced recurring blood and blood clots in his urine. On May 3, 2024, R4 complained of pain, and a registered nurse (RN) obtained a verbal order for a urinalysis. The following day, R4 was confirmed to have a UTI, and an antibiotic, Augmentin, was prescribed and administered. However, the culture and sensitivity results, which confirmed sensitivity to Augmentin, were not documented in R4's medical record. Interviews with staff revealed gaps in the facility's processes. RN-A, who did not receive proper orientation, learned the facility's processes from travel nurses. The Director of Nursing (DON) stated that the infection control log did not include organisms due to lack of access to the clinic's electronic medical record system. The campus-wide Infection Preventionist (IP) followed the urine culture results but did not share them with the DON. The facility's Antibiotic Stewardship Policy, reviewed in February 2023, outlined the need for tracking and documenting antibiotic use, but these procedures were not followed in R4's case.
Resident Privacy Violation Due to Staff Inaction
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident, identified as R19, who was observed exposed from the hallway. R19, who had severe cognitive impairment and diagnoses including Alzheimer's disease and anxiety, was dependent on staff for all abilities. The care plan for R19 did not include measures to maintain his privacy. During an observation, R19 was seen lying in bed with his room door wide open, and his back, legs, and incontinent brief were visible due to bunched-up blankets and gown. Multiple staff members, including nursing assistants, walked past R19's room without addressing his exposure, although one eventually covered him after a delay. Interviews with staff revealed that it was expected for staff to check on residents and ensure their privacy by covering them if exposed. However, staff admitted to being preoccupied with other tasks or not noticing R19's condition. The Director of Nursing acknowledged the importance of care planning interventions to prevent such exposure and stated that staff had been educated on maintaining resident privacy. The facility's Quality of Life policy emphasized the importance of maintaining resident dignity and privacy, including keeping residents covered when outside their rooms.
Inappropriate Use of Recliner as Restraint for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was free from physical restraints. R13, who had severe cognitive impairment and exhibited wandering behaviors, was observed being placed into a recliner by a nursing assistant (NA-C) without consent. NA-C removed R13's wheelchair out of reach, effectively using the recliner as a restraint to prevent R13 from wandering. This action was witnessed by a registered nurse (RN-A) and was reported to the director of nursing (DON). The incident was corroborated by video surveillance, which showed NA-C placing R13 in a recliner and moving the wheelchair away, preventing R13 from self-transferring. Despite the facility's policy to keep residents restraint-free, staff, including NA-C, admitted to routinely placing wandering residents in recliners to prevent them from entering other residents' rooms. The DON acknowledged that moving the wheelchair out of reach constituted a restraint. Interviews with staff revealed a misunderstanding or disregard for the facility's restraint policy. The DON initially did not consider the recliner as a restraint and did not review the surveillance footage until later. The facility's policy defined physical restraints as any item that confined a person, including recliners, if the resident could not remove themselves independently. This incident highlighted a failure to adhere to the policy, resulting in the inappropriate use of a recliner as a restraint for R13.
Failure to Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of rough treatment and the use of a recliner as a restraint for a resident identified as R13. R13, who had severe cognitive impairment and exhibited wandering behaviors, was reportedly handled roughly by nursing assistant NA-C. NA-C was observed grabbing R13 by the underarms and placing her into a recliner against her will, with the intent to prevent her from wandering. Despite witnessing the incident, RN-A did not ensure the incident was reported to the appropriate authorities, and the Director of Nursing (DON) did not investigate further, believing it to be a personal issue between staff members. Additionally, the facility failed to report an injury of unknown origin for another resident, R4, who had severe cognitive impairment and was at risk for pressure ulcers. R4 was found to have a skin tear in a sensitive area, which was not documented thoroughly in the medical record. The DON acknowledged that the injury should have been reported as it was in a suspicious location and the resident could not explain how it occurred. However, the injury was not reported to the State Agency as required by the facility's policy. The facility's policy on abuse, neglect, and injuries of unknown origin mandates immediate reporting of such incidents to the administrator and the Minnesota Department of Health. Despite this policy, the incidents involving R13 and R4 were not reported in a timely manner, highlighting a failure in the facility's adherence to its own procedures for ensuring resident safety and compliance with federal and state laws.
Failure to Investigate Allegations of Rough Treatment and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of rough treatment and the use of a recliner as a restraint for a resident with severe cognitive impairment. The incident involved a nursing assistant (NA-C) who was observed placing the resident into a recliner against her will to prevent wandering, which was witnessed by a registered nurse (RN-A). Despite RN-A's concerns and communication with the Director of Nursing (DON), no immediate investigation was initiated, and NA-C continued to work without any intervention. The facility did not review available video surveillance that captured the incident, which showed NA-C handling the resident roughly and not using proper transfer techniques. Additionally, the facility failed to report and investigate an injury of unknown origin for another resident who had a severe cognitive impairment. The resident was found to have a significant skin tear in a sensitive area, which was not documented or explained in the medical records. The injury was discovered during routine care, and staff were unable to determine how or when it occurred. The facility's policy required such injuries to be reported and investigated, but this was not done. The facility's lack of action in both cases violated its own policies on abuse and injury investigation. There was no evidence of staff interviews or protective measures taken for the residents involved. The DON acknowledged the oversight and the need for an investigation but failed to act promptly, leaving the residents without the necessary protection and care.
Failure to Address Skin Tear in Resident with Cognitive Impairment
Penalty
Summary
The facility failed to properly identify, assess, and implement interventions to promote skin integrity and healing for a resident with a skin tear on the scrotum. The resident, who had severe cognitive impairment and a diagnosis of bladder cancer, was at risk for pressure ulcers and frequently incontinent. Despite these risks, the care plan and interventions were not adequately followed or updated to address the resident's skin condition. Observations revealed that the resident was transferred using a standing lift, during which the removal of a soaked incontinent brief caused discomfort and potentially contributed to the skin tear. The brief was soaked with bloody urine and blood clots, which may have obscured the presence of the skin tear. Staff members, including nursing assistants and a licensed practical nurse, were unaware of the skin tear's existence or its cause, and the resident's medical record lacked comprehensive documentation of the injury. Interviews with staff indicated a lack of communication and follow-through regarding the resident's wound care. The Director of Nursing acknowledged that the incident slipped through the cracks, and the resident was not added to wound rounds or provided with appropriate interventions. The facility's Skin Breakdown Prevention Protocol was not adhered to, as weekly skin checks and documentation were not consistently performed, leading to the oversight of the resident's skin tear and inadequate care planning.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement appropriate interventions for preventing pressure ulcers for a resident identified as being at risk. The resident, who had severe cognitive impairment and conditions including hemiplegia and Alzheimer's disease, was noted to have a healing unstageable pressure injury on the left heel. Despite the care plan directing staff to use heel protectors while the resident was in bed, observations revealed that the resident was wearing fuzzy slippers instead of the prescribed heel protectors. Additionally, the resident's heels were observed resting on the mattress rather than being offloaded with a pillow as required. Staff interviews confirmed that the fuzzy slippers were incorrectly used as heel protectors, and the resident's care plan was not consistently followed. The LPN acknowledged that the resident should always wear heel protectors in bed to maintain skin integrity, especially given the resident's limited mobility. The director of nursing emphasized the importance of adhering to the care plan to prevent the recurrence of pressure injuries. A policy on pressure ulcer care and interventions was requested but not provided, indicating a potential gap in the facility's documentation and adherence to care protocols.
Deficiencies in Resident Transfer and Supervision Practices
Penalty
Summary
The facility failed to ensure safe resident transfer practices for a resident with severe cognitive impairment, identified as R13. The incident involved a nursing assistant, NA-C, who improperly transferred R13 by lifting her under the arms and placing her into a recliner against her will. This action was taken to prevent R13 from wandering in her wheelchair, which was used as a restraint. The transfer was conducted without the use of a gait belt, and the wheelchair brakes were not locked, posing a risk of falls. The incident was witnessed by RN-A, who intervened by asking another nursing assistant, NA-D, to transfer R13 back to her wheelchair. However, NA-C, visibly upset, proceeded to transfer R13 back to her wheelchair without proper technique, dragging R13's feet on the floor. The facility also failed to provide a safe environment and adequate supervision for a resident identified as R19, who had severe cognitive impairment and a history of wandering. R19 was observed moving aimlessly in his wheelchair in the common area, coming into close contact with a family member, FM-A, who had to push R19 away multiple times. Staff did not intervene during these interactions, and R19's movements were not redirected to prevent potential harm. Observations showed that R19's wheelchair bumped into furniture and other residents, yet staff did not take action to ensure R19's safety or the safety of others. The facility's policies on safe lifting and movement of residents, as well as elopement and wandering, were not adequately followed. The policy on safe lifting did not specify when gait belts should be used, and the wandering policy did not address maintaining safety for wandering residents within the facility. The Director of Nursing acknowledged the deficiencies, noting that staff failed to communicate effectively and did not intervene appropriately to safeguard the residents involved.
Failure to Follow Dementia Care Plan Leads to Resident Agitation
Penalty
Summary
The facility failed to provide appropriate dementia care interventions for a resident diagnosed with Alzheimer's disease and dementia with behavioral disturbances. The resident, identified as having moderate cognitive impairment, required assistance with daily activities and had a history of agitation and aggression, particularly when personal items were removed from his sight. The care plan for the resident included specific interventions to manage these behaviors, such as keeping the resident in line of sight when out of his room and removing items only when he was not present to prevent agitation. However, these interventions were not followed during an incident where a nursing assistant attempted to remove a banana from the resident's wheelchair, leading to the resident becoming agitated and physically aggressive. The incident was captured on video surveillance, showing the nursing assistant's inappropriate approach, which escalated the situation. The nursing assistant attempted to take the banana, which the resident perceived as a threat to his personal belongings, resulting in the resident grabbing and squeezing the assistant's arm. The assistant's response, including loud verbal exchanges, further aggravated the resident. The director of nursing acknowledged that the approach was not appropriate and that the care plan's directives were not followed. The facility did not provide a policy on caring for residents with dementia when requested.
Failure to Implement Physician-Prescribed Medication Taper Order
Penalty
Summary
The facility failed to ensure that a resident's physician-prescribed medication taper order was implemented, which did not meet professional standards of quality. The resident, who was moderately cognitively impaired and had multiple diagnoses including cancer, Parkinson's disease, and diabetes mellitus, was prescribed Tramadol for chronic back pain. Despite a pharmacy consultant's recommendation to taper the Tramadol dosage to address urinary retention issues, the order was not executed. The resident's pain was identified as mild and rarely impacted his daily activities, yet the medication taper was not implemented as prescribed by the physician. The pharmacy consultant recommended a reduction in Tramadol from three times a day (TID) to twice a day (BID) to potentially alleviate urinary retention, a side effect of the medication. This recommendation was documented and signed by the physician but was not acted upon. The physician expected the order to be processed, but it was not, leading to the resident continuing on the higher dosage of Tramadol. The Director of Nursing (DON) confirmed that the signed order was not processed and attributed the delay to a system glitch and communication issues between the medical staff. Interviews with the pharmacy consultant, the physicians involved, and the DON revealed that there was a lack of follow-through on the medication taper order. The DON acknowledged that the pharmacy review forms should have been returned and acted upon more promptly. The facility's policy on medication and treatment review was not adhered to, resulting in the resident continuing to receive a medication dosage that potentially contributed to his urinary retention issues.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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