La Crescent Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in La Crescent, Minnesota.
- Location
- 101 South Hill Street, La Crescent, Minnesota 55947
- CMS Provider Number
- 245319
- Inspections on file
- 18
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 25 (1 serious)
Citation history
Health deficiencies cited at La Crescent Health Services during CMS and state inspections, most recent first.
A resident with a g-tube, cognitive impairment, dysphagia, and hypercalcemia had repeated nausea, vomiting, and abdominal pain with multiple hospital transfers. Staff did not follow pharmacy directions or standard practice during g-tube med administration: meds were prepared together, timing with tube feeds and interacting meds was not verified, dilution and flushing were inconsistent, and the HOB was not kept at 30 to 45 degrees during or after administration. The care plan also lacked resident-specific interventions for the ongoing GI symptoms and fluid volume concerns.
Medical Director Oversight of Resident Tube Feeding and Medication Care: The facility failed to ensure the MD provided appropriate oversight of care for a resident with a g-tube, moderate cognitive impairment, hyperparathyroidism with hypercalcemia, and multiple medications given via the tube. The resident’s care plan lacked key details for skin breakdown, refusal of care, fluid balance, HOB elevation timing, and monitoring for endocrine-related symptoms, while the physician orders lacked electrolyte monitoring, I&O tracking, medication interaction management, and guidance for symptoms or refusals. Interviews showed the PA was unsure about electrolyte monitoring and relied on consulting services and the pharmacist, while the DON stated the MD was new to the role and seeing outpatients.
Food was not consistently held and served at proper temperatures, and multiple residents reported meals were frequently cold in the dining room and in their rooms. Two residents were observed asking dietary staff to reheat French toast and eggs, while the DM said residents often requested reheating and that plate covers had only just been started in response to complaints. The OM reported ongoing concerns since October 2025, and the facility policy required food to be held at appropriate temperatures.
Failure to assess self-administration of nebulizer medication: A resident with intact cognition was left alone to complete a nebulizer treatment after staff set up the equipment and placed the mask on her face. The MAR, order summary, and care plan lacked evidence of a self-administration assessment, physician order, or documentation showing she had been evaluated as able to self-administer the medication, and RN, ADON, and DON all acknowledged the assessment had not been completed.
A resident with moderate cognitive impairment and an activated POA had repeated refusals of care and treatment, including labs, weights, bowel meds, and other treatments, but the facility did not document notifying the POA. The care plan and orders lacked direction for staff on when to notify the provider or POA about refusals, and there was also no documentation that the POA was notified before the resident went to the ER after a fall.
A resident receiving olanzapine had ordered orthostatic BP monitoring in the lying, sitting, and standing positions, but the measurements were not completed for several months. The resident had no cognitive impairment or psychosis noted on the MDS, and pharmacy reviews did not address the missed monitoring. The DON stated monthly orthostatic BP checks were expected, while the pharmacist said she reviewed the order but did not routinely verify completion.
Failure to notify the LTC Ombudsman of hospitalizations and a discharge: two residents had documented hospital/transfer events, but progress notes and the facility’s monthly ombudsman notice did not show required communication. One resident had moderate cognitive impairment, used a walker, and needed assistance with multiple ADLs; the other had moderately impaired cognition, significant ADL dependence, and diagnoses including hip fracture, CAD, HF, HTN, and DM. Social services staff acknowledged the ombudsman notifications were behind and that one resident’s discharge had not been coordinated with the ombudsman.
A resident with moderate cognitive impairment, a walker, urinary incontinence, and G-tube dependence had an incomplete comprehensive care plan. The plan listed pressure ulcer risk and tube feeding needs, but did not address the actual coccyx skin breakdown, refusals of care, fluid-volume imbalance risk, specific HOB elevation timing during and after tube feeds, or symptoms and side effects related to hypercalcemia, hypothyroidism, and hyperparathyroidism. The TARs also lacked added skin-protection interventions such as repositioning, heel protectors, barrier cream, toileting, and pressure offloading.
A resident with a g-tube and moderate cognitive impairment received morning meds through the tube without proper HOB elevation, PPE for EBP, or correct medication dilution and flushing. The RN used tap water, added unmeasured amounts to force meds through the tube, failed to flush between some meds, and did not account for ordering instructions for levothyroxine, prednisone, and iron-vitamin liquid. The resident reported nausea and abdominal pain during the pass and was later sent to the ER for vomiting.
Failure to monitor and individualize pressure injury prevention for a resident with coccyx and heel skin breakdown. A resident with cognitive impairment, incontinence, diabetes, malnutrition, and weakness returned from the hospital with a stage I coccyx pressure injury and fragile heel skin, but the care plan and TAR lacked resident-specific interventions such as repositioning, heel offloading, toileting support, barrier creams, and pressure redistribution measures. Weekly skin checks documented no skin issues, the resident reported buttock breakdown and sore heels, and the PA and DON later confirmed the coccyx pressure injury and that the dressing was not placed correctly.
A resident with a g-tube, dysphagia, and malnutrition had tube feedings and frequent water flushes ordered, but the facility did not maintain a clear system to monitor daily intake and output, including urine, emesis, bowel movements, and oral intake. The care plan and nutrition assessments lacked resident-specific detail for aspiration, hydration balance, and GI symptoms, and the record did not document a large emesis episode observed by surveyors. The PA was not actively monitoring intake/output or electrolyte labs, and the DON acknowledged the care plan and monitoring were not sufficiently resident-specific.
A resident with chronic respiratory failure with hypoxia and continuous O2 use was observed multiple times with oxygen tubing from both a concentrator and portable tank that was undated and unlabeled. The care plan and MAR/TAR lacked a clear order for tubing changes during the review period, and staff interviews showed uncertainty about who was responsible, while nurses and leadership stated tubing and supplies should be changed weekly and dated/labeled.
A resident with ESRD receiving hemodialysis had an inaccurate dialysis care plan and inconsistent dialysis documentation. The care plan lacked the dialysis clinic’s contact info, the resident’s actual CVC access type, and clear coordination details, while orders incorrectly referenced a fistula/AV graft and staff documented thrill/bruit checks and dressing removal for a non-existent access type. The chart also lacked complete dialysis summaries, and staff and leadership acknowledged they were not consistently receiving or requesting dialysis paperwork or other key information from the dialysis clinic.
A resident with a g-tube, moderate cognitive impairment, and multiple chronic conditions had care planning and provider orders that did not address several aspects of tube feeding and medication management. The care plan lacked details for actual coccyx skin breakdown, refusal of care, fluid-volume imbalance, HOB elevation timing, and monitoring for hypercalcemia, hypothyroidism, and hyperparathyroidism. Orders also lacked directions for electrolyte monitoring, I&O, fluid balance, medication interactions, adverse-effect monitoring, and when to notify the provider if the resident refused meds or treatments. The PA stated she relied on consultants and pharmacy for monitoring and was unsure of the electrolyte schedule or the nutrition team’s involvement.
Pharmacist monthly med reviews failed to identify irregularities for a resident on antipsychotic therapy and a resident receiving multiple meds via g-tube. One resident had an order for monthly orthostatic BP checks, but several months had no documented completion and the pharmacist did not note the missing monitoring. Another resident with moderate cognitive impairment and tube feeding had ongoing nausea, vomiting, and abdominal pain while receiving several meds through the g-tube, yet medication timing, tube-feed interactions, and related care plan interventions were not consistently evaluated.
Medication administration errors resulted in an 8.57% error rate, above the required threshold. An RN prepared a resident’s g-tube medications without knowing when tube feeds had ended, gave meds with conflicting pharmacy instructions, failed to follow directions for levothyroxine, prednisone, and iron-multivitamin suspension, and prepared the iron-multivitamin at the wrong dose. The ADON, pharmacist, and administrator all confirmed that medication administration must follow the five rights and pharmacy directions.
Facility Assessment and G-Tube Care Deficiencies: A resident with a g-tube, cognitive impairment, malnutrition, dysphagia, diabetes, hypothyroidism, hyperparathyroidism, and hypercalcemia had repeated hospital transfers for decreased cognition, nausea and vomiting, abdominal pain, and pneumonia. The care plan lacked resident-specific interventions for nausea, vomiting, abdominal pain, hypercalcemia symptoms, and fluid volume deficit risk. During a g-tube medication pass, an RN mixed medications together, did not follow timing and administration instructions for levothyroxine, prednisone, and iron-vitamin suspension, failed to maintain HOB elevation and PPE requirements, used improper dilution and flushing, and the resident reported increased nausea and abdominal pain.
Failure to Follow Enhanced Barrier Precautions: An RN provided care to two residents on EBP without wearing the required gown and gloves. One resident had an indwelling urinary catheter and received oral meds, a respiratory assessment, inhaler use, and nebulizer treatment without gown use; the other resident had a g-tube and received morning meds without the appropriate PPE. The RN acknowledged the omissions, and the DON stated proper PPE was expected for residents on EBP.
Missing Mandatory Communication Training for Staff: The facility failed to ensure required effective communication training was completed for an LPN and a nursing assistant. The facility assessment stated all staff were to receive communication training, but the administrator verified the training was not completed and the education was not found in the personnel files provided.
Mandatory QAPI training was not completed for an RN, an LPN, and four NAs reviewed for training requirements. The facility assessment stated all staff were to receive QAPI training, but the administrator confirmed the RN and LPN had not completed it and further review showed the four NAs also had not completed the training. The administrator stated QAPI training was not completed at orientation and was done through the online training program.
Failure to Timely Report Alleged Verbal Abuse: A resident with impaired cognition and Alzheimer’s disease was identified as vulnerable to abuse, yet an allegation that an NA used disparaging language toward the resident was not promptly reported to the SA. The complainant said they told the administrator about the incident, but the facility had no grievance or abuse record for the resident, and the resident’s notes did not show an abuse investigation. The administrator stated verbal abuse required immediate reporting, but she was not aware of the allegation until later.
Survey results were not fully posted or readily accessible for resident or visitor review. A resident council meeting showed residents did not know where the most recent survey results were located, and an admin tour found the survey binder near the entrance lacked the POC and LSC survey components, had no LSC surveys for the past 3 years, and had no signage stating additional survey results were available upon request.
The facility failed to properly manage food storage and expiration dates, as observed during a kitchen tour where expired and improperly stored food items were found. A box of oranges with white fuzz, a leaking bag of grapes, and a half-gallon of expired milk were identified. Dietary staff were unaware of the purpose of the expired milk and the presence of personal items in the refrigerator used for resident meals, indicating a lapse in adherence to food safety policies.
A facility failed to ensure proper use of PPE for a resident on enhanced barrier precautions due to a surgical wound. Despite signs and available PPE, nursing assistants did not consistently wear gowns and gloves during care activities such as showers and transfers. Interviews revealed a lack of adherence to EBP protocols, with staff unaware of the resident's wound and PPE requirements. The facility's policy emphasized the need for PPE during high-contact activities to prevent the transmission of multidrug-resistant organisms.
Improper G-Tube Medication Administration and Inadequate Monitoring of Resident Symptoms
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who required nutrition, hydration, and medications through a gastrostomy tube. The resident had moderate cognitive impairment and a history that included moderate protein-calorie malnutrition, dysphagia, muscle weakness, type 2 diabetes, hypothyroidism, hyperparathyroidism, and hypercalcemia. The resident also had repeated hospital and emergency room transfers for hypercalcemia, nausea, vomiting, abdominal pain, and later pneumonia. The record showed ongoing nausea and vomiting, intermittent abdominal pain, and repeated episodes of refusal or intolerance of medications and flushes before the resident was sent out for care. During medication administration through the g-tube, the nurse did not follow the pharmacy directions or standard practice. The nurse prepared multiple medications together, did not verify the timing of levothyroxine in relation to tube feeds, iron, or omeprazole, and did not identify that prednisone should be given with food. The nurse also used more water than ordered for one medication, diluted medications inconsistently, and had to apply pressure to the syringe plunger for some medications to pass through the tube. The nurse did not maintain the head of bed at 30 to 45 degrees during administration, did not keep it elevated afterward, and did not consistently flush between medications. The resident stated during the process that she was having increased nausea and abdominal pain. The resident’s care plan did not include resident-specific interventions to monitor or prevent recurrence of nausea, vomiting, and abdominal pain, and it lacked assessment and interventions for fluid volume deficit risk. The record also showed multiple episodes where the resident had nausea or vomiting after medications or flushes, with no documented provider or POA notification in several instances. Staff interviews reflected uncertainty about g-tube care, medication timing, positioning, and symptom recognition, and the facility’s g-tube education did not identify practice standards for medication administration and tube feeding administration.
Medical Director Oversight of Resident Tube Feeding and Medication Care
Penalty
Summary
The facility failed to ensure the medical director provided appropriate oversight of resident care policies and coordination of medical care for a resident who had a gastrostomy tube and multiple ongoing medical issues. The resident had moderate cognitive impairment, used a walker, and required hydration and nutrition through a g-tube. Her care plan addressed urinary incontinence and potential pressure ulcer development, but it did not identify actual skin breakdown on the coccyx, did not include goals or interventions for the resident’s refusal of cares and treatments, did not address her risk for fluid-volume imbalance, and did not include specific time requirements for elevating the head of the bed during and after tube feedings. The care plan also lacked specific symptoms, side effects, and monitoring related to hypercalcemia, hypothyroidism, and hyperparathyroidism. The resident’s physician orders included tube feedings, water flushes, and multiple medications administered through the g-tube, including levothyroxine, prednisone, iron-vitamin liquid, folic acid, apixaban, metoprolol, senna, cinacalcet, omeprazole suspension, and ascorbic acid. The orders lacked monitoring of electrolytes, accurate intake and output, fluid balance management related to tube feedings and free water, medication interaction monitoring and interventions to prevent adverse effects, a process for monitoring ongoing symptoms such as nausea, vomiting, and abdominal pain, and guidance for when staff should alert the provider if the resident refused medications or treatments. During interviews, the PA stated the resident had a complicated GI tract and hyperparathyroidism causing hypercalcemia, and that electrolyte imbalances would remain an ongoing concern. The PA stated she did not have plans to order follow-up bloodwork because she thought consulting services would monitor electrolytes, and she was unsure of the electrolyte monitoring schedule and the nutrition team’s involvement. The DON stated the medical director was seeing patients at his outpatient clinic, had been in the role only a short time, and this was his first medical director position in LTC. Additional interviews showed the PA relied on the pharmacist for timing medications in relation to tube feedings and had not directly communicated the resident’s medication needs to the consultant pharmacist. The facility Medical Director Responsibilities policy stated the medical director was responsible for coordination of medical care, implementation of resident care policies, and ensuring the appropriateness and quality of medical care.
Food Served Cold and Not Held at Proper Temperature
Penalty
Summary
The facility failed to ensure food was served in a timely manner to preserve desired temperatures and palatability for 4 of 4 residents reviewed who voiced concerns about cold food. During an informal resident council meeting, residents stated meals served in the dining room were frequently cold, including one resident who said food was "ice cold" even with a cover on it, another who said meals were almost always cold when they should be hot, and another who said the issue had been ongoing for a long time. One resident with no cognitive impairment and independent with eating stated during interview that food was cold and had to be sent back often, and that eggs, mashed potatoes, and beans were especially difficult to keep warm. Another resident with no cognitive impairment and setup/clean up assistance with eating stated food was cold sometimes and that staff did not change how they kept food hot. During observations in the dining hall, one resident was seen tasting French toast and motioning for dietary staff to come to the table to heat up the food, and another resident was observed doing the same with French toast and eggs. The dietary manager stated plate covers in the dining hall had just been started that day in response to complaints about cold food, and later stated residents frequently asked for foods to be reheated during meal service and that she was unsure whether the lids were helping. The ombudsman stated residents had started reaching out in October 2025 about ongoing concerns with food temperatures and food being served cold. The administrator stated she expected residents to tell staff about cold food and acknowledged it was important to keep foods warm so residents enjoy their food. The facility policy titled Food Temperatures stated food must be cooked to appropriate temperatures and held at appropriate temperatures.
Failure to Assess Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to comprehensively assess and care plan for self-administration of medication for one resident who was observed receiving a nebulizer treatment in her room. The resident’s quarterly MDS, dated 3/12/26, identified intact cognition. On 4/8/26 at about 7:20 a.m., RN-A administered the resident’s morning oral medications and inhaler, then prepared the nebulizer and placed the mask on the resident’s face. RN-A also placed the resident’s call light pad on her lap and instructed her to turn it on when the treatment was completed. Later that morning, the ADON stated she had removed the nebulizer mask and performed the post-respiratory assessment while the resident had been alone in her room. The resident’s April MAR and order summary showed an order for ipratropium-albuterol inhalation solution twice daily for chronic respiratory failure with hypoxia, but neither document contained evidence that the resident was able to administer the medication independently after staff set up. The resident’s care plan, initiated after survey entrance, stated that nursing staff were to set up the nebulizer and place the mask on the resident for her to complete without supervision, then return to remove the mask and complete the respiratory assessment when finished. However, the record lacked any assessment, physician order, or care planning showing the resident had been evaluated for the ability to self-administer the medication. RN-A, the ADON, and the DON all acknowledged that a self-administration assessment was expected for a resident left alone with a nebulizer, and RN-A and the ADON verified that no such assessment had been completed for this resident.
Failure to Notify POA of Refusals of Care and Treatment
Penalty
Summary
The facility failed to notify the resident representative/POA about refusals of care and treatment for a resident whose POA had been activated after a hospitalization. The resident had moderate cognitive impairment, used a walker, had a g-tube for hydration and nutrition, and the hospital physician documented that she was unable to receive and evaluate information effectively or communicate decisions necessary to manage her health, recommending activation of her Power of Attorney for Health Care. After the POA was activated, the care plan and orders did not address the resident’s refusals of care or provide direction for staff on when to notify the provider and POA about refusals of care and medications. The record showed multiple refusals or related events after POA activation, including refusal of blood draw, refusal of weight measurements, refusal of constipation medication on more than one occasion, and statements that her pain was worse, with no POA notification documented. There was also no documentation that the POA was notified before the resident left the facility for the ER after a fall. During interviews, the DON stated the facility did not notify the POA of refusals and acknowledged it probably should when the resident does not understand her condition or medications. The PA stated she would expect to be notified of ongoing refusals and that the POA should be informed so they understand what treatments the resident is or is not receiving.
Missed Orthostatic BP Monitoring for Resident on Olanzapine
Penalty
Summary
The facility failed to ensure appropriate side effect monitoring for orthostatic hypotension was completed for one resident who was receiving olanzapine 10 mg every evening at bedtime. The resident’s quarterly MDS identified no cognitive impairment and no hallucinations or delusional thinking during the review period, and also showed use of antipsychotic, antidepressant, and antianxiety medications. A review of olanzapine information noted that the medication may cause low blood pressure and postural hypotension when moving from lying or sitting to standing. The resident’s orders included orthostatic blood pressure measurements in the lying, sitting, and standing positions to be documented in the electronic medical record on the 9th of every month. Review of the resident’s orthostatic blood pressures from October 2025 through April 2026 showed they were not completed in October, January, March, or April. The pharmacy reviews from 11/4/26, 2/5/26, and 4/7/26 did not address the missed orthostatic blood pressures. During interviews, the DON stated the resident should have orthostatic blood pressures completed monthly and that the consultant pharmacist would identify when they were not being completed, while the pharmacist stated she reviewed whether the order existed but did not routinely check actual completion and would expect nursing to complete the orders as written.
Failure to Notify Ombudsman of Hospitalizations and Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman for 2 of 2 residents reviewed for hospitalization and discharge events. For one resident, the quarterly MDS showed clear speech, no hearing deficits, use of corrective lenses, moderate cognitive impairment, no rejection of care, no upper extremity impairment, walker use, and assistance needs with several ADLs; the resident was hospitalized and later hospitalized again, but the progress notes did not show communication with the ombudsman after either hospitalization. The facility’s notice sent to the ombudsman did not include the resident’s hospitalizations, and the ombudsman stated she had only received a notification containing information from prior months and had not received notifications for January, February, or March. For the second resident, the admission MDS showed moderately impaired cognition and moderate to maximum staff assistance with ADLs, with diagnoses including displaced fracture of the left femur base, hip fracture, coronary artery disease, heart failure, hypertension, and diabetes mellitus. The resident was admitted and later discharged home to a new apartment, but the progress notes lacked any communication with the ombudsman during the discharge planning process. The facility’s notice sent to the ombudsman also did not include this resident, and the social services staff member stated he had not coordinated with or updated the ombudsman before discharge and was unsure whether the ombudsman was notified afterward.
Incomplete Comprehensive Care Plan for Resident With Skin Breakdown and G-Tube Needs
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for one resident who had multiple medical needs. The resident’s MDS showed clear speech, no hearing deficits, corrective lenses, moderate cognitive impairment, use of a walker, independence with eating, assistance needs with oral hygiene, toileting, showering/bathing, dressing, and personal hygiene, occasional urinary incontinence, and continuous bowel continence. The resident also received nutrition and hydration through a G-tube. A hospital discharge summary documented a red, blanchable pressure injury to the coccyx treated with offloading, barrier cream, and open-to-air care, along with skin problems to both heels treated with offloading and open-to-air care. The resident’s care plan identified urinary incontinence, potential for pressure ulcer development, and the need for a feeding tube, but it did not identify the actual coccyx skin breakdown, did not include goals or interventions for monitoring, treating, and documenting the existing skin injury, and did not address the resident’s refusals of cares and treatments. The care plan also lacked identification of the resident’s risk for fluid-volume imbalances, lacked specific time requirements for elevating the HOB to 30-45 degrees during and after tube feeding, and did not include specific symptoms and side effects of hypercalcemia, hypothyroidism, and hyperparathyroidism. The TARs for February, March, and April 2026 included monitoring the Mepilex dressing to the buttock, but lacked additional interventions such as a position change schedule, heel protectors, barrier creams, a toileting program, and pressure offloading interventions. The DON and PA stated the resident was complicated and expected care plans for skin breakdown, fluid intake-output, refusals of care, and tube feeding care.
G-tube Medication Administration Not Performed per Standards
Penalty
Summary
Professional standards of practice were not followed during medication administration through a g-tube for one resident who required nutrition and hydration via feeding tube. The resident had moderate cognitive impairment, clear speech, no hearing deficits, used corrective lenses, had no upper extremity impairment, and was receiving tube feedings through a g-tube. Her orders included Vital Advanced Formula at 100 ml/hr for 13 hours, 150 ml free-water flushes every 4 hours, and 150 ml water flushes after medication administration for the morning medication pass. Her medication list included levothyroxine, prednisone, iron-vitamin liquid, folic acid, apixaban, metoprolol tartrate, senna, cinacalcet, omeprazole suspension, and ascorbic acid. During observation, the RN prepared the morning medications and placed each one in a medication cup. The RN did not know when the resident’s last tube feeding had ended, did not apply the required PPE for enhanced barrier precautions, and did not position the head of the bed at the ordered 30-45 degrees; the resident remained slouched in bed at approximately 10 degrees. The RN stated the resident received a 30 ml water flush before medications, 30 ml between each medication, and a 150 ml flush at the end. The RN diluted each medication with about 2 ml of tap water, then added additional unmeasured tap water until the medication would flow through the tube, and for two medications had to use the syringe plunger to force the medication through. The RN also failed to flush the g-tube between levothyroxine and metoprolol. The resident stated she was having increased nausea and abdominal pain during the medication pass. The RN did not recognize that the resident was still not positioned correctly and was experiencing symptoms during administration. The RN also failed to identify that levothyroxine was ordered on an empty stomach and not within 4 hours of iron supplements or antacids, and failed to identify that prednisone should be given with food or that the iron-vitamin suspension should be given on an empty stomach. The RN was unsure how much additional water had been added and stated she had not had g-tube education for some time and thought tap water was fine for dilution and flushes. Later that day, the resident was taken by ambulance to the emergency room due to vomiting after receiving medications that morning.
Failure to monitor and individualize pressure injury prevention for a resident with coccyx and heel skin breakdown
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient because the facility did not monitor and implement individualized interventions for a resident with multiple risk factors and an existing coccyx pressure injury. The resident had moderate cognitive impairment, used a walker, required assistance with several activities of daily living, had occasional urinary incontinence, and carried diagnoses including moderate protein-calorie malnutrition, dysphagia, muscle weakness, type 2 diabetes, hypothyroidism, hyperparathyroidism, and hypercalcemia. The hospital discharge summary noted a pressure injury to the coccyx described as red and blanchable, along with skin problems to both heels, with offloading ordered for the coccyx and heels. The resident’s care plan identified urinary incontinence and potential for pressure ulcer development, but it lacked resident-specific interventions such as repositioning changes, specialty pressure redistribution boots for the heels, a toileting program to prevent wet skin, specialty padding for chairs, and barrier protection creams. The February, March, and April 2026 TAR only noted monitoring a Mepilex dressing to the buttock and changing it every 3 days and as needed when soiled, and it did not include additional interventions to prevent or mitigate worsening skin issues. Weekly skin assessments completed from late January through early April stated there were no skin issues and failed to identify the coccyx stage I pressure injury or provide ongoing monitoring and assessment. During interview, the resident stated she had breakdown on her buttocks, that staff covered it every few days and replaced it when it got wet from incontinence, and that her buttocks and heels sometimes got sore. The PA and DON later evaluated the coccyx and identified it as a stage I pressure ulcer, and the PA noted the Mepilex dressing was not placed correctly to prevent further skin breakdown. The DON stated the facility had not updated the care plan or TAR to include interventions to prevent or mitigate skin breakdown, was unaware of fragile skin on the heels, and confirmed the resident had not been assessed weekly on the coccyx since early March 2026.
Failure to Monitor Intake and Output for Resident With G-Tube
Penalty
Summary
The facility failed to monitor daily oral intake and daily output for a resident who required nutrition and hydration via a gastrostomy tube. The resident had diagnoses including moderate protein-calorie malnutrition and dysphagia, and the care plan called for tube feeding, hydration, flushes, checking tube placement, head-of-bed elevation, and reporting signs of aspiration or intolerance. However, the care plan did not identify decreased hydration risk, specific signs and symptoms of aspiration, resident-specific interventions to reduce complications, or guidance for monitoring fluid balance and imbalance. The physician orders included Vital Advanced Formula at 100 ml/hour for 13 hours through the g-tube and 150 ml water flushes every 4 hours, including during tube feeding and after medication administration, but the orders lacked a clear system for monitoring intake and output such as urine output, emesis amounts, bowel movement amounts, and oral intake. The resident’s nutrition assessments failed to accurately identify oral intake, gastrointestinal concerns such as nausea and vomiting, and the amount of emesis experienced. The medical record lacked collaboration, assessment, and outcome documentation identifying who was responsible for overseeing daily intake and output in relation to tube feeding and free water flushes. The record also lacked follow-up to monitor previously known electrolyte imbalances, including high calcium, low potassium, high sodium, and a low albumin level. During interview, the resident stated she felt she was receiving too much liquid and became nauseous and vomited at times. During observation, the resident was actively vomiting and produced approximately 300 ml of emesis, which was not documented in the TAR or a progress note. The PA stated she was not actively monitoring daily intake and output and did not have laboratory orders to assess electrolyte imbalances. The DON stated the tube feeding care plan should have been more resident-specific and acknowledged that intake and output, especially emesis amounts, should have been monitored more closely.
Failure to Change and Date Oxygen Tubing
Penalty
Summary
The facility failed to ensure oxygen tubing was changed according to standards of care for a resident receiving continuous oxygen for chronic respiratory failure with hypoxia. The resident’s record showed multiple significant respiratory and cardiac diagnoses, including chronic respiratory failure with hypoxia, biventricular heart failure, dependency on supplemental oxygen, pulmonary hypertension, and pleural effusion. During observation, the resident was seen using oxygen via nasal cannula from both an oxygen concentrator and a portable oxygen tank, and the tubing on both setups was observed without a date or label. The resident was unsure when the oxygen tubing had last been changed. The care plan identified the resident as at risk for respiratory impairment and included oxygen administration per MD orders, but it did not specify how often tubing should be changed or who was responsible. The order summary included continuous oxygen at 2 L/minute, but there was no order to change oxygen tubing. The MAR/TAR for March 2026 lacked any order for oxygen use or tubing changes, and the task log and progress notes did not document any tubing changes. Survey observations on multiple days showed the oxygen tubing remained undated or unlabeled while the resident continued to use oxygen from the portable tank and concentrator. Staff interviews indicated nursing assistants did not change oxygen tubing and believed nurses were responsible. Nurses and leadership stated oxygen tubing and supplies should be changed weekly and dated/labeled, but the record reviewed by surveyors did not show an order for tubing changes until after survey entrance. The facility’s respiratory services instruction sheet stated tubing should be changed every month and the nasal cannula every week.
Dialysis Communication and Access Documentation Deficiencies
Penalty
Summary
The facility failed to maintain an appropriate communication and collaboration system with an outside dialysis clinic for a resident with end-stage renal disease who received hemodialysis three times weekly. The resident had intact cognition and required extensive assistance with ADLs. His care plan identified dialysis treatment and general monitoring interventions, but it did not include the dialysis clinic’s contact information, the resident’s specific dialysis access type, or clear direction on how or how often the facility would coordinate with the offsite dialysis clinic. The care plan also lacked specific monitoring instructions for the resident’s actual access site. The resident’s orders and documentation were inconsistent and inaccurate. The order summary included an order to monitor a fistula/AV graft site at the right internal jugular area for thrill, bruit, and signs of infection, even though the resident actually had a right tunneled catheter/CVC and there was no evidence he had a fistula or graft. Staff documented completion of this order and related TAR entries, including checking for thrill and bruit and removing a dressing for a fistula/graft site, despite later notes acknowledging the resident had a tunneled chest catheter and that thrill/bruit could not be assessed because he did not have a fistula or graft. The record also showed some dialysis-related assessments were blank, used old vital sign data, or contained inconsistent findings such as documenting thrill/bruit as present or absent without clear relation to the resident’s actual access type. The resident’s chart lacked a complete dialysis summary after treatments, including vital signs, pre- and post-dialysis weights, medications administered during dialysis, orders, or overall concerns. The record also lacked timely communication with the dialysis center about medication refusals or changes in condition unrelated to dialysis. During interviews, nursing staff stated they often did not receive paperwork back from dialysis and did not follow up if it was missing, and they acknowledged they did not check for thrill or bruit on the resident’s catheter because they knew the access was a tunneled catheter. The DON and ADON confirmed the facility was not receiving needed information from the dialysis center, had not been requesting it, and that the dialysis clinic’s contact information was not listed on the care plan or electronic banner. The facility policy required the dialysis facility name and phone number to be included and required ongoing communication and collaboration between nursing home and dialysis staff.
Failure to Manage G-Tube Care and Medication Monitoring
Penalty
Summary
The facility failed to ensure a physician assistant appropriately managed the care of a resident who required nutrition and hydration via a gastrostomy tube and who had complications related to tube feedings and medication administration through the g-tube. The resident had moderate cognitive impairment, used a walker, and required assistance with several activities of daily living. Her care plan addressed tube feeding and some general skin and incontinence issues, but it did not identify actual skin breakdown on the coccyx, refusal of cares and treatments, risk for fluid-volume imbalance, specific head-of-bed elevation requirements during and after tube feedings, or symptoms and monitoring related to hypercalcemia, hypothyroidism, and hyperparathyroidism. The resident’s orders included Vital Advanced Formula via g-tube, scheduled water flushes, and multiple medications administered through the g-tube, including levothyroxine, prednisone, iron-vitamin liquid, folic acid, apixaban, metoprolol tartrate, senna, cinacalcet, omeprazole suspension, and ascorbic acid. The physician orders lacked directions for monitoring electrolytes, accurate intake and output, fluid balance related to tube feedings and free water, medication interactions, prevention of adverse effects, ongoing monitoring for nausea, vomiting, and abdominal pain, and when staff should notify the provider if the resident refused medications or treatments. During interviews, the physician assistant stated the resident had a complicated GI tract and hyperparathyroidism causing hypercalcemia, and that symptom management was the primary direction of care because she was no longer a surgical candidate. The physician assistant also stated she did not plan to order follow-up bloodwork because she thought consulting services would monitor electrolytes, was unsure of the electrolyte monitoring schedule, was unsure how involved nutrition services were, and had not directly communicated with the consultant pharmacist about medication timing in relation to tube feedings. Another provider stated facility providers were expected to manage calcium levels after discharge and that medication interactions and administration times should be assessed by the facility provider and pharmacist.
Pharmacist Review Missed Monitoring and Medication Administration Issues
Penalty
Summary
The facility failed to identify irregularities during the monthly pharmacist drug regimen review for a resident receiving olanzapine. The resident’s quarterly MDS showed no cognitive impairment and no hallucinations or delusional thinking, yet the record reflected ongoing olanzapine 10 mg every evening along with antidepressant and antianxiety medications. The resident also had an order for orthostatic blood pressures to be documented monthly, but the record showed no orthostatic blood pressures completed in October, January, March, or April. The pharmacist’s monthly reviews on 11/4/25, 2/5/26, and 4/7/26 did not address the missing blood pressure monitoring. The DON stated the resident was taking an antipsychotic medication and should have orthostatic blood pressure completed monthly, and that the consultant pharmacist was expected to identify when the monitoring was not being completed and include a reminder in monthly recommendations. The pharmacist stated she reviewed the orders to confirm there was an order for orthostatic blood pressures, but did not routinely check whether the measurements were actually completed and would not include a reminder in the monthly review. She also stated orthostatic blood pressure monitoring can be important because medication issues may be identified if a resident has positive orthostatic blood pressures. The facility also failed to identify medication administration issues for a resident receiving medications through a g-tube. The resident’s MDS showed moderate cognitive impairment and dependence on tube feeding for hydration and nutrition. The resident had ongoing nausea, vomiting, and intermittent abdominal pain after returning from the hospital, and the care plan did not include resident-specific interventions to monitor or prevent recurrence of those symptoms or address signs and symptoms of hypercalcemia. The resident received multiple medications via g-tube, including levothyroxine, prednisone, iron-vitamin liquid, apixaban, metoprolol, senna, cinacalcet, omeprazole suspension, and ascorbic acid, along with tube feedings and water flushes. Interviews with the PA and pharmacists showed medication timing and interactions in relation to tube feedings were not evaluated consistently, and the pharmacist stated she did not check when medications were administered in relation to tube feedings.
Medication Administration Error Rate Exceeded Standard
Penalty
Summary
The facility failed to ensure a medication administration error rate of less than 5%, resulting in an 8.57% medication error rate identified during 3 of 25 medication administration observations. One resident had a quarterly MDS indicating moderate cognitive impairment with no rejection of care and required hydration and nutrition via a g-tube. The resident’s physician orders included levothyroxine 88 mcg via g-tube daily with instructions to give on an empty stomach and not within 4 hours of iron supplements or antacids, prednisone 4 mg via g-tube daily with instructions to take with food, iron-vitamins oral liquid 15 ml via g-tube daily, folic acid 1 mg via g-tube daily, apixaban 2.5 mg via g-tube twice daily, metoprolol tartrate 12.5 mg via g-tube twice daily, senna 8.6 mg via g-tube twice daily, cinacalcet 30 mg via g-tube twice daily, omeprazole-syrspend oral suspension 10 ml daily, and ascorbic acid 500 mg via g-tube daily. During observation, an RN prepared the resident’s morning medications and placed each medication in a cup, but did not know when the most recent tube feeds had ended. The RN failed to identify that levothyroxine had a pharmacy warning to be given on an empty stomach and not within 4 hours of iron supplements or antacids, while preparing it with iron-multivitamin suspension and omeprazole suspension at the same time. The RN also failed to identify that prednisone should be given with food and that the iron-multivitamin suspension should be given on an empty stomach. In addition, the RN prepared the iron-multivitamin suspension at 15 ml instead of the ordered 10 ml. The RN stated she had not had g-tube education for some time and acknowledged she should have read the pharmacy alerts and verified the liquid dose a second time. The ADON stated medication administration requires the right resident, dose, route, drug, and time, and that pharmacy directions are expected to be followed. The pharmacist stated nursing should follow the pharmacy administration directions, and the administrator stated the facility’s medication error rate should be less than 5% and that staff are expected to follow pharmacy directions or seek clarification.
Facility Assessment and G-Tube Care Deficiencies
Penalty
Summary
The facility failed to implement its facility assessment to identify a resident who required specialty care and services, and it failed to train and perform skill competencies as outlined in the facility assessment. The resident had moderate cognitive impairment, no rejection of care, and required hydration and nutrition via a g-tube. The resident was admitted with diagnoses including moderate protein-calorie malnutrition, dysphagia, muscle weakness, type 2 diabetes, hypothyroidism, hyperparathyroidism, and hypercalcemia. The resident’s record showed multiple hospitalizations and emergency room visits after admission, including transfer after a fall with decreased cognition, transfer for increased nausea and vomiting, transfer for abdominal pain, and transfer for pneumonia. The care plan included tube feeding, hydration, flushes per order, and elevation of the head of the bed 30-45 degrees, but it did not provide direction for when and how long to elevate the head of the bed. The care plan also lacked resident-specific interventions to monitor or prevent recurrence of nausea, vomiting, and abdominal pain, lacked interventions related to signs and symptoms of hypercalcemia, and lacked assessment and interventions for the risk of fluid volume deficits. During observation of morning medication administration through the g-tube, the RN prepared multiple medications together and did not know when the most recent tube feeding had ended. The RN did not identify that levothyroxine was to be given on an empty stomach and not within 4 hours of iron supplements or antacids, did not identify that prednisone should be given with food, and did not identify that the iron-vitamin suspension should be given on an empty stomach. The RN also prepared the iron-vitamin suspension with 20 ml instead of the ordered 15 ml, failed to apply the appropriate PPE for enhanced barrier precautions, did not ensure the head of the bed was elevated to 30-45 degrees during administration, diluted medications with approximately 2 ml of water and then added unmeasured amounts until they would flow, and failed to flush between some medications. The resident stated she was having increased nausea and abdominal pain during the medication pass. Staff interviews showed the RN had not had g-tube education for some time, the LPN stated emesis was not documented and described a g-tube medication process that did not include head-of-bed elevation during or after administration, and leadership stated staff were educated annually or sporadically but specific education for this resident had not been provided.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for two residents with indwelling medical devices. One resident had an indwelling urinary catheter and was dependent on staff for ADLs except eating, with intact cognition noted on the quarterly MDS. During an observation, an RN entered the resident’s room, performed hand hygiene, and provided morning oral medications, a respiratory assessment, inhaler use, and nebulizer treatment. Although EBP signage and PPE were available at the doorway, the RN did not wear a gown while providing this care and later stated she should have worn one because the resident was on EBP and the respiratory assessment was performed. The resident’s records showed orders for nebulizer treatments, respiratory assessments, catheter care, catheter irrigation, and monthly catheter changes. The care plan identified the indwelling urinary catheter and related interventions, but it did not identify that the resident was on EBP. During interview, the RN confirmed she did not wear a gown because she did not touch the catheter, but acknowledged she should have worn one because the resident was on EBP and the sign was on the door. A second resident required hydration and nutrition via a g-tube and had moderate cognitive impairment with no rejection of care. During observation, the same RN prepared and administered morning medications to this resident without applying the appropriate PPE. The RN later stated she should have worn gown and gloves because the resident required EBP due to the g-tube. The DON stated the expectation was that proper PPE would be worn for residents on EBP, including during respiratory assessments and nebulizer treatments. The facility policy stated EBP applies to residents with indwelling medical devices, including urinary catheters and feeding tubes.
Missing Mandatory Communication Training for Staff
Penalty
Summary
The facility failed to ensure that mandatory effective communication training was completed for 2 of 10 staff reviewed, including a nursing assistant and an LPN. The facility assessment dated [DATE] stated that the facility had developed a training program with an orientation process and ongoing training for all new and existing staff, and that all staff were to receive training in communicating effectively. During an interview on 4/13/26, the administrator stated she was responsible for overseeing and ensuring all staff completed the required training. On 4/14/26, during a follow-up interview, the administrator was informed that the education on effective communication was not found in the personnel files provided for the LPN and the nursing assistant, and she verified that the trainings had not been completed for either staff member. A facility policy regarding required staff training was requested but not received.
Failure to Complete Required QAPI Training for Multiple Staff
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not completed for 6 of 10 staff reviewed, including an RN, an LPN, and four NAs. The facility assessment dated [DATE] stated that the facility had developed a training program with orientation and ongoing training for all new and existing staff, and that all staff were to receive QAPI training. During interviews, the administrator stated she was responsible for overseeing and ensuring staff completed required training. On follow-up review, the administrator confirmed that QAPI education was not found in the personnel files provided for the RN and LPN and verified those trainings had not been completed. The administrator also stated that QAPI training was not completed at orientation and was instead completed through the online training program. Further review showed that training had not been completed for the four NAs, and a facility policy regarding required staff training was requested but not received.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure the State agency was notified in a timely manner for an allegation of verbal abuse involving a resident with moderately impaired cognition. The resident’s significant change in status MDS dated 1/24/26 identified moderately impaired cognition, maximum staff assistance with dressing, moderate assistance with transfers, and no hallucinations, delusions, or rejection of care behaviors. The resident’s care plan identified the resident as a vulnerable adult at risk for potential abuse due to Alzheimer’s disease and stated staff were educated on reporting abuse and would follow facility policy and procedures. A complainant reported witnessing a nurse aide tell the resident to “shut the [expletive] up” and “you need to stop acting like that.” The complainant stated they spoke to the administrator about the incident when they saw her walking by, but did not recall the exact date. The complainant later reported the allegation to the State Agency because they did not think anything at the facility was being done. Review of grievances for the past 6 months and allegations of abuse reported in the past 6 months did not show any abuse investigation involving the resident, and the resident’s progress notes from 2/1/26 through 4/6/26 did not identify abuse or an abuse investigation. During interviews, the administrator stated that if abuse was suspected it should be reported immediately to management and the State Agency, and that verbal abuse would require immediate intervention and reporting. The administrator stated she was not aware of the incident until after the surveyor interviewed the complainant and then initiated a full investigation and filed a facility-reported incident. The administrator later stated staff needed additional education on how to report abuse and that a new step requiring staff to write a statement was being implemented because, in this incident, information had been missed.
Survey Results Not Fully Posted or Accessible
Penalty
Summary
The facility failed to ensure the most recent survey results were posted in a prominent location and readily accessible to anyone wishing to review them. The CMS Provider History Report showed the most recently completed recertification survey exited on 2/6/25, and during an informal resident council meeting on 4/8/26, residents were asked whether the most recent survey results were readily posted for review. None of the residents stated they knew the location of the results, and they reported the results had not been discussed during resident council meetings. During an interview and tour on 4/10/26, the administrator stated she was responsible for the survey results binder, which was located near the main entrance at waist level and labeled State Survey Results. Review of the binder showed the most recent survey did not include the plan of correction or the life safety code component, and it did not contain any life safety code surveys for the past 3 years. There was also no signage on the binder or nearby bulletin board indicating that additional survey results were available upon request. The administrator stated she did not realize the life safety code surveys and plan of corrections needed to be included. A facility policy titled Availability of Survey Results stated the facility would maintain reports of any survey, certifications, and complaint investigations for the preceding 3 years, along with any plan of correction in effect.
Improper Food Storage and Expiration Management in Facility Kitchen
Penalty
Summary
The facility failed to ensure that refrigerated food items were disposed of after their expiration date and were properly stored, labeled, and dated. During an initial tour of the kitchen, surveyors observed a box of oranges with white fuzz and a bag of grapes leaking brown liquid. Additionally, a half-gallon of expired milk was found in the refrigerator, along with personal items such as a can of soda and an opened bottle of water. Dietary aide DA-B was unaware of the purpose of the expired milk and the presence of personal items in the refrigerator used for storing prepared foods for residents. Interviews with dietary staff and the interim dietary manager revealed a lack of awareness and adherence to the facility's food labeling and storage policies. The registered dietician mentioned that a monthly audit is conducted to check for expired or moldy items, but the expired milk remained in the refrigerator during a follow-up visit. The director of nursing and interim dietary manager stated that dietary staff are trained on food handling and are expected to report any concerns. However, the presence of expired and improperly stored food items indicates a failure in following these procedures, potentially affecting all residents, staff, and visitors consuming food from the facility's kitchen.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident with enhanced barrier precautions (EBP) due to a surgical wound on the left ankle. The resident, who was cognitively intact and had a history of osteomyelitis and streptococcal arthritis, required EBP as indicated by the provider orders and care plan. During observations, it was noted that nursing assistants did not consistently wear gowns and gloves while providing care, such as during a shower and transfers, despite the presence of EBP signs and available PPE. The resident confirmed that staff only wore gowns when changing bandages, not during other care activities. Interviews with staff revealed a lack of adherence to EBP protocols. A nursing assistant, employed through a staffing agency, admitted to not knowing the resident had a wound and acknowledged that PPE should have been worn during the shower. Another nursing assistant confirmed awareness of the EBP sign but noted that the PPE cart was not conveniently located outside the resident's room. The Director of Nursing stated that PPE should be worn for all high-contact activities for residents on EBP, as outlined in the facility's policy. The policy emphasized the importance of using gowns and gloves during specific care activities to prevent the transmission of multidrug-resistant organisms.
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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