Lakeside Generations Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dassel, Minnesota.
- Location
- 439 William Avenue East, Dassel, Minnesota 55325
- CMS Provider Number
- 245533
- Inspections on file
- 19
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Lakeside Generations Health Care Center during CMS and state inspections, most recent first.
A resident with CHF and chronic respiratory failure was discharged from the hospital with an order for Furosemide 40 mg daily, but facility staff failed to transcribe this order into the EHR and did not initiate the CHF order set, including daily weights and respiratory monitoring. The resident was not placed on daily weights at admission, later showed significant, documented weight gain over multiple days, and received no Furosemide doses for 13 consecutive days, as confirmed by the MAR. The medication error was discovered only after an outside vascular clinic requested medication and weight information, prompting staff to review the hospital discharge summary and recognize that the Furosemide order and CHF order set had been omitted. Interviews with an LPN and an RN revealed distractions during admission order transcription and failure to identify the CHF diagnosis, and subsequent documentation showed the resident experienced rapid weight gain, worsening respiratory status, hypoxia, and hospitalization for acute on chronic CHF and hypoxic respiratory failure.
The facility failed to date and store food items properly in the freezer, affecting all residents who consume meals from the kitchen. During a kitchen tour, it was found that several food items were not in their original packaging and lacked dates indicating when they were opened. A staff member mentioned removing items from boxes to save space. A follow-up tour revealed additional items without proper labeling, highlighting a need for staff education on dating opened packages.
The facility failed to assess and document the appropriate use and placement of an hourglass sling for three residents during Hoyer transfers, leading to a fall and injury for one resident. The residents' medical records lacked evidence of assessments for sling size and usage, and improper sling placement was confirmed by staff. The facility's procedures for selecting and documenting sling size were inadequate, contributing to the deficiency.
A resident with complex medical conditions and a recent femur fracture was at risk for pressure injuries due to inadequate updates to her care plan. Despite being wheelchair-bound and primarily seated in a recliner, the facility failed to implement or document necessary interventions for pressure relief. The care plan did not reflect the resident's current condition or address her refusal to use a pressure redistribution mattress due to pain.
A resident with acute respiratory disease and a urinary catheter was observed receiving care without proper hand hygiene practices by staff. Nursing assistants and a registered nurse failed to perform hand hygiene between glove changes during incontinence, catheter, and wound care, despite handling soiled materials. The facility's policy requires hand hygiene to prevent infection spread, but staff interviews revealed lapses in following these protocols.
Failure to Transcribe and Administer Furosemide for CHF Resident Leading to Harm
Penalty
Summary
The deficiency involves the facility’s failure to transcribe and administer a prescribed diuretic, Furosemide, for a resident with a diagnosis of chronic congestive heart failure and chronic respiratory failure with hypoxia. The resident was discharged from the hospital with an order for Furosemide 20 mg tablets, with instructions to begin on a specified date and take two tablets (40 mg) by mouth once daily in the morning for acute chronic diastolic congestive heart failure. This order was not entered into the facility’s electronic health record (EHR) when the resident was admitted, and the congestive heart failure (CHF) order set was not initiated as required by the facility’s admission checklist and procedures. As a result, the resident’s physician orders in the EHR did not include Furosemide, and the CHF monitoring order set, including daily weights and respiratory assessments, was not started as expected. The resident’s care plan indicated that medications were to be administered as ordered and that staff were to monitor fluid restriction and record weights according to facility policy. However, the resident was not placed on daily weights upon admission, and daily weights were only initiated later, after a delay. Weight records showed a progressive and significant weight gain over a period of days, including an increase of more than 7 pounds in three days and a total gain of over 17 pounds in less than three weeks. Despite these documented weight increases, there was no evidence in the record of a comprehensive assessment or analysis to determine the cause of the weight gain. The January medication administration record confirmed that the resident did not receive any doses of Furosemide 40 mg for 13 consecutive days following the date the medication was to be started per the hospital discharge order. The medication incident was eventually identified when an outside vascular clinic contacted the facility for the resident’s medication administration and weight information and discovered that Furosemide had not been given as ordered. Facility staff then reviewed the hospital discharge summary and confirmed that the Furosemide order and CHF order set had not been transcribed into the facility’s physician orders. Interviews with the LPN who transcribed the admission orders and the RN who verified them revealed that distractions during order transcription and failure to recognize the CHF diagnosis contributed to missing the Furosemide order and not initiating the CHF order set. Subsequent progress notes and hospital records documented that the resident experienced rapid weight gain, worsening respiratory status, hypoxia, and was transferred and admitted to the hospital with acute on chronic congestive heart failure and hypoxic respiratory failure. Multiple clinical staff, including nursing, a physician assistant, a pharmacist, the regional clinical director, and the medical director, acknowledged that the resident did not receive the prescribed Furosemide doses and described the relationship between missed Furosemide and the resident’s fluid overload, weight gain, and respiratory distress.
Failure to Date and Store Food Properly in Freezer
Penalty
Summary
The facility failed to properly date and store food items in the freezer, which could potentially affect all 43 residents who consume meals prepared in the kitchen. During an initial kitchen tour, it was observed that a bag of precooked chicken and a bag of ravioli were not in their original packaging and lacked a packaging date. Additionally, two partial bags of chicken patties and two partial bags of cheese curds were opened but did not have any indication of when they were opened. An unidentified staff member mentioned that items were removed from their boxes to save space in preparation for a delivery. A follow-up tour of the freezer revealed further issues, including an open bag of onions and a bag of mixed vegetables, both of which lacked labeling to indicate when they were opened. The Director of Food and Nutrition Services acknowledged the issue and noted that the vegetables were not present the previous day, indicating a need for further staff education on the importance of dating opened packages. The facility's policy on Refrigerator and Freezer Storage requires all food in the freezer to be wrapped tightly, labeled, and dated if not in the original container, which was not adhered to in these instances.
Failure to Assess and Properly Use Hourglass Sling Leads to Resident Fall
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice by not completing assessments for the use and placement of an hourglass sling during Hoyer transfers for three residents. These residents, who were dependent on staff for transfers, had various medical conditions such as cognitive impairment, stroke, coronary artery disease, hypertension, diabetes, and hemiplegia. The medical records for these residents lacked evidence of assessments for the appropriate size, usage, and application of the full body lift sling, as well as the residents' cognition levels or appropriateness to use the sling. One resident, who was severely cognitively impaired, experienced a fall from the Hoyer sling during a transfer, resulting in a small laceration to the head. The fall occurred because the sling was improperly placed, with the lower thick section at the base of the buttock instead of between the middle of the lower thigh and just above the knee joint. Nursing assistants involved in the transfer confirmed the improper placement of the sling, which led to the resident sliding out of it. The facility's procedures for selecting and documenting the appropriate sling size and type were inadequate. The registered nurse manager and director of nursing acknowledged that there was no formal assessment tool or documentation process in place for determining the correct sling size and placement. The facility's policy required assessments for sling size on admission and with significant weight changes, but this was not followed, contributing to the deficiency in care.
Failure to Update Care Plan for Resident at Risk of Pressure Injuries
Penalty
Summary
The facility failed to adequately review and update the care plan for a resident (R10) who was at risk for pressure ulcers/injuries. R10, who was alert and oriented, had a history of complex medical conditions including diabetes, hypertension, and peripheral vascular disease. Despite being independent in many activities of daily living, R10 had experienced a fall resulting in a right femur fracture and was subsequently wheelchair-bound. Upon returning from the hospital, R10's care plan was not updated to reflect her new condition, including the recent fracture and her inability to rest in bed due to pain. Observations and interviews revealed that R10 was primarily seated in a recliner and had not used her bed since returning from the hospital. The care plan lacked interventions for offloading or changing positions to prevent pressure injuries, despite R10's Braden Scale score indicating a risk for skin breakdown. The facility's documentation did not reflect discussions about the risks and benefits of not using pressure-relieving interventions, such as pressure reduction cushions or laying down in bed, which were necessary given R10's condition. The facility's policy required care plans to be updated routinely to reflect the resident's current condition, but this was not adhered to in R10's case. The director of nursing acknowledged the lack of interventions and documentation regarding R10's skin condition and the potential for further skin breakdown. Despite having a pressure redistribution mattress, R10's care plan did not address her refusal to use it due to pain, nor did it include alternative interventions to mitigate the risk of pressure injuries while she remained in her recliner.
Failure to Implement Hand Hygiene Protocols During Resident Care
Penalty
Summary
The facility failed to consistently implement hand hygiene during the provision of personal care for a resident identified as R99, who was observed for wound care. R99's primary diagnosis was acute respiratory disease, and the resident also had a urinary catheter due to urine retention. During an observation on December 4, 2024, nursing assistants NA-A and NA-B were noted to perform hand hygiene before entering the room and donning gowns and gloves. However, throughout the care process, they repeatedly failed to perform hand hygiene between glove changes, despite handling soiled materials and using a walkie-talkie without sanitizing their hands. The report details multiple instances where hand hygiene was neglected. NA-A and NA-B did not perform hand hygiene after removing soiled gloves and before donning new ones, even after handling contaminated items. This occurred during incontinence care, catheter care, and wound care. Additionally, RN-B, who arrived to complete wound care, also failed to perform hand hygiene after removing gloves and gown, carrying contaminated items out of the room without sanitizing hands. The facility's policy requires hand hygiene to be performed before and after glove use, and between glove changes, to prevent the spread of infections. Interviews with the staff revealed an awareness of the hand hygiene protocol, yet it was not consistently followed. NA-A acknowledged the absence of pocket sanitizer and the improper handling of the walkie-talkie. RN-A also admitted to not sanitizing between glove changes during wound care. The Director of Nursing confirmed the expectation for hand hygiene to be completed at various stages of care to prevent infection spread, aligning with the facility's infection control policy.
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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