Little Falls Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Little Falls, Minnesota.
- Location
- 1200 First Avenue Northeast, Little Falls, Minnesota 56345
- CMS Provider Number
- 245399
- Inspections on file
- 39
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Little Falls Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, vascular neurocognitive disorder, gait abnormalities, repeated falls, and hemiparesis experienced multiple unwitnessed falls over several weeks. Although the care plan addressed extensive ADL assistance, toileting, repositioning, and behavioral analysis, it did not incorporate a psychiatric recommendation for 24-hour supervision. Documentation showed inconsistent or absent root cause analyses after several falls, and the care plan was not revised to reflect the resident’s ongoing fall pattern or the psychiatric evaluation. Staff interviews revealed that NAs and nurses were unaware of new interventions, had not received education on managing the resident’s repeated falls, and did not know about the psychiatric recommendation, while the DON confirmed that supervision levels and the care plan had not been updated despite the facility’s fall prevention policy requiring comprehensive analysis after multiple falls. A family member reported inconsistent toileting, lack of notification about falls, and finding the resident incontinent and unattended.
A resident with significant mobility and cognitive impairments was transferred for a weight check without required footwear or a gait belt, and was left unsupported by staff. The resident lost balance while stepping off the scale, fell, and sustained a head injury resulting in a brain bleed. Staff and family interviews confirmed that the care plan was not followed during the transfer, leading to the incident.
A resident with severe cognitive impairment sustained a skin tear that was treated by nursing staff, but the physician was not notified until two days later and the resident's representative was not promptly informed. Staff interviews and documentation confirmed that required notifications were delayed, contrary to facility expectations for immediate reporting of new injuries.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive the necessary behavioral health care and services required, as observed and documented by surveyors.
A resident reported feeling uncomfortable and fearful during personal care by a nursing assistant, who allegedly continued despite her request to stop. The incident, involving the assistant's inappropriate behavior, was not reported to the State Agency until nearly two days later, violating the facility's guidelines for immediate reporting of abuse allegations.
A resident with type 2 diabetes and hypertension fell out of bed while trying to reach the fridge. Despite safety measures, the incident was not reported to the provider or resident representative due to a chaotic night shift. The facility's policy requires immediate notification, which was not followed, resulting in a deficiency.
A facility failed to follow physician orders for pressure ulcer care and infection control practices during a dressing change for a resident with multiple pressure ulcers. The RN did not perform hand hygiene between glove changes and omitted applying Santyl ointment as ordered. The resident had significant tissue damage, and the nurse practitioner highlighted the importance of following orders and maintaining hand hygiene for wound healing.
The facility failed to submit accurate direct care staffing information to CMS for Quarter 1. The PBJ report indicated excessively low weekend staffing, which was not supported by staffing schedules. The administrator stated that a data entry error at the corporate office affected all 15 facilities and was corrected before the next quarter's submission. No PBJ entry policy was available.
The facility failed to notify the families of two residents timely regarding significant changes in condition and their deaths. One resident's family was informed two hours after the resident passed away, and another resident's family was not notified about a fall, facial injuries, or hospitalization until much later. Staff interviews confirmed the lack of timely family notification, contrary to the facility's policy.
The facility failed to ensure three residents were comprehensively assessed for self-administration of medications. Despite assessments indicating they could not self-administer and did not wish to, residents were observed self-administering nebulizer treatments and an inhaler without proper oversight or documentation.
The facility failed to provide a written bed hold policy to a resident or their representative during a hospital transfer. The resident, who required assistance with ADLs, was hospitalized and returned without documented evidence of bed hold communication, contrary to the facility's policy.
The facility failed to follow provider orders for monitoring vital signs for a resident with serious diagnoses and did not obtain a necessary physician order for a lap positioning belt for another resident. Documentation and interviews confirmed these deficiencies.
The facility failed to assess past trauma and implement a trauma-informed care plan for a resident with PTSD, anxiety, and depression. Staff were unaware of the resident's trauma history, and the care plan lacked necessary interventions and trigger identification.
The facility failed to ensure the consulting pharmacist identified irregularities in monthly drug regimen reviews for three residents. The medical records lacked evidence of required orthostatic blood pressure monitoring and AIMS assessments, and the facility's psychotropic medication policy did not address these needs.
The facility failed to monitor orthostatic blood pressures and conduct AIMS assessments for residents on psychotropic medications, leading to a deficiency in ensuring the safety and well-being of these residents. Interviews revealed gaps in the monitoring process and inadequacies in the facility's psychotropic medication policy.
The facility failed to ensure that three residents were offered and/or provided the Influenza and pneumococcal vaccines as recommended by the CDC. Documentation of declination forms, education, and shared clinical decision-making with physicians was missing.
The facility failed to notify the LTC Ombudsman of hospitalizations for five residents, despite their medical records indicating various serious conditions requiring hospitalization. The Ombudsman had not received any notices of transfers or discharges for over a year, and the facility could not provide records or policies to show compliance with notification requirements.
The facility failed to review and revise its infection control policies annually, potentially affecting all residents, staff, and visitors. Key policies had not been updated for several years, and interviews revealed that the facility relied on corporate policies without conducting individual annual reviews.
The facility failed to ensure timely call light responses, leading to prolonged waiting times and incontinence for two residents. One resident waited up to 62 minutes for toileting assistance, while another waited up to 45 minutes, causing feelings of neglect and embarrassment. Staff interviews confirmed that the expected response time was 15 minutes, but this was not met, violating the facility's policies on call light response and resident dignity.
The facility failed to respond to call lights in a timely manner for two residents, leading to significant delays in providing necessary assistance. One resident experienced multiple instances of waiting over 20 minutes, and in one case over an hour, for help with toileting, resulting in urine accidents and discomfort. Another resident also faced delays, leading to incontinence episodes and feelings of shame and embarrassment. Staff interviews confirmed that the expected response times were not being met due to insufficient personnel.
A resident who recently had hip surgery and required assistance with toileting was not checked or changed for almost seven hours due to staffing issues. The resident was found with a large amount of stool and urine in his brief, indicating that the scheduled toileting plan was not followed.
The facility failed to follow physician orders for a resident with moisture-associated skin damage (MASD), leading to the deterioration of the wound. Staff used inappropriate materials and techniques, such as peri wipes and packing the wound with fingers, instead of following the prescribed wound care procedures. The resident's wound showed signs of worsening, including increased tunneling and a strong foul odor.
The facility failed to implement recommended influenza A infection control procedures, specifically the use of masks, during direct care with two residents who tested positive. Staff members were observed entering and exiting the rooms without the necessary PPE, despite the residents' frequent coughing. Interviews revealed a lack of clarity and adherence to infection control policies.
The facility failed to notify a resident's representative and physician of multiple falls, both with and without injuries. The resident, diagnosed with dementia and anxiety disorder, experienced several falls over a period, with no documented notifications to the representative or physician. Interviews with staff confirmed that the expected notifications were not made, contrary to the facility's policy.
A resident with dementia and benign prostatic hyperplasia showed signs of a UTI, including hematuria and increased confusion. Despite these symptoms, the facility failed to implement the UTI protocol or notify the physician promptly. The resident's condition worsened, leading to hospitalization and death. Staff interviews confirmed awareness of symptoms but non-compliance with the facility's UTI protocol.
A facility failed to re-assess and revise the care plan for a cognitively impaired resident with multiple falls. Despite several falls and discussions by the interdisciplinary team (IDT), interventions were not consistently documented or implemented. Incident reports, root cause analyses, and care plan revisions were also lacking for several falls, and staff were not fully aware of all fall interventions.
The facility failed to identify target behaviors, revise care plans to include non-pharmacological interventions, and monitor effectiveness for three residents prescribed psychotropic medications. The Director of Nursing confirmed the lack of evidence in the medical records for target behaviors and monitoring, contrary to the facility's policy.
Failure to Complete RCAs and Adjust Supervision After Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and provide adequate supervision and fall prevention for a resident with significant cognitive and mobility impairments, and failure to complete consistent root cause analyses (RCAs) after multiple falls. The resident had diagnoses including major neurocognitive disorder due to vascular disease with behavioral disturbance, severe cognitive impairment, abnormalities of gait and mobility, repeated falls, CVA with left hemiparesis, acute encephalopathy, and chronic pain. A psychiatric mental health evaluation dated 2/25/26 specifically recommended 24-hour supervision, noted that simple ADLs needed to be initiated by caregivers, and that continual supervision might be needed to correct the resident’s behaviors. Despite this, the resident’s care plan did not incorporate the recommendation for 24-hour supervision or enhanced supervision, and there was no documented reassessment of supervision needs in response to the psychiatric evaluation. The resident’s care plans addressed assistance with ADLs, including substantial/maximal assistance for toileting and transfers, use of two staff with stand assist or full mechanical lift as needed, turning and repositioning every 2–3 hours, and directions to analyze time of day, places, circumstances, triggers, and de-escalating factors for behaviors. The care plan also directed staff to assess and anticipate toileting needs, comfort, positioning, and pain. However, from February through March 2026, the medical record showed no adequate documented analysis of root causes for the resident’s repeated falls, no evidence that the interdisciplinary team revised the care plan in response to these falls, and no documentation that supervision needs were reassessed in light of the psychiatric evaluation. The facility’s own Fall Prevention and Management Policy required a falls analysis when a resident has two or more falls, to review trends, identify individual and systemic causes, and evaluate and adjust interventions, but this was not consistently carried out for this resident. Between 2/18/26 and 3/29/26, the resident experienced at least seven unwitnessed falls in various locations, including the lounge, hallway, and bedroom. Some progress notes contained limited or incomplete RCAs, while several falls had no documented RCA at all. For example, after a fall on 2/18/26 when the wheelchair became stuck near a brick wall and the resident slipped onto the pedals, the note did not identify a root cause, and interventions were limited to toileting every two hours, repositioning, lowering the bed, and ensuring the call light was within reach. A 2/25/26 fall in the hallway identified that the resident slipped due to an unused right foot pedal being down, and the intervention was to remove and store that pedal, but there was no broader analysis of other contributing factors. Subsequent falls on 3/4/26, 3/16/26 (two separate unwitnessed falls), 3/17/26, 3/18/26, and 3/29/26 lacked comprehensive RCAs in the documentation. Interviews with staff and a family member further demonstrated gaps in assessment, supervision, and communication. The family member reported not always being informed of falls, stated that the resident was supposed to be toileted every two hours but this was not consistently done, especially with agency staff, and described finding the resident incontinent, sitting alone in the pod with a wet, foul-smelling wheelchair. Nursing assistants reported that the resident frequently tried to get up without help, that staff were not always present to watch her, that she needed to be checked every two hours, and that environmental factors such as noise, loud music, or light might contribute to her falls. They also stated they were unaware of any new interventions or team discussions following the multiple falls. The LPN case manager, an RN, and the DON all acknowledged the resident was a frequent faller, were unaware of the psychiatric evaluation recommending 24-hour supervision, and confirmed that supervision levels and the care plan had not been updated despite the ongoing fall pattern and the facility policy requiring comprehensive assessment and falls analysis after multiple falls. Overall, the facility did not consistently assess or address the factors contributing to the resident’s repeated falls, did not complete or document comprehensive RCAs after multiple unwitnessed falls, did not revise the care plan to reflect the psychiatric recommendation for continuous supervision, and did not ensure staff were informed of and implementing appropriate interventions as required by the facility’s fall prevention policy.
Failure to Follow Care Plan During Transfer Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a transfer, resulting in a fall and significant injury. The resident, who had diagnoses including hypertension, atrial fibrillation, generalized weakness, and mobility impairments, required substantial or maximal assistance for transfers and mobility, as well as the use of a gait belt and appropriate footwear. On the day of the incident, a nursing assistant transferred the resident from bed to the bathroom for a weight check without providing footwear or using a gait belt, and left the resident standing unsupported on the scale. While stepping off the scale, the resident lost balance and fell, hitting her head against the wall. The fall was witnessed, and it was documented that the staff did not assist the resident during the transfer as required by the care plan. The resident was on blood thinners, which increased the risk of complications from head injuries. Following the fall, the resident exhibited increased confusion and drowsiness, and was later found to have a brain bleed confirmed by CT and MRI scans. Interviews with staff and family confirmed that the care plan was not followed during the transfer, and that the resident was left unsupported and without necessary safety measures. The incident was reported to the provider and family, and neuro checks were initiated. The failure to adhere to the care plan and established safety protocols directly led to the resident's fall and subsequent injury.
Failure to Timely Notify Physician and Representative of Resident Injury
Penalty
Summary
The facility failed to notify a resident's physician and resident representative in a timely manner following the discovery of a new skin tear injury. The resident, who had a history of traumatic subdural hemorrhage, cerebral infarction, anxiety disorder, and severely impaired cognition, was found to have a skin tear on the left lower shin while being assisted by staff. The injury was assessed and treated by a registered nurse, but the physician was not notified until two days later, and there was no evidence that the resident's representative was notified at the time of the incident. Documentation showed that the resident's representative only learned of the injury later in the day after inquiring about a bruise, and the physician's office confirmed delayed notification. Interviews with staff and review of facility procedures revealed that staff were expected to notify the physician and resident representative immediately or within the same shift when new injuries occurred. However, the nurse who discovered the injury did not complete the required notifications, citing a busy shift and incomplete charting. The incident report was not completed until later, and the facility was unable to provide a copy of its notification policy when requested. This failure to promptly notify the appropriate parties constituted a deficiency in the facility's response to resident injuries.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and findings that the required behavioral health interventions and supports were not provided to residents as needed. The lack of appropriate behavioral health care and services was directly observed and documented by surveyors during the review.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse immediately to the State Agency as required. A resident, who was cognitively intact and had diagnoses of heart failure and bipolar disorder, reported feeling uncomfortable during personal care provided by a nursing assistant. The resident stated that the nursing assistant continued washing her despite her request to stop and that she felt the assistant's erection, which made her feel anxious and fearful. This incident was reported to the director of nursing nearly two days later, which was not in compliance with the facility's guidelines that require immediate reporting within two hours. The director of nursing was informed of the alleged abuse on the evening of the incident but did not become aware of the details until two days later when reviewing written statements from the staff. The facility's Maltreatment Reporting Guidelines clearly state that any allegations of abuse must be reported to the appropriate authorities immediately, but not later than two hours after the allegation is made if it involves abuse. The delay in reporting this incident to the State Agency constitutes a deficiency in the facility's adherence to these guidelines.
Failure to Notify Provider and Representative of Resident Fall
Penalty
Summary
The facility failed to notify the provider and resident representative of a fall experienced by a resident. The resident, who had diagnoses including type 2 diabetes and hypertension, rolled out of bed while attempting to reach the fridge and fell to the floor. Despite the implementation of safety measures such as a low bed and fall mat, the incident was not reported to the necessary parties as required by the facility's policy. The incident occurred during a chaotic night shift, and the floor nurse forgot to complete an incident report and notify the provider and resident representative. The facility's policy mandates immediate notification of a family member or responsible party when a resident suffers an injury due to an accident or incident. However, in this case, the notification was not carried out, leading to a deficiency in the facility's adherence to its own policies.
Failure to Follow Pressure Ulcer Care Orders and Infection Control Practices
Penalty
Summary
The facility failed to adhere to physician orders for pressure ulcer care and did not follow proper infection control practices during a dressing change for a resident with multiple pressure ulcers. The resident, who had diagnoses of peripheral vascular disease, quadriplegia, and spinal stenosis, was cognitively intact and fully dependent on staff for activities of daily living. The resident had a Stage 4 sacral pressure ulcer, an unstageable left buttock pressure ulcer, and a Stage 3 right buttock pressure ulcer, all of which were documented to have significant tissue damage and drainage. During an observation of wound care, a registered nurse (RN) did not perform hand hygiene between glove changes, which is a critical step in preventing infection. The RN also failed to apply Santyl ointment to the wound beds as ordered by the nurse practitioner, which is essential for removing dead tissue and promoting healing. The RN admitted to forgetting to perform hand hygiene and not following the physician's orders due to nervousness. The nurse practitioner emphasized the importance of following physician orders and maintaining hand hygiene to protect the wound from bacteria and ensure proper healing. The facility's administrator acknowledged that staff should adhere to care plans, orders, and the hand hygiene policy. However, the facility did not provide a policy on pressure ulcers when requested.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information, including data for agency and contract staff, to CMS for Quarter 1. During the review, it was found that the Payroll Based Journal (PBJ) report identified excessively low weekend staffing, which was not supported by the staffing schedules and daily postings for the weekends in question. Interviews revealed that the scheduler was unaware of who submitted the information, and the administrator indicated that the corporate office was responsible for the submission. A data entry error at the corporate office affected all 15 facilities, including this one, and was corrected before the next quarter's submission. No policy related to PBJ entries was available by the end of the survey.
Failure to Notify Family of Significant Changes and Death
Penalty
Summary
The facility failed to ensure timely notification of residents' family members or representatives regarding significant changes in condition, including the death of two residents. For Resident R203, the electronic health record (EHR) indicated that the resident was found unresponsive and without vital signs at 9:45 p.m., and the hospice agency was contacted at 9:51 p.m. However, there was no documentation that the family or resident representative was informed of the resident's passing. A family member reported that the facility did not contact them during the resident's decline and only informed them two hours after the resident had passed away. The Assistant Director of Nursing (ADON) confirmed that typically hospice would update the family, but no documentation of family notification was found in this case. For Resident R205, the facility also failed to notify the family timely regarding significant changes in condition and the resident's death. The EHR showed that the resident experienced weakness, shortness of breath, and was unable to bear weight, but there was no record of family notification. The resident was later found face down on the floor with facial injuries and received CPR before passing away. The family was informed about the fall and the resident's death but not about the facial injuries until the funeral home contacted them. Additionally, the family was not notified when the resident was sent to the hospital earlier. Interviews with staff confirmed the lack of timely family notification during these critical events, and the facility's policy required immediate notification of significant changes, including accidents, health deterioration, transfers, or death.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were comprehensively assessed for self-administration of medications for three residents. Resident 24, who was cognitively intact but required assistance with activities of daily living (ADLs), was observed with a nebulizer machine on her nightstand containing a solution from the morning, indicating she forgot to perform her nebulizer treatment. The medication self-administration assessment for Resident 24 indicated she could not correctly administer nebulizer medications and did not wish to self-administer medications, yet she was still left to self-administer her nebulizer treatment without proper oversight or documentation by the nursing staff as per medical doctor orders. Resident 34, also cognitively intact and requiring assistance with ADLs, was observed self-administering a nebulizer treatment without staff present. The medication self-administration assessment for Resident 34 indicated he was not able to self-administer medications and did not wish to do so. Despite this, nursing staff left the nebulizer solution for Resident 34 to self-administer at a later time, and staff only checked afterward to ensure the treatment was completed. This practice was inconsistent with the assessment and medical doctor orders. Resident 46, who had intact cognition and required assistance with all ADLs, was observed with an albuterol inhaler on his over-the-bed table and was seen using it independently. The medication self-administration assessment for Resident 46 indicated he could not correctly administer inhalant medications and did not wish to self-administer medications. Despite this, the inhaler was left within his reach, and he was observed using it without proper assessment or an order for self-administration. The facility's policy required a comprehensive assessment and an order for self-administration, which was not followed for these residents.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident or their representative at the time of hospital transfer. The resident, who was cognitively intact and required assistance with activities of daily living, was hospitalized and returned to the facility without any documented evidence that a bed hold policy was communicated. The assistant director of nursing confirmed that there was no communication regarding the bed hold for the resident's hospitalization, which is a requirement according to the facility's policy. The facility's Bed Hold Election & Hospital Transfer policy mandates that residents or their representatives be informed of the bed hold option during hospitalization or therapeutic leave. In the case of an emergency transfer, the policy requires that a copy of the notice be sent with the transfer papers and a phone call be made to the responsible party. Additionally, the policy states that documentation of this communication should be made in the resident's progress notes, and a copy of the bed hold policy should be mailed within 24 hours. This procedure was not followed for the resident in question, leading to the deficiency noted in the report.
Failure to Follow Provider Orders and Obtain Necessary Orders for Devices
Penalty
Summary
The facility failed to ensure provider orders were followed for monitoring vital signs for a resident with multiple serious diagnoses, including arteriosclerotic heart disease, hypertension, congestive heart disease, and a nontraumatic subarachnoid hemorrhage. The nurse practitioner had ordered vital signs to be taken three times daily due to the increased risk of brain bleed, but the electronic health record and the resident's closed hard chart did not show that these vital signs were recorded for three days. Interviews with the nurse consultant and the assistant director of nursing confirmed the absence of these vital signs in the electronic health record, indicating missed documentation as shown by pink boxes in the electronic medication administration record. Additionally, the facility failed to obtain a provider order for a lap positioning belt for a resident with cerebral palsy and neuromuscular scoliosis, who preferred to wear a seat belt when in his electric wheelchair. The resident's care plan and restrictive device assessment indicated the use of a lap positioning belt, but the physician orders lacked evidence of an order for this device. The assistant director of nursing confirmed that a physician's order was needed for the lap positioning seatbelt and that the facility could not locate such an order. A provider order policy was requested but not received in both cases.
Failure to Implement Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for a resident diagnosed with PTSD, anxiety disorder, and depression. The resident's significant change Minimum Data Set (MDS) indicated cognitive intactness and required assistance with activities of daily living (ADLs). Despite a trauma assessment completed earlier, which indicated the resident had trauma affecting her daily life, the care plan lacked individualized trauma-informed approaches, identification of triggers, and interventions to avoid potential re-traumatization. Interviews with various staff members, including a nurse practitioner, trained medication assistants, and a licensed practical nurse, revealed that they were unaware of the resident's past trauma and PTSD diagnosis. The assistant director of nursing confirmed that the care plan should have included behavior monitoring, PTSD triggers, and interventions to avoid those triggers, but it did not. The facility's policy on trauma-informed care indicated that care practices should account for residents' experiences and preferences to mitigate triggers, but this was not followed in the resident's case.
Failure to Identify Irregularities in Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified irregularities in the monthly drug regimen reviews for three residents. Resident 11, who had multiple medical conditions including hypertension and depression, had an order for monthly orthostatic blood pressure monitoring while on trazodone. However, the medical record lacked evidence of this monitoring from August 30, 2023, to April 18, 2024, and there was no recommendation from the pharmacy consultant regarding this monitoring. Resident 21, who had severe cognitive impairment and was dependent on staff, had orders for psychotropic medications lorazepam and paliperidone. The medical record lacked evidence of orthostatic blood pressure monitoring, and there was no recommendation from the pharmacy consultant for this monitoring. Similarly, Resident 34, who was cognitively intact but required assistance with activities of daily living, had orders for psychotropic medications olanzapine and hydroxyzine. The medical record lacked evidence of orthostatic blood pressure monitoring and an initial assessment for abnormal involuntary movements (AIMS). Interviews with facility staff, including the nurse consultant, pharmacist, licensed practical nurse, and assistant director of nursing, confirmed the lack of monitoring and recommendations. The pharmacist admitted to missing the recommendation for orthostatic blood pressure monitoring and AIMS assessment. The facility's psychotropic medication policy did not address the need for orthostatic blood pressure monitoring, contributing to the oversight.
Failure to Monitor Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring for potential cardiovascular and neurological adverse effects in residents using psychotropic medications. Specifically, three residents were identified as not having their orthostatic blood pressures monitored as required. Resident 11, who had a complex medical history including hypertension and schizotypal disorder, had an order for monthly orthostatic blood pressure monitoring while on trazodone, but only one reading was recorded over several months. Similarly, Resident 21, with severe cognitive impairment and multiple diagnoses including cardiovascular disease and depression, also lacked evidence of orthostatic blood pressure monitoring despite being on multiple psychotropic medications. Resident 34, who was cognitively intact but required assistance with activities of daily living, also did not have orthostatic blood pressures monitored or AIMS assessments completed as required for their psychotropic medication use. Interviews with facility staff, including the pharmacy consultant, nurse consultant, and assistant director of nursing, revealed gaps in the monitoring process. The pharmacy consultant admitted to missing recommendations for orthostatic blood pressure monitoring and AIMS assessments for residents on psychotropic medications. The nurse consultant and assistant director of nursing confirmed that the facility relied on the pharmacy consultant's recommendations for monitoring and assessments, and acknowledged the absence of these critical evaluations in the residents' medical records. The facility's psychotropic medication policy did not address the need for orthostatic blood pressure monitoring, which contributed to the oversight. The policy was intended to ensure appropriate use, evaluation, and monitoring of medications to minimize risks, but it failed to include specific guidelines for monitoring orthostatic blood pressures. This lack of comprehensive policy and oversight led to the deficiency in monitoring residents for potential adverse effects from psychotropic medications.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that three residents were offered and/or provided the Influenza vaccine and/or the pneumococcal vaccine series as recommended by the CDC. Specifically, one resident declined the PCV20 and Influenza vaccines, but there was no documentation of the declination form, education, or progress note in the electronic health record (EHR). Another resident received the PCV13 but lacked evidence of shared clinical decision-making with the physician for the PCV20. The third resident received the PPSV23 but also lacked evidence of shared clinical decision-making with the physician for the PCV20. Both of these residents were not offered or provided education on the PCV20 vaccine. During an interview, the infection preventionist (IP) confirmed that immunizations are reviewed upon admission and that the CDC pneumococcal vaccine recommendations were used for eligibility. The IP verified that the two residents had not been offered or provided education on the PCV20 and that there had been no shared clinical decision-making with the provider regarding pneumococcal immunizations. The facility's policy indicated that all residents would be offered vaccinations based on CDC recommendations and physician orders, but this was not followed in these cases.
Failure to Notify LTC Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to ensure the LTC Ombudsman was notified of hospitalizations, which are considered facility-initiated discharges, for five residents. These residents were identified as having various medical conditions and required hospitalization for issues such as elevated temperature, pain, dehydration, urinary tract infection (UTI), shortness of breath, low oxygen saturations, hypotension, and other complications. Despite these hospitalizations, the medical records for these residents lacked evidence that the LTC Ombudsman had been notified as required by regulations. Interviews and document reviews revealed that the LTC Ombudsman had not received any notices of transfers or discharges from the facility for over a year. The Ombudsman had previously discussed this issue with the facility's administrator and activity director. Additionally, the facility's nurse consultant confirmed that they could not locate records indicating that the LTC Ombudsman had been notified of the transfers and/or discharges. The facility's policy on Transfer and Discharge from Facility was requested but not provided, further highlighting the deficiency in compliance with notification requirements.
Failure to Annually Review Infection Control Policies
Penalty
Summary
The facility failed to review and/or revise its infection control program's policies and procedures at least annually, potentially affecting all 51 residents, staff, and visitors. During a review of the facility's infection control policies, it was found that several policies had not been reviewed or amended for several years. For instance, the 'Infection Surveillance' policy had not been reviewed since 2017, and the 'Resident Tuberculosis Prevention and Control' policy had not been reviewed since 2019. Other policies, such as the 'COVID-19 Vaccination' and 'Antibiotic Stewardship Program,' also had outdated review dates, indicating a lack of regular updates and reviews as required by regulations. Interviews with the infection preventionist (IP), assistant director of nursing (ADON), and nurse consultant (NC) revealed that the facility relied on corporate policies and did not conduct individual annual reviews of these policies. The IP and ADON were unaware of the requirement to review the policies annually, while the NC confirmed that the quality team reviewed and amended policies as needed but did not include infection control policies in their recent review. This oversight in policy review and revision could lead to outdated practices and potential risks for infection control within the facility.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner, which compromised the dignity of two residents. One resident, identified as R8, had moderately impaired cognition and required substantial assistance with toileting. On multiple occasions, R8's call light was not answered promptly, leading to prolonged waiting times of up to 62 minutes. During this period, R8 experienced discomfort and had urine accidents due to the delay in assistance. Observations revealed that staff members either ignored the call light or were too busy to provide immediate help, resulting in R8 feeling neglected and afraid of falling when attempting to get up by herself. Another resident, identified as R9, also experienced delays in call light response. R9, who had intact cognition but required assistance with toileting due to limited mobility, reported waiting up to 45 minutes for help. This delay led to instances of incontinence, causing R9 to feel ashamed and embarrassed. Observations confirmed that R9 had to wait for assistance while her roommate, R8, was using the shared bathroom, further highlighting the inadequacy of the facility's response to call lights. Interviews with staff members, including nursing assistants and the assistant director of nursing, revealed that the expected response time for call lights was 15 minutes. However, the actual response times observed were significantly longer, failing to meet the facility's policy. The facility's policies on call light response and maintaining resident dignity were not adhered to, resulting in adverse events and a lack of timely assistance for the residents' toileting needs.
Failure to Respond to Call Lights Timely
Penalty
Summary
The facility failed to respond to call lights in a timely manner for two residents, leading to significant delays in providing necessary assistance. Resident R8, who had moderately impaired cognition and required substantial assistance with toileting, experienced multiple instances where her call light was not answered promptly. On several occasions, R8 had to wait over 20 minutes, and in one instance, over an hour, for assistance to use the bathroom. This delay caused R8 to have urine accidents, leading to discomfort and fear of falling when attempting to get up by herself. Observations confirmed that staff walked past R8's room without responding to her call light, and even when staff did respond, they were unable to assist her immediately due to the unavailability of necessary equipment like the lift. Resident R9, who had intact cognition but required assistance with toileting due to limited mobility and a history of urinary tract infections, also experienced delays in call light responses. R9's call light activity report showed multiple instances where the call light was not answered for over 20 minutes, and in some cases, up to 45 minutes. R9 reported feeling ashamed and embarrassed due to incontinence episodes caused by the delays in receiving assistance. Observations and interviews with staff confirmed that the expected response time for call lights was not being met, with staff citing a lack of sufficient personnel to address all call lights promptly. Interviews with nursing assistants and other staff members revealed that the facility's policy required call lights to be answered within 15 minutes to ensure resident safety and dignity. However, the actual response times frequently exceeded this limit, leading to residents' needs not being met in a timely manner. The assistant director of nursing and the floor manager both acknowledged the importance of prompt call light responses and the negative impact of delays on residents' well-being. The facility's failure to adhere to its call light policy resulted in residents experiencing unnecessary discomfort, incontinence, and a lack of timely assistance with toileting needs.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R3) who was dependent on staff for assistance due to a recent hip fracture. R3's care plan required toileting every two to three hours, but during an observation, it was found that R3 had not been checked or changed for almost seven hours. R3 was found with a large amount of stool and urine in his brief, indicating that the scheduled toileting plan was not followed. The nursing assistants (NA-A and NA-C) confirmed that they were short-staffed, which led to the delay in providing the necessary care. Interviews with the nursing assistants and a registered nurse revealed that R3 had recently undergone hip surgery and was no longer independent, requiring more assistance with activities of daily living. The staff acknowledged that R3 should have been checked and changed multiple times during the day but were unable to do so due to staffing issues. The facility's failure to adhere to the scheduled toileting plan resulted in R3 remaining in soiled briefs for an extended period, which was confirmed by the observations and staff interviews.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for a resident with moisture-associated skin damage (MASD). The resident, who had multiple medical conditions including peripheral vascular disease, cerebral vascular accident, and chronic obstructive pulmonary disease, was at high risk for skin breakdown as indicated by a Braden assessment score of 11. The resident had a physician order to cleanse the buttocks daily and apply Med-honey with an adhesive foam dressing, but this order was not consistently followed. Observations revealed that the wound dressing was often saturated, and inappropriate materials such as peri wipes were used to clean the wound, which is not designed for wound care and could spread germs instead of cleaning the wound effectively. The resident's wound showed signs of deterioration, including increased tunneling and a strong foul odor, indicating possible infection. Staff were observed using improper techniques, such as packing the wound with their fingers instead of using a small cotton swab, and failing to use the prescribed wound cleaner. The wound continued to worsen, with moderate serosanguinous drainage and a significant amount of slough present. Despite the resident's refusal to reposition, which likely affected the healing process, the staff did not adhere to the physician's orders or the facility's protocols for wound care. Interviews with the nursing staff and the assistant director of nursing revealed a lack of awareness and adherence to the proper wound care procedures. The staff did not follow the physician's orders and failed to verify or seek clarification when the appropriate supplies were not available. The facility's policy required the use of wound cleaner and proper packing techniques, but these were not followed, leading to the worsening of the resident's wound condition.
Failure to Implement Influenza A Infection Control Procedures
Penalty
Summary
The facility failed to implement recommended influenza A infection control procedures for the use of personal protective equipment (PPE), specifically masks, during direct care with residents. This deficiency was observed in two residents who tested positive for influenza A. Despite the presence of contact precaution signs, there was no mention of droplet precautions or the requirement for masks, which are essential to prevent the spread of influenza A. Staff members were observed entering and exiting the rooms of these residents without wearing the necessary PPE, such as masks and gowns, even though the residents were frequently coughing and unable to cover their mouths, increasing the risk of infection spread. One resident tested positive for influenza A and was observed multiple times lying in bed with a frequent loose cough. The contact precaution sign outside the resident's room did not mention the need for masks, and staff members were seen entering the room with inadequate PPE. For instance, an LPN entered the room wearing only gloves and no mask or gown while performing wound care, despite the resident's continuous coughing. Another resident also tested positive for influenza A and was observed sitting in a recliner with the door open and a contact precaution sign that did not mention masks. Staff members were seen entering the room without the required PPE, even though the resident had a frequent loose cough. Interviews with staff members, including nursing assistants and registered nurses, revealed a lack of clarity and adherence to the facility's infection control policies. Staff members acknowledged that droplet precautions, including the use of masks, should have been implemented immediately upon confirmation of influenza A. However, the appropriate signs and PPE usage were not enforced, leading to potential exposure and spread of the infection. The facility's policy on standard and droplet precautions clearly outlined the need for masks when dealing with infections like influenza A, but these guidelines were not followed in practice.
Failure to Notify Resident Representative and Physician of Falls
Penalty
Summary
The facility failed to ensure that the resident representative and physician were notified of falls with and without injuries for one resident reviewed for accidents. The resident, who had diagnoses including dementia and anxiety disorder, experienced multiple falls on various dates. The facility's documentation lacked evidence of notification to the resident's representative or physician for these incidents. Specific falls occurred on 8/8/23, 8/10/23, 8/14/23, 8/20/23, 8/24/23, 9/10/23, 9/19/23, 9/28/23, 10/6/23, and 10/13/23, with no documented notifications to the resident's representative or physician. Additionally, progress notes for falls on 9/19/23, 9/28/23, 10/6/23, and 10/13/23 also lacked evidence of such notifications. Interviews with the registered nurse (RN) and the director of nursing (DON) confirmed that the nursing staff who completed the incident reports were expected to notify the resident's representative and physician following each fall, regardless of injury. The facility's policy required immediate notification of the family or responsible party in case of injury and within a reasonable time frame if there was no injury. The policy also mandated immediate physician notification for injuries or medical treatment and within a reasonable time frame for other events. The RN and DON confirmed that these notifications were not documented for the specified falls, indicating a failure to adhere to the facility's policy.
Failure to Monitor and Treat UTI Symptoms
Penalty
Summary
The facility failed to comprehensively assess and implement continuous monitoring for signs and symptoms of a urinary tract infection (UTI) and notify the physician timely with a change in condition and/or worsening symptoms for one resident. The resident had diagnoses including dementia, anxiety disorder, and benign prostatic hyperplasia (BPH), and required intermittent catheterization. The care plan lacked evidence of being at risk for UTIs or staff direction on monitoring for UTI signs and symptoms. Despite the resident showing signs of a UTI, such as hematuria, increased confusion, and tiredness, the facility did not implement the UTI protocol or notify the physician promptly. On multiple occasions, staff noted the resident's symptoms, including hematuria, increased confusion, foul-smelling urine, and back pain. However, there was no evidence of additional monitoring or timely notification to the physician. The resident's temperature was not recorded until two days after the initial symptoms were noted. The facility's policy required obtaining vital signs every shift and reassessing for UTI symptoms once identified, but this was not followed. The resident's condition worsened, and they were eventually taken to the emergency department, where they passed away. Interviews with staff revealed that they were aware of the resident's symptoms but did not follow the facility's UTI protocol. The Director of Nursing (DON) confirmed that the UTI protocol was not implemented and that the physician was not notified of the resident's condition until it had significantly worsened. The facility's policy required a thorough assessment and monitoring for UTI symptoms, but this was not done, leading to a delay in treatment and the resident's subsequent hospitalization and death.
Failure to Re-assess and Revise Care Plan for Cognitively Impaired Resident with Multiple Falls
Penalty
Summary
The facility failed to comprehensively re-assess and revise a resident's care plan, who was cognitively impaired and had multiple falls resulting in minor injuries. The resident had diagnoses including dementia and anxiety disorder, and was noted to have severely impaired cognition. Despite multiple falls, the care plan lacked evidence of implemented interventions to prevent further falls. The resident's care plan included interventions such as a low bed with fall mats and staff assistance with proper footwear, but these were not consistently implemented or updated following each fall. The resident experienced several unwitnessed falls, and the interdisciplinary team (IDT) discussed the incidents but failed to ensure that the interventions were documented and implemented in the care plan. For instance, after a fall on 8/10/23, the IDT determined that the resident should sleep in his bed at night with the bed low and floor mats down, but this intervention was not reflected in the care plan. Similarly, after a fall on 8/20/23, the IDT decided that the resident should be laid in bed after supper unless restless, but this intervention was also not documented in the care plan. Additionally, the facility's staff failed to complete incident reports, root cause analyses, and IDT reviews for several falls. Progress notes for falls on 9/19/23, 9/28/23, 10/6/23, and 10/13/23 lacked evidence of incident reports, root cause analyses, or care plan revisions. Interviews with staff revealed that they were not aware of all the fall interventions or the need for safety or hourly checks. The facility's policies on accident/incident reporting and fall prevention were not followed, leading to a lack of comprehensive re-assessment and revision of the resident's care plan to prevent further falls.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to identify target behaviors, revise care plans to include non-pharmacological interventions, and monitor effectiveness for three residents who were prescribed scheduled psychotropic medications. Resident 1 had a diagnosis of depression and was prescribed sertraline, but there was no evidence of behavior monitoring, target behaviors, or non-pharmacological interventions in the care plan. Similarly, Resident 2, who had a diagnosis of depression and exhibited verbal behavioral symptoms, was prescribed Cymbalta without evidence of behavior monitoring or target behaviors in the care plan. Resident 3, diagnosed with Parkinson's Disease and depression, was prescribed Venlafaxine, but the care plan lacked evidence of target behaviors and non-pharmacological interventions. The Director of Nursing confirmed that the medical records for all three residents lacked evidence of target behaviors identified in the care plan and monitoring of behaviors to determine unnecessary psychotropic medication use. The facility's policy on psychotropic medications required the primary care physician to identify target behavior symptoms and for nursing staff to monitor psychotropic drug use daily, noting any adverse effects and the presence of target behaviors. Social Services was expected to develop a behavioral care plan, but this was not done for the three residents reviewed.
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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