Littlefork Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Littlefork, Minnesota.
- Location
- 912 Main Street, Littlefork, Minnesota 56653
- CMS Provider Number
- 245542
- Inspections on file
- 23
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Littlefork Care Center during CMS and state inspections, most recent first.
Two residents were involved in an incident where one physically assaulted the other, resulting in injury. Although internal documentation was completed promptly, the required report to the state agency was not made in a timely manner, contrary to facility policy.
A resident with severe cognitive impairment and behavioral disturbances was sent to the ED after physically assaulting another resident. The facility subsequently refused re-admission and discharged the resident without providing the required notice of intent to discharge, as confirmed by the administrator. The facility's discharge policy was not provided upon request.
The facility failed to implement transmission-based precautions for residents with respiratory symptoms, leading to an influenza A outbreak affecting eight residents. The facility did not initiate droplet precautions for a resident who tested positive for influenza A and lacked strategies to mitigate the outbreak, such as active surveillance and isolation of symptomatic residents. Staff were observed not wearing appropriate PPE, and there was a lack of signage to alert staff and visitors of the outbreak.
The facility failed to limit the use of as-needed psychotropic medication to a 14-day period and ensure re-evaluation by a provider for two residents. One resident with severe cognitive impairment received lorazepam multiple times without a documented provider evaluation. Another resident was prescribed multiple psychotropic medications without documented monitoring of specific behaviors or justification for dosage increases. The facility did not adhere to its policy requiring evaluation and documentation for continued medication use.
A resident with severe cognitive impairment and a history of Alzheimer's and MRSA developed a hematoma that was not timely communicated to the physician. The hematoma was first noted after a fall but was not documented until weeks later when the medical director assessed it during routine rounds. The hematoma later opened and drained, but the physician was not notified of this change until days later, contrary to the facility's policy requiring immediate notification of significant changes.
A resident with severe cognitive impairment and multiple falls did not have their care plan updated in a timely manner to include necessary fall prevention interventions. Despite the facility's policy requiring frequent reviews and updates, the care plan was not revised to reflect new interventions such as assisting the resident back to their room after meals and toileting every two hours until days after the incidents.
A resident with hemiplegia and dietary needs was left without necessary assistance during a meal, despite requiring supervision and help to cut food. The resident was observed in the dining room with food not prepared to their needs, and staff failed to offer assistance for an extended period. Interviews revealed a lack of communication and clarity regarding the resident's dietary requirements.
A facility failed to provide adequate wound care and edema management for two residents. One resident with a hematoma did not receive timely monitoring or physician notification, leading to infection and surgical intervention. Another resident with edema did not have prescribed Ace Wraps applied, resulting in unmanaged swelling. The facility did not adhere to its skin integrity policies, leading to these deficiencies.
The facility failed to provide timely repositioning for a resident at risk for pressure ulcers and did not follow treatment orders for another resident with existing pressure ulcers. Despite care plans and policies in place, staff did not assist with repositioning or complete daily dressing changes as required, leading to deficiencies in care.
A resident with severe cognitive impairment and high fall risk experienced multiple falls due to the facility's failure to update the care plan with necessary interventions. Despite being identified as needing regular toileting and assistance, the care plan was not revised promptly, and staff did not consistently offer toileting every two hours. This oversight contributed to repeated falls, highlighting a lack of adherence to care plan protocols.
A facility failed to assess and address trauma-informed care for a resident with PTSD, anxiety, insomnia, and bipolar disorder. The resident's care plan lacked specific interventions for PTSD, despite a history of childhood sexual abuse. The social worker admitted to not completing a Trauma-Informed Care Assessment, leaving staff unaware of potential triggers. The DON confirmed the necessity of such assessments to ensure individualized treatment, as outlined in the facility's policy.
A resident with severe cognitive impairment and dementia-related behaviors was inadequately managed, leading to multiple altercations with other residents. Despite being on psychotropic medications, the resident's care plan lacked specific interventions for resident-to-resident interactions. Observations and interviews revealed frequent intrusions into other residents' spaces, causing distress and confrontations. The facility's policy required a comprehensive assessment and individualized care plan, which was not adequately implemented, and staff interventions were inconsistent due to staffing limitations.
The facility failed to act on the consulting pharmacist's recommendations for three residents, leading to unaddressed medication irregularities. One resident was prescribed quetiapine without appropriate diagnosis verification, another received multiple PRN antipsychotics without required evaluations, and a third was at risk due to a combination of benzodiazepines and opioids. The lack of physician response and documentation highlights a communication breakdown in medication management.
A resident with chronic lung disease and mild cognitive impairment was not offered a pneumococcal vaccination upon admission, despite being identified as not up to date with vaccinations. The facility's policy required offering vaccinations based on CDC guidelines, but the staff failed to do so, and there was no documentation of vaccine education or offering in the resident's electronic health record.
The facility failed to ensure that state agency survey results were accessible to residents, as two residents who attended council meetings were unaware of their location. The survey binder, labeled for Minnesota Department of Health results, was missing several recent surveys and lacked a notice about the availability of the last three years of results. The DON acknowledged the binder should have contained these results, but the most recent entry was from 2022, and no policy for survey posting was provided.
The facility did not update the nurse staffing information daily or include the census on the posting, as required. Observations showed the posting was outdated, and the DON was unaware of who was responsible for updates. The facility's policy required daily updates by the Night Charge Nurse, but this was not consistently done, potentially affecting all 38 residents and visitors.
A resident with Alzheimer's and mobility impairments experienced multiple falls from bed due to inadequate interventions by the facility. Despite being identified as high risk for falls, the facility's measures, such as staff assistance and non-skid strips, failed to prevent repeated incidents. The interdisciplinary team did not effectively address the root causes, such as the resident's tendency to slide out of bed, leading to ongoing fall risks.
A resident with cerebral palsy, PTSD, bipolar disorder, and anxiety filed a grievance alleging verbal abuse by staff, but the facility failed to act on it. The social services designee did not file the grievance as the resident's family member advised against it, despite the resident being her own decision-maker. The grievance was reported to the DON but not submitted to the administrator, contrary to facility policy requiring investigation and written response.
A resident with cerebral palsy, PTSD, bipolar disorder, and anxiety alleged emotional abuse and neglect by staff, but the facility failed to report the allegations to the state agency within the required timeframe. The DON and administrator were aware of the allegations but did not report them, citing the resident's history of false accusations. The facility's policy required immediate reporting of suspected maltreatment, leading to a deficiency in reporting the alleged abuse.
A resident with multiple diagnoses, including cerebral palsy and PTSD, reported feeling emotionally abused and neglected by staff during the p.m. shift. Despite the resident's care plan noting her tendency to make false accusations, the facility failed to investigate her allegations thoroughly. The DON was aware of the complaints but did not provide evidence of an investigation, and the administrator's expectation for a comprehensive investigation was not met.
A resident with moderate cognitive impairment and daily wandering behaviors was at risk for elopement. The facility failed to conduct an elopement risk assessment when removing and reinstating a Wander Guard (WG). The resident was found outside the facility, and the fenced area was inadequately secured with a bungee cord and an unsecured latch.
Failure to Timely Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of resident-to-resident abuse to the state agency for two residents. One resident, who had a diagnosis of neurocognitive disorder with dementia, agitation, and psychotic disturbance, was identified as having severe cognitive impairment and a risk for harm to self or others. This resident engaged in aggressive behavior at the nurses' station, where he grabbed another resident's walker, yelled, pushed, and struck the other resident multiple times in the chest and shoulder before staff could intervene. The second resident, who had a history of cerebral infarction and was identified as potentially verbally aggressive, sustained injuries including pain and a lump on her right shoulder and bicep as a result of the incident. Despite facility policy requiring immediate reporting of suspected maltreatment to the state agency, the incident was not reported in a timely manner. The social service designee completed an internal report promptly but did not notify the correct agency. The administrator confirmed that the incident was not reported to the state agency until it was identified by a corporate consultant, which was not within the required timeframe outlined in facility policy.
Failure to Provide Required Discharge Notice After Resident Transfer
Penalty
Summary
The facility failed to provide the required notice of intent to discharge for a resident who was sent to the hospital and subsequently discharged from the facility. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, dementia with mood disturbance, agitation, and psychotic disturbance, was identified as having severe cognitive impairment and a risk for harm to self or others. The care plan included specific interventions for managing aggressive behavior and directed staff to contact law enforcement and send the resident to the emergency department if necessary. On the day of the incident, the resident physically assaulted another resident, leading staff to intervene and send the resident to the emergency department for further placement. Following the incident, the facility received notification that the hospital intended to return the resident, but the facility administrator instructed staff not to accept the resident back, citing a lack of resources to meet his needs. The resident was officially discharged and placed in a behavioral health unit. During an interview, the administrator confirmed the discharge was due to the resident's aggression and acknowledged that the facility did not provide the required notice of intent to discharge. The facility's discharge policy was requested but not provided.
Failure to Implement Transmission-Based Precautions Leads to Influenza A Outbreak
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) for residents exhibiting respiratory symptoms until confirmatory test results were obtained. This oversight affected six residents who showed symptoms but were not isolated or placed on TBP, leading to the spread of influenza A among eight residents. The facility also failed to initiate droplet precautions for a resident who tested positive for influenza A, and did not implement strategies to mitigate the risk of an influenza outbreak, such as active surveillance, isolation of symptomatic residents, and posting signage to notify visitors of the outbreak. The deficiency was further compounded by the facility's failure to track and trend all resident infections on the monthly tracking form, which hindered the identification of symptoms and the reduction of infection spread. Specific cases included residents who were not placed on droplet precautions despite testing positive for influenza A, and others who exhibited symptoms but were not isolated or monitored adequately. Staff were observed not wearing appropriate personal protective equipment (PPE) when interacting with symptomatic residents, and there was a lack of signage to alert staff and visitors of the necessary precautions. The facility's infection prevention and control program was inadequate, as evidenced by the lack of active surveillance and the delayed implementation of droplet precautions. The Director of Nursing (DON) and the infection preventionist acknowledged the lapses in protocol, including the failure to isolate symptomatic residents and the absence of a system for ongoing active surveillance. These deficiencies resulted in a system-wide failure to prevent the spread of influenza A within the facility, placing all residents at a high risk of serious illness.
Failure to Re-evaluate Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the use of as-needed psychotropic medication was limited to a 14-day period and re-evaluated by the provider for two residents. Resident R18, who had severe cognitive impairment and diagnoses including Alzheimer's disease and dementia, was administered lorazepam on multiple occasions without a documented face-to-face provider evaluation to assess the continued need for the medication. The nursing progress notes indicated instances where R18 exhibited anxiety and agitation, leading to the administration of lorazepam, but there was no evidence of a provider evaluation to justify the ongoing use of the medication. Resident R11, who had severe cognitive impairment and was at risk for elopement and wandering, was prescribed quetiapine, gabapentin, and escitalopram for behavior management. However, the medical record lacked documentation of specific behaviors being tracked or monitored to ensure the efficacy of these medications. The care plan did not address R11's anxiety, and there was no assessment to support the increase in gabapentin dosage. Interviews with staff revealed that R11 was generally pleasant and did not exhibit aggressive behaviors, raising questions about the necessity of the prescribed psychotropic medications. The facility's policy on psychotropic medications required that the underlying cause of behavioral symptoms be determined and that non-pharmacological interventions be utilized before resorting to medication. The policy also mandated that PRN psychotropic medications be limited to 14 days, with a documented evaluation by the prescribing practitioner. The facility failed to adhere to these guidelines, as evidenced by the lack of documented evaluations and assessments for the continued use of psychotropic medications for residents R18 and R11.
Failure to Notify Physician of Resident's Hematoma
Penalty
Summary
The facility failed to timely notify the physician when a hematoma was identified and subsequently opened, requiring a new intervention for a resident with severe cognitive impairment and a history of Alzheimer's disease and MRSA infection. The resident had an undated care plan that directed staff to monitor and provide wound care, but the hematoma was not documented in the medical record until several weeks after it was first noted by staff. On the night of the incident, the resident was found on the floor with a large bruised lump on her right inner shin. Although the resident's son was contacted and the resident was sent to the emergency room, the hematoma was not properly documented or communicated to the physician until the medical director happened to be in the facility for routine rounds. The medical director assessed the hematoma and recommended monitoring, but no further treatment was deemed necessary at that time. The hematoma later opened and began draining, but the physician was not notified of this change in condition until several days later. The facility's policy required immediate notification of significant changes to the resident's condition, but this was not followed. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition, leading to a delay in appropriate medical intervention.
Failure to Update Care Plan Timely for Fall Prevention
Penalty
Summary
The facility failed to update the care plan in a timely manner to prevent falls for a resident with severe cognitive impairment and diagnoses including Alzheimer's disease, dementia, and osteoporosis. The resident experienced multiple falls, including one without injury and another with injury. Despite these incidents, the care plan was not revised to include new interventions such as assisting the resident back to their room after meals, toileting every two hours, and placing a flat sensor under the sheet. These interventions were identified after the falls but were not promptly incorporated into the care plan. The facility's policy required that care plans be reviewed every 90 days or more frequently if necessary, with updates made as needed based on changes in the resident's condition. However, the care plan for this resident was not updated to reflect the necessary fall interventions until several days after the incidents occurred. Interviews with the RN and DON confirmed that the care plan was not revised to include the identified interventions, which were expected to be followed to prevent further falls.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to ensure that a resident, identified as R38, received the necessary assistance with meal setup to promote safety and independence in eating. R38, who had intact cognition, required supervision or touching assistance with eating due to hemiplegia following cardiovascular disease and venous insufficiency. Despite being assessed by Occupational Therapy as needing supervision and assistance to cut up food, and having a care plan that required supervision during meals, R38 was left without the necessary assistance during a meal in the dining room. On the day of the incident, R38 was observed sitting in the dining room with a meal that included a sloppy joe bun cut into quarters and whole french fries, which were not cut into small bite-sized pieces as required. R38 did not attempt to eat and remained seated with his hands in his lap, indicating he was hungry but unable to eat the food without assistance. Despite the presence of staff in the dining room, no one approached R38 to offer help for an extended period. It was only after the Director of Nursing intervened that R38 was assisted to his room with his meal. Interviews with staff revealed a lack of clarity and communication regarding R38's dietary needs and assistance requirements. Nursing assistants and a registered nurse acknowledged the oversight in not providing the necessary assistance, and the dietary aide was unaware of any current order for small bite-sized food, despite R38's known difficulties. The facility's policy on Activities of Daily Living was not effectively implemented, as staff failed to supervise and assist R38 adequately, leading to the deficiency in care.
Failure in Wound Care and Edema Management
Penalty
Summary
The facility failed to provide ongoing monitoring and appropriate wound care for a resident with a significant hematoma on the right leg. The resident, who had severe cognitive impairment and a history of Alzheimer's disease and MRSA infection, sustained a fall resulting in a large hematoma. Despite the presence of a care plan directing staff to monitor and provide wound care, the hematoma was not documented until several weeks after the incident. The hematoma eventually broke open, leading to significant drainage and infection, but the physician was not notified of the change in condition until much later, resulting in the resident requiring surgical intervention. Another resident with a history of hemiplegia and venous insufficiency was not provided with the necessary interventions for edema management. The resident's care plan included the use of Ace Wraps to manage leg swelling, but these were not applied as ordered. Nursing staff failed to apply the wraps before the resident got out of bed, leading to visible edema. The lack of communication and responsibility among staff members resulted in the resident not receiving the prescribed treatment, which was crucial for managing the resident's condition. The facility's policies on skin integrity and wound care were not adhered to, as evidenced by the lack of timely documentation, monitoring, and communication with healthcare providers. The deficiencies in care for both residents highlight a failure to follow established protocols, resulting in inadequate treatment and monitoring of their conditions.
Failure in Pressure Ulcer Care and Repositioning
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident identified as R4, who was at risk for pressure ulcers. Despite being cognitively intact and having a care plan that included repositioning every two hours, R4 was observed propelling herself in a wheelchair from breakfast to the activity room and then to a common area without any staff offering to assist with repositioning. Interviews with nursing assistants and the registered nurse confirmed that staff were aware of the need to encourage repositioning but failed to do so on the day of observation. Another resident, R31, who had intact cognition and was at risk for pressure ulcer development, was found to have deficiencies in the care of existing pressure ulcers. R31 had a stage two and a stage four pressure ulcer acquired at the facility, and the care plan included specific interventions such as elevating the leg and daily dressing changes. However, observations revealed that the dressing on R31's left calf was not changed daily as ordered, and the right heel was left open to air with drainage on the bed sheet. The Treatment Administration Record showed multiple days where dressing changes were not documented as completed. Interviews with nursing staff indicated that if orders were not initialed on the Treatment Administration Record, it was assumed the care was not provided. The Director of Nursing stated that dressings were expected to be completed daily to promote healing and prevent infection. The facility's policy on skin integrity emphasized the need for daily observation and documentation of pressure ulcers, which was not adhered to in R31's case.
Failure to Update Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to comprehensively assess and update the care plan for a resident identified as a high fall risk, leading to multiple falls. The resident, who had severe cognitive impairment and conditions such as Alzheimer's disease, dementia, and osteoporosis, experienced several falls, some resulting in injury. Despite being identified as a high fall risk, the resident's care plan was not timely updated to include necessary interventions such as regular toileting and assistance back to the room after meals. The resident's care plan lacked specific interventions for toileting, which was a significant oversight given the resident's history of falls and incontinence. Incident reports documented several falls where the resident attempted to move independently, often resulting in falls. Staff interviews revealed that the resident was not consistently offered toileting every two hours, despite being identified as needing this intervention. Additionally, the care plan was not revised promptly to reflect new interventions after each fall, such as the use of sensor alarms. The facility's failure to update the care plan and implement timely interventions contributed to the resident's repeated falls. Staff interviews indicated a lack of consistent adherence to the care plan, with some staff unaware of the need for regular toileting. The director of nursing acknowledged that care plans should be revised with identified fall interventions, but this was not consistently done, leading to ongoing risks for the resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and address trauma-informed care for a resident diagnosed with PTSD, anxiety, insomnia, and bipolar disorder. The resident's care plan did not identify PTSD triggers or specific interventions related to PTSD, despite the resident's history of childhood sexual abuse. The care plan included general interventions for behavior management but lacked specific strategies to prevent re-traumatization. The facility's social worker, who was also the activities director, acknowledged that a Trauma-Informed Care Assessment was not completed for the resident. The social worker had recently learned of her responsibility to conduct such assessments and had done so for another resident. The absence of this assessment meant that staff were not fully informed of the resident's trauma history and potential triggers, such as the presence of male caregivers during personal care tasks. The director of nursing confirmed that a Trauma-Informed Care Assessment should have been completed to ensure individualized treatment for the resident. The facility's policy on trauma-informed care outlined a multi-faceted approach to identifying a resident's trauma history, including the use of a universal screening tool and the incorporation of trauma-related interventions into the care plan. However, these procedures were not followed for the resident in question.
Inadequate Management of Dementia-Related Behaviors
Penalty
Summary
The facility failed to adequately assess and manage the dementia-related behaviors of a resident, identified as R22, who exhibited severe cognitive impairment and a range of challenging behaviors. R22's behaviors included delusions, physical and verbal aggression towards others, pacing, rummaging, and wandering, which significantly impacted his care and posed risks to other residents. Despite being on antipsychotic, antidepressant, and antianxiety medications, R22's care plan lacked specific interventions to address his interactions with other residents, leading to multiple incidents of resident-to-resident altercations. Observations and interviews revealed that R22 frequently intruded into other residents' personal spaces, leading to confrontations. For instance, R22 was observed pacing hurriedly, pushing staff, and attempting to enter other residents' rooms, which caused distress among the residents. Several residents reported feeling threatened by R22's actions, such as shaking his fist and making verbal threats. Staff interventions were inconsistent, and there was no comprehensive behavior assessment to identify triggers or effective interventions for R22's behaviors. The facility's policy on dementia care required a comprehensive assessment and individualized care plan for residents with dementia-related behaviors. However, R22's medical record lacked such an assessment, and the care plan did not adequately address the resident-to-resident incidents. Interviews with staff indicated that while some attempts were made to manage R22's behaviors through one-to-one supervision and diversional techniques, these measures were insufficient due to staffing limitations. The medical director was not informed of R22's interactions with other residents, indicating a communication gap in managing the resident's care.
Failure to Address Pharmacist Recommendations on Medication Use
Penalty
Summary
The facility failed to ensure that the consulting pharmacist's recommendations were addressed, acted upon, and documented in the medical records for three residents reviewed for unnecessary medication use. For one resident with severe cognitive impairment and Alzheimer's disease, the pharmacist identified an irregularity with the prescription of quetiapine, noting that dementia was not an appropriate diagnosis for its use. Despite the recommendation to verify the indication's accuracy, there was no recorded response from the physician, and the issue was not addressed within the specified timeframe. Another resident with severe cognitive impairment and neurocognitive disorder with Lewy bodies was prescribed multiple PRN antipsychotic and psychotropic medications without appropriate stop dates or face-to-face evaluations as required by CMS guidelines. The pharmacist's recommendations to re-evaluate the clinical appropriateness and add stop dates were not acted upon, and the resident continued to receive these medications frequently without the necessary evaluations or documentation. A third resident with intact cognition and multiple diagnoses, including anxiety and bipolar disorder, was prescribed a combination of benzodiazepines and opioids, which posed a risk for CNS/respiratory depression. The pharmacist recommended reassessing the use of these medications and providing clinical rationale for their continued use, but there was no recorded response from the physician. The facility's failure to address these recommendations highlights a lack of communication and follow-up on medication reviews, leading to potential risks for the residents involved.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a pneumococcal vaccination to a resident, identified as R36, according to CDC guidelines. R36 was admitted to the facility with a history of chronic lung disease, tobacco use, and mild cognitive impairment. The admission Minimum Data Set (MDS) indicated that R36 was not up to date with pneumococcal vaccinations, and the vaccine was not offered upon admission. Although R36 had previously received the PPSV23 and PCV13 vaccines, there was no evidence in the electronic health record that R36 or their representative were offered education or a booster vaccine, such as PCV15 or PCV20, in conjunction with their provider. During interviews, RN-A stated that vaccines were discussed and offered upon admission, using the CDC's PneumoRecs VaxAdvisor to determine vaccine needs. However, RN-A acknowledged that the pneumococcal vaccine should have been offered to R36 but was not. The Director of Nursing (DON) confirmed that staff were expected to use the PneumoRecs vaccination website to ensure residents were up-to-date with their vaccines but was unaware of when residents were offered the vaccine. The facility's Resident Immunizations policy, revised in January 2025, required that all residents be offered vaccinations based on CDC recommendations, with documentation in the electronic medical record, which was not followed in this case.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the state agency (SA) survey results were available and accessible for residents, as evidenced by the experiences of two cognitively intact residents who regularly attended resident council meetings. These residents were aware that the survey results should be available but did not know where to find them. During an observation, it was noted that the binder labeled 'Minnesota Department of Health Survey Results' was missing several recent survey results, including those from 2023 and 2024, as well as a recertification survey from 2025. Additionally, there was no notice indicating that the last three years of survey results were available upon request or information on whom to contact for them. The director of nursing (DON) confirmed that the survey binder should contain the past three years of survey results for review by residents, family, and visitors. However, the most recent survey result in the binder was dated December 5, 2022. The facility did not provide a policy for survey binder posting when requested, indicating a lack of adherence to proper procedures for maintaining and displaying survey results. This deficiency had the potential to affect all 38 residents and their families who might wish to review the survey results.
Failure to Update Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was updated daily and that the census was included on the nurse staff posting. This deficiency was observed during a survey when the nurse staff posting, located near the front entrance, was found to be outdated. The posting was dated 2/21/25, but during a subsequent observation on 2/25/25, it had not been updated. The Director of Nursing (DON) was unaware of who was responsible for updating the posting. A review of the nurse staff postings from 1/19/25 through 2/25/25 revealed that the postings were not updated with actual working staff hours on 12 days and the facility census was not recorded on 26 days. Interviews with the DON indicated that night shift staff were responsible for completing the nurse staff posting, and each shift's nurse was expected to update the posting to reflect staffing changes. However, this was not consistently done. The facility's policy required the Night Charge Nurse to count the number of nursing staff responsible for resident care daily, include the facility census, and update the information as needed. The policy also required the information to be posted by the main entrance and kept for eighteen months. Despite these requirements, the facility failed to maintain accurate and up-to-date nurse staffing information, potentially affecting all 38 residents and visitors who may wish to view the information.
Inadequate Fall Prevention Measures for Resident with Multiple Falls
Penalty
Summary
The facility failed to perform a comprehensive assessment of falls for a resident, identified as R2, who experienced multiple falls from bed. R2 was admitted to the facility with diagnoses including Alzheimer's disease, hemiplegia, hemiparesis, dementia, and insomnia. Despite being identified as having moderate cognitive impairment and a high risk for falls, the facility's interventions were insufficient in preventing repeated falls. R2's care plan included measures such as staff assistance with mobility, ensuring the call light was within reach, and placing non-skid strips on the floor. However, these interventions did not effectively address the root causes of R2's falls, which included sliding out of bed and impulsive behavior due to cognitive impairments. The facility's interdisciplinary team (IDT) reviewed R2's falls but failed to implement effective interventions to prevent further incidents. R2 experienced several falls, often late at night or early in the morning, and was found on the floor multiple times. The IDT's actions included educating R2 on call light use, ensuring proper footwear, and moving R2 closer to the nurse's station. Despite these efforts, R2 continued to fall, indicating that the interventions were not adequately addressing the underlying issues. Observations and interviews revealed that R2 often slept perpendicular on the bed and had a tendency to slide off, which was not sufficiently mitigated by the existing interventions. The facility's policy on fall prevention and management required a comprehensive analysis of falls when a resident experienced two or more incidents. This analysis was intended to identify trends, evaluate current interventions, and develop new strategies if necessary. However, the facility did not effectively follow this policy, as evidenced by the repeated falls and lack of new, effective interventions for R2. The IDT's failure to conduct a thorough root cause analysis and implement appropriate measures contributed to the ongoing risk of falls for R2.
Failure to Address Resident Grievance of Verbal Abuse
Penalty
Summary
The facility failed to act on a grievance filed by a resident who alleged verbal abuse by staff. The resident, who had diagnoses including cerebral palsy, PTSD, bipolar disorder, and anxiety, filed a grievance report indicating verbal abuse by a staff member on multiple occasions. Despite the resident being her own decision-maker, the social services designee (SSD) did not file the grievance because the resident's family member advised against it. The SSD reported the concerns to the Director of Nursing (DON) but did not submit the grievance to the administrator. The facility's policy required that grievances be investigated within 72 hours and that a written response be provided. However, the grievance was not formally filed or investigated as per the policy. The administrator expected written grievances to be responded to in writing, but this process was not followed. The facility's failure to adhere to its grievance policy resulted in the grievance not being properly addressed, leaving the resident's concerns unresolved.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the state agency within the required timeframe for a resident who alleged abuse from staff. The resident, who had diagnoses including cerebral palsy, PTSD, bipolar disorder, and anxiety, was dependent on staff for toileting and transfers. Her care plan noted a history of making false accusations of abuse and directed staff to manage her behaviors by discussing them if reasonable or leaving her alone to calm down. Despite these instructions, the resident wrote a letter to the administrator alleging emotional abuse and neglect by staff, which was not reported to the state agency as required. The Director of Nursing (DON) and the administrator were aware of the allegations but did not report them, citing the resident's history of false accusations as the reason. The facility's policy required reporting any suspected maltreatment to the state agency immediately, but not later than two hours after the allegation if it involved abuse. Interviews with the DON and the administrator revealed that they conducted an internal review and decided the allegations were not reportable due to the resident's history, which led to the deficiency in reporting the alleged abuse.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse reported by a resident with cerebral palsy, post-traumatic stress disorder, bipolar disorder, and anxiety. The resident, who was dependent on staff for toileting and transfers, had a care plan that noted her tendency to make false accusations of abuse and directed staff on how to manage her behavior. Despite this, the resident reported feeling emotionally abused and neglected by staff, particularly during the p.m. shift, and expressed these concerns in a letter to the administrator. The resident also filed a grievance report alleging verbal abuse by a nursing assistant. Interviews and document reviews revealed that the Director of Nursing (DON) was aware of the resident's allegations but did not conduct a thorough investigation. The DON had conversations with staff and the resident but could not provide evidence of an investigation. The administrator expected a comprehensive investigation, including interviews with other residents, but this was not carried out. The facility's policy required a completed investigation report to be submitted within five working days, which was not adhered to in this case.
Failure to Assess and Secure Resident at Risk of Elopement
Penalty
Summary
The facility failed to comprehensively assess and manage the use of a Wander Guard (WG) for a resident with moderate cognitive impairment and daily wandering behaviors. The resident was identified as being at risk for elopement, and a WG was initially placed. However, the WG was removed at the family's request without a documented elopement risk assessment. Subsequently, the resident was found outside the facility grounds, indicating a lapse in supervision and security measures. The incident revealed that the fenced area where the resident was allowed to sit was not adequately secured, as the gate was only held by a bungee cord and an unsecured latch. Staff interviews confirmed that no changes had been made to the fence since the resident's elopement. Additionally, there was no documented elopement assessment when the WG was removed or when it was reinstated after the incident, contrary to the facility's policy requiring such assessments for residents at risk of elopement.
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Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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