Meeker Manor Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Litchfield, Minnesota.
- Location
- 600 South Davis Avenue, Litchfield, Minnesota 55355
- CMS Provider Number
- 245361
- Inspections on file
- 30
- Latest survey
- May 20, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Meeker Manor Rehabilitation Center, Llc during CMS and state inspections, most recent first.
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.
Nursing assistants failed to follow enhanced barrier precautions and proper hand hygiene during direct care for three residents, including those with indwelling catheters and a history of wounds. Staff were observed providing perineal care and handling equipment without donning required gowns or performing hand hygiene after glove removal, despite posted signage and care plan instructions. Interviews revealed confusion among staff regarding when to implement EBP, and facility policies for infection control were not consistently followed.
A resident with moderate cognitive impairment and multiple diagnoses was not supported in care planning by the facility, which failed to inform or involve the resident's designated representative regarding a podiatry referral and a requested nerve block injection. Staff interviews confirmed that the representative was not updated about the resident's care decisions or appointment status, despite being the power of attorney and responsible party.
A resident with renal insufficiency and a history of hypotension experienced multiple low blood pressure readings, including a critically low value, but the provider was not notified as required by facility policy. The nurse manager was unaware of the event, and the NP confirmed that neither she nor the physician had been informed, despite the resident later requiring emergency care.
The facility did not report allegations of abuse, neglect, and improper care to the state agency within the required timeframe after receiving an anonymous complaint naming multiple residents and staff. The administrator chose to investigate the claims internally before reporting, despite facility policy requiring immediate notification. The residents involved had complex medical conditions, and the allegations included both physical and verbal abuse as well as unlicensed staff performing nursing tasks.
After receiving an anonymous email alleging abuse and neglect by staff, the facility did not thoroughly investigate or protect residents as required. The investigation did not include interviews with all staff named in the complaint, failed to remove or suspend implicated employees, and was not conducted by an impartial party, despite facility policy requiring such measures when administration is involved in the allegation.
Three residents did not receive necessary care and services as physician orders for medication, lab draws, and treatments were not implemented or followed. One resident with dialysis needs did not have medication or dietary changes carried out, blood pressure monitoring was not performed as ordered, and a required lab draw was missed, leading to hospitalization. Another resident with multiple comorbidities did not have ordered labs or compression stockings provided, resulting in an ED transfer for heart failure. A third resident did not receive a prescribed anticonvulsant due to an incorrectly recorded allergy, with no timely follow-up to resolve the issue.
A resident with renal insufficiency and on dialysis did not receive appropriate care due to the facility's failure to maintain communication and collaboration with the dialysis provider. The care plan contained conflicting information about fluid restrictions and lacked details on blood pressure monitoring. Orders from the dialysis center for increased blood pressure checks and medication adjustments were not implemented, and there was no process to ensure urgent communications were received when the nurse manager was absent. This resulted in the resident being sent to dialysis with undetected hypotension and ultimately requiring emergency care.
The facility did not consistently monitor or document dishwasher, refrigerator, freezer, and food temperatures, and failed to properly date and store food items. Multiple logs were incomplete or missing, and staff were unaware of correct temperature standards. Undated and expired food was found in storage, and residents reported receiving cold food, with documentation gaps especially for evening meals.
Two residents were found to have self-administered medications, including OTC supplements and a nebulizer treatment, without proper provider orders or documented assessments for safe self-administration and storage. Facility staff were unaware of the presence of these medications and did not follow policy for assessment and removal of unauthorized medications at bedside.
Three cognitively intact residents with complex medical histories were not provided with requested therapy evaluations or dietary accommodations. One resident was denied a power wheelchair evaluation despite a provider's order, another was restricted from having peanut butter without clear assessment or documentation, and a third's request for physical therapy was not followed up or documented. Care plans and staff communication lacked clarity and failed to support resident choice and self-determination.
A resident with multiple chronic conditions was found to have significant dental plaque and missing teeth, and had not received assistance with arranging routine dental appointments as required by facility policy. Staff confirmed that the process for assessing and facilitating dental care upon admission was missed for this resident.
Staff failed to sanitize mechanical lifts between uses and did not consistently perform proper hand hygiene during personal care for two residents with significant care needs. Multiple staff members, including nursing assistants and other personnel, were observed transferring residents and handling soiled items without cleaning equipment or changing gloves as required by facility policy. Interviews revealed confusion about cleaning responsibilities and inconsistent adherence to infection control protocols.
A resident who was eligible for the PCV20 pneumococcal vaccine, based on prior immunization history, was not offered or provided the vaccine as recommended by CDC guidelines. The DON confirmed that the resident was not educated about or offered the vaccine, and the facility's policy for timely assessment and offering of immunizations was not followed.
The facility did not consistently post up-to-date daily nurse staffing information as required, with several days missing from the posted records. The staffing coordinator was responsible for weekday postings, while the charge nurse was delegated this task on weekends, but postings were not completed on weekends, resulting in outdated information being displayed.
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 Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices when nursing assistants did not follow enhanced barrier precautions (EBP) or perform appropriate hand hygiene during direct care for three residents. Observations revealed that staff provided perineal care, changed briefs, and handled resident equipment without donning required gowns or performing hand hygiene at critical points, such as after glove removal or after contact with soiled materials. In several instances, staff only wore gloves, disregarding posted EBP signage that directed the use of gowns for high-contact care activities, especially for residents with indwelling devices or wounds. One resident with a suprapubic catheter and dependent on staff for activities of daily living was observed receiving care without staff donning gowns, despite clear signage and care plan instructions for EBP. Staff also failed to change gloves and perform hand hygiene after providing perineal care and before handling clean items or equipment. Another resident, who previously had a wound but no longer required EBP, still had an EBP sign posted on the door, leading to inconsistent application of precautions. Staff provided care without gowns and did not consistently perform hand hygiene after glove changes or after direct care. Interviews with nursing assistants, an LPN, an RN, and the DON revealed confusion and inconsistent understanding of when EBP should be implemented, with some staff believing it was only necessary for catheter care or contagious illnesses. Facility policies required EBP for residents with wounds, indwelling devices, or infections, and mandated hand hygiene before and after glove use and after incontinence care. However, these protocols were not consistently followed during the observed care activities.
Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The facility failed to include a resident's representative in the development and implementation of the resident's person-centered plan of care. The resident, who had moderate cognitive impairment and diagnoses including traumatic brain injury, stroke, and hemiplegia, had a designated family member as her power of attorney and responsible party. Despite this, the facility did not inform or involve the representative regarding a podiatry referral for the resident's bilateral toe sores, nor did they update her when the resident declined the podiatry service. Additionally, the facility did not provide updates to the representative about the status of a requested nerve block injection appointment, which had been discussed during a care conference and requested by the family due to the resident's increased discomfort. Interviews with facility staff confirmed that communication with the resident's representative was lacking. The care coordinator acknowledged not contacting the representative about the podiatry referral, and the health information manager was unaware of the resident's refusal of podiatry services. The representative confirmed she had not been updated on either the podiatry referral or the nerve block appointment. The regional nurse consultant stated that the representative should have been involved and updated when new orders or consents were needed, and that the care team should have addressed the appointment request made during the care conference.
Failure to Notify Provider of Significant Change in Condition for Dialysis Resident
Penalty
Summary
The facility failed to provide timely notification to a provider regarding a significant change in condition for a resident who was receiving dialysis and had a history of hypotension. The resident's care plan directed staff to keep the medical doctor informed of changes, and physician orders required vital signs to be taken after dialysis on specific days. Blood pressure records showed multiple low readings, including a notably low value of 76/43, but there was no evidence that the physician or nurse practitioner was notified of this critical change. The nurse manager was unaware of the low reading and could not confirm if the provider had been informed. Further, the nurse practitioner confirmed that neither she nor the physician had been notified of the resident's low blood pressure, which she considered concerning and would have warranted immediate action. The nurse practitioner was also unaware that the resident had been sent to the emergency department from dialysis with an even lower blood pressure and was subsequently admitted to the intensive care unit. Facility policy required that changes in a resident's condition be reported to the attending physician, but this protocol was not followed in this instance.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and theft to the state agency within the required two-hour timeframe for three residents who were named in an external complaint. The complaint, received via anonymous email, included specific allegations such as residents being neglected and abused daily, wounds not being treated, unlicensed staff performing nursing tasks, and staff members physically and verbally abusing residents. The administrator in training acknowledged receiving the email but did not report the allegations to the state agency, citing a belief that the information was invalid and that the allegations were unsubstantiated after an internal investigation conducted within two hours. The residents involved had significant medical histories, including dementia, anxiety, hypertension, diabetes, chronic obstructive pulmonary disease, cognitive communication deficits, post-traumatic stress disorder, Parkinson's disease, hemiplegia, epilepsy, adjustment disorder, major depressive disorder, and traumatic brain injury. Despite the facility's policy requiring immediate reporting of suspected abuse or neglect, the administrator did not notify the state agency as required, instead choosing to investigate first and report only if the allegations were substantiated.
Failure to Properly Investigate and Protect Residents After Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and protect residents following an anonymous external email alleging abuse and neglect by staff. The allegations included neglect, improper wound care, unqualified staff performing medical procedures, and direct abuse by specific staff members toward three residents with varying cognitive statuses. The facility's investigation consisted of resident and staff interviews, as well as audits of wounds, showers, insulin administration, and catheter placements, all completed within a two-hour timeframe. The investigation concluded that the allegations were unsubstantiated, with residents denying the reported events and no discrepancies found in the audits. However, the investigation did not include interviews with all employees named in the abuse complaint, nor did it document the removal or suspension of any staff during the investigation or the implementation of protections for residents. Additionally, the investigation was not conducted by a partial or non-biased party, as required by facility policy when administration is named in the allegation. The administrator, who was named in the complaint, oversaw the investigation and conducted staff interviews, despite policy requiring a separate party to investigate in such circumstances.
Failure to Provide Needed Care and Services per Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services to three residents whose changes in health status were not adequately assessed, and physician's orders and treatments were not administered as required. For one resident with renal insufficiency, diabetes, and depression who received dialysis, there was a lack of evidence that physician orders for medication adjustments and dietary changes were implemented. Orders to increase phosphorus supplementation and to change from a fluid-restricted to a fluid-pushing diet were not reflected in the resident's medical record. Additionally, orders to monitor blood pressure twice daily following hypotensive episodes were not carried out, and a basic metabolic panel lab draw was not completed as ordered. Communication lapses between the dialysis unit and facility staff, as well as missed medication administration and failure to document attempted lab draws, contributed to the resident being sent to the emergency department due to low blood pressure and suspected electrolyte imbalances. Another resident with anemia, hypertension, diabetes, and hyponatremia had orders for lab work and compression stockings that were not fulfilled. The lab draws were not completed prior to the provider's next visit, and the resident was found to be pale and edematous, requiring transfer to the emergency department where acute on chronic congestive heart failure was diagnosed. There was confusion among staff regarding the status of the compression stockings, with the nursing assistant unaware of the order and the clinical coordinator stating the resident refused them, but the resident later expressed willingness to try a larger size. The facility lacked a system to track lab completion, and staff absences contributed to the missed lab draws. A third resident with heart failure, seizure disorder, and traumatic brain injury did not receive a prescribed anticonvulsant medication due to an allergy being incorrectly recorded in the facility's records, despite the resident having taken the medication prior to admission without issue. The medication was not administered for nearly two weeks after admission, and there was a lack of follow-through in clarifying the allergy status and ensuring the medication was provided as ordered. The facility's policies required timely and accurate transcription of medication orders and prompt resolution of medication errors, but these were not followed, resulting in the resident not receiving necessary treatment.
Failure to Ensure Communication and Implementation of Dialysis Orders
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with dialysis services for a resident with renal insufficiency, diabetes mellitus, and depression who required dialysis. The resident's care plan lacked specific instructions regarding the management of hypotension, the need for blood pressure monitoring, and contained conflicting information about fluid restrictions. Hospital discharge orders indicated no fluid restriction was needed, but facility physician orders and the care plan included a fluid restriction and a high sodium diet, creating inconsistency in care directives. Additionally, the care plan did not detail how communication with the dialysis center should occur, what information should be shared, or who was responsible for follow-up. Medical records showed that after the dialysis center communicated the need for twice daily blood pressure checks due to the resident's low blood pressure and high ostomy output, the facility failed to consistently implement this order. Blood pressure readings were not documented as required, and there was no evidence that medication orders to increase phosphorus supplementation or to adjust fluid intake were implemented as communicated by the dialysis provider. The resident continued to arrive at dialysis with low blood pressure, and the dialysis center reported difficulty reaching facility staff to relay urgent orders. Interviews revealed that the nurse manager was absent when a critical voicemail was left by the dialysis center regarding new medication orders, and there was no process in place to ensure voicemails were checked in her absence. As a result, the resident did not receive the necessary medications or blood pressure monitoring prior to dialysis, leading to a situation where the resident was sent to dialysis with undetected hypotension and ultimately required transfer to the emergency department. The facility's own hemodialysis policy required ongoing communication and collaboration with the dialysis team, which was not maintained in this case.
Failure to Monitor and Document Food Safety Practices
Penalty
Summary
The facility failed to consistently monitor and document dishwasher temperatures for both wash and rinse cycles, as well as to take timely corrective action when temperatures were not within required ranges. Observations revealed that dietary staff were not uniformly checking temperatures at the appropriate times, and logs for several months showed missing entries and temperatures below manufacturer and policy requirements. The administrator and culinary director were unaware of the correct temperature standards, and staff had been following outdated instructions for the rinse cycle temperature. Additionally, temperature logs for previous months were incomplete or missing, and the facility policy required more frequent and accurate monitoring than was being performed. Food storage practices were also deficient, with multiple instances of undated or expired food items found in both the walk-in cooler and freezer. Items such as gelatin, spinach, stew meat, ice cream, and sherbet were either undated or past their acceptable use dates. Some food items were stored improperly, such as a large bag of ice and bananas placed directly on the freezer floor. The facility's policy required all foods in refrigerators and freezers to be covered, labeled, and dated, but this was not consistently followed, and the policy lacked clear direction for storage in certain areas. Temperature monitoring of refrigerators, freezers, and prepared foods was inconsistent, with numerous missing entries in the logs for January, February, and March. Some recorded temperatures were outside the acceptable range, and there was a lack of documentation for many meals, particularly evening meals. Resident Council meeting minutes reflected complaints about cold food, which was attributed to delays in tray delivery. The facility's policy outlined the importance of maintaining food temperatures outside the danger zone, but staff did not consistently document or verify that these standards were met.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to properly identify and manage the presence of over-the-counter (OTC) medications in a resident's room, as well as failed to ensure appropriate assessment and provider orders for self-administration of medications. One resident, who was cognitively intact and had multiple diagnoses including anemia, heart failure, hypertension, end stage renal disease, diabetes, and depression, was observed with several OTC supplements and medications at their bedside. These included iron tablets, berberine, gummies, ashwagandha, shilajit, and a blood sugar supplement. The resident reported self-administering iron tablets daily, despite the absence of a provider order for iron supplementation and without documentation of an assessment for safe self-administration or proper storage of these medications. Staff were unaware of the presence of these medications in the resident's room and had not followed facility policy regarding the removal and assessment of unauthorized medications at bedside. Additionally, another resident, also cognitively intact and independent with activities of daily living, was observed self-administering albuterol sulfate via nebulizer. The resident's medical record included an order for staff to administer the medication but did not include a provider order permitting self-administration. There was no documented assessment of the resident's ability to safely self-administer the nebulizer treatment, nor was this ability reflected in the resident's care plan. Staff confirmed that the resident performed the breathing treatment independently after staff set up the medication, but the required assessment and provider order for self-administration were missing. Facility policy required that residents be assessed by the interdisciplinary team for cognitive and physical ability to self-administer medications, with documentation in the medical record and care plan, and that medications authorized for self-administration be stored securely. The policy also stated that any unauthorized medications found at bedside should be removed and returned to the nurse in charge. In both cases, these procedures were not followed, resulting in deficiencies related to medication management and resident safety.
Failure to Address Resident Requests for Therapy Evaluation and Dietary Preferences
Penalty
Summary
The facility failed to address and facilitate resident requests for further therapy evaluation, impacting three residents who were reviewed for choices. One resident, who was cognitively intact and had multiple medical diagnoses including anemia, heart failure, and end stage renal disease, was denied a re-evaluation for the use of an electric wheelchair despite a neurology provider's order recommending a power chair evaluation. The interdisciplinary team decided not to proceed with the evaluation due to the resident's past incidents with the power wheelchair, but this decision was not documented, nor was it communicated to the resident or the ordering provider. The resident's care plan did not include parameters for re-evaluation or staff assistance with mobility, and there was no guidance on when or how to reassess the situation. Another resident, also cognitively intact and with diagnoses such as COPD, anemia, and diabetes, was denied peanut butter as part of their diet without a clear or documented rationale. The resident had historically eaten peanut butter without difficulty, but was told by dietary staff that it was not allowed due to its texture. The speech therapy assessment did not address peanut butter specifically, and there was confusion among staff regarding the restriction. The care plan and dietary orders lacked clarity, and staff were not uniformly aware of the restriction or the need for further evaluation to determine if the resident could safely consume peanut butter. A third resident, who was cognitively intact and had a history of cancer and other chronic conditions, requested a physical therapy evaluation to maintain mobility. Despite expressing this request to staff and the administrator, no follow-up or assessment was completed. The care plan directed staff to assist with mobility and transfers, but did not address the resident's request for therapy. The director of nursing and clinical coordinators were unaware of the request, and there was no documentation or tracking of the resident's expressed desire for therapy evaluation. The facility's resident rights policy did not provide direction on how to implement or ensure residents' rights to self-determination and choice were upheld in practice.
Failure to Provide Routine Dental Services for Resident
Penalty
Summary
The facility failed to meet the oral health needs of a resident who was reviewed for routine dental services. The resident, who had intact cognition and diagnoses including heart failure and chronic kidney disease, was observed to have significant plaque and debris on her teeth, as well as several missing teeth. The resident reported that she could brush her own teeth with staff assistance for set-up, but could not recall her last dental check-up and believed it had been years. Staff interviews confirmed that while assistance with oral hygiene set-up was provided, the process for arranging routine dental appointments and transportation was not completed for this resident upon admission. Further interviews with facility staff, including a nursing assistant, clinical manager, and DON, revealed that the established procedure was to assess residents' oral/dental needs and assist with making dental appointments and transportation arrangements upon admission. However, this process was missed for the resident in question, and the date of the last dental appointment was not confirmed. The facility's policy required that routine and emergency dental services be available in accordance with the resident assessment and plan of care, but this was not followed in this instance.
Failure to Sanitize Mechanical Lifts and Ensure Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain sanitary conditions for mechanical lifts used for resident transfers, as observed during multiple instances where staff did not sanitize the equipment between uses. Staff, including nursing assistants, a clinical coordinator, an activities director, and a registered nurse, were seen transferring residents with mechanical lifts and then placing the equipment in the hallway or moving it to another resident's room without cleaning or disinfecting it. This occurred even when residents were on enhanced barrier precautions due to multidrug-resistant organisms (MDROs). Interviews with staff revealed confusion and inconsistency regarding the cleaning protocols, with some staff believing that cleaning was the responsibility of the night shift, while others acknowledged that lifts should be sanitized after each use but did not consistently follow this practice. The facility's policy required disinfection of lifts after each use, but this was not adhered to in practice. Additionally, the facility failed to ensure proper hand hygiene during personal care activities for two residents. In one instance, a nursing assistant provided perineal care, discarded soiled wipes, and then continued to assist the resident with dressing and repositioning without removing gloves or performing hand hygiene. The nursing assistant later confirmed she was not trained to remove gloves after perineal care and did not want to touch the resident without gloves. In another case, a nursing assistant performed perineal care, removed a soiled brief, and then touched clean items such as clothing and the bed controller without changing gloves or performing hand hygiene. The staff member acknowledged that the normal practice was to change gloves after removing a soiled brief but did not do so during the observed care. The residents involved had significant care needs, including cognitive impairments, incontinence, paraplegia, and dependence on staff for personal hygiene and transfers. The facility's policies on mechanical lift sanitation and hand hygiene were not consistently followed, as confirmed by staff interviews and policy review. The lack of adherence to these protocols was directly observed during care activities and confirmed by staff statements, indicating a systemic issue with infection prevention and control practices within the facility.
Failure to Offer Recommended Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the recommended pneumococcal vaccination series according to CDC guidelines. Specifically, the resident, who was over the age threshold and had previously received PPSV23 and PCV13 vaccines, was eligible for the PCV20 vaccine at least five years after the last pneumococcal dose. However, the medical record did not contain evidence that the resident was offered or received the PCV20 vaccine, nor was there documentation of shared clinical decision-making with the physician regarding this vaccination. The director of nursing (DON), who is responsible for the infection control program and ensuring residents' eligibility for routine vaccinations, acknowledged that the resident had not been educated about the risks and benefits or offered the PCV20 vaccine as per CDC recommendations. The facility's policy required assessment of immunization status within five days of admission and offering the vaccine within thirty days if indicated, but this process was not followed for the resident in question.
Failure to Consistently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post the current daily nurse staffing information as required. During an observation, the nurse staff posting displayed near the receptionist's desk was found to be outdated, showing a date several days prior. Further review revealed that postings for multiple consecutive days were missing, and only older postings were available. The facility's policy requires daily posting of nursing staff data at the beginning of each shift, including staff numbers, hours worked, and resident census. Interviews with the staffing coordinator and the director of nursing confirmed that the responsibility for posting this information was assigned to the staffing coordinator during weekdays and to the designated charge nurse on weekends. However, the staffing coordinator admitted that postings were not completed on weekends, and updates were only made upon her return on Mondays. This lapse resulted in the absence of required staffing information for several days, affecting the ability of residents, families, visitors, and staff to access current nurse staffing data.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
