Minnewaska Community Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Starbuck, Minnesota.
- Location
- 605 Main Street, Starbuck, Minnesota 56381
- CMS Provider Number
- 245537
- Inspections on file
- 25
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Minnewaska Community Health Services during CMS and state inspections, most recent first.
The facility failed to ensure that 13 single resident rooms on the A-wing met the required 100 sq ft of usable floor space, and 6 occupied rooms were identified as noncompliant. The DON confirmed the rooms did not meet the standard, while an RN reported no resident complaints about room size and the Administrators stated they had no requests for room moves or complaints from current residents. One resident said staff care was not inhibited by the room size, and the facility reported it had previously moved a resident to a larger room for family visiting needs.
A resident with multiple health conditions and moderate risk for pressure ulcers developed a deep tissue injury on the sacrum. Facility staff failed to consistently monitor and document the wound daily, with incomplete records and unclear communication among nursing staff. The facility's policy required only weekly wound assessments, and there were no clear orders for daily observation or treatment, resulting in the wound being identified as severe upon hospital transfer.
Several residents with significant mobility and cognitive impairments reported being handled roughly and rushed during transfers and personal care by a nursing assistant, leading to discomfort, pain, and emotional distress. Staff interviews confirmed that the emergency button on the lift was used inappropriately to lower residents quickly, and some staff failed to report concerns about rough handling and disrespectful comments. Management was unaware of these issues until they were raised during the survey, despite facility policy requiring dignified and respectful treatment.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy between the resident's DNR wishes and the EHR indicating CPR. Staff interviews confirmed they would have followed the incorrect documentation, potentially administering unwanted CPR. The facility's policy required the POLST to be documented and reviewed, but this was not followed.
The facility was cited for deficiencies in food service and sanitation practices, including improper handling of beverages by an activities aide, unsanitary conditions of the ice and coffee machines, and failure to maintain proper food temperatures. These practices could lead to contamination and potential illness among residents.
The facility failed to submit complete and accurate staffing information to CMS for Quarter 4 due to not including contracted staff hours in their PBJ submissions. The administrator and CFO confirmed that invoices for contracted staff were received after the submission deadline, leading to inaccuracies in reported staffing levels. This affected all 30 residents in the facility.
The facility failed to maintain an effective infection control program, lacking comprehensive surveillance of resident infections and proper hand hygiene practices. The infection control log did not track necessary data such as signs, symptoms, and antibiotic usage. Additionally, nursing assistants did not sanitize their hands during water pitcher delivery, increasing the risk of infection spread.
The facility failed to provide single resident rooms with at least 100 square feet of usable floor space for 10 residents on the A-wing. The administrator confirmed the deficiency, and room measurements were provided by the maintenance director, showing rooms were less than the required size. Some residents expressed satisfaction with their room size, while others were unable to respond. No complaints were reported by staff, and the administrator planned to apply for a waiver.
A facility failed to secure cleaning chemicals, leaving them accessible to residents on the B-wing. Observations showed open doors to rooms with unsecured chemicals, including Vindicator+ and QT-TB, with no staff present. Two residents with cognitive impairments and wandering behaviors were seen near these areas. Staff interviews confirmed the expectation for doors to be closed, but the chemicals were not properly stored, posing a potential risk.
A resident with cognitive impairment and high fall risk had a call light out of reach, contrary to the care plan and facility policy. Observations and staff interviews confirmed the deficiency, highlighting a failure to ensure call light accessibility for the resident.
A resident with a history of atrial fibrillation experienced a significant medication error when Warfarin doses were missed due to a transcription error in the electronic medical record. This error led to subtherapeutic INR levels, increasing the resident's risk for blood clots. The issue was identified after several days, highlighting a lapse in medication management and monitoring.
Insufficient Room Size in A-Wing Single Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 single resident rooms on the A-wing had at least 100 square feet of usable floor space for 6 residents who were occupying those rooms, including A24, A25, A27, A33, A35, and A36. During the entrance conference, the DON confirmed the rooms in hallway A did not meet the required square footage. During the initial screening on the A-wing, those rooms were observed to be occupied by residents. In interviews, one resident stated that staff care was not inhibited by the room size, and an RN reported she was not aware of any resident complaints related to room size. The Administrators stated they had no requests for room moves or complaints that rooms were too small from current residents, and they reported they would accommodate any resident request for more space as allowed. The facility also reported that it had previously moved a resident to a larger room at family request so a large family could visit together. A policy on room size was requested but not received.
Failure to Provide Daily Monitoring and Assessment of Pressure Ulcer
Penalty
Summary
The facility failed to implement daily monitoring and assessment of a deep tissue injury for a resident who was at moderate risk for pressure ulcers. The resident had multiple diagnoses, including diabetes mellitus and a history of stroke, and required significant assistance with activities of daily living. Upon admission, the resident had no unhealed pressure ulcers, and care plans identified interventions such as regular repositioning, use of pressure-relieving devices, and weekly skin assessments. However, after a pressure wound was identified on the sacrum, documentation showed inconsistent and incomplete monitoring, with several entries lacking details on the wound's condition, such as pain, size, drainage, and tissue description. Nursing staff interviews revealed confusion and lack of clarity regarding the assessment and documentation of the pressure ulcer. Some staff were unaware of the wound, while others could not recall or describe its characteristics. There were no clear orders for daily wound observation or treatment, and the wound was not consistently evaluated or documented each day. The facility's policy required weekly wound assessments but did not specify daily monitoring for existing pressure ulcers, contributing to the lack of consistent care. The resident's medical record lacked evidence of daily monitoring of the pressure ulcer, and the wound was ultimately described as a severe decubitus ulcer upon transfer to the emergency room. The deficiency was further highlighted by the absence of clear documentation and communication among staff regarding the wound's status and the lack of a specific treatment plan or daily assessment orders in the resident's records.
Failure to Ensure Dignified and Respectful Care During Transfers and Personal Care
Penalty
Summary
Multiple residents with significant physical and cognitive impairments reported being treated in a manner that lacked dignity and respect by a specific nursing assistant (NA-A) and, at times, other staff. Residents described being rushed during transfers and personal care, handled roughly, and not given adequate time to participate in their own care. Several residents recounted incidents where their bodies were bumped, pinched, or positioned improperly during transfers with mechanical lifts, resulting in discomfort, pain, and emotional distress. One resident with a history of polio and severe mobility limitations described being left alone in a lift harness, feeling like a 'horse with a harness,' and being lowered too quickly, sometimes resulting in her head being struck by the lift bar. Another resident reported embarrassment and discomfort due to improper application of incontinence briefs and insensitive comments from staff about the odor in her room. Staff interviews corroborated resident accounts, with several nursing assistants and LPNs acknowledging that NA-A worked quickly, used the emergency button on the lift inappropriately to lower residents rapidly, and sometimes failed to ensure residents' safety and comfort during transfers. Some staff admitted to witnessing or being told about rough handling, improper positioning, and lack of attention to residents' needs, but did not always report these concerns to management. There were also reports of staff making inappropriate comments about the time required to care for certain residents and expressing annoyance in front of residents. Despite multiple complaints from residents and some staff, management, including the DON and administrator, stated they were unaware of any concerns regarding inappropriate treatment by staff until the issues were brought to their attention during the survey. The facility's policy required staff to treat residents with dignity and respect, explain procedures before care, and maintain residents' quality of life, but these expectations were not consistently met, as evidenced by the repeated resident and staff reports of undignified and disrespectful care.
Discrepancy in Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately documented in the clinical record, leading to a discrepancy between the resident's wishes and the documented orders. The resident, who was cognitively impaired and had diagnoses including dementia, asthma, and hypertension, had a Physician's Order for Life-Sustaining Treatment (POLST) indicating a Do Not Resuscitate (DNR) status. However, the electronic health record (EHR) and other documentation inaccurately reflected that the resident wanted cardiopulmonary resuscitation (CPR). This discrepancy was identified through observations, interviews, and document reviews, revealing that the facility's records did not align with the resident's current wishes. Interviews with facility staff, including licensed practical nurses and registered nurses, confirmed that they would have followed the incorrect documentation in the event of an emergency, potentially administering CPR against the resident's wishes. The assistant director of nursing and director of nursing acknowledged the discrepancy and confirmed that the facility's policy was not followed, as the POLST should have been the guiding document for the resident's care preferences. The facility's policy required that the POLST be documented in the EHR and reviewed quarterly, but this was not adhered to, resulting in the potential for the resident to receive unwanted medical intervention.
Removal Plan
- All residents' records were reviewed to ensure the POLST form, the electronic medical records were updated to ensure resident's wishes for advance directives, were accurate.
- R9's EHR record was updated to match the current POLST.
- All current licensed staff were educated on the policy for advance directives, updating the POLST and the EHR to reflect the resident's wishes, as evidenced by the education sign in sheet and interviews.
- A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift, by notification of required education via phone/text. All staff would sign off once education had been completed.
- The advance directive policy was reviewed and determined no changes were required.
Deficiencies in Food Service and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food service and sanitation practices. During an observation, an activities aide was seen serving beverages without washing her hands or wearing gloves, and she handled the top rims of glasses and cups, which could lead to contamination. The aide also served uncovered desserts from a food cart, which were exposed to potential contamination as staff walked by. The assistant director of nursing confirmed that staff were expected to handle glasses by the bottom and that desserts should be covered to prevent contamination. The facility also failed to maintain the ice and coffee machines in a sanitary manner. Observations revealed a white powdery substance on the coffee machine's hot water spout and a white scaley buildup inside the ice machine's spout. The dietary manager confirmed these findings and acknowledged that there were no cleaning logs for these machines, which could lead to bacterial contamination and illness among residents. The maintenance director was unaware of the buildup and stated that dietary staff were responsible for cleaning the machines. Additionally, the facility did not maintain proper food temperatures, as evidenced by a large bin of cole slaw that was found to be at 49.5 degrees Fahrenheit, above the safe cold holding temperature. The dietary aide was unaware of the correct temperature range, and the dietary manager confirmed the lack of a policy for keeping foods cold. The Food and Drug Administration food code specifies that food should be kept out of the danger zone, which is between 40 and 140 degrees Fahrenheit, to prevent bacterial growth and foodborne illness.
Incomplete Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for Quarter 4. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Report, which showed excessively low weekend staffing. The issue arose because the facility did not include contracted staff hours in their submissions to CMS. The administrator confirmed that the contracted staff hours were not calculated into the system before submission, leading to inaccuracies in the reported staffing levels. During interviews, the administrator and chief financial officer (CFO) explained that the contracted staff hours were obtained from invoices received from the contract company. However, these invoices were received after the required submission date for the facility's PBJ information to CMS. As a result, the facility's PBJ submissions continued to be incomplete and inaccurate, as they did not include the necessary contracted staff hours. This practice had the potential to affect all 30 residents residing in the facility.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish an ongoing infection control program that included comprehensive surveillance of resident infections. The infection control surveillance log, titled Peerlytics, used by the facility from October 2024 to March 2025, was found lacking in necessary data tracking. The log only highlighted rooms with diagnosed infections but did not track signs and symptoms, culture results, or antibiotic usage. During interviews, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) admitted that the mapping document only included diagnosed illnesses and did not track other critical data. They were unaware that all signs and symptoms needed to be tracked for every resident, and the facility had not implemented a process for tracking and trending infections. Additionally, the facility failed to ensure proper hand hygiene during the delivery of water pitchers to residents. Nursing assistants were observed delivering water pitchers without sanitizing their hands before entering resident rooms or after handling used water pitchers. This practice was confirmed by the nursing assistants and verified by the ADON, who acknowledged that staff were expected to sanitize their hands to prevent the spread of germs. The facility's policy on infection control surveillance was requested but not provided, and the existing hand hygiene policy was undated, indicating a lack of proper procedural documentation.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that the 13 single resident rooms on the A-wing had at least 100 square feet of usable floor space, as required by regulations. This deficiency affected 10 residents who were currently residing in those rooms. During the entrance conference, the administrator confirmed that the rooms in hallway A did not meet the required size. Observations during the initial screening of residents on the A-wing confirmed that the rooms for the identified residents did not have the required floor space. Interviews with residents revealed mixed responses; some residents expressed satisfaction with their room size, while others were unable to respond due to their condition. Further interviews with staff, including a nursing assistant and the director of nursing, indicated that no complaints had been received regarding room sizes. The maintenance director provided room measurements, confirming that the rooms were less than 100 square feet. The administrator acknowledged the deficiency and mentioned plans to apply for a waiver. Despite the deficiency, no facility policy regarding room size was provided upon request.
Unsecured Chemicals Pose Risk to Residents
Penalty
Summary
The facility failed to ensure that cleaning chemicals were secured in a locked cabinet or cart, posing a potential risk to all residents residing on the B-wing. Observations revealed that the tub/shower room door was propped open with a trash can, and various cleaning chemicals, including Vindicator+, QT-TB, and Barrier II, were left unsecured on the floor and on carts. The storage room B-50's door was also open, with a bottle of pine liquid odor control sitting on the floor. These chemicals were accessible to residents, as no staff were present in the hallway or at the nurses' station during multiple observations. Two residents, identified as R22 and R10, were observed walking down the hallway past the open doors where the chemicals were stored. Both residents were severely cognitively impaired, with diagnoses including dementia and other conditions. Their care plans noted wandering behaviors, and they were independent with transfers and mobility, increasing the risk of them accessing the unsecured chemicals. Interviews with staff, including a nursing assistant and the director of nursing, confirmed that the doors to the rooms with chemicals were supposed to be closed at all times. However, the doors did not have locks, and the chemicals were not stored properly even when the doors were closed. The director of nursing acknowledged that having chemicals sitting out could lead to a harmful situation. The facility's policy on hazard communication emphasized the importance of securing hazardous substances to protect health and safety, but this was not adhered to in practice.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident identified as R9, who was cognitively impaired and had diagnoses including dementia, asthma, and hypertension. R9 was dependent on staff for activities of daily living such as bed mobility, toileting, and transfers. The care plan for R9, dated 1/28/25, indicated that R9 was at high risk for falls due to weakness and age-related osteoporosis, with an intervention to ensure the call light was within reach and to encourage the resident to use it for assistance as needed. During observations on 3/23/25 and 3/24/25, R9 was seated in a stationary chair about five feet from the bed, with the call light attached to the bedrail and out of reach. Interviews with a nursing assistant and an LPN confirmed that the call light was not within R9's reach, although R9 was able to use it. The Director of Nursing also verified that the expectation was for call lights to be within reach at all times. The facility's policy on call light accessibility, revised on 10/1/24, required staff to ensure call lights were within reach during each interaction in the resident's room or bathroom.
Significant Medication Error with Warfarin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Warfarin, a blood thinner. The resident, who had a history of atrial fibrillation and other cardiovascular issues, was supposed to transition from Eliquis to Warfarin as per the cardiologist's orders. However, the orders for Warfarin were not correctly transcribed into the electronic medical record, resulting in the resident missing six doses of Warfarin 5 mg. The resident's INR levels, which are critical for monitoring the effectiveness of Warfarin, were not maintained within the therapeutic range due to these missed doses. The INR levels dropped from 2.9 to 1.2, indicating a subtherapeutic level, which increased the resident's risk for blood clots. The error was discovered when the INR clinic nurse noted the discrepancy in the medication administration record and communicated it to the facility staff. Interviews with facility staff, including the medical director, registered nurse, and director of nursing, revealed that the transcription error was not identified until several days after it occurred. The staff acknowledged that the missed doses of Warfarin were due to a transcription error in the electronic medical record, which was not corrected in a timely manner. This oversight placed the resident at an increased risk for adverse health outcomes, as the therapeutic management of their condition was compromised.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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