Mount Olivet Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 5517 Lyndale Avenue South, Minneapolis, Minnesota 55419
- CMS Provider Number
- 24E102
- Inspections on file
- 18
- Latest survey
- May 14, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Mount Olivet Home during CMS and state inspections, most recent first.
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.
Failure to provide personal hygiene care: A resident with severe cognitive impairment, Parkinsonism, and ADL dependence was documented as refusing showers, nail care, and shaving, but the record lacked evidence that staff re-approached or rescheduled care. Observations showed oily hair, long jagged nails, and unshaven facial hair, and staff confirmed the resident needed assistance and had not had a shower for weeks.
The facility failed to implement and document appropriate interventions and root cause analyses after falls for two residents, resulting in serious injuries including fractures. Additionally, the facility did not complete an elopement risk assessment for a resident who attempted to leave unsupervised, and did not provide required monitoring for a resident with reported swallowing difficulties during meals. Staff interviews and record reviews revealed lapses in care plan updates, supervision, and adherence to facility policies.
Surveyors found that food items in kitchenettes were not consistently labeled or dated, and beverage machines—including coffee, ice/water, and juice machines—were not properly cleaned, with visible residues and standing liquids present. Staff interviews confirmed that all items should be labeled and machines kept clean, but there was confusion about cleaning responsibilities. Facility policy assigned cleaning duties to culinary staff, but observations showed these tasks were not reliably completed.
Two residents with histories of trauma did not have comprehensive care plans that included their identified trauma-related triggers or individualized trauma-informed interventions. Despite assessments and clinical notes detailing specific triggers and care preferences, these were not documented in the care plans or Kardexes, and staff were not consistently aware of them. Facility policy required such documentation, but it was not followed, as confirmed by staff interviews and record reviews.
A resident with MASD to the buttocks did not receive wound care as ordered, including the use of a cloth pillow case over cushions to wick away moisture. Staff were unaware of this intervention due to its absence from the care plan and Kardex, and adhesive dressings were applied despite orders to avoid them. The facility failed to ensure wound care orders were followed and properly documented.
Two residents with histories of trauma did not have their trauma-related triggers or individualized trauma-informed interventions documented in their care plans or Kardexes. One resident with PTSD and other mental health diagnoses had identified triggers and coping strategies that were not included in her care documentation, and staff were unable to identify these triggers. Another resident with severe cognitive impairment and a history of childhood sexual abuse also lacked documentation of specific triggers and preferences, such as a preference for male caregivers, despite clinical recommendations. Staff interviews confirmed the absence of this information in care documentation, contrary to facility policy.
A resident with advanced dementia and other conditions was admitted to hospice care, but the facility did not arrange a required care conference with the hospice team, family, and staff after hospice admission. Documentation and interviews confirmed that no care conference occurred within the expected timeframe, despite facility policy and agreements mandating such collaboration.
The facility failed to properly sanitize dishware due to the high-temperature sanitizing dishwasher not reaching adequate wash and rinse temperatures. The Ecolab dishwasher required a wash temperature of 160 degrees F and a rinse temperature of 180 degrees F, but logs showed these were not consistently met. During an observation, the dishwasher's electronic thermostat showed low temperatures, with alarms that were not acknowledged by the dietary aide. The Culinary Director confirmed the low readings and noted regular servicing by Ecolab, but the issue persisted. Facility policies required monitoring and recording of temperatures to ensure proper sanitization.
The facility failed to ensure proper pharmaceutical services, leading to potential medication errors. An RN prepared insulin for a resident using a pen labeled for another resident, and the facility did not follow procedures for medication storage and disposal for a discharged resident. Staff interviews revealed a lack of routine auditing and misunderstanding of medication handling protocols.
The facility failed to properly label and securely store insulin pens, affecting two residents during insulin administration. Insulin pens were mislabeled, with one pen having a different resident's name and another pen's concentration information covered. Additionally, insulin pens were stored in an unlocked drawer, accessible without unlocking, posing a risk to all residents on the memory care unit.
Three cognitively intact residents expressed frustration over their inability to open windows in their rooms due to facility-imposed restrictions. The facility removed window cranks and installed stoppers to limit window openings, citing safety concerns. However, no individualized assessments were conducted to evaluate residents' ability to manage windows safely, leading to dissatisfaction among residents who valued fresh air.
A resident with cognitive impairment and mobility issues was using an electric lift chair without proper assessment or supervision. The facility's care plan and records did not reflect the use of the chair, and staff interviews revealed a lack of routine assessments for such devices, despite facility policy requiring them.
A resident with moderate cognitive impairment and arthritis experienced frequent pain but did not receive non-pharmacological interventions, despite being on scheduled pain medications. Staff interviews revealed a lack of implementation of non-pharmacological approaches, contrary to the facility's Pain Management Program policy.
A facility failed to use nonpharmacological interventions before administering PRN antipsychotic medication to a resident with anxiety and bipolar disorder, who showed no behaviors requiring intervention. The resident received Seroquel without documentation of attempted interventions, and the medication order lacked a required 14-day limit. Staff interviews revealed a lack of adherence to policy, which mandates nonpharmacological attempts and documentation before PRN medication use.
A facility failed to ensure proper hand hygiene and disinfection of a shared glucometer during blood sugar checks for three residents. An RN did not change gloves or perform hand hygiene between tasks, and the glucometer was not disinfected between uses. Interviews with staff confirmed the lack of adherence to infection control protocols, despite facility policies requiring hand hygiene and glucometer disinfection between residents.
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.
Failure to Provide Personal Hygiene Care
Penalty
Summary
The facility failed to provide personal hygiene care for one dependent resident who was unable to complete activities of daily living without staff assistance. The resident’s MDS indicated severe cognitive impairment, verbal behaviors, refusal of bathing, and need for assistance with toileting, dressing, shoes, and personal hygiene. The care plan identified a potential alteration in completion of ADLs related to Parkinson’s disease and directed staff to assist with bathing, grooming, and lower body dressing. The Kardex also indicated the resident needed assistance of one with bathing, grooming, and personal hygiene. Weekly skin checks showed the resident had a shower on 4/7/26, but then refused showers, nail care, and shaving on 4/14/26, 4/21/26, and 5/5/26. The medical record lacked documentation of attempts to re-approach or reschedule the showers. During observations, the resident had oily, dull hair, overgrown facial hair, and fingernails that were uneven, jagged, long, and untrimmed. A NA confirmed the resident had dirty hair and long nails and stated he needed to be shaved. An RN stated the resident’s behavior varied, that he needed supervision and verbal redirection, and verified there had been no shower since 4/7/26. The DON and ADON stated staff were expected to re-approach residents, try a different person or time for the shower, and that showers, nail care, and shaving were important for cleanliness and dignity. The facility policy stated that if a resident refuses ADL assistance, staff should ensure the resident is safe, re-approach, and notify the nurse or manager if refusal continues.
Failure to Implement Fall Interventions, Complete Root Cause Analyses, and Assess Elopement and Swallowing Risks
Penalty
Summary
The facility failed to ensure that interventions were implemented and root cause analyses were completed following falls for two residents, resulting in actual harm. One resident with severe cognitive impairment, Alzheimer's disease, and osteoporosis experienced two unwitnessed falls. The first fall occurred when the resident slid out of bed, with improper footwear identified as a predisposing factor. Although a perimeter mattress was implemented, the intervention for gripper socks was not added to the care plan or consistently documented as refused. The resident later suffered a second fall, again slipping on socks, resulting in a right femur fracture that required surgical intervention. Observations revealed that staff did not consistently provide the required supervision or follow care plan interventions, such as using a walker, transfer belt, or wheelchair during ambulation, and did not ensure proper footwear. Another resident with multiple comorbidities, including COPD, CHF, and a history of falls, experienced two unwitnessed falls in the bathroom, resulting in a head laceration and a fractured clavicle. After the first fall, there was no documentation of a root cause analysis or new interventions added to the care plan, despite facility policy requiring such actions. The only intervention following the second fall was a referral to physical and occupational therapy. Interviews with staff confirmed that root cause analyses and care plan updates were not consistently completed after falls, and there was a lack of clarity on how to determine the resident's safety for independent transfers and toileting after such incidents. The facility also failed to complete an elopement risk assessment for a resident who attempted to leave the facility without supervision, despite policy requiring such assessments upon admission. Additionally, a resident with reported coughing during meals was not monitored while eating in their room, and the care plan and Kardex lacked information about swallowing difficulties or the need for supervision. Staff interviews revealed inconsistent understanding and documentation of monitoring requirements for residents with potential swallowing issues, and there was no evidence that the provider was updated or that a risk versus benefit assessment was completed for eating in the room.
Failure to Properly Label Food and Maintain Cleanliness of Kitchenettes and Beverage Machines
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and storage of food items, as well as adequate cleaning of kitchenettes and beverage machines on multiple floors. Unlabeled and uncovered food items were found in refrigerators and freezers, and various beverage machines—including coffee, ice/water, and juice machines—had visible residues such as white flaky substances, standing water, and dried or standing brown liquid. These issues were confirmed by staff interviews, who acknowledged that all food items should be labeled and dated, and that machines should be clean and free of stains or water drippings. Further review revealed that there was confusion among staff regarding responsibility for cleaning the machines, with some staff unsure whether culinary or housekeeping was responsible. The facility's policy and cleaning log indicated that culinary staff were responsible for cleaning beverage machines, refrigerators, freezers, and microwaves, and that a cleaning schedule and sign-off log were maintained. However, observations showed that cleaning was not consistently performed according to policy, as evidenced by repeated findings of residue and unclean conditions in all three kitchenettes inspected.
Failure to Develop and Implement Comprehensive Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed trauma-related triggers and individualized trauma-informed care approaches for two residents with a history of trauma. For one resident with diagnoses including anxiety, depression, bipolar disorder, and PTSD, assessments identified specific traumatic experiences, emotional responses, and potential triggers such as being touched, loud noises, lack of control, and certain anniversaries. The resident also identified activities that could help her cope. However, her care plan and Kardex did not document these triggers or resident-specific interventions to mitigate the risk of re-traumatization. Interviews with staff confirmed that trauma-related triggers were not included in her care plan, and staff were unable to identify or reference these triggers in her records. For another resident with severe cognitive impairment, Alzheimer's disease, aphasia, depression, PTSD, and a history of childhood sexual abuse, the trauma assessment indicated that his trauma could influence his resistance to bathing and other behaviors. While his care plan acknowledged his trauma history and included some general behavioral interventions, it did not specify his trauma-related triggers or preferences for male versus female caregivers, despite documentation in clinical notes that he responded better to male caregivers and benefited from paired care with female staff. The Kardex also lacked documentation of specific triggers and preferences, and staff interviews revealed inconsistent awareness of his trauma-related needs. Facility policy required individualized care plans to address past trauma and minimize exposure to triggers, but the care plans and Kardexes for both residents did not meet these requirements. Staff interviews confirmed that trauma-related triggers and interventions were not consistently documented or communicated, increasing the risk that staff would not be aware of or able to avoid re-traumatizing residents with PTSD. The deficiency was identified through interviews, document reviews, and direct observation of care planning practices.
Failure to Implement and Document Wound Care Orders for Skin Integrity
Penalty
Summary
The facility failed to follow and implement wound care orders for a resident with moisture associated skin damage (MASD) to the buttocks. The resident, who was cognitively intact, ambulatory, and independent with most activities of daily living, had a care plan indicating a potential for skin integrity issues due to urinary incontinence, but was not at risk for pressure ulcers according to the most recent assessments. Despite this, the resident developed MASD, and wound care orders were issued by the nurse practitioner, including specific instructions not to use adhesive dressings and to ensure that any cushions or pads used by the resident were covered with a cloth pillow case to wick away moisture. Observations and interviews revealed that these wound care interventions were not consistently implemented. The resident was repeatedly observed sitting on a cushion without a cloth or pillow case, contrary to the wound care plan. Staff interviews confirmed that the intervention to cover cushions with a pillow case was not included in the resident's care plan or Kardex, and nursing assistants were unaware of the requirement. Additionally, there were instances where staff applied dressings to the affected area despite explicit orders not to use adhesives, and the resident reported that staff did not consistently apply prescribed creams and did not communicate with him about the progress of his skin condition. Documentation review further showed that the care plan and Kardex lacked the necessary interventions for moisture management as directed by the nurse practitioner. The facility's policy required that interventions be care planned according to resident assessment and risk factors, but this was not done in this case. The director of nursing confirmed that orders should be followed and care planned, and staff should be aware of all interventions, but this expectation was not met, resulting in the deficiency.
Failure to Document Trauma-Related Triggers and Interventions in Care Plans
Penalty
Summary
The facility failed to ensure that trauma-related triggers and individualized trauma-informed interventions were documented in the comprehensive care plans for two residents with a history of trauma. One resident, who had diagnoses including PTSD, anxiety, depression, and bipolar disorder, had completed a trauma assessment identifying specific traumatic experiences, emotional responses, and potential triggers such as being touched, loud noises, lack of control, and certain anniversaries. The assessment also listed activities that could help her cope. However, her care plan and Kardex did not include these identified triggers or resident-specific interventions to mitigate the risk of re-traumatization. Staff interviewed were unable to identify her trauma-related triggers and confirmed that such information was not present in the care documentation they used. Another resident, who had severe cognitive impairment, aphasia, and a history of childhood sexual abuse, was also missing documentation of trauma-related triggers in his care plan and Kardex. Although his care plan acknowledged his trauma history and included some general behavioral interventions, it did not specify his preference for male versus female caregivers, despite clinical notes indicating he responded better to male caregivers and benefited from paired care with female caregivers. Staff interviews revealed a lack of awareness of his trauma-related triggers and preferences, and the recommended interventions from clinical notes were not consistently transcribed into the care plan or Kardex. Staff relied on word of mouth and daily huddles for information, but key details were not formally documented. Facility policy required individualized care plans to address past trauma and identify and decrease exposure to triggers that may re-traumatize residents. Despite this, the care plans and Kardexes for both residents lacked the necessary documentation of triggers and specific interventions. Multiple staff members, including nursing assistants, nurses, and social services, confirmed that trauma-related triggers and recommended interventions were not present in the care documentation, which could have impacted the care provided to these residents.
Failure to Coordinate Hospice Care Conference After Admission
Penalty
Summary
The facility failed to collaborate with hospice for the development, implementation, and revision of a coordinated plan of care for a resident who was receiving hospice services. The resident, who had diagnoses including Alzheimer's disease, non-Alzheimer's dementia, depression, and anxiety, was identified as having severely impaired cognition and was on hospice care. Documentation showed that the care plan directed staff to work cooperatively with the hospice team to meet the resident's needs, and the hospice plan of care emphasized coordination between the facility, hospice, the resident, and her family. However, there was no documentation of a care conference after the resident's admission to hospice, despite facility policy and hospice agreement requiring such collaboration. Interviews with the resident's family, hospice RN, social services, and the DON confirmed that a care conference had not been held within the expected timeframe after the resident's admission to hospice. The last documented care conference occurred prior to the resident's hospice admission, and both facility and hospice staff acknowledged that the required meeting had not taken place. The facility's policy and hospice agreement both specified the need for coordinated care and family involvement, but these were not followed in this instance.
Dishwasher Sanitization Failure
Penalty
Summary
The facility failed to ensure proper sanitization of dishware used for meal preparation and resident service due to the high-temperature sanitizing dishwasher not reaching adequate wash and rinse temperatures. The Ecolab EC-66HH dishwasher specifications required a wash temperature of 160 degrees F and a sanitizing rinse temperature of 180 degrees F. However, the facility's Culinary Services Dish Washer Temperature Log indicated that the final rinse temperatures only reached 180 degrees F once from June 1 to June 26, 2024. During an observation, the dishwasher's electronic thermostat showed wash temperatures as low as 140.1 degrees F and rinse temperatures as low as 175 degrees F, with alarms sounding for low temperatures that were not acknowledged by the dietary aide (DA). The DA was unaware of the alarm and did not monitor the temperatures, stating he was unsure of the required wash and rinse temperatures. The Culinary Director (CD) verified the low temperature readings and reset the alarm, confirming that the dishwasher used heat for sanitizing dishes and that the temperature gauges indicated a need for 150 degrees F for wash and 180 degrees F for rinse. Despite regular servicing by Ecolab, the facility logs showed rinse temperatures below the required 180 degrees F. The assistant administrator expected dishwasher temperatures to be monitored to ensure proper sanitization, and if not met, the CD should notify maintenance or Ecolab for assistance. Facility policies directed staff to monitor and record dish machine temperatures to ensure proper sanitization, with the dietary manager responsible for spot-checking logs and ensuring appropriate temperatures were maintained.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper pharmaceutical services, specifically in the administration of insulin to the correct resident and adherence to medication receiving procedures. During an observation, RN-D prepared an insulin pen labeled for a different resident and facility, intending to administer it to a resident with moderate cognitive impairment and multiple diagnoses, including diabetes. Despite recognizing the label discrepancy, RN-D proceeded to prepare for administration until stopped by another staff member. The insulin pen was not found in the designated storage, and the pharmacy was contacted for clarification. Further investigation revealed that the facility did not follow proper procedures for medication storage and labeling. A discharged resident's medications, including insulin, were found in the medication storage room and cart, contrary to the facility's policy. The medications were not disposed of or returned to the pharmacy, and there was no discharge drug disposition form in the resident's electronic health record. Interviews with staff indicated a lack of routine auditing of medication storage and a misunderstanding of procedures for handling medications of discharged residents. The facility's policies required staff to verify medications upon delivery and ensure correct labeling before administration. However, the staff failed to adhere to these protocols, leading to potential medication errors. The director of nursing and consulting pharmacist emphasized the importance of following the six rights of medication administration and the three-check process, which were not consistently practiced, as evidenced by the incidents involving insulin administration and medication storage.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure that insulin pens were labeled in accordance with professional standards for two of the three residents observed during insulin administration. Specifically, insulin pens for residents R18 and R53 were not properly labeled. R18's insulin pen had a label with a different resident's name and a different facility's name, which was not the name of the resident for whom the insulin was prepared. R53's insulin pen had a label that covered the concentration information, and the facility's label did not include the order directions such as the prescribed dose. These labeling issues were identified during observations and interviews with nursing staff, who acknowledged the potential for medication errors due to incorrect labeling. Additionally, the facility failed to store insulin pen-injectors in a locked compartment, which had the potential to affect all 31 residents residing on the locked memory care unit. During observations, insulin pens were found in an unlocked drawer behind the nursing station, which was accessible without unlocking. The nursing staff, including RN-D and LPN-C, confirmed that the insulin pens were kept in an unlocked drawer and that the half-door to the nursing station was also unlocked. This lack of secure storage posed a risk of unauthorized access to the insulin pens. The facility's policy on medication storage indicated that medications and biologicals were to be stored safely, securely, and properly, accessible only to authorized personnel. However, the policy did not specify the information required on pharmacy labels. Interviews with the director of nursing and consulting pharmacist highlighted the expectation that medication labels should not cover important information and that insulin pens should be locked up to prevent unauthorized use. Despite these expectations, the facility's practices did not align with the policy, leading to the identified deficiencies.
Failure to Accommodate Resident Preferences for Window Operation
Penalty
Summary
The facility failed to accommodate the preferences of three residents who wished to open the windows in their rooms. Resident 16, who was cognitively intact and had several medical conditions including depression and heart failure, expressed frustration over the inability to open their windows due to the removal of window cranks. The facility had removed the cranks following a directive to prevent windows from being opened more than four inches, citing safety concerns. However, Resident 16, who was not at risk of jumping or falling out, was unable to open the windows independently, leading to dissatisfaction. Similarly, Resident 60, who was also cognitively intact and had a preference for fresh air, was unable to fully open their sliding window due to a black stopper that limited the opening to six inches. Despite understanding the safety rule for confused residents, Resident 60 expressed frustration over the restriction, as they valued having fresh air. Resident 61, another cognitively intact individual, faced the same issue with their sliding window, which was also restricted by a black stopper. This resident expressed frustration, questioning the necessity of the restriction given their cognitive status. Interviews with staff revealed that the facility had not conducted individualized assessments to determine if residents were capable of safely managing their windows. The assistant administrator and director of nursing acknowledged the restriction was based on a consultant's recommendation to mitigate safety risks. However, the facility's policy emphasized respecting residents' rights to self-determination, which was not upheld in this instance, as the residents' preferences for window operation were not accommodated.
Failure to Assess Electric Lift Chair Use for Resident
Penalty
Summary
The facility failed to ensure that an electric lift chair was assessed for safe use for a resident with cognitive impairment and multiple diagnoses, including osteoporosis, spinal stenosis, and dementia. The resident required partial to moderate assistance for transfers and used a walker for mobility. Despite these needs, the resident's care plan, Kardex, and medical records lacked any indication of the use of an electric lift chair or the need for assistance with it. Observations revealed the resident was using the lift chair independently, but was confused about its operation, indicating a lack of proper assessment and supervision. Interviews with staff, including a trained medication assistant, LPN, RN, and the Director of Nursing, revealed inconsistencies in the assessment process for electric lift chairs. The staff acknowledged that assessments for such devices were not routinely completed, and there was no provider order for the chair. The chair was brought in by the resident's family, and the facility's policy required assessments for physical devices upon admission, annually, and with significant changes. However, this policy was not followed, leading to the deficiency in ensuring the resident's safety while using the electric lift chair.
Failure to Implement Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to implement resident-specific non-pharmacological interventions for pain management for a resident with moderate cognitive impairment and multiple diagnoses, including rheumatoid arthritis and osteoarthritis. The resident, who was independent with ambulation, reported frequent pain in the knees and right hip, rating it at a level four on a 1-10 scale. Despite receiving scheduled pain medications such as acetaminophen, methotrexate, prednisone, and Voltaren, the resident did not receive any PRN medications or non-pharmacological interventions. The care plan lacked resident-centric approaches to address the resident's pain, and the resident expressed a desire not to be on more medications. Interviews with staff, including a trained medication aide, nursing assistant, registered nurse, and the director of nursing, revealed that non-pharmacological interventions were not utilized or documented in the care plan. The staff acknowledged the importance of trying alternatives to limit medication use, but no such interventions were in place for the resident. The facility's Pain Management Program policy emphasized the need for both pharmacological and non-pharmacological interventions, but this was not reflected in the resident's care plan or practice.
Failure to Utilize Nonpharmacological Interventions and Adhere to PRN Antipsychotic Medication Policy
Penalty
Summary
The facility failed to ensure nonpharmacological interventions were utilized before administering a PRN antipsychotic medication to a resident, identified as R9, who was cognitively intact and diagnosed with anxiety disorder and bipolar disorder. Despite R9 exhibiting no behaviors that required intervention, the resident received Seroquel, an antipsychotic medication, on two occasions without documentation of attempted nonpharmacological interventions. The care plan for R9 included interventions such as calming activities and family interactions, but these were not documented as attempted prior to the administration of the medication. The facility also failed to ensure that the PRN antipsychotic medication order for R9 included a 14-day limit, as required by policy. The order for Seroquel did not have an end date, and staff interviews revealed a lack of awareness and adherence to the policy requiring a stop date for PRN antipsychotic medications. The consulting pharmacist and the Director of Nursing both confirmed the expectation for a 14-day limit and the need for provider documentation to extend the order. Interviews with nursing staff indicated that nonpharmacological interventions should be attempted and documented before administering PRN medications. However, there was no documentation of such interventions or behaviors in R9's medical record. The facility's policy on psychotropic drugs emphasized the importance of recognizing and responding to resident behaviors with interventions to eliminate the need for medication, and required PRN antipsychotic medications to be ordered for no longer than 14 days.
Infection Control Deficiency in Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper hand hygiene and disinfection of a shared glucometer during blood sugar checks for three residents. The observations revealed that a registered nurse (RN-D) did not change gloves or perform hand hygiene between dirty and clean tasks while checking blood glucose levels. The RN used the same gloves to handle clean items such as alcohol wipes, lancets, and test strips after touching potentially contaminated surfaces. This practice was observed during blood sugar checks for three residents, where the RN did not disinfect the glucometer between uses, increasing the risk of cross-contamination. Interviews with the RN and other staff members, including a licensed practical nurse (LPN-C) and infection preventionists (IP-E and IP-F), confirmed the lack of adherence to infection control protocols. The RN admitted to not disinfecting the glucometer between residents and acknowledged the risk of infection. The LPN and infection preventionists emphasized the importance of disinfecting the glucometer after each use and performing hand hygiene before and after procedures to prevent the spread of germs. The facility's policies on hand hygiene and blood glucose testing required staff to perform hand hygiene after potential contamination and to disinfect glucometers between each resident. However, these protocols were not followed, as evidenced by the RN's actions during the blood sugar checks. The director of nursing (DON) also confirmed the expectation for staff to change gloves and perform hand hygiene to prevent infection and cross-contamination.
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.
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