Park River Healthcare And Rehabilitation Center Ll
Inspection history, citations, penalties and survey trends for this long-term care facility in Coon Rapids, Minnesota.
- Location
- 9899 Avocet Street Northwest, Coon Rapids, Minnesota 55433
- CMS Provider Number
- 245448
- Inspections on file
- 24
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 22 (2 serious)
Citation history
Health deficiencies cited at Park River Healthcare And Rehabilitation Center Ll during CMS and state inspections, most recent first.
The facility failed to provide appropriate dialysis care for two residents. One resident with ESRD, cardiac conditions, anemia, and anticoagulant use had no consistent communication between the facility and dialysis center, missed vital sign checks before metoprolol with hold parameters, had water and soda despite a fluid restriction, lacked EBP, and had repeated bleeding from a dialysis access site with no documented physician orders for CVC dressing care or AV fistula monitoring. A second resident on dialysis also had a fluid restriction and care plan needs, but the record lacked evidence of ongoing communication with the dialysis center and showed a water pitcher in the room despite the restriction.
Failure to Maintain Infection Control Surveillance and Precautions: The DON described an infection surveillance process based on monthly antibiotic lists rather than real-time symptom tracking, and five residents developed respiratory symptoms without being placed on TBP, monitored consistently, or tested for a possible outbreak. One resident had pneumonia with a wet cough and delayed treatment, another had wheezing and low O2 saturation, and others had ongoing cough or congestion without documented illness monitoring. The facility also failed to implement EBP for a resident with dialysis access devices and a resident with a stage 4 pressure ulcer, despite policy identifying those conditions as requiring EBP.
The facility failed to ensure the DON worked on a full-time basis. The staffing coordinator stated the DON served as charge nurse on weekday day shift, and the DON said she worked 40 hours per week with at least 4 hours spent as infection preventionist. However, nursing schedules did not show the DON’s scheduled hours, while the facility assessment and policy described a full-time DON as 40 or more hours per week.
Failure to implement an ongoing ASP was identified when the DON/IP stated monthly antibiotic data were pulled from the EMR and entered into the surveillance log, but no investigation was being completed, test results were not consistently reviewed in real time, and an antibiotic time out program had not been implemented. She also stated she did not use available hospital EMR access to follow up on urine cultures, despite recognizing the importance of identifying resistant organisms and matching the right antibiotic to the right bug. Facility policy required regular review of culture and sensitivity reports and monitoring of antibiotic use.
The facility failed to ensure the DON, who was covering the IP role, met the criteria for current certification and ongoing education. The DON had completed IP specialized training with a certificate that expired, and she stated she had done a lot of learning but had not tracked it separately. Training records after the expiration showed limited infection control education hours, while the facility policy required the IP to maintain current knowledge through ongoing education and related infection control activities.
The facility failed to ensure the current RBOR was posted for residents, visitors, and staff and provided to all residents. Surveyors found outdated 2016 RBOR postings and paper copies in common areas, while the admission packet contained a newer RBOR. SS staff said updated pamphlets were ordered for new admissions, but residents admitted earlier had not been informed of the update, and the administrator was unaware the RBOR had changed.
Unnecessary psychotropic medication management failures were identified for multiple residents. A resident had a PRN lorazepam order without the required stop date or documented GDR support, another resident’s psychoactive review omitted scheduled and PRN antipsychotics, and lab monitoring for antipsychotic use was not documented for another resident. A fourth resident had PRN lorazepam for dental procedures without an end date, and staff interviews confirmed missing documentation for PRN duration, GDRs, and monitoring.
Food inventory in the dry storage area was found not to be rotated or used before expiration dates. Surveyors observed a container of rice covered with loose foil, along with salad dressing and prepared mustard that had expired, and staff confirmed the items were not properly date marked or checked consistently for expiration dates.
Failure to Maintain Resident Dignity: A resident with vascular dementia, aphasia, hemiplegia/hemiparesis, depression, and anxiety was observed in a shared room with incontinence briefs, a washable pad, and clothing items left on an unoccupied bed where they were easily visible from the hallway and doorway. The resident stated he preferred his clothes not be left there, and an LPN and ADON acknowledged that personal care items should not be stored in view of others because it affected dignity.
Self-Administration Assessments Did Not Match Medication Orders and Bedside Access The facility failed to ensure residents’ choices and current abilities for self-administration of meds were reflected in assessments and orders. One resident with COPD and other serious diagnoses was observed receiving a nebulizer treatment while asleep, yet the current SAM assessment said he did not self-administer even though an active order still allowed SAM. Another resident with Alzheimer’s disease and COPD had an inhaler left at bedside, but the current assessment also said she did not self-administer despite an active bedside order. A third resident with cognitive decline kept multiple meds in a bedside drawer; the current assessment said no, while an older assessment and active orders still supported bedside self-administration.
A resident with intact cognition, ADL assistance needs, COPD, and chronic respiratory failure was transferred to the ED and hospitalized three times for respiratory issues. The record lacked evidence that staff provided or documented bed-hold rights information, including the option to reserve the bed and any applicable costs for this private pay resident, and SW staff could not locate documentation of any bed-hold discussion.
The facility failed to include EBP in the care plans for two residents who met criteria for precautions. One resident had a stage 4 pressure ulcer with no EBP order, no signage, and no precautions in place when observed, while another resident with a suprapubic catheter also lacked an EBP order and had delayed care plan inclusion of EBP. Staff and leadership confirmed that signage, PPE, and care plan documentation should reflect precautions.
A resident with vascular dementia, aphasia, hemiplegia/hemiparesis, depression, anxiety, and a history of stroke and temporal lobectomy had a care plan that listed ROM/PROM with AM/PM cares and did not identify a right-hand splint. However, the assignment sheet and task tab did not direct staff to provide ROM or note the splint, the resident said staff did not help with exercises to the right side, and staff interviews showed the actual restorative nursing ROM schedule differed from what the care plan reflected.
A facility failed to provide needed ADL assistance for two residents with significant care needs. One resident with encephalopathy, dementia, and dependence for grooming was observed with facial hair present, while staff said shaving was only done on request and grooming preferences were not assessed for TCU residents. Another resident with severe cognitive impairment and multiple diagnoses was observed unable to locate or wear hearing aids and struggled to eat when an overbed table rolled away, while staff were unaware the hearing aids had been delivered and no care sheet direction was in place.
A facility failed to follow physician orders and accurately document care for two residents ordered to wear compression stockings. One resident with PVD and edema and another resident with severe cognitive impairment, PVD, and hemiparesis were repeatedly observed wearing only socks despite TAR entries showing the stockings were applied. The facility also failed to ensure proper wheelchair positioning for a resident who was repeatedly observed leaning to the right with an arm hanging over the armrest, while staff noted the resident kept returning to that position and documentation for therapy or positioning devices could not be located.
A resident with vascular dementia, aphasia, hemiplegia/hemiparesis, depression, anxiety, and a history of stroke and temporal lobectomy did not consistently receive ordered ROM/PROM. The care plan directed daily ROM with AM/PM cares, but the care assignment sheet and EMR task tabs lacked matching directions, and ROM was documented only a few times over the review period. Staff interviews showed the RNA provided PROM only several times per week, nursing staff were unaware of the twice-daily ROM direction, and the ADON acknowledged discrepancies between the care plan, care list, and EMR documentation.
The facility failed to timely review and act on consultant pharmacist MRR recommendations for two residents. One resident with dementia, anxiety, depression, HTN, orthostatic hypotension, and failure to thrive had a missed monthly pharmacist review after a unit transfer, and another resident with cognitive impairment, dementia, anxiety, and COPD had pharmacist recommendations for monitoring with citalopram, olanzapine, and trazodone that were not documented as reviewed, communicated, or implemented in the EMR or order records.
A resident with HTN, atrial fibrillation, CAD, HF, and ESRD received Metoprolol Tartrate with hold parameters for SBP and pulse, but staff did not obtain or document BP or pulse before administration as ordered. Interviews with a TMA, LPN, ADON, DON, and consultant nurse confirmed that vital sign monitoring was not being completed prior to giving medications with parameters, despite the physician order requiring it.
Failure to timely review and offer recommended immunizations affected two residents. One resident with ESRD, dialysis dependence, and cardiac disease had incomplete pneumococcal documentation in the EMR, and the DON had not identified the full vaccine history before interview. Another resident with HTN, DM, cognitive impairment, and wheelchair use had a prior PPSV23 documented, but the record lacked evidence that the next pneumococcal vaccine was reviewed, offered, or communicated to the responsible party; the DON stated no vaccines had been offered.
Three residents with significant medical conditions and care needs were left unsupervised during mealtimes, despite requiring assistance or monitoring with eating. Staff interviews confirmed that a NA was expected to be present in the dining room at all times during meals, but this did not occur, and no policy was provided when requested.
A medication cart was repeatedly left unlocked and unattended, allowing a resident with severe cognitive impairment to access and remove items from the cart. Staff interviews confirmed the expectation that medication carts should be locked when not in use, but the cart was left out of sight and unsecured for several minutes, with no policy provided upon request.
A resident with diabetes and multiple comorbidities was not given the option to continue using a Continuous Glucose Monitoring (CGM) device, despite hospital discharge orders including both CGM and Accu-Chek methods. The facility implemented only Accu-Chek monitoring without consulting the resident or family, and staff confirmed that CGMs were allowed and used by others. No documentation or policy was provided to show that resident choice was considered.
A resident with multiple medical conditions and a fall risk was placed in an electric recliner that they could not operate independently, as staff placed the remote out of reach. Staff confirmed the resident could not get out of the chair alone or use the remote due to cognitive impairment. The care plan and health record lacked documentation or assessment for the recliner's use, contrary to facility policy requiring such evaluation.
Two residents received PRN psychotropic medications without required 14-day stop dates or provider justification for extended use. One resident was given ongoing Prochlorperazine for nausea and vomiting, and another received frequent PRN lorazepam for anxiety, with both orders lacking appropriate time limitations. Staff interviews and policy review revealed a lack of awareness and missing procedures regarding the 14-day rule for PRN psychotropic medications.
A resident with a Foley catheter and a diagnosis of benign prostatic hyperplasia was admitted and required assistance with all ADLs. The care plan did not address catheter use or monitoring for side effects, despite staff acknowledging the need for such documentation to ensure proper monitoring for infection and other catheter-related care. Facility policy required comprehensive and current care plans, but this was not followed.
A resident with multiple chronic conditions and moderate cognitive impairment developed a non-pressure wound on the right foot, but the care plan was not updated to reflect this new skin concern. The care plan only addressed general risks for skin alterations and did not include specific interventions for the identified wound, despite facility policy and expectations for timely updates.
Two residents dependent on staff for ADL support did not receive appropriate assistance with personal hygiene and grooming. One resident, with multiple health conditions, was not asked about or assisted with shaving despite expressing a preference to be clean-shaven. Another resident received improper peri-care when a nursing assistant used the same washcloth for both the buttocks and groin, contrary to infection control procedures. Care plans lacked specific directions for these needs.
The facility failed to provide routine assistance with proper positioning for a resident dining in bed, did not consistently assess and monitor a non-pressure wound for another resident, and did not monitor blood pressure and pulse prior to administering Metoprolol as ordered. Staff did not consistently offer or provide positioning help, wound documentation was incomplete with gaps in progress notes, and vital sign monitoring was not performed or documented before medication administration.
A resident with multiple chronic conditions and a stage four pressure ulcer did not receive weekly wound assessments as required by facility policy. Although care plans and provider orders specified regular monitoring and treatment, documentation showed that wound audits were missed between two assessment dates. Both the ADON and DON confirmed the lapse in weekly assessments, which is contrary to the facility's protocol for pressure ulcer management.
A resident with an indwelling Foley catheter did not receive proper catheter care when a nursing assistant cleaned the catheter tubing in the wrong direction, used the same rag for both bowel movement residue and catheter care, and failed to sanitize the catheter and collection bag connections before switching bags. These actions did not follow facility policy or infection control standards, as confirmed by interviews with the NA, infection preventionist, and DON.
A resident with end-stage renal disease who received hemodialysis outside the facility did not have required monitoring of their dialysis shunt for bruit and thrill, as directed by their care plan and facility policy. Nursing staff did not perform or document these assessments, and both an LPN and the DON confirmed that such monitoring was not conducted.
Pharmacist consultant recommendations regarding medication orders were not acted upon, and irregularities in monthly drug regimen reviews were not identified or addressed for multiple residents. For example, a resident's PRN antipsychotic order lacked a required stop date despite repeated pharmacist recommendations, and other residents' records lacked evidence of necessary lab monitoring or proper documentation for PRN psychotropic use. Facility policies did not address these requirements, contributing to the deficiencies.
A resident with multiple diagnoses and prescribed antipsychotic, antidepressant, and statin medications did not receive appropriate laboratory monitoring for potential side effects or treatment effectiveness. The facility lacked documentation of pharmacy consultant recommendations for lab monitoring, and staff interviews revealed no standing orders or policies for medication-related lab testing. The facility's policy required monitoring for side effects but did not address lab monitoring for antipsychotic medications.
Staff failed to consistently perform hand hygiene after glove removal and did not properly use PPE, such as gowns, during high-contact care for two residents with significant care needs, including incontinence and indwelling devices. Despite facility policies and posted precautions, staff often neglected required infection control practices, as confirmed by staff interviews and direct observation.
A resident with significant cognitive impairment and right-sided hemiplegia was repeatedly found without access to a call light within reach, as staff placed the device on the resident's affected side despite his inability to use it. The care plan did not direct staff to place the call light on the resident's functional side, and no facility policy for call light use was available. Staff and resident interviews confirmed the deficiency.
The facility did not make available the required survey and complaint investigation results, including 2567 reports and facility responses, for residents, families, visitors, and staff to review. Only recertification survey results were posted, while documentation from complaint investigations was missing, and the administrator was unaware of the full posting requirements.
A resident with Alzheimer's disease and osteoarthritis, who was non-ambulatory and required two staff and a mechanical lift for transfers, was instead transferred by one nursing assistant using a gait belt. This deviation from the care plan led to the resident falling into her wheelchair and sustaining a comminuted distal humeral shaft fracture. Staff interviews and documentation confirmed that the care plan was not followed, resulting in actual harm.
The facility failed to clarify and document a resident's advance directive upon admission, despite conflicting documentation and the resident's alert and oriented status. Multiple staff members confirmed the absence of the advance directive in the resident's chart, contrary to facility policy.
The facility failed to ensure that the consulting pharmacist identified irregularities in the monthly drug regimen reviews for four residents taking psychotropic medications. The pharmacist did not recommend necessary monitoring for hypotension or conducting AIMS assessments, and the medical records lacked evidence of these measures. The DON confirmed the oversight, emphasizing the importance of monitoring for adverse effects and preventing falls.
The facility failed to monitor for potential cardiovascular and neurological adverse consequences and obtain informed consent for psychotropic medication use in four residents. Medical records lacked evidence of pharmacy consultant recommendations, monitoring for hypotension, AIMS assessments, and informed consent documentation.
The facility failed to ensure that four residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. The immunization records lacked documentation of being offered or receiving the PCV20 vaccine, and there was no evidence of shared clinical decision-making with their physicians.
The facility failed to ensure the proper assessment and use of a reclining wheelchair for a resident with severe cognitive impairment and multiple diagnoses, leading to several falls. Despite therapy recommendations and staff education, the wheelchair was often fully reclined, contrary to guidelines. The director of nursing confirmed that necessary assessments, provider orders, and consents were not obtained as required by facility policy.
Dialysis Care and Access Monitoring Deficiencies
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for two residents receiving hemodialysis. One resident had ESRD, heart failure, atrial fibrillation, hypertension, anemia, hyperparathyroidism, and long-term anticoagulant use, and was independent with ADLs and cognitively intact. The resident’s care plan identified offsite hemodialysis and daily assessment of the AV fistula site, but the record did not show a consistent communication system with the dialysis center, and the facility’s uploaded dialysis documents contained only a portion of the treatment run sheets received from the dialysis center. The resident stated he did not recall documents being sent with him to dialysis or returned with him. The facility also failed to follow physician orders for monitoring and medication administration. The resident had an order for metoprolol tartrate with hold parameters for low SBP or pulse, but the MAR did not show blood pressure or pulse were obtained before administration. The resident also had a 1500 ml fluid restriction, yet water pitchers and soda were observed at the bedside, and staff stated they were not aware which residents were on fluid restrictions. The resident’s room lacked EBP signage and readily available PPE, and the EMR did not show EBP had been initiated despite the presence of dialysis access devices, including a CVC. The resident experienced repeated bleeding from the dialysis access site after a recent AV fistula revision and placement of a CVC. Progress notes documented bleeding from the port area, heavy blood saturation of the dressing, bruising, pain, and transfer to the ER. The record did not show physician orders for facility staff to perform CVC dressing changes or monitor the AV fistula site, including bruit and thrill assessments. The EMR also did not show evidence of monitoring or documentation of the access site, and there was no evidence that sterile supplies or aseptic technique were used during CVC dressing changes completed by facility staff. A second resident receiving dialysis also had a fluid restriction and care plan interventions for fistula monitoring and communication with the dialysis center, but the record again lacked evidence of a consistent communication system with the dialysis center and showed a water pitcher and cup in the room despite the restriction.
Failure to Maintain Infection Control Surveillance and Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program with an ongoing system for identifying, monitoring, reporting, investigating, and controlling infections. The director of nursing stated the infection surveillance process consisted of receiving a monthly list of antibiotics and entering them into a tracking log at the end of the month. Infections were not entered as they occurred, symptoms such as cough or diarrhea were not tracked unless an antibiotic was started, and the logs did not identify symptom start dates, testing, or symptom resolution. The DON also stated there was no system for antibiotic time-outs to review appropriateness of antibiotics, lab cultures, or resident response. Five residents developed respiratory symptoms over the course of the observation period, but the facility did not identify a potential outbreak, did not place the residents on TBP, and did not conduct outbreak testing. One resident with vascular dementia, asthma, dysphagia, and pneumonia had a wet cough for several days, abnormal chest x-ray results, delayed antibiotic initiation, nausea, refusal to eat, and limited illness monitoring documented in the record. Another resident with dementia had wheezing, cough, and oxygen saturation of 91%, but the record lacked ongoing illness monitoring and no TBP or respiratory testing was initiated. A third resident with COPD and CHF had a congested cough for approximately 2 weeks, reported mucus with blood, and was observed coughing during interview, yet had no TBP or respiratory testing. A fourth resident with Alzheimer’s disease had cold symptoms, occasional cough, and hoarse voice, but there was no ongoing monitoring or TBP. A fifth resident with significant cognitive impairment had a loose productive cough and reported coughing for 2 days, but was not placed on TBP and no testing was completed. The DON acknowledged the lack of monitoring and the absence of TBP and respiratory outbreak testing for these residents. The facility also failed to identify the need for and implement EBP for two residents. One resident receiving offsite hemodialysis had an AV fistula and a CVC, but the care plan did not identify the CVC or direct special infection control techniques, and staff confirmed the resident was not on EBP. Another resident with a stage 4 sacral pressure ulcer had no signage or PPE outside the room, and staff performed dressing care using gloves only; the ADON stated the resident did not need precautions because the wound was not considered chronic. The facility policy identified EBP for residents with wounds and indwelling medical devices, including hemodialysis catheters, but the residents were not managed under EBP at the time of the survey.
DON Not Documented as Full-Time
Penalty
Summary
The facility failed to ensure the DON worked in the facility on a full-time basis. During interview, the staffing coordinator stated that on Monday through Friday day shift the DON served as the charge nurse, although one of the nurses on the TCU typically also served as charge nurse. The DON stated she worked 40 hours per week and that at least 4 of those hours each week were spent covering the role of infection preventionist for the facility. Review of nursing staff schedules from 4/20/26 through 4/27/26 did not indicate the DON’s scheduled hours. Review of the facility assessment dated 6/9/25 indicated the staffing pattern included one DON full-time day shift, and the facility policy stated the DON would be designated on a full-time basis, defined as 40 or more hours per week.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an ongoing antibiotic stewardship program. During interview, the DON/IP stated that monthly an antibiotic stewardship report was pulled from the EMR and the antibiotics ordered in the past month were entered into the surveillance log, but she was not completing any investigation at that time. She also stated that test results were not consistently reviewed in real time and that an antibiotic time out should have been completed on every antibiotic to determine whether it was effective, but that she had not implemented an antibiotic time out program yet. The DON/IP stated she was consistently following up on cultures performed at the hospital, including in the ER or upon discharge/transfer to the facility, and that she had access to the hospital EMR but did not use it to follow up on urine cultures. She stated this was important in case a resident had a resistant organism and was on the wrong antibiotic, noting it was important to treat the right bug with the right med. Facility policy required the IP to review microbiology culture and sensitivity reports regularly, monitor antibiotic use for appropriateness, and ensure the antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. A separate ASP policy stated the facility was to maintain an ASP to promote appropriate antibiotic use and reduce possible adverse reactions associated with antibiotic use.
Infection Preventionist Lacked Current Certification and Documented Ongoing Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) met the criteria for current certification and ongoing education. During interview, the DON stated she had completed the Infection Preventionist Specialized Training through an online training site and had received a certificate issued 4/21/21 with an expiration date of 4/21/24. The online training site required either a passing test score of 80% or completion of the course again for recertification, but the DON stated she had done a lot of learning and had not tracked it separately. After a request for infection control training completed after the certification expiration date, the facility provided training records showing sponsored online infection control education totaling two hours in 2024, two hours in 2025, and one hour in 2026. Facility online training modules completed after 4/21/24 totaled 2.35 hours. During a later interview, the DON stated that although she worked 40 hours per week, at least four hours each week were spent covering the IP role for the facility. The facility policy required the IP to be designated for management of the infection prevention and control program, to have completed specialized training, and to maintain current knowledge through ongoing education and access to current infection control practices and regulations.
Outdated Resident Rights Notices Posted and Distributed
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident of Rights (RBOR) was provided to each resident and displayed for residents, visitors, and staff to review. Surveyors observed that the RBOR posted at the transitional care unit entrance and outside the dining room in long term care was revised 2016, and a hanging bin by the long term care entrance contained paper copies of the RBOR dated February 2016. The facility admission packet reviewed later contained a new RBOR dated 1/1/26. During interview, social services staff stated new pamphlets were ordered in January and March and that residents admitted after those orders received the updated RBOR in their packets, but residents admitted before then had not been informed there was an update. The administrator stated they were not aware there were changes to the RBOR until locating an email from Care Providers in January identifying the update. The facility policy dated 10/22 stated residents would be provided prompt notice of changes in State or Federal laws related to resident rights or facility rules during their stay.
Unnecessary psychotropic medication management failures
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications by not maintaining required PRN stop dates, not documenting gradual dose reductions (GDRs), not obtaining or monitoring laboratory testing as indicated, and not monitoring for adverse consequences for multiple residents reviewed for unnecessary medications. The report identified deficiencies involving residents R11, R23, R27, and R29, each of whom had diagnoses and medication regimens involving psychotropic drugs, including antipsychotics and anxiolytics. For R27, the record showed a PRN lorazepam order initiated on 2/23/26 for anxiety, but the EMR lacked evidence of a 14-day stop date, discontinuation, renewal, or clinical re-evaluation after 14 days. The psychoactive medication review marked GDR as not applicable and stated reduction was contraindicated, yet the EMR lacked documentation supporting a GDR discussion or clinical rationale on 2/23/26. Staff interviews confirmed the PRN lorazepam order did not include an end date, and the consultant pharmacist stated PRN psychotropic medications should have a 14-day duration with provider documentation to support continued use beyond that timeframe. The DON and consultant nurse also acknowledged there was no documented evidence that GDRs had been completed for R27. For R29, the admission record and MDS showed severe cognitive impairment and dependence for all ADLs, with diagnoses including Alzheimer’s disease, dementia, psychotic disturbance, mood disturbance, and anxiety. The physician orders included scheduled haloperidol three times daily, PRN haloperidol every hour as needed, and PRN lorazepam for agitation. The psychoactive medication review documented only the PRN lorazepam and did not include the scheduled haloperidol or PRN haloperidol. The consultant pharmacist noted the PRN lorazepam required a 14-day stop date and recommended target behavior and side effect monitoring, while the DON stated staff should have documented the 14-day stop date when the first dose was given and updated the primary physician. For R23, the MDS identified severe cognitive impairment and use of an antipsychotic medication, with diagnoses including bipolar disorder, anxiety, major depression dementia, and Lewy body neurocognitive disorder. The resident was prescribed aripiprazole, olanzapine, and venlafaxine, but the EMR lacked evidence of other monitoring labs while antipsychotics were prescribed. The consultant pharmacist’s medication regimen reviews from October 2024 through March 2026 noted no significant irregularities and did not direct lab monitoring. The DON stated CBC and LFTs would be expected at least yearly and after medication changes, but could not locate those labs in the record. For R11, the record showed a PRN lorazepam order for anxiety prior to dental work that lacked an end date and extended beyond the 14-day period allowed for PRN psychotropic medication. The provider note described anxiety and resistance during dental procedures and initiated lorazepam, but did not specify an end date. The care plan noted oral and dental problems, poor nutrition, poor oral hygiene, and a history of refusing dental care, with sedation recommended by the dentist. The ADON acknowledged the medication was time specific for dental work but stated a follow-up review date was not identified.
Food Items Stored Past Expiration and Not Properly Date Marked
Penalty
Summary
Food inventory purchased and stored in the dry storage area was not rotated and used before expiration dates. During a full kitchen tour, surveyors observed a clear 5-gallon plastic food storage container holding approximately 2 pounds of white rice on the top shelf of a storage rack. The container was covered with a loosely fitting piece of aluminum foil and marked with the date 4/9 in green marker. Also observed on the same shelf were 2 one-gallon containers of salad dressing with an expiration date of March 2026 and 3 one-gallon containers of prepared yellow mustard with an expiration date of November 2025. The kitchen manager and clinical certified dietary manager verified the findings during interview. The CMS stated the rice container should have had a matching lid to seal the container, and the CDM stated the salad dressing and mustard should have been rotated and used before their expiration dates. The CDM also stated the department had begun a marking system for received dates, but none of the 5 condiment containers were marked with a received date. A cook stated that when food items are needed from dry storage, staff do not always look at the expiration date, but do check whether containers are sealed and not dented or leaking.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to implement interventions to maintain dignity for 1 of 2 residents reviewed for dignity, R11. R11’s comprehensive/annual MDS assessment, completed on 2/28/26, identified multiple diagnoses including vascular dementia, aphasia, hemiplegia/hemiparesis, depression, anxiety, and personality change due to physiological condition. Although R11 had cognitive impairments, the assessment noted that he was able to understand others and make himself understood, and he required personal assistance with all aspects of care. During observations on 4/22/26 and 4/23/26, R11 was seen in his room while the unoccupied bed in the shared room had incontinence briefs, a washable incontinence pad, small unused garbage bags, and shorts turned inside out placed on it and easily visible from the hallway and doorway. On 4/23/26, an LPN stated R11’s bed was being repaired and linens were on the other bed, and acknowledged that R11’s personal items should not be stored on the foot of the bed and that this was important for his dignity. R11 stated he preferred his clothes not be left on the unoccupied bed. On 4/27/26, the ADON stated personal care items were to be stored out of sight of others and not on the foot of an unoccupied bed where they could be easily visualized by others.
Self-Administration Assessments Did Not Match Residents’ Current Medication Use
Penalty
Summary
The facility failed to ensure residents were permitted to make choices regarding self-administration of medications and failed to ensure physician orders and care processes reflected residents’ current abilities or choices for 3 residents reviewed for self-administration of medications. The facility’s own policy stated residents had the right to self-administer medications, but required a nursing assessment, a medication-specific physician order, and inclusion of the self-administration plan in the care plan. In practice, the most current self-administration assessments for the residents reviewed were marked "No" and left the remaining sections blank, yet active orders and bedside access remained in place for some medications. For one resident with diagnoses including chronic respiratory failure with hypoxia, schizophrenia, COPD, dysphagia, parkinsonism, and oxygen dependence, the MDS identified intact cognition and oxygen therapy use. During observation, the resident was sitting in a recliner with a nebulizer treatment running while appearing to sleep, with the mask slumped away from the chin and no nursing staff present. The resident’s most current self-administration assessment indicated he did not self-administer medication, but an active physician order still stated it was okay to self-administer nebulizer treatments once set up by staff. The EMR banner did not show approval for self-administration, and there was no evidence the order had been clarified, discontinued, or revised. For another resident with Alzheimer’s disease, anxiety, depression, and COPD, an inhaler was observed on the bed within reach while the resident stated it was used as needed. The resident’s most current self-administration assessment also indicated she did not self-administer medication, and the EMR banner did not show approval to self-administer or keep the inhaler at bedside. However, an active order allowed levalbuterol inhalation aerosol to be kept at bedside. Staff stated they relied on the EMR banner to identify whether residents could self-administer medications, and the DON confirmed the assessment was not accurate. For the third resident, who had diagnoses including senile degeneration of the brain, chronic pain syndrome, COPD, and late-onset Alzheimer’s disease, the resident was observed requesting cough syrup and then returning to his room, where he kept albuterol inhaler, Bengay cream, and cortisone cream in a bedside drawer. The resident’s most current self-administration assessment marked that he did not self-administer medication, but a prior assessment had indicated he could self-administer the same medications. The resident’s BIMS score changed from cognitively intact to moderately cognitively impaired, yet the earlier assessment remained in use according to the DON until clarified later by the consulting RN, who stated the most current assessment invalidated the prior one and that the resident should have been reassessed.
Failure to Provide Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to ensure required bed-hold information was provided to a private pay resident at the time of transfer to the hospital, including written notification or a verbal explanation of bed-hold rights and the option to reserve the bed. R27 had intact cognition, required assistance with ADLs, and had diagnoses including chronic respiratory failure with hypoxia and COPD; the resident also received oxygen therapy. The record identified R27 as private pay. R27 was transferred to the ED and hospitalized three times for respiratory-related concerns, including wheezing, chest tightness, shortness of breath, increasing cough, dyspnea on exertion, and acute on chronic hypoxic respiratory failure. The resident's EMR and clinical record, including transfer documentation and progress notes, lacked evidence that the facility informed R27 or the resident representative of bed-hold rights during any of the three hospitalizations. There was no documentation that the facility discussed the option to hold the bed or the applicable costs associated with bed hold for a private pay resident. During interview, social work staff stated bed-hold discussions were expected to be documented in progress notes, but they were unable to locate documentation of such discussions for all three transfers. The facility's Bed Hold Notice Upon Transfer policy stated written notice would be provided at the time of transfer, or within 24 hours for emergency transfers, including the bed-hold period, reserve bed payment requirements, the right to return to the next available bed, and conditions for return.
Failure to Include EBP in Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that included Enhanced Barrier Precautions (EBP) for 2 residents who met criteria for EBP. R2 had severe cognitive impairment and required assistance with ADLs, with diagnoses including a stage 4 pressure ulcer of the right ankle, malnutrition, and dysphagia. Review of the EMR showed the stage 4 pressure ulcer met criteria for EBP, but the Order Summary Report did not contain a physician order for EBP, and the care plan did not include EBP until more than one month after the pressure ulcer was identified. During observation, no EBP signage was posted outside R2’s room, EBP precautions were not in place, and a PPE cart was located in the hallway without clear designation for R2. R9 had moderate cognitive impairment and required assistance with ADLs, with diagnoses including urinary retention and benign prostatic hyperplasia. The EMR showed R9 had a suprapubic catheter, which met criteria for EBP, but the Order Summary Report did not contain a physician order for EBP. The care plan addressed the suprapubic catheter with interventions for intake and output, pain, UTI signs and symptoms, and catheter positioning, but EBP was not added until more than four months after the catheter care plan began. Staff interviews confirmed that precautions should be indicated by signage and PPE placement, and the DON and ADON acknowledged that EBP should be included in the care plan and reflected in the medical record.
Care plan not updated to match ROM and splint care
Penalty
Summary
The facility failed to maintain an updated care plan for a resident with vascular dementia, aphasia, hemiplegia/hemiparesis, depression, anxiety, and personality change due to a physiological condition. The resident’s comprehensive/annual MDS identified cognitive impairment, though the resident was able to understand others and make self-understood, and required personal assistance with all aspects of care. The care plan, last revised on 6/5/25, identified altered neurological status related to a stroke and a history of temporal lobectomy for seizures, with a goal for the resident to function at the fullest potential possible through the interdisciplinary team review date last revised on 2/28/26. The care plan listed ROM/PROM with AM/PM cares daily by nursing/CNA, but it did not identify the use of any splint to the right hand. The resident care assignment sheet and resident task tab lacked directions for staff to provide ROM with cares and did not indicate a right-hand splint, while the EMR task tab listed restorative nursing ROM with directions to document the number of minutes performed. The resident was observed with a splint on the right hand and stated staff did not assist with exercises to the right side during morning and evening cares. Staff interviews showed the RNA provided PROM three to five times a week, a CNA was unaware of directions for twice-daily ROM, and the ADON acknowledged the care plan still reflected twice-daily ROM even though the resident was receiving restorative nursing ROM three to five times a week. A restorative nursing document also identified right upper extremity PROM daily and a right palm protector during AM cares, with lower extremity ROM seven times a week, and the facility policy stated changes in resident status would be identified in the care plan.
Failure to Provide Required ADL Assistance and Personal Care
Penalty
Summary
The facility failed to provide assistance with personal cares for dependent residents, including shaving, placement of hearing aids, set up for eating, and grooming. For one resident, the nursing assessment and care plan identified the resident as admitted with encephalopathy, alert and oriented times one to two, forgetful, and unable to use the call light, with needs for assistance with mobility, transfers, dressing, grooming, and bathing. The care list directed assistance with grooming, teeth, and glasses, but did not specify shaving or facial hair preference. The resident was observed with facial hair present under the nose, cheeks, chin, and under the chin, and the family member stated a shaver had been brought to the facility and staff had been asked to complete routine shaving, but the resident had not been shaved since admission. Staff interviews showed shaving was not consistently included for residents on the transitional care unit. An LPN stated residents were only shaved upon request and that grooming preferences were interviewed for long-term care residents, but not for transitional care residents. A nursing assistant stated she would only shave the resident if directed on the care list and would not perform the care unless cleared with the nurse. The DAS and ADON stated grooming preferences, including facial hair and shaving, were important and should be identified, but acknowledged this was not being done for transitional care residents. The consultant RN confirmed the preference interview was only completed for residents on the long-term care unit. For another resident, the quarterly MDS showed severe cognitive impairment, moderate to maximum assistance with ADLs, and diagnoses including bipolar disorder, anxiety, major depression, dementia, osteoarthritis, neurocognitive disorder with Lewy bodies, bradycardia, muscle weakness, and osteoporosis. The resident’s care plan identified ADL self-care deficits and need for assistance with all destinations. During observations, the resident could not locate hearing aids, was not wearing hearing aids at multiple times, and had difficulty propelling the wheelchair to the overbed table while trying to eat. The overbed table repeatedly rolled away as the resident attempted to eat, and staff walked past without providing assistance. Review of the EMR showed hearing aids had been delivered and staff had been educated, but the hearing aids were later found charging at the nurses’ desk, and the DON stated the expectation was to enter an order to apply them every morning, remove them every evening, and charge them for the resident.
Failure to Follow Orders for Compression Stockings and Wheelchair Positioning
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and failed to document care accurately for two residents who were ordered to wear compression stockings. R27 had diagnoses including PVD, localized edema, and dependence on supplemental oxygen, and the MDS indicated intact cognition and assistance with ADLs. The physician ordered compression stockings to be applied in the morning for edema and removed at bedtime, but repeated observations from 4/20/26 through 4/23/26 showed R27 wearing only yellow gripper socks, with bilateral pitting edema noted in the lower extremities on multiple occasions. The TAR for that same period documented the stockings as applied as ordered despite the stockings not being observed in place. R46 had severe cognitive impairment and diagnoses including PVD and hemiparesis. The physician ordered knee-high TED stockings to be applied in the morning and removed at bedtime, with ace wraps permitted as an alternative, related to cellulitis of the left lower limb, a blister of the left foot, and localized edema. During observations from 4/20/26 through 4/22/26, R46 was seen with bilateral lower extremity swelling and wearing only socks, with no compression stockings in place. The TAR for 4/20/26 through 4/23/26 documented the stockings as applied as ordered, except for one day-shift entry coded as 9 on 4/22/26, while the same date also showed the stockings removed on evening shift, creating inconsistent documentation. The facility also failed to ensure proper positioning for R23, who had severe cognitive impairment, required moderate to maximum assistance with ADLs, and used a wheelchair for mobility. R23’s care plan identified a mobility deficit and need for assistance with transfers. On multiple observations from 4/20/26 through 4/27/26, R23 was repeatedly seen leaning to the right in the wheelchair, with the right side resting on the armrest and the right arm hanging over the side with the hand toward the floor. Staff interviews indicated R23 was often repositioned but returned to the leaning position, and the DON stated the expectation was to obtain an order for therapy to evaluate and treat wheelchair positioning, though documentation regarding therapy and/or positioning devices could not be located.
Inconsistent ROM Assistance and Documentation
Penalty
Summary
The facility failed to consistently provide range of motion (ROM) assistance for a resident with vascular dementia, aphasia, hemiplegia/hemiparesis, depression, anxiety, and personality change due to physiological condition. The resident’s comprehensive/annual MDS identified cognitive impairment but also noted the resident could understand others and make self-understood, and the resident received personal assistance with all aspects of care. The care plan, last revised on 2/28/26, directed staff to provide ROM/PROM with morning and evening cares daily by nursing/CNA, but the care plan did not identify the use of any splint to the right hand. Documentation reviewed showed the resident care assignment sheet lacked directions for staff to provide ROM, either active or passive, and lacked indication of a right-hand splint. The resident task tab in the EMR also lacked directions for nursing assistants to perform ROM with morning/evening cares, while the EMR restorative nursing task tab identified ROM with directions to document the number of minutes performed. Review of the EMR showed ROM was completed only seven times in the previous 30 days. On observation, the resident was resting in bed with a splint on the right hand and stated staff did not assist with exercises to the right side during morning and evening cares. Staff interviews and additional records showed the resident received PROM inconsistently and at a frequency different from what was reflected in the care plan. The restorative nursing aide stated she assisted with PROM three to five times a week and said the EMR task tab did not accurately reflect the frequency. Additional documentation showed therapy was offered and sometimes refused, but was not provided on multiple days in March and April, including periods when the restorative nursing aide was away from the facility. Nursing staff stated they were unaware of directions for twice-daily ROM and that it was not on the care list or task section. The assistant director of nursing acknowledged the discrepancy between the care plan, care list, and task tab, and stated the resident had previously had twice-daily ROM directions that were changed to restorative nursing, though the timing and coverage were unclear.
Delayed Review of Consultant Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist’s monthly medication regimen review were reviewed and acted upon in a timely manner for 2 of 6 residents reviewed for unnecessary medications, including R9 and R65. The facility’s Pharmacy Recommendations policy required monthly pharmacist review of resident medication regimens, communication of recommendations to nursing and physicians, documentation in the medical record, and timely resolution of recommendations. The policy also required unresolved recommendations to be tracked, re-reviewed the following month, and escalated if non-response continued. For R65, whose diagnoses included Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, depression, hypertension, orthostatic hypotension, and adult failure to thrive, the consultant pharmacist’s reviews were present for several months after admission, but no review was present for December 2025 after the resident changed units. The DON stated the monthly review was missed because of the unit transfer, and the consultant pharmacist confirmed no record review was completed that month. For R9, who had moderate cognitive impairment and diagnoses including Alzheimer’s disease with late onset, non-Alzheimer’s dementia, anxiety disorder, and COPD, the consultant pharmacist identified medication regimen recommendations related to citalopram, olanzapine, and trazodone, including patient-specific target behavior monitoring, side effect monitoring, and orthostatic blood pressure monitoring. Review of the EMR and physician order records showed no evidence that the facility reviewed, acknowledged, communicated, or acted on these recommendations in a timely manner, and no rationale was documented for not implementing them.
Failure to obtain required vital signs before administering Metoprolol
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards of practice for one resident who was reviewed for unnecessary medications. The resident had intact cognition and was independent with ADLs, and had diagnoses including hypertension, atrial fibrillation, coronary artery disease, heart failure, and end stage renal disease. A physician order dated 3/20/2026 directed Metoprolol Tartrate 50 mg by mouth twice daily for ESRD, with instructions to hold the medication if systolic blood pressure was less than 90 or pulse was less than 50. Review of the MAR from 3/20/2026 through 4/22/2026 showed Metoprolol Tartrate was administered as ordered, but there was no documentation that blood pressure or pulse were obtained before administration as required by the order. During interviews, a TMA stated blood pressure and pulse were not being obtained before giving the medication, and an LPN confirmed no vital signs were being obtained that morning related to medication administration. The ADON, LPN, DON, and consultant nurse all acknowledged that vital sign monitoring was not in place or was not being completed prior to administering medications with hold parameters, and the DON stated staff were expected to follow physician orders and obtain vital signs before giving medications with parameters.
Failure to Timely Review and Offer Immunizations
Penalty
Summary
The facility failed to ensure recommended influenza, pneumococcal, and Covid-19 vaccinations were offered and/or provided in a timely manner for 2 of 5 residents reviewed for immunizations, R16 and R19. The deficiency was identified during interview and document review, which showed that the facility’s admission immunization review process was intended to verify resident vaccination status through MIIC and determine whether additional vaccines were recommended, with the resident or responsible party consulted as appropriate. R16’s admission MDS showed he was cognitively intact, independent with ADLs, and used a walker/wheelchair. His diagnoses included ESRD with dialysis dependence and multiple cardiac conditions. On review, his immunization record initially showed pneumococcal vaccines on 7/2/15 and 12/22/22, but the documentation did not identify which vaccine types had been given, and there was no indication that additional pneumococcal vaccination had been offered or that the record had been reviewed to determine whether more vaccination was needed. Later review of the EMR added historical pneumococcal information, including PPSV23 on 8/25/11, PCV13 on 7/2/15, and PCV20 on 12/22/22; however, this information had not been identified before the DON interview, and the third dose had not been listed initially. R19’s admission MDS showed some cognitive impairment, need for ADL assistance, and wheelchair use. Her diagnoses included hypertension, diabetes, and Klebsiella pneumoniae. Her EMR showed a Pneumovax 23 vaccine on 6/4/07, but there was no documentation showing review of what vaccine was indicated next, no documentation that PCV13 had been received, and no documentation that the vaccine information had been provided to the resident’s responsible party. PneumoRecs indicated a dose of PCV15 or PCV20 was recommended at least one year after the last PPSV23 dose, but the record lacked evidence that any vaccine had been offered. The DON stated there was no indication any vaccines had been offered, and an email later noted a consent was to be sent regarding the Pneumovax vaccine, which had not been completed before the interview.
Failure to Provide Required Supervision During Mealtimes
Penalty
Summary
The facility failed to provide required supervision during mealtimes for three residents who needed assistance or monitoring while eating. Observations showed that these residents, who had diagnoses such as cerebral palsy, dementia, malnutrition, progressive neurological conditions, Alzheimer's disease, Parkinson's disease, cancer, and heart failure, were left unsupervised in the dining room during breakfast. Staff were not present in the dining room for several minutes while residents were eating, despite the residents' care plans indicating a need for supervision or assistance with eating. One resident was observed coughing while eating, but no staff were present at that time to provide immediate assistance. Interviews with dietary and nursing staff confirmed that facility policy and expectations required a nursing assistant to be present in the dining room whenever residents were eating, to ensure safety and provide assistance if needed. Staff acknowledged that there were periods when no staff were present in the dining room during meals, and that this was not consistent with facility expectations. The facility was unable to provide a policy regarding dining supervision when requested.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the safe storage of medications as required, specifically by leaving a medication cart unlocked and unattended on the west unit. Multiple observations showed a resident with severe cognitive impairment and a history of fidgeting with items accessing the medication cart and its contents while staff were not present. The resident was seen sitting at, touching, and retrieving items from the medication cart, including supplement drinks, and was able to remove and conceal items in his wheelchair. At times, the medication cart was left in the hallway, unlocked, and out of the direct line of sight of nursing staff. Interviews with staff, including the LPN, ADON, DON, and consultant pharmacist, confirmed that the expectation was for medication carts to be locked whenever not in use or when the nurse was not in direct control of the cart. Staff acknowledged the resident's tendency to wander and pick up items, and confirmed that the cart was left unlocked for several minutes while unattended. The facility was unable to provide a policy regarding medication cart security when requested.
Failure to Honor Resident Choice in Blood Glucose Monitoring Method
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding the method of blood glucose monitoring. A resident with a history of diabetes mellitus, neuropathy, aphasia, hemiplegia, cancer, hypertension, hyperlipidemia, arthritis, depression, and cataracts, and who had experienced cognitive decline since admission, was not given the option to continue using a Continuous Glucose Monitoring (CGM) device as previously used. The resident's hospital discharge summary included orders for both traditional Accu-Chek monitoring and CGM supplies, but the facility only implemented Accu-Chek monitoring without consulting the resident or their family about their preference. During interviews, the resident's family expressed concern that the facility did not allow the use of CGM devices and that no choice was offered regarding the monitoring method. Facility staff, including an LPN and the DON, confirmed that CGMs were permitted and used by other residents, and that the expectation was to discuss monitoring preferences with the resident or their representative. However, there was no documentation of such a discussion or a process for CGM use in the facility's policies. Additionally, the facility was unable to provide policies regarding the admission process, order implementation, or resident choice when requested.
Failure to Assess and Prevent Use of Electric Recliner as Physical Restraint
Penalty
Summary
A deficiency occurred when a resident with intact cognition and multiple medical diagnoses, including cancer, heart failure, and malnutrition, was placed in an electric recliner that functioned as a physical restraint. The resident required assistance with all activities of daily living and was identified as a fall risk. Observations revealed that staff placed the resident in the recliner, elevated the footrest, and then positioned the remote control out of the resident's reach, preventing independent operation of the chair. The care plan did not address the use of the electric recliner, and the electronic health record lacked documentation of an assessment for its use. Interviews with staff confirmed that the resident was unable to get out of the recliner independently and did not know how to use the remote due to cognitive impairment. The facility's policy required a physical device assessment to ensure safe operation of such devices, but no assessment was completed for this resident. The director of nursing acknowledged that without the ability to operate the chair, its use constituted a restraint, and confirmed that the required assessment had not been performed.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days or Provide Justification
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days or extended with a specific date and supporting rationale from the medical provider for two residents. For one resident with diagnoses including cancer, diabetes, arthritis, and malnutrition, the medication administration record showed an ongoing order for Prochlorperazine Maleate, an antipsychotic often used for nausea and vomiting, without a stop date or documented rationale for continued use beyond 14 days. This omission was consistent across several months of medication records. Interviews with nursing staff revealed a lack of awareness regarding the requirement for a stop date on such orders, and the facility's policy did not address the 14-day limitation or the need for provider evaluation for continued PRN psychotropic use. Another resident, with a history of Alzheimer's, dementia, anxiety, and other chronic conditions, had an active order for PRN lorazepam for anxiety that also lacked a 14-day stop date. Medication records indicated frequent administration of lorazepam over several weeks. Observations documented the resident repeatedly calling out for help, with staff responding to needs but the behavior persisting. Interviews with staff confirmed regular administration of PRN lorazepam and acknowledged the absence of a required stop date or provider justification for extended use. The facility's policy on psychotherapeutic medications required documentation of diagnosis, consent, and assessment prior to administration but did not specify requirements for PRN psychotropic medication duration, provider evaluation, or clear parameters for use. Both the director of nursing and consultant pharmacist confirmed that the orders should have included a stop date or provider justification, but these were not present in the reviewed cases.
Failure to Include Urinary Catheter Management in Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a urinary catheter included management and monitoring of the catheter. The resident, who had intact cognition and required assistance with all activities of daily living, was admitted with a diagnosis of benign prostatic hyperplasia and had a Foley catheter in place as ordered in the electronic health record. However, review of the care plan revealed that it did not address the use of the Foley catheter or include monitoring for side effects related to the catheter. Interviews with facility staff confirmed that the catheter was not included in the care plan upon admission, and that it should have been documented to ensure appropriate monitoring for signs and symptoms of infection, urine output, and other catheter-related care. The facility's policy required that care plans be comprehensive, current, and updated as the resident's care needs changed, but this was not followed in the case of the resident with the urinary catheter.
Care Plan Not Updated for Non-Pressure Wound
Penalty
Summary
The facility failed to revise the care plan to include a non-pressure wound for a resident who had moderate cognitive impairment and required extensive assistance with activities of daily living. The resident had multiple diagnoses, including chronic respiratory failure, congestive heart failure, heart disease, osteoarthritis, anemia, hypertension, and Alzheimer's disease. Although the care plan addressed the potential for skin alterations due to immobility and incontinence, it did not identify or include interventions for a non-pressure wound on the resident's right foot second toe, which was identified by staff. The director of nursing confirmed that care plans were expected to be updated with any change in resident status or new skin concerns, and facility policy required care plans to be current at all times.
Failure to Provide Adequate ADL Assistance and Proper Hygiene Practices
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents who were dependent on staff support. One resident, with intact cognition and multiple diagnoses including cancer, heart failure, and malnutrition, required help with all ADLs. The resident's care plan did not include preferences or instructions for shaving and personal hygiene. Observations over several days showed the resident had significant facial hair, and interviews revealed that staff had not inquired about or assisted with shaving. The resident expressed a preference to be clean-shaven and stated that staff had not asked about or provided shaving assistance. The director of nursing confirmed that staff were expected to ask about shaving preferences and provide assistance, especially since the resident might not be able to request it due to confusion. Another resident, with moderate cognitive impairment and multiple chronic conditions, also required staff assistance with all ADLs. The care plan indicated a need for help with grooming but lacked specific directions for personal hygiene. During peri-care after incontinence, a nursing assistant used the same washcloth to clean both the buttocks and groin, which was acknowledged as an infection control concern by both the assistant and the infection preventionist. The facility's procedure required separate cleaning methods to prevent cross-contamination, but this was not followed. The activities of daily living policy was requested but not provided.
Failure to Provide Proper Positioning, Wound Monitoring, and Medication Administration Monitoring
Penalty
Summary
The facility failed to provide routine assistance with proper positioning for a resident who was dining in bed, despite the resident's care plan indicating the need for support due to hemiplegia, GERD, dysphagia, and COPD. Observations showed the resident repeatedly leaning to one side while eating, with staff either not noticing or not providing hands-on assistance unless prompted. The care plan did not include instructions for eating in bed, and facility policy lacked guidance on proper body alignment or support for dining in bed. Staff interviews confirmed that assistance was not consistently offered or provided, and the resident acknowledged improved comfort and ability to eat when repositioned. The facility also failed to consistently assess and monitor a non-pressure wound for another resident. Although the wound was identified and measured at times, there were multiple gaps in documentation and progress notes regarding the wound's status, measurements, and assessments over several months. The care plan did not reflect the presence of the wound, and weekly wound audits were not always accompanied by corresponding progress notes. Staff interviews revealed that daily assessments were not documented in the electronic medical record, and the assistant director of nursing was responsible for weekly measurements, but gaps occurred when the wound was scabbed over without clear documentation of changes. Additionally, the facility did not monitor blood pressure and pulse prior to administering Metoprolol to a resident with physician-ordered parameters. Review of the medication administration record showed no documentation of vital sign monitoring before medication administration over a period of more than two months. Staff interviews confirmed that nurses were unaware of the need to check blood pressure and pulse before giving the medication, despite the order being present in the record. The director of nursing and consultant pharmacist both confirmed that the order required monitoring, but it was not performed or documented.
Failure to Complete Weekly Pressure Ulcer Assessments
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a pressure ulcer for a resident with multiple complex medical conditions, including moderate cognitive impairment, multiple sclerosis, peripheral vascular disease, neurogenic bladder, arthritis, Alzheimer's disease, non-Alzheimer's dementia, malnutrition, and localized edema. The resident was identified as being at risk for pressure sores and had an existing stage four pressure ulcer on the left heel. Provider orders and the care plan included specific interventions such as the use of pressure redistribution boots, nutritional supplementation, wound cleansing, and weekly skin audits by licensed staff. Despite these interventions, documentation and interviews revealed that wound assessments were not completed weekly as required by facility protocol and policy. The electronic medical record showed that wound audits were performed on two specific dates, with no assessment documented in the intervening period. Both the assistant director of nursing (ADON) and the director of nursing (DON) confirmed that weekly wound assessments were not conducted as expected, acknowledging that this lapse could hinder the ability to monitor healing and detect complications in a timely manner. The facility's policy on the treatment and prevention of pressure ulcers mandates weekly wound assessments and documentation, including detailed wound descriptions and progress notes. The failure to adhere to this protocol resulted in a lack of consistent monitoring for the resident's stage four pressure ulcer, which could compromise the effectiveness of the treatment plan and the resident's overall skin integrity management.
Improper Catheter Care and Infection Control Lapse
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) failed to provide proper catheter care to a resident with an indwelling Foley catheter. The resident, who had moderate cognitive impairment and multiple diagnoses including neurogenic bladder, multiple sclerosis, and dementia, required assistance with all activities of daily living. During evening care, the NA cleaned the catheter tubing in the wrong direction, wiping from the tubing up toward the urethral opening, and used the same rag to clean both bowel movement residue and the catheter. Additionally, the NA did not sanitize the ends of the catheter tubing or the overnight collection bag before connecting them. Interviews with the NA, infection preventionist, and DON confirmed that the catheter care provided did not follow facility policy or standard infection control practices. The facility's policy required cleaning from the urethral opening down the tubing, using separate rags for cleaning BM and catheter care, and sanitizing connections with alcohol before attaching a new collection bag. The observed actions were identified as improper and posed a potential risk for urinary tract infection.
Failure to Monitor Dialysis Shunt for Bruit and Thrill
Penalty
Summary
The facility failed to ensure appropriate post-dialysis assessment and monitoring for a resident with end-stage renal disease who received hemodialysis outside the facility. The resident's care plan required daily assessment of the dialysis shunt, including checking for a palpable thrill and auscultating for a bruit, with instructions to report the absence of these signs to the dialysis unit and physician. However, the medical record lacked documentation of any monitoring for bruit and thrill, and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include directions or evidence of such monitoring. Interviews with the resident and staff confirmed that nursing staff did not perform or document these assessments. Further, an LPN was unaware of the requirements to check for bruit and thrill and stated that nothing needed to be done with the access site, while the DON confirmed that staff did not check for bruit and thrill on dialysis patients. The facility's own Hemodialysis Access Care policy required staff to check the patency of the site at regular intervals by palpating for thrill or auscultating for bruit, but this was not followed for the resident in question.
Failure to Act on Pharmacist Recommendations and Identify Medication Irregularities
Penalty
Summary
The facility failed to ensure that pharmacist consultant recommendations were acted upon and that irregularities in monthly drug regimen reviews were properly identified and addressed for several residents. For one resident with multiple diagnoses including cancer, diabetes, and chronic pain, the consultant pharmacist made recommendations regarding a PRN order for Prochlorperazine, noting the need for a 14-day stop date or a switch to an alternative medication. These recommendations were documented in the consultant pharmacist's reports for two consecutive months, but there was no evidence in the medical record that the recommendations were implemented or that the provider was contacted for clarification. The medication remained on the resident's record without use, and the facility lacked a tracking system to ensure follow-up on pharmacist recommendations. For another resident with diagnoses including bipolar disorder and major depression, the medical record showed active orders for several medications, including statins and antipsychotics, but lacked evidence of pharmacy consultant recommendations for necessary laboratory monitoring. Interviews with nursing staff and the DON revealed that there was no facility policy or standing order for lab monitoring of these medications, and the consultant pharmacist did not identify or recommend lab monitoring during monthly reviews, relying instead on the provider to order labs. A third resident with Alzheimer's disease and anxiety had an active PRN order for lorazepam without a required 14-day stop date. The consultant pharmacist did not identify or recommend an end date for this medication during the monthly review, and the order remained in place without proper documentation or justification for continued use. The facility's policies and procedures were also found to be lacking, as they did not address requirements for lab monitoring, PRN psychotherapeutic medication use, or the necessary 14-day stop date and face-to-face provider evaluation for PRN psychotropic medications.
Failure to Monitor Antipsychotic and High-Risk Medications with Required Lab Testing
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not appropriately monitoring antipsychotic and other high-risk medications in accordance with standard-of-care laboratory testing. The resident, who was cognitively intact but totally dependent on staff for activities of daily living, had multiple diagnoses including bipolar disorder, major depression, and hyperlipidemia, and was prescribed several medications such as rosuvastatin, aripiprazole, venlafaxine, and olanzapine. Despite these prescriptions, the resident's medical record lacked evidence of laboratory monitoring for potential side effects and treatment effectiveness of the statin, antidepressant, or antipsychotic medications since admission. Additionally, there was no documentation of pharmacy consultant recommendations for laboratory monitoring related to these medications. Interviews with facility staff, including an LPN, the DON, and the consultant pharmacist, revealed that there were no standing orders or facility policies regarding lab monitoring for medication safety, and that the consultant pharmacist did not routinely check for annual lab monitoring, relying instead on the provider to order necessary labs. The facility's policy on psychotherapeutic medications required ongoing monitoring for side effects but did not address laboratory monitoring for antipsychotic medications.
Failure to Consistently Implement Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to consistently implement proper hand hygiene and use of personal protective equipment (PPE) during resident care activities. In one instance, a nursing assistant did not perform hand hygiene after removing gloves and before exiting a resident's room, subsequently touching a door handle and attempting to enter another room. The nursing assistant acknowledged not performing hand hygiene and recognized the importance of this practice to prevent the spread of germs. Facility policies required handwashing before and after resident care, but these were not followed in this case. Another deficiency was observed regarding the use of Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and a stage four pressure ulcer. Although signage and supplies for EBP were present, a nursing assistant provided peri-care and catheter care while wearing gloves but not a gown, despite coming into contact with the resident and their environment. Multiple staff interviews confirmed that gowns and gloves should be used for residents on EBP, but it was reported that gowns were rarely used, and staff often did not follow posted precaution guidance. The infection preventionist and other staff members acknowledged that compliance with EBP protocols was lacking, with staff frequently neglecting to wear gowns as required. The facility's EBP policy specified that gowns and gloves should be worn during high-contact care activities for residents at increased risk for multidrug-resistant organisms (MDROs), such as those with wounds or indwelling devices. Despite repeated education, staff did not consistently adhere to these protocols, resulting in the observed deficiencies.
Failure to Ensure Call Light Accessibility for Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when staff failed to consistently ensure that a resident with significant cognitive impairment and right-sided weakness had access to a working call light within reach. The resident's care plan identified cognitive deficits, vascular dementia, cerebral infarction, and hemiplegia affecting the right side, but did not provide specific instructions for staff to place the call light on the resident's unaffected left side. Multiple observations showed the call light was repeatedly placed on the resident's right side, which he was unable to use due to his physical limitations. Interviews with the resident confirmed he could not reach or use the call light when it was placed on his right side, and staff acknowledged the improper placement during the survey. The care plan lacked direction for staff to accommodate the resident's self-care deficits by ensuring necessary items, including the call light, were accessible on his functional side. Additionally, the facility did not have a policy available for call light use. The failure to provide the call light within reach limited the resident's ability to communicate needs, as observed and confirmed through staff and resident interviews.
Failure to Post Complete Survey and Complaint Investigation Results
Penalty
Summary
The facility failed to ensure that both recertification survey results and documentation from complaint investigations, including the 2567 reports and facility responses, were available for review by residents, families, visitors, and staff. Observations showed that only recertification survey results from the past three years were posted, while documentation related to complaint investigations was missing. Review of the Aspen Central Office system confirmed that several complaint investigations had been completed, some with citations, but these were not posted as required. During an interview, the administrator acknowledged unawareness of the requirement to post all investigation letters and 2567 documentation. No facility policy regarding the posting of survey results was available.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses of Alzheimer's disease and osteoarthritis and was non-ambulatory, was not transferred according to her care plan. The care plan, nursing assistant care sheet, and physical therapy discharge plan all directed that the resident required the assistance of two staff members and the use of a mechanical lift for transfers. However, on the day of the incident, a nursing assistant transferred the resident from her bed to her wheelchair using only a gait belt and without the assistance of a second staff member. During this transfer, the resident fell backward into her wheelchair, resulting in immediate pain and a comminuted distal humeral shaft fracture, as confirmed by x-ray. Interviews with staff and review of documentation confirmed that the care plan was not followed, despite clear instructions on the care sheets and recent updates to the resident's transfer requirements due to her decline in mobility. The incident report, progress notes, and staff interviews all indicated that the resident was expected to be transferred with two staff and a mechanical lift, but this protocol was not adhered to at the time of the accident. The director of nursing and assistant director of nursing both acknowledged that the root cause of the injury was the failure to follow the established care plan.
Failure to Clarify and Document Advance Directive
Penalty
Summary
The facility failed to clarify the current advance directive for a resident (R328) when there was conflicting documentation in the record. R328 had diagnoses including Parkinson's Disease, adult failure to thrive, and chronic kidney disease, with a BIMS score indicating intact cognition. The hospital discharge summary indicated a DNR status, but there was no evidence of a discussion about changing the code status. Despite being alert and oriented, R328 stated that no one in the facility had talked to her about her wishes in the event of an emergency. Multiple staff members, including an LPN, TMA, ADON, and LSW, were interviewed and confirmed that there was no advance directive document present in the resident's chart, and the resident's code status was not clarified upon admission. The facility's policy required that advance directives be reviewed and documented upon admission, but this was not done for R328. The DON confirmed that the resident did not have any advance directives available in either the electronic medical record or paper copies. The failure to clarify and document the resident's advance directive could lead to staff not knowing how to respond in an emergency. The facility's policy stated that advance directives should be reviewed and updated at least quarterly, but this was not adhered to in this case.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified irregularities in the monthly drug regimen reviews for four residents who were taking psychotropic medications. Specifically, the pharmacist did not recommend monitoring for hypotension or conducting AIMS assessments for residents R4, R25, R35, and R69. These residents had various diagnoses, including Alzheimer's disease, anxiety disorder, depression, Parkinson's disease, and dementia, and were prescribed medications such as Seroquel, Bupropion, Lorazepam, Haloperidol, Pimavanserin, Trazadone, and Citalopram. The medical records for these residents lacked evidence of the necessary monitoring and assessments as recommended by the pharmacist, such as orthostatic blood pressures and AIMS assessments, which are crucial for detecting side effects like hypotension and involuntary movements associated with psychotropic medications. The pharmacist admitted during an interview that he had missed recommending the necessary monitoring and assessments for these residents. He stated that orthostatic blood pressures should be done at least monthly for anyone taking psychotropic medications and that AIMS assessments should be completed as a baseline with the start of an antipsychotic. The pharmacist also acknowledged that he had missed recommending the facility to obtain new orders from the provider for the continued use of prn psychotropic medications like Lorazepam and Haloperidol for R25. The Director of Nursing (DON) confirmed that the facility relied on the pharmacist's recommendations and that the medical records for the residents in question lacked the necessary monitoring and assessments. The DON emphasized the importance of these measures for monitoring adverse effects and preventing falls. The facility's policy on psychotherapeutic medications also required documentation of outcomes, consent, and baseline AIMS assessments, which were not followed in these cases.
Failure to Monitor Psychotropic Medication Use and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure proper monitoring for potential cardiovascular and neurological adverse consequences and obtaining informed consent with the use of psychotropic medications for four residents. These residents had various diagnoses, including Alzheimer's disease, Parkinson's disease, and major depressive disorder, and were prescribed psychotropic medications such as Seroquel, Bupropion, Lorazepam, Haloperidol, Pimavanserin, Trazadone, and Citalopram. The medical records for these residents lacked evidence of pharmacy consultant recommendations for monitoring hypotension and conducting AIMS assessments, as well as documentation of informed consent for the use of antipsychotic medications. For Resident 4, the medical record did not show any monitoring for hypotension or AIMS assessments since the initiation of psychotropic medications. Similarly, Resident 25's record lacked evidence of communication with the provider to obtain new orders for continued use of Lorazepam and Haloperidol. Resident 35's record also did not include monitoring for hypotension or pharmacy consultant recommendations. Resident 69's record was missing evidence of monitoring for hypotension, AIMS assessments, and informed consent for the use of antipsychotic medications. Interviews with the pharmacy consultant and the Director of Nursing (DON) confirmed these deficiencies. The pharmacy consultant admitted to missing recommendations for monitoring and AIMS assessments, while the DON acknowledged the lack of orthostatic blood pressure monitoring and informed consent documentation. The facility's policy on psychotherapeutic medications requires documentation of outcomes, informed consent, and baseline AIMS assessments, which were not followed in these cases.
Failure to Offer and Provide Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that four residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. Specifically, residents R29, R33, R35, and R69 did not receive the PCV20 vaccine at least five years after their last pneumococcal dose, nor was there evidence of shared clinical decision-making with their physicians regarding this vaccination. The immunization records for these residents lacked documentation of being offered or receiving the PCV20 vaccine, despite having received previous doses of PPSV23 and PCV13 within the recommended timeframes. During an interview, the infection preventionist confirmed that immunizations are reviewed upon admission and that the CDC's pneumococcal vaccine recommendations were used to determine eligibility. However, the infection preventionist verified that the four residents had not been offered or provided education on the PCV20 vaccine and that there had been no shared clinical decision-making with their providers. The facility's policy indicated that adults of the specified age should receive a single dose of PCV15 followed by PPSV23 or a single dose of PCV20, but this was not adhered to in these cases.
Failure to Assess and Properly Use Reclining Wheelchair
Penalty
Summary
The facility failed to ensure the initial and ongoing assessment of physical device equipment restricting independent movement for a resident using a reclining wheelchair. The resident, who had severely impaired cognition and multiple diagnoses including non-Alzheimer's dementia and Parkinson's disease, experienced several falls from the reclining wheelchair. The care plan indicated the need for a high-backed wheelchair and identified the risk for falls related to poor safety awareness and balance problems. However, the medical record lacked a physical device assessment and care plan identifying the use of the reclining wheelchair as a potential physical restraint. The occupational therapy (OT) evaluation and plan of treatment identified the need for staff education on the proper use of the reclining wheelchair, specifically recommending the use of the tilt feature rather than fully reclining the chair. Despite multiple instances of staff education and labeling of the wheelchair, staff continued to fully recline the chair, which was against the therapy recommendations. Observations confirmed that the resident was often found fully reclined in the chair, and staff interviews revealed a lack of awareness of the therapy recommendations. The director of nursing (DON) confirmed that the fully reclined position and footrests of the wheelchair could hinder the resident from safely rising when attempting self-transfers. The DON also confirmed that a physical device assessment had not been completed, a provider order had not been obtained, and responsible party education on the risks and benefits or consent for use had not been obtained. The facility's policy on physical device assessment required these steps to be taken, but they were not followed in this case.
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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