Parkview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wells, Minnesota.
- Location
- 55 Tenth Street Southeast, Wells, Minnesota 56097
- CMS Provider Number
- 245436
- Inspections on file
- 24
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Parkview Care Center during CMS and state inspections, most recent first.
The facility failed to maintain complete and accurate accounting records for multiple residents’ personal funds held in a commingled trust account. Resident trust statements only showed balances without itemized deposits or withdrawals, and did not reflect any allocation of interest earned. Bank statements for the checking and savings accounts listed deposits under a single resident’s name and did not document other residents’ debits or credits, despite several residents having funds managed by the facility. An activity director reported managing several residents’ funds, paying for items like haircuts by check, but did not know how to record deposits and withdrawals in the electronic system, resulting in records that did not match bank statements. The Administrator confirmed that a sister facility’s business office handled deposits and transfers and acknowledged that the facility lacked proper tracking and individual ledgers for resident expenditures.
A resident with chronic hepatic failure and alcoholic cirrhosis was ordered Lactulose three times daily for bowel management, but the MAR showed that only a small fraction of ordered doses were administered over a month and that multiple subsequent doses were refused. Despite a provider notification form noting ongoing refusals and staff interviews acknowledging frequent medication refusals, there was no documentation in progress notes that the physician was notified of the repeated Lactulose refusals, and the physician’s visit note did not address them. Staff demonstrated limited understanding of the purpose of Lactulose and monitoring needs, the care plan lacked specific interventions for hepatic failure/cirrhosis beyond bowel management, and the DON was unaware of current documentation practices, contrary to the facility’s Notification of Changes policy requiring prompt physician consultation.
Surveyors found that the facility failed to update care plans after significant changes in two residents’ conditions. One resident with dementia and documented behavioral issues had multiple aggressive episodes toward another resident and staff, but the care plan was not revised to include these new behaviors or additional interventions. Another resident with hepatic failure and alcoholic cirrhosis repeatedly refused Lactulose, with MARs showing the majority of doses not given over more than a month, yet the care plan was not reviewed or updated to address the ongoing refusals, associated risks, or individualized strategies. Staff interviews showed inconsistent understanding of the purpose of Lactulose and the resident’s liver disease, and the DON was unaware that there was no specific care plan for cirrhosis beyond bowel management.
The facility failed to complete comprehensive assessments to determine appropriate sling sizes for full-body mechanical lift transfers for two residents who were fully dependent on staff for transfers and required mechanical lifts. Care plans and Kardexes did not specify sling sizes, and one resident was observed being transferred with an unmarked sling whose size label had worn off. NAs reported choosing sling sizes based primarily on resident weight, sling strap color, or visual estimation, without consistently using neck-to-tailbone measurements as outlined on posted guidance and in manufacturer instructions. A nurse confirmed that sling sizing should be determined by nursing or therapy using both weight and measurements and documented in the care plan and Kardex, but this had not been done, contrary to facility policy and lift manufacturer guidelines.
A resident admitted after major colorectal surgery with a perineal incision did not have hospital aftercare instructions for offloading, limited sitting, and skin protection transcribed into facility orders or incorporated into the baseline care plan. For nearly two weeks, there were no comprehensive skin assessments or monitoring of the surgical site, and staff were unaware of the need to keep the resident off the surgical area, while the resident routinely sat for extended periods. When the wound began to dehisce, the facility delayed developing a comprehensive care plan, failed to obtain and follow complete wound treatment orders, used non-ordered Vashe cleanser, inconsistently packed the wound, and did not thoroughly document or analyze increasing drainage, odor, and changes in wound size, nor consistently notify the surgical team. These failures, along with poor documentation of refusals and lack of timely reassessment, contributed to progression from partial to complete wound dehiscence with increased depth, tunneling, and pain.
Two residents at high risk for pressure injuries did not receive adequate pressure ulcer prevention and treatment. One resident with multiple comorbidities and limited mobility was identified as at risk but was not initially placed on a turning/repositioning program, had no heel treatments, and lacked a comprehensive tissue-tolerance assessment. When a right heel ulcer and a sacral wound developed, wound assessments were repeatedly inaccurate, ordered heel boots and sacral dressings were not consistently used, pressure-redistributing cushions were improperly positioned, and several ordered treatments were missed; the RD was not informed of the ulcers and made no nutrition recommendations. Another resident with hemiplegia and very poor Braden scores was readmitted with red heels and ordered heel-floating, but developed right heel blisters and subsequent stage 2 ulcers; documentation lacked detailed wound characteristics, treatment orders were delayed, and observations showed the heel resting on the mattress despite heel protectors. The DON and hospice RN later confirmed that assessments were inaccurate and that improper repositioning and failure to float the heel contributed to ulcer development and worsening.
Two residents experienced changes in transfer status recommended by therapy that were not timely incorporated into their care plans. One resident with cancer and recent GI surgery had a care plan indicating assist of one with a walker, while a Rehab Communication form documented that the resident was independent in the room with a walker. Another resident with chronic kidney failure, heart failure, atrial fibrillation, a hip fracture, and a heel pressure ulcer had a care plan requiring a sit-to-stand mechanical lift for toilet transfers, but a Rehab Communication form changed the transfer method to assist of one with a gait belt and wheeled walker. CNAs reported relying on Rehab Communication forms rather than the care plan/Kardex, and the DON acknowledged that the care plans had not been updated to reflect the therapy recommendations, contrary to facility policy requiring care plan review and revision upon status change.
A resident with venous stasis ulcers and multiple comorbidities received wound care during which the ADON removed soiled dressings, handled wound cleanser, and cleaned the wounds while wearing the same pair of gloves, then changed to a new pair of gloves without performing hand hygiene between tasks. The ADON stated that hand hygiene was only needed after completing the entire dressing change and cited the lack of hand sanitizer in the room, despite the RN infection preventionist and the facility’s hand hygiene policy specifying that hand hygiene must be performed before donning gloves, between glove changes, and after contact with soiled items, and that glove use does not replace hand hygiene.
Staff failed to ensure dishes were fully air dried before storage, with wet plates, trays, and covers observed being stacked without proper drainage. Additionally, outdated food items remained in the refrigerator past the required seven-day limit, with unclear staff responsibility for timely disposal. These actions were not in accordance with facility policy and had the potential to affect all residents.
A resident with anxiety and depression, who was cognitively intact, reported $100 in cash missing from her billfold. The social services director was informed but did not report the potential theft to the State Agency or law enforcement, contrary to facility policy. Staff interviews and document review confirmed the incident was not documented or reported as required.
A resident with anxiety and depression, who was cognitively intact and dependent on staff, reported missing cash from her billfold. The social services director conducted a limited investigation, interviewing only a few nursing staff and the resident's family member, and failed to document interviews with other relevant staff or the resident. The investigation and documentation did not meet facility policy requirements for thoroughness and completeness.
A resident with schizophrenia and diabetes mellitus was documented in both the care plan and MAR as receiving olanzapine for schizophrenia, but the MDS assessment incorrectly indicated no antipsychotic use. The DON confirmed the error, acknowledging that the MDS should have reflected the resident's antipsychotic medication use.
A dietary aide used a dusty fan to blow directly on clean, wet dishes during air drying, despite facility policy prohibiting such devices in the dish drying area. Multiple staff, including the dietary director and infection preventionist, were unaware of the fan's condition or cleaning schedule, and the fan had visible dust and debris on its blades and cage.
A resident with a history of edema developed a stage 2 pressure ulcer on the right toe, which progressed to stage 3 due to the facility's failure to consistently assess, monitor, and follow wound care orders. Staff did not document wound healing, missed regular assessments, and failed to communicate changes to the medical provider, resulting in deterioration of the ulcer.
A resident with multiple comorbidities was not properly monitored for fluid intake or changes in condition following a CT scan with contrast dye, despite physician orders intended to protect kidney function. Staff failed to document or communicate critical changes, and the resident was ultimately hospitalized with acute kidney injury and died. Additionally, another resident with a complex wound did not receive consistent or comprehensive wound assessments, with missing measurements and delayed physician notification, contrary to facility policy.
A resident with multiple health issues did not receive timely administration of provider-ordered medications, Rocephin and Z-Pak, despite their availability in the facility's E-Kit. The RN on duty failed to process or administer the medications, and the DON also did not administer them, leading to a deficiency in care.
The facility did not follow proper food safety protocols for thawing frozen meat, as observed when turkey breast and pork were thawed in a water bath without continuous running cold water. This practice contradicts FDA guidelines, which require thawing under refrigeration or running water to prevent foodborne illness. Staff training confirmed the use of a cold-water bath, but the necessary conditions were not met.
A long-term care facility failed to adhere to infection control practices, including hand hygiene and PPE use. Staff were observed not performing hand hygiene when entering and exiting resident rooms, and not wearing required PPE when assisting a resident with an indwelling urinary catheter. Mechanical lifts were not sanitized after use, and an agency staff member used an N95 mask without proper fit-testing. These deficiencies were acknowledged by facility leadership.
The facility failed to clean rooms of residents on transmission-based precautions (TBP) and maintain the environment in good repair. Housekeeping did not clean TBP rooms, and nursing staff were not trained for this task. Observations showed soiled bathrooms and tables, and the infection preventionist was unsure of cleaning responsibilities. Additionally, the tub room flooring was in disrepair, with chipped paint and missing tiles, and there was no policy for facility maintenance.
Two residents in an LTC facility did not receive adequate personal hygiene care, including bathing and oral care, due to staff inaction and lack of adherence to facility policies. One resident, under COVID-19 precautions, was not offered a bed bath as an alternative to a tub bath, and another resident in quarantine did not receive a bath for 10 days. Staff interviews revealed a lack of awareness of policies for bathing residents with COVID-19.
A resident with severe cognitive impairment and multiple health conditions went five days without a bowel movement due to the facility's failure to implement the BM protocol. Despite having standing orders for constipation management, the resident did not receive the prescribed milk of magnesia until the fifth day. Interviews revealed a lack of awareness among staff regarding the alert system in the EMR, and the facility did not provide a bowel management policy when requested.
Failure to Maintain Accurate Accounting Records for Resident Trust Funds
Penalty
Summary
The facility failed to properly maintain complete and accurate accounting records for resident personal funds held in a commingled trust account for ten residents. Trust statements provided for these residents only showed a single balance figure without any itemized accounting of deposits (credits) or withdrawals (debits), and did not identify or allocate any interest earned on the funds. Individual balances ranged from small positive amounts to a negative balance for one resident, but there was no supporting transaction detail. Review of the facility checking account statements over several months showed deposits recorded only under one resident’s name, with no documentation of other residents’ debits or credits, despite multiple residents having funds managed by the facility. The related business savings account showed minimal interest earnings, but there was no evidence that this interest was tracked or attributed to individual residents’ accounts. During interviews, the activity director reported managing funds for seven residents but stated she did not have access to the bank account and believed it was a non–interest-bearing account. She described paying for resident items such as haircuts by check and then giving the checks to the Administrator, and acknowledged that although the electronic record system had an area to record deposits and withdrawals, she did not know how to use it, resulting in records that did not match the bank statements. She also stated she printed and mailed balance-only statements to families every three months. The Administrator reported that a business office staff member at a sister facility handled deposits into savings and transfers to checking, and acknowledged that the bank statements only reflected one resident’s name and that the facility lacked appropriate education and systems to track and deposit resident funds with individual ledgers showing each resident’s expenditures.
Failure to Notify Physician of Recurrent Refusals of Lactulose in Resident With Hepatic Failure
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician of a resident’s recurrent refusals of a critical physician‑ordered medication. The resident had diagnoses of chronic hepatic failure without coma and alcoholic cirrhosis of the liver, as documented on the face sheet, and was care planned for constipation and risk of constipation when refusing bowel medications. The care plan identified use of Lactulose and MiraLAX for bowel management related to cirrhosis, with interventions to administer medications as ordered, document refusals, encourage toileting, and follow the bowel protocol. A subsequent care plan entry also noted the resident often refused medications and hygiene and emphasized allowing the resident to make reasonable decisions about treatment. Physician orders dated 3/19/26 directed Lactulose 45 ml by mouth three times daily for hepatic failure, and the MAR for 3/2026 showed that only 19 of 93 ordered Lactulose doses were actually administered. A provider notification form on 3/18/26 documented ongoing medication refusals with an MD response that the issue would be addressed on rounds, but the physician visit note on 3/19/26 did not identify or address the refusals. Further review of the MAR for 4/2026 showed that from 4/1/26–4/7/26, all 8:00 a.m. Lactulose doses were marked as refused, and progress notes for that period did not document the refusals or any physician notification regarding them. Interviews with staff revealed inconsistent understanding and implementation of notification and monitoring responsibilities. A TMA stated that nurses should be notified immediately when a resident refuses medication but could not explain why the resident took Lactulose or what to monitor when it was refused. An LPN stated the resident took Lactulose for chronic constipation, refused frequently, and that the physician should be notified if medications were refused for three days, but could not identify care plan content or monitoring related to hepatic failure/cirrhosis beyond bowel management. An RN stated the resident took Lactulose for an alcoholic liver, that the resident refused medications often, and that the physician should be notified right away of refusals with education and a progress note. The DON was unaware whether refusals were being documented in progress notes and did not realize there was no care plan addressing cirrhosis of the liver. The facility’s Notification of Changes policy required prompt consultation with the physician when there is a change requiring notification, but the requested abuse policy was not provided.
Failure to Revise Care Plans After Aggression and Ongoing Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to revise and update care plans in response to significant changes in resident status and behavior, as required. For one resident with Alzheimer’s disease, anxiety disorder, mild cognitive impairment, and right-eye blindness, the record showed existing care plans addressing inappropriate touching of females and verbal aggression toward another specific resident, with interventions such as calm approaches, diversion, monitoring whereabouts, and analyzing triggers. Physician orders also directed staff to monitor and note behaviors such as irritability, verbal aggression, walking the halls, and not eating, and to check the resident’s room daily for weapons after recent episodes of aggression. The resident’s MDS documented severe cognitive impairment, inattention, disorganized thinking, and behavioral problems including physical and verbal symptoms directed toward others, rejection of care, and wandering. On a specific date, progress notes documented that this resident had been agitated all day and engaged in multiple aggressive episodes toward another resident and staff. In the morning, the resident swung at another resident in the hallway, with staff observing the incident; later, the resident hit out at another resident at the breakfast table, and again approached the same resident in the dining room, mumbling in anger and causing the other resident to appear frightened and move away without a walker until staff intervened. The note indicated staff speculated about a possible misunderstanding regarding a wet bed. Despite these documented aggressive behaviors toward another resident and staff, review of the record showed no evidence that the care plan interventions were evaluated for effectiveness, and the care plan was not revised to identify the new aggression toward that resident and staff or to add new interventions to manage these behaviors. Interviews with nursing assistants indicated they were aware the resident could be aggressive, particularly if awakened, but some were unaware of the specific incident between the two residents. The deficiency also includes the facility’s failure to revise the care plan to reflect an ongoing pattern of medication refusals for another resident with chronic hepatic failure and alcoholic cirrhosis of the liver. This resident’s care plan addressed constipation and risk for constipation related to cirrhosis, with interventions focused on laxative use (Lactulose and MiraLAX), documenting refusals, following bowel management protocols, and allowing the resident to make reasonable decisions about treatment. The resident’s MDS showed no cognitive impairment and documented rejection of care on some days. Physician orders required Lactulose 45 ml by mouth three times daily for hepatic failure, but the MAR for one month showed only 19 of 93 scheduled doses were administered, and the following month’s MAR showed all reviewed morning doses marked as refused. A provider notification form documented ongoing medication refusals, but the subsequent physician visit note did not address these refusals. Record review from early March through early April showed that, despite 74 documented refusals of Lactulose and prior notification to the physician about continued refusals, there was no indication that the care plan for refusals was reviewed, evaluated for effectiveness, or updated to address the resident’s treatment needs, associated risks such as encephalopathy, patterns of refusal, or individualized interventions to manage the behavior. Progress notes during the early April period did not include follow-up on the refusals. Interviews with a TMA, an LPN, and an RN revealed limited understanding of the purpose of Lactulose, the diagnosis of hepatic failure/cirrhosis, and associated monitoring needs, and the LPN could not find a care plan addressing hepatic failure/cirrhosis beyond bowel management. The DON stated unawareness of recent documentation of refusals in progress notes and did not realize there was no care plan specific to cirrhosis of the liver, further underscoring that the care plan had not been revised to reflect the resident’s ongoing medication refusals and related condition.
Failure to Complete Comprehensive Sling Sizing Assessments for Mechanical Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure comprehensive assessments for appropriate sling sizes for full body mechanical lifts according to manufacturer guidelines for two residents. One resident had diagnoses including a healing closed fracture and muscle weakness, with an admission MDS showing severe cognitive impairment and total dependence on staff for dressing, rolling, and all transfers. The baseline care plan stated the resident required staff assistance for transfers but did not specify how transfers would be accomplished, and the subsequent care plan required a mechanical lift with two staff but did not identify the sling size. During observation, the sling in use for this resident had an unreadable tag with dissolved printing, and staff used this unmarked sling to transfer the resident from bed to wheelchair. For this same resident, a nursing assistant reported that NAs determined sling size based on resident weight and sling strap color, referencing a sign in the linen closet that listed weight ranges and strap colors for small, medium, large, and extra-large slings, as well as neck-to-tailbone measurements for each size. However, the nursing assistant did not consider the neck-to-tailbone measurement when choosing the sling and confirmed that the resident’s Kardex did not list a sling size. Record review showed no evidence of a completed comprehensive assessment to determine sling size for this resident prior to the survey date. The second resident had diagnoses including spinal stenosis, lumbago with bilateral sciatica, and age-related physical debility, and was documented as dependent on staff for dressing, rolling, and all transfers. The care plan required a full-body mechanical lift with two staff for all transfers but did not specify sling size. Record review showed no indication of a comprehensive sling-sizing assessment prior to the survey date. Staff interviews revealed inconsistent understanding of how to determine sling size: one NA relied on sling labels and the linen-closet sign based on weight, another NA was unsure how to determine sling size and chose based on resident size appearance, and both expected sling sizes to be on the Kardex. A registered nurse stated that sling sizes should be determined by therapy or nursing using neck-to-tailbone measurements and weight, and that NAs should not choose sling sizes, but acknowledged that sling sizes were not present in the care plans or Kardexes. The facility’s Safe Resident Handling/Transfers policy and the lift manufacturer’s instructions required correct measurement and appropriate sling selection based on more than weight alone.
Failure to Transcribe Aftercare Orders and Manage Surgical Wound Led to Dehiscence
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, monitor, care plan, and follow physician and hospital aftercare orders for a resident with a recent abdominoperineal resection and perineal surgical wound. The resident was admitted after major colorectal surgery with hospital after-visit instructions that included strict offloading of the surgical area, limits on sitting time, use of a pillow, frequent position changes, and avoidance of hard surfaces and shearing. These aftercare instructions were not transcribed into the facility’s physician orders from admission through at least 1/13, and the baseline care plan dated shortly after admission did not identify any skin integrity issues or the rectal/perineal incision. The admission MDS documented a recent GI surgery and a surgical wound, but the corresponding CAA did not trigger skin issues, and there was no baseline or comprehensive care plan addressing the surgical wound or GI surgery-related nursing care until 1/14, 12 days after admission. During the period from admission through 1/13, the record lacked comprehensive skin assessments and monitoring of the rectal surgical incision, despite the resident having a recent major surgery requiring active skilled nursing. Staff later reported that on admission the incision was closed with sutures and without dehiscence, but there was no ongoing documented assessment. On 1/14, concern for purulent drainage from the surgical site was documented, and a skin integrity care plan and physician orders were initiated to limit sitting and promote offloading; however, prior to that date there was no documentation that offloading had been offered or attempted, and no documentation of refusals. The facility’s own appointment communication form later acknowledged that the resident had not been offloaded as ordered and had been sitting more than 10 minutes per hour without appropriate pillow or cushion use. Nursing staff also reported they were unaware of the surgical incision and offloading requirements until after the wound began to open, and there was no documentation of resident refusals or re-approach efforts. Once the wound began to dehisce, the facility did not consistently obtain or follow complete wound treatment orders, nor did it document thorough wound assessments or timely care plan revisions in response to changes. A skin assessment on 1/15 identified a partially dehisced surgical wound with drainage and a dressing in place, but there were no corresponding wound treatment orders specifying the dressing type or duration at that time. After the surgeon ordered daily packing with iodoform or gauze and later increased packing frequency and volume, facility documentation showed use of Vashe cleanser without a physician order, incomplete descriptions of the amount of packing used, and failure to document or analyze increased drainage, odor, and wound deterioration. Progress notes described heavy, odorous drainage and changes in wound size and depth, including development of undermining and tunneling, but there was no documented comprehensive assessment of these changes, no timely notification of the surgical team when directed, and no evidence that the care plan was revised in response. Observations on 1/30 showed the wound not fully packed to the brim, saturated dressings, and mechanical debridement performed without rinsing, while the resident reported significant pain and prolonged sitting earlier in the stay. The colorectal surgeon stated that aftercare instructions were not followed, the wound was not packed correctly, there was no communication from the facility, and questioned whether facility nurses were properly trained in wound packing, while the DON acknowledged missing the hospital aftercare orders at admission and failing to ensure admission and weekly wound assessments were completed as required. The facility’s documentation between the initial partial dehiscence and later complete dehiscence did not clearly identify when the wound fully opened or when significant changes in size occurred. Although the TAR showed dressing changes as completed per order, narrative notes revealed use of non-ordered cleansing solutions and incomplete packing. The resident reported not being instructed to limit sitting time until after the first surgical follow-up and described routinely sitting for extended periods early in the stay. Staff interviews confirmed lack of awareness of the surgical wound and offloading needs, lack of re-approach or education when repositioning was reportedly refused, and absence of refusal documentation. The DON further stated there was no documentation of monitoring that fully addressed changes to the wound between assessments since admission, despite a facility policy requiring wound treatments to follow physician orders, obtain orders when absent, and monitor effectiveness through ongoing assessment and modification when wounds fail to progress or characteristics change. These combined failures—omission of hospital aftercare orders from admission, lack of early and ongoing comprehensive wound assessment and monitoring, delayed and incomplete care planning for the surgical wound, failure to consistently follow and clarify physician and surgical wound care orders, use of non-ordered wound cleansers, inadequate documentation of wound changes and resident refusals, and lack of timely communication with the surgical team—resulted in documented deterioration of the resident’s surgical wound from partial to complete dehiscence, with increased depth, tunneling, heavy drainage, strong odor, and increased pain requiring ongoing treatment.
Failure to Accurately Assess and Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment for two residents at risk for pressure injuries, resulting in actual harm to one resident. One resident with chronic kidney failure, heart failure, atrial fibrillation, obesity, decreased mobility, incontinence, and oxygen use was identified on admission as at risk for pressure ulcers, with dry skin on both heels and a foam dressing on the coccyx. The Braden assessment showed risk but did not include clinical suggestions to reduce pressure ulcer development, and the baseline care plan did not include pressure reduction interventions. The admission MDS identified the resident as dependent for bed mobility and transfers and at risk for pressure ulcers, but the resident was not placed on a turning and repositioning program, had no nutrition or hydration interventions, and had no dressing or treatments to the feet. There was no comprehensive assessment of tissue tolerance to pressure over time to support the chosen repositioning schedule. Several days after admission, staff documented a pressure area on the right heel with redness and a blue area, applied skin prep, a foam dressing, and puffy boots, and notified the provider, but the note lacked detailed wound characteristics. An incident report identified an unstageable pressure ulcer on the right heel, and a skin integrity care plan was initiated two days later, listing multiple interventions such as heel protection boots, pressure-relieving mattress and cushions, and turning and repositioning every two hours. However, the record between admission and this care plan did not show a comprehensive assessment to determine appropriate repositioning frequency. Subsequent wound assessments of the right heel and sacral/coccyx area were repeatedly inaccurate: a dark purple heel wound was documented as a stage 1 pressure injury instead of a deep tissue injury, and an open sacral wound was documented as an open lesion or stage 2 coccyx ulcer instead of an unstageable or stage 3 sacral pressure ulcer as later confirmed by the DON and a wound clinic. The wound clinic documented a stage 3 sacral pressure ulcer requiring debridement and recommended frequent turning and repositioning, but there was no indication that the facility reassessed the repositioning schedule after this visit. Observations showed that ordered interventions were not consistently implemented. The resident was seen in a wheelchair with the right heel resting directly on the metal foot pedal without Prevalon boots, despite care plan directions for heel protection when foot pedals were in use, and the resident reported heel soreness. The sacral area was observed without the ordered dressing on more than one occasion. The pressure-redistributing wheelchair cushion was found slipping forward so that most of the resident’s buttocks were on the bare wheelchair seat, and the NA acknowledged the cushion needed an antiskid pad. Treatment records showed missed applications of ordered skin protectant to the heel and wound dressings to the coccyx/sacrum on multiple days. The consulting RD reported not being informed of the resident’s pressure ulcers and therefore made no nutrition recommendations. A second resident, with hemiplegia, heart failure, atrial fibrillation, and high Braden risk (constantly moist, chairfast, completely immobile, very poor nutrition), was readmitted from the hospital with heels noted as a little red and with instructions that heels had been floated. The facility revised the care plan to include turning, repositioning, and heel protectors, but again there was no comprehensive assessment of tissue tolerance to justify the every-two-hour schedule. For this second resident, a new right heel open area was documented, but the skin assessment lacked detailed wound characteristics and there was no corresponding physician order at that time. A subsequent skin issue assessment described a blister that had reabsorbed fluid, but again lacked detailed descriptors. Hospice documentation identified a right heel blister with peeled skin and a non-adherent dressing, with instructions to ensure heels were floated and to use a foam dressing, but the facility’s physician orders for heel treatment were delayed and changed over several days. Later wound assessments described a blister with light drainage and foam dressing, while corresponding images showed an open blister extending from the lateral to the back of the heel with shiny, macerated skin and irregular edges. The DON acknowledged that the wound appeared worsened and that the assessment was inaccurate. During observation, the resident was in bed with heel protectors, but the right heel was resting directly on the air mattress rather than being fully floated. A hospice RN removed the dressing and identified two stage 2 pressure ulcers on the right heel (lateral and back), and stated these were caused by incorrect repositioning and failure to keep the heel floated. The facility’s own pressure injury prevention and management policy required a systematic approach with prompt assessment, intervention, monitoring, and modification of interventions, which was not followed in these cases.
Failure to Timely Revise Care Plans After Therapy Changes in Transfer Status
Penalty
Summary
The deficiency involves the facility’s failure to revise residents’ comprehensive care plans in a timely manner after changes in transfer status were identified by therapy. For one resident with malignant neoplasm of the anal canal and recent gastrointestinal surgery, the admission MDS documented that the resident was cognitively intact, had no rejection of care behaviors, was independent with bed mobility, and required set up or clean-up assistance for transfers. The ADL care plan dated 1/11/26 documented a self-care performance deficit related to gastrointestinal surgery, with interventions stating the resident was able to transfer with one staff and a front-wheeled walker, requiring partial assistance for bed-to-chair and chair-to-bed transfers and sit-to-stand. However, a Rehab Communication form dated 1/13/26 indicated that the resident’s transfer status had changed to independent in the room with a four-wheeled walker. On the day of surveyor observation, the nursing assistant caring for this resident stated she believed the resident could be independent in the room but had not verified the care plan or Kardex at the beginning of her shift. Upon review, she confirmed that the care plan still showed the resident required assist of one for transfers, while a separate Rehab Communication form showed the resident had been changed to independent on 1/13/26. The DON confirmed that the resident’s care plan for transfers still indicated assist of one and acknowledged that the care plan had not been revised in a timely manner to reflect the physical therapy recommendation for independent transfers with a walker, stating she had not had time to update the care plan. A second resident with chronic kidney failure, heart failure, atrial fibrillation, and a right heel pressure ulcer had an admission MDS indicating dependence for rolling and transfers, risk for pressure ulcers/injuries, and the presence of a surgical wound. The ADL care plan dated 1/6/26 documented a self-care deficit related to a hip fracture, with a goal to improve transfer function and an intervention specifying substantial one-staff assist with a sit-to-stand mechanical lift for toilet transfers. A Rehab Communication form dated 1/26/26 changed this resident’s transfer status to assist of one with a gait belt and wheeled walker, discontinuing the sit-to-stand lift. During observation, a nursing assistant prepared to transfer the resident to the commode using a walker and gait belt and stated she relied on the Rehab Communication form rather than the care plan/Kardex to determine transfer status. She verified that the care plan still required use of the sit-to-stand lift. The DON confirmed that the resident’s transfer status had been changed by therapy on 1/26/26 but that the care plan still reflected the sit-to-stand lift because it had not yet been updated, despite facility policy requiring review and revision of the care plan upon status change.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for one resident. The resident had multiple diagnoses including chronic venous hypertension with ulcer, CHF, diabetes mellitus with foot ulcer, and atrial fibrillation, and had venous stasis ulcers to both lower extremities. Physician orders and hospital after-visit instructions directed that the bilateral lower extremity wounds be cleansed with normal saline or wound cleanser, followed by application of nonadherent dressings, ABD pads, and Kerlix. During an observed wound care procedure, the ADON wore a gown and gloves, removed the dressing from the resident’s left leg, discarded it, and then handled the wound cleanser bottle without removing gloves or performing hand hygiene. The ADON then sprayed the ulcer, grabbed gauze, and patted the wound with the same gloved hand. After this, the ADON removed her gloves and donned a new pair without performing hand hygiene in between. She then removed the dressing from the right leg and discarded it, again without performing hand hygiene as required. When questioned, the ADON stated that she did not need to perform hand hygiene until the entire dressing change was completed and questioned how she was supposed to perform hand hygiene between steps when there was no hand sanitizer in the room. In contrast, the RN infection preventionist stated that hand hygiene should be performed prior to entering a resident room, before applying gloves, between glove changes, and after contact with soiled items such as wound cleaning, and before touching clean wound supplies. The facility’s Hand Hygiene Policy required all staff to perform proper hand hygiene procedures to prevent the spread of infection, and additional facility guidance specified that glove use does not replace hand hygiene and that hand hygiene must be done before donning and immediately after removing gloves and after handling potentially contaminated items.
Failure to Properly Dry Dishes and Timely Discard Refrigerated Food
Penalty
Summary
The facility failed to ensure that dishes, including plates, trays, and plate covers, were completely dry before being stored. During an observation, a dietary aide was seen stacking dishes that still had visible water droplets on them, without allowing adequate air drying or spacing for drainage. The dietary aide stated she routinely put dishes away before leaving her shift and believed they were dry at the time. The dietary director later confirmed that dishes should be fully air dried or stacked in a way that allows for proper drainage and airflow, and the infection preventionist noted that not allowing dishes to air dry could lead to bacterial growth. The assistant administrator and administrator both stated that dishes should not be put away wet and that staff should follow the dietary director's instructions. Additionally, the facility did not dispose of refrigerated food items in a timely manner. During an inspection of the kitchen refrigerator, food items such as hot fudge and cheese sauce were found to be stored beyond the seven-day limit indicated by a sign on the refrigerator. The dietary aide was unaware of who was responsible for discarding outdated food, and the dietary director admitted she had not checked the refrigerator since the weekend. Facility policies required that refrigerated, ready-to-eat foods be discarded within seven days, and that the head cook or designee check the refrigerator daily for expiring items.
Failure to Report Alleged Theft of Resident Property
Penalty
Summary
The facility failed to report a potential theft of money belonging to a resident to the State Agency as required. The resident, who had diagnoses of anxiety and depression and was cognitively intact, reported that approximately $100 in cash was taken from her billfold while she was out of her room. The resident stated she had received the money from a family member and kept it in her recliner. She informed the social services director (SSD) about the missing money. Despite this, a review of progress notes, grievances, and state agency reports revealed no documentation or reporting of the alleged theft. Interviews with staff indicated that the registered nurse and nursing assistant were unaware of the missing money, while the SSD acknowledged being informed by the family member but did not report the incident. The SSD stated she did not think reporting was necessary because the family member did not want law enforcement involved or any action taken. However, facility policy required reporting all allegations of missing money to the state agency and law enforcement when applicable. The facility's assessment and policies indicated staff were trained in procedures for reporting abuse, neglect, exploitation, and misappropriation of property, but these procedures were not followed in this instance.
Failure to Thoroughly Investigate Alleged Theft of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential theft of money belonging to a resident with diagnoses of anxiety and depression, who was cognitively intact and dependent on staff for most activities of daily living. The resident reported to the social services director (SSD) that $100 in cash was missing from her billfold, which she kept in her recliner. The SSD documented limited interviews with four nursing staff and the resident's family member, but did not interview other relevant staff such as housekeeping, laundry, or activities personnel, nor did she document her interview with the resident. The documentation provided was incomplete, lacking dates, full names, titles, and proper authentication. The SSD admitted that the investigation was not thorough and that documentation was insufficient. The facility's policy required immediate and comprehensive investigation of suspected abuse, neglect, or exploitation, including interviewing all involved persons and providing complete documentation. However, the investigation did not include all potentially involved staff or residents, and the documentation did not meet facility policy standards. The assistant administrator and director of nursing were aware of the missing money and the incomplete investigation.
Inaccurate Coding of Antipsychotic Medication Use on MDS
Penalty
Summary
The facility failed to accurately code the use of antipsychotic medication on Section N of the Minimum Data Set (MDS) for one resident. The resident, who had a diagnosis of schizophrenia and diabetes mellitus, was documented in the care plan and medication administration record as receiving olanzapine, an antipsychotic medication, for management of schizophrenia. However, the quarterly MDS assessment indicated that the resident had not received any antipsychotic medications since admission. During an interview, the DON confirmed that she completed the MDS and acknowledged that Section N was inaccurately coded, as it should have reflected the resident's ongoing antipsychotic medication use. The facility's policy requires accurate assessments reflective of the resident's status at the time of assessment by qualified staff.
Dirty Fan Used in Dish Drying Area
Penalty
Summary
The facility failed to ensure that a fan blowing directly on clean dishes in the kitchen was free of dust and debris, which had the potential to affect all 18 residents. During an observation, a dietary aide was seen washing dishes and allowing them to air dry near a dishwasher while a small oscillating fan, visibly covered in dust and debris, was blowing directly onto the clean, wet dishes. The dietary aide acknowledged the fan was dirty and was unsure who was responsible for cleaning it or when it was last cleaned. Interviews with the dietary director, infection preventionist, assistant administrator, and administrator revealed that none were aware of the fan's condition or its use in the dish drying area. The dietary director believed the fan had been cleaned recently but noted that the air conditioner contributed to dust buildup. The infection preventionist and assistant administrator both stated they were unaware of the fan's use and expressed concerns about its appropriateness in the clean dish area. The facility's dish machine policy specifically prohibited the use of air circulation devices, such as fans, in the dish drying area.
Failure to Assess and Monitor Pressure Ulcer Resulting in Worsening Condition
Penalty
Summary
The facility failed to comprehensively assess, monitor, and provide appropriate interventions for a resident who developed a pressure ulcer, resulting in the progression of a stage 2 pressure ulcer to a stage 3. The resident, who had a history of edema and was at risk for pressure injuries, initially developed a small stage 2 ulceration on the right medial 4th toe. Podiatry provided specific wound care orders, including keeping the foot dry and maintaining the dressing, but documentation shows that these orders were not consistently followed. The treatment administration record indicated that the daily wound care order was discontinued after only one day, and there was no documentation that the wound had healed at that time. Nursing staff interviews revealed a lack of consistent wound assessment and monitoring. LPNs and RNs could not recall the specifics of the wound care provided, and there was confusion about the location and status of the ulcer. Weekly skin checks were reportedly performed, but staff admitted to not always checking between the toes, where the ulcer was located. The resident's care plan and facility policies required regular assessment and documentation of wounds, but there was no evidence of wound assessment or measurement for several months. The wound was eventually found to have deteriorated to a stage 3 pressure ulcer with significant slough and maceration, and the podiatrist noted that the wound had worsened since the initial evaluation. Communication failures were also evident, as the medical doctor had not received updates on the wound's status between the initial and follow-up evaluations. Staff interviews indicated that the wound was not consistently reported or documented, and there was no clear protocol for monitoring the wound after it was considered healed. The director of nursing confirmed that there was no documentation of the wound being healed and that a scabbed wound would not be considered healed. Facility policies required evidence-based wound care and ongoing assessment, but these were not followed, leading to the resident's pressure ulcer worsening.
Failure to Monitor Post-Contrast Renal Risk and Inadequate Wound Assessment
Penalty
Summary
The facility failed to comprehensively assess and monitor a resident following a CT scan with contrast dye, despite the resident's significant risk factors for acute renal failure. The resident had multiple comorbidities, including hemiplegia, heart failure, renal failure, diabetes, and morbid obesity, and was dependent on staff for all activities of daily living. Although there was a physician order for the resident to drink a specified amount of water daily before the dye study to protect kidney function, the order was transcribed incorrectly as 'encourage' rather than 'drink,' and there was no documentation or monitoring of the resident's actual fluid intake. Additionally, staff did not monitor or document urine output, and there was no evidence that the physician was notified of the resident's elevated temperature or significant weight gain, both of which could indicate fluid overload or infection. Staff interviews revealed a lack of awareness and communication regarding the need to monitor fluid intake and the risks associated with the CT scan with contrast. Nursing assistants and LPNs were not informed about the fluid order or the importance of monitoring intake and output, and there was confusion about the resident's care needs. The director of nursing acknowledged the error in transcribing the order and the lack of monitoring, and also noted that changes in the resident's condition were not documented in a timely manner. The resident's condition deteriorated over several days, with symptoms including wheezing, decreased appetite, and minimal fluid intake, but appropriate assessments and notifications were delayed. Ultimately, the resident was transferred to the hospital with severe acute kidney injury and died due to acute and chronic kidney failure. The facility also failed to comprehensively assess, monitor, and treat wounds for another resident with non-pressure skin concerns. Documentation showed inconsistent and incomplete wound assessments, with missing measurements and lack of weekly evaluations as required by the care plan and facility policy. There was confusion among staff regarding the nature and management of the wound, and the physician was not promptly informed of the wound's location and severity. The wound persisted for several months, with ongoing drainage and changes in treatment orders, but without consistent documentation or communication. The facility's policies required weekly comprehensive wound assessments and timely physician notification for changes, but these were not consistently followed.
Failure to Administer Timely Medications
Penalty
Summary
The facility failed to administer provider-ordered medications in a timely manner for a resident who was admitted with multiple diagnoses, including a fracture of the left ulna, chronic kidney disease stage 3A, diabetes, urinary tract infection, and atherosclerotic heart disease. The resident had completed an antibiotic course but continued to experience symptoms such as fever, chills, and confusion. On November 4th, the provider ordered Rocephin and a Z-Pak to be administered, which were available in the facility's Emergency Medication Kit (E-Kit). However, the registered nurse on duty did not process or administer these medications, despite knowing they were available in the E-Kit. The Director of Nursing, who came on duty the following morning, also did not administer the medications, although she processed the orders for the pharmacy. The physician confirmed that the medications should have been administered promptly after the order was faxed to the facility. The facility's policy on medication orders requires that medications be administered only upon signed orders and documented appropriately, but this process was not followed, leading to the deficiency.
Improper Thawing of Frozen Meat in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food preparation safety requirements, specifically in the thawing of frozen meat, which could potentially lead to foodborne illness. During an observation, it was noted that oven-roasted turkey breast and a pork product were being thawed together in a water bath in the middle section of a three-section sink. However, there was no continuous running cold water to minimize or prevent the risk of foodborne illness, as required by safety standards. The dietary aide interviewed confirmed that staff training had been completed, and they were taught that a cold-water bath was an appropriate technique for thawing frozen meat. This technique and the facility's training were corroborated by the dietary manager. According to the FDA's Food Code 2022, proper thawing should occur under refrigeration or completely submerged under running water at a temperature of 70 degrees F or below, with sufficient water velocity to agitate and float off loose particles, ensuring the food temperature does not rise above 41 degrees F.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not performing hand hygiene and not using personal protective equipment (PPE) as required. A nursing assistant (NA-B) was observed entering and exiting resident rooms without performing hand hygiene, despite facility policy requiring it upon entering and exiting resident rooms. Additionally, NA-B did not wear a gown or gloves when assisting a resident (R2) with a bed bath, despite a sign on the door indicating the need for enhanced barrier precautions (EBP) due to the resident's indwelling urinary catheter. Further observations revealed that mechanical lifts used for resident transfers were not sanitized after use. NA-B and another nursing assistant (NA-A) used a mechanical lift for transferring R2 without wearing the required PPE and did not sanitize the lift afterward. The lift was then left at the nurse's station and later used for another resident without being cleaned, increasing the risk of infection spread. NA-A confirmed the oversight and acknowledged the expectation to sanitize equipment immediately after use. Additionally, an agency staff member (NA-F) was observed using an N95 mask without being fit-tested for the specific brand used at the facility, which is a requirement for proper protection. The director of the long-term care staffing agency confirmed that the agency did not provide N95 fit training. These lapses in infection control practices were acknowledged by the facility's leadership, who stated that staff were expected to follow facility policies for hand hygiene, equipment cleaning, and PPE use.
Deficiencies in Cleaning and Maintenance for TBP Residents
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation in the rooms of residents on transmission-based precautions (TBP), affecting several residents. Housekeeping staff did not clean these rooms, and nursing staff were expected to do so but were not adequately trained or informed about the cleaning procedures and supplies. Observations revealed that shared bathrooms and over-bed tables were soiled with substances resembling feces, and nursing assistants admitted to not having received proper training for cleaning these areas. The infection preventionist was unsure of who was responsible for cleaning TBP rooms, acknowledging the need for regular cleaning and disinfecting. Additionally, the facility failed to maintain the environment in good repair, particularly in the west unit tub room. The flooring was in disrepair, with chipped paint and missing tiles, creating an uneven and potentially unclean surface. The environmental services director was aware of the flooring condition but had not addressed it, and there was no policy on facility upkeep and maintenance. These deficiencies were noted during interviews and observations, highlighting a lack of clarity and responsibility in maintaining a safe and clean environment for residents.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide routine personal hygiene care, including oral care and bathing, for two residents who were dependent on staff for their activities of daily living (ADLs). One resident, identified as R80, had diagnoses including chronic kidney disease, fibromyalgia, and anxiety, and was under transmission-based precautions for COVID-19. Despite being dependent on staff for bathing and requiring assistance for oral care, R80 did not receive a bath as scheduled and was not offered a bed bath as an alternative. Additionally, R80 reported not being offered assistance with brushing teeth, and there was a lack of oral care supplies in the room. Another resident, R26, who had intact cognition and was receiving hospice care, also did not receive adequate personal hygiene care. R26 was in quarantine due to COVID-19 and had not been bathed since being placed in isolation. Despite needing substantial assistance with personal hygiene, R26 was not offered a bed bath during the quarantine period, which lasted 10 days. Staff interviews revealed a lack of awareness regarding the facility's policy for bathing residents with COVID-19, and it was noted that 10 days without a bath was too long, especially for a hospice patient. The facility's policies on resident showers and bed baths, as well as oral care, were reviewed and indicated that residents should be assisted with bathing to maintain proper hygiene. However, there was no specific policy available for residents with COVID-19 regarding bathing. The Director of Nursing (DON) stated that residents in isolation should receive weekly bed baths unless refused, and other hygiene care should be provided twice daily. The lack of documentation and adherence to these policies contributed to the deficiency in care for both residents.
Failure to Implement Bowel Movement Protocol for Resident
Penalty
Summary
The facility failed to implement the bowel movement (BM) protocol for a resident with severe cognitive impairment, congestive heart failure, kidney failure, and diabetes. The resident was dependent on staff for toileting and frequently incontinent of bowel and bladder. Despite having a physician's order for milk of magnesia to be given every 24 hours as needed for constipation, and standing orders for escalating interventions if no BM occurred over several days, the resident went five days without a BM before receiving milk of magnesia on the fifth day. Interviews revealed that a Licensed Practical Nurse (LPN) was aware of an alert system in the electronic medical record (EMR) that notified staff if a resident went longer than 48 hours without a BM, but another LPN was not familiar with this system. The Director of Nursing (DON) expected nursing staff to monitor and utilize standing orders to prevent constipation. However, the facility did not provide a policy regarding the management of bowel elimination when requested.
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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