Parkview Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellsworth, Minnesota.
- Location
- 308 Sherman Avenue, Ellsworth, Minnesota 56129
- CMS Provider Number
- 245553
- Inspections on file
- 21
- Latest survey
- May 12, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Parkview Manor Nursing Home during CMS and state inspections, most recent first.
Expired buttermilk and undated pre-made salads were found in the prep-area refrigerator, while thawing meats in the walk-in cooler were stored together on the same tray in blood juices and one sleeve of ground beef had a hole with exposed dried meat. The walk-in freezer was overcrowded with boxes blocking the walkway, open seafood was left unsecured, thawed chicken was placed on a plastic cover on the floor, and the cooler floor had spilled juices, debris, and a dirty cup. The cook and C-B confirmed the storage and thawing problems, and the admin acknowledged ongoing concerns with expired items and kitchen cleaning.
The facility failed to fully document infection surveillance and RTW decisions during a COVID outbreak. Multiple staff members reported symptoms such as sore throat, headache, congestion, diarrhea, vomiting, fever, and cough, but the employee illness logs were incomplete and left the RTW date blank, with no indication they were tested for COVID or cleared per CDC guidance. At the same time, multiple residents were diagnosed with COVID and others had GI symptoms with unknown testing status. The IP said she worked infection control only a few hours per week and had not thoroughly reviewed the logs for trends, while the DON had not been reviewing the surveillance logs.
Infection preventionist oversight was limited because the IP spent only about 4 to 5 hours per week on infection control duties while also working as a charge nurse, and she said she had not really looked for trends or patterns. The employee illness logs were incomplete, with return-to-work dates left blank, and there was no indication symptomatic staff during a COVID outbreak were tested for COVID or cleared using CDC guidance before returning to work.
Failure to Timely Notify Physician for Worsening Cough: A resident with CHF, edema, and other cardiac diagnoses developed a persistent worsening cough with SOB and severe discomfort after being placed on comfort care and do-not-hospitalize orders. Staff gave PRN morphine and cough syrup with little relief, but the RN and DON knew about the decline and relied on faxing the MD rather than timely direct notification. The care plan did not reflect the comfort care orders or guidance for managing a change in condition.
A resident with diabetes had quarterly MDS assessments that incorrectly coded insulin use despite current orders showing weekly semaglutide injections and no insulin orders. The resident stated she did not receive insulin, and an RN confirmed the MDS was coded incorrectly and needed modification. The DON stated the MDS should accurately reflect each resident’s status.
Failure to care plan fall risk for a resident with severe vision impairment: A resident identified on MDS/CAA as being at risk for falls had no fall-risk interventions documented in the care plan. The resident required assistance with transfers, dressing, and hygiene, had severely impaired vision, and later sustained an unwitnessed fall from a wheelchair after falling asleep and not locking the brakes, resulting in facial bruising and a skin tear. The MDS nurse stated fall risk was not always added to the care plan if there was no prior fall history, while the DON stated any resident assessed at risk for falls was expected to have care plan guidance for staff.
Failure to Update Care Plans for Comfort Care and Pressure Ulcers: The facility did not revise the care plan for a resident placed on comfort care after a clinic visit showed worsening fluid retention, cough, swelling, and decreased strength; the plan omitted the no-hospitalization order, discontinuation of labs, and guidance for comfort if the resident declined. The facility also failed to update another resident’s care plan after the MDS identified four Stage II pressure ulcers, leaving only general skin-risk interventions instead of wound-specific goals and treatment measures.
The facility failed to complete a comprehensive antibiotic time-out review for two residents receiving doxycycline for sinus infection and cellulitis. Progress notes showed ongoing symptoms and, for one resident, increased confusion with minimal improvement, but the documentation did not show that the prescribing provider was notified or that a decision was made to continue, change, or stop the antibiotic. The DON, IP, and administrator confirmed the facility documented the review in progress notes but did not communicate the assessment to the provider.
Surveyors observed that the exhaust vent above the gas stove was coated with a thick, black grease-like substance. The CDM acknowledged the buildup and stated it had not been recently noticed, while the maintenance supervisor reported the vent had been replaced months earlier but was unaware of the current accumulation. The facility could not provide a policy for cleaning kitchen vents and equipment. This issue had the potential to affect all residents receiving food from the kitchen.
A Bunn coffee warmer and glass coffee pots containing hot coffee were placed on a counter in the dining room within easy reach of residents, with no consistent staff supervision present. The hot surface and pots created a potential burn hazard, and no safety policy for the dining room was provided when requested.
Staff failed to use appropriate PPE and perform hand hygiene during blood glucose testing and insulin administration for two residents, handling blood-contaminated items with bare hands and storing them in personal pockets. Additionally, a mechanical lift was not cleaned or disinfected between use with different residents, contrary to facility policy and infection control standards.
A resident with morbid obesity, arthritis, and reduced mobility experienced significant pain and discomfort in her wheelchair, leading her to remain isolated in her room and avoid activities. Although staff were aware of her discomfort and reported it to the DON, there was no documentation of therapy assessment or interventions to address her wheelchair fit, and the care plan directives regarding pain and mobility were not followed.
The facility did not properly integrate hospice care plans with its own care plans for two residents receiving hospice services. The care plans lacked clear information on when hospice visits would occur and did not specify which services were to be provided by hospice versus facility staff. Communication issues between hospice and facility staff further contributed to confusion about care responsibilities.
The facility failed to ensure that nurse aides were properly trained in cleaning and disinfecting the whirlpool tub according to the manufacturer's instructions. Observations revealed that aides were not following correct procedures, were unaware of appropriate disinfectant use, and lacked personal protective equipment. Interviews with aides and the DON highlighted a lack of formal training and competency checks specific to the whirlpool tub, with training being conducted informally on the job.
The facility failed to implement a comprehensive assessment protocol to ensure staff competencies, with the administrator unable to locate the previous assessment and starting a new one. Interviews revealed a lack of direct skills review and incomplete annual evaluations, with the DON not conducting necessary training or competencies.
The facility failed to analyze and document data submitted to the QAPI committee, lacking documentation of goals and analysis. An interview with the DON confirmed the absence of data analysis, measurable goals, and actions to meet those goals. Additionally, there was no formal process for feedback from staff, residents, or families. The QAPI Plan policy lacked mention of measurable goals or data analysis, and there was no evidence of a review to ensure regulatory compliance.
The facility did not have evidence of a Performance Improvement Project (PIP) as part of its QAPI program, which is crucial for identifying high-risk areas. The QAPI minutes showed no PIP projects, and the DON confirmed that the new administrator opted out of participating in such projects. The QAPI Plan policy lacked guidance on identifying and measuring PIP projects, and there was no evidence of an annual review to ensure compliance with regulations.
The facility failed to ensure proper reconciliation of controlled medication counts, risking potential diversion. An RN and LPN were unable to verify documentation for the emergency kit (Ekit) containing controlled medications, and the DON confirmed that monitoring and documentation were not conducted as required. The Ekit contained medications like morphine sulfate and lorazepam, but the last documented removal was months prior, with no policy provided.
The facility failed to properly clean and disinfect a whirlpool tub, affecting two residents. Observations showed that nurse aides did not follow manufacturer guidelines and used incorrect cleaning solutions. The correct disinfectant was inaccessible due to a water heater installation, and the staff lacked formal training on proper procedures. The facility's outdated policies and training materials contributed to the deficiency.
Expired Foods, Unsafe Thawing, and Unsanitary Kitchen Storage
Penalty
Summary
The facility failed to ensure food was not outdated, that foods were thawed in a safe and sanitary manner, and that the walk-in freezer and walk-in cooler floors were kept sanitary in the kitchen. During observation and interview, a 1/2 gallon container of buttermilk was found in the refrigerator next to the prep area with the lid off, with pancake-batter-like residue on the outside and inside of the container, and the best used-by date was 4/6/26. In the same refrigerator, five bowls of undated pre-made salad were covered with plastic wrap and the lettuce was starting to turn brown. The dietary cook confirmed the buttermilk was expired and the salads should have been dated. In the walk-in cooler, two sheet pans were observed on the bottom shelf of a wire rack with thawing meat items sitting in juice on the trays. One tray held a bag of turkey thawing with juice on the tray, and another tray held two wrapped items and a 10-pound sleeve of ground beef sitting in blood juice from one of the items. The ground beef sleeve had a hole in the plastic with dark, hard-looking exposed ground beef. A later observation identified another wrapped item labeled ham dated 5/5/26 on the bottom shelf. The dietary cook and later the cook confirmed the meat should have been on separate trays and that the items were sitting in blood juices on the same tray. The walk-in freezer inside the cooler was observed to be full of stacked boxes in the walk-through space, with some boxes tipped over, some on the floor, and some on a plastic crate, preventing entry into the freezer. One box labeled seafood was open and dated 3/27/26, with the bag inside not closed or secured. A plastic tote cover on the freezer floor held five bags of thawed chicken, which the cook stated had just been placed there because there was no room on the shelf. The walk-in cooler floor also had a large amount of blood or brown juices spilled under both wire racks, along with butter packets and a dirty plastic cup in the spilled material. The administrator stated there had been ongoing concerns with expired items and cleaning in the kitchen, and the dietician stated the kitchen needed better monitoring and cleaning protocols with audits.
Incomplete COVID Surveillance and Return-to-Work Tracking
Penalty
Summary
The facility failed to ensure its infection prevention and control program documented employee illness monitoring, testing, and return-to-work decisions during a COVID outbreak. The report states that 7 of 9 staff members with symptoms of COVID were not documented as having been tested, their illnesses were not tracked to identify possible links between resident COVID cases and staff exposure or subsequent illness, and there was no indication when they could return to work according to CDC guidance. The January 2026 resident infection surveillance log showed 12 residents diagnosed with COVID during the outbreak and exhibiting symptoms including cough, runny nose, congestion, and wheezing. Five additional residents had loose stools and vomiting, but it was unknown whether they had been tested or found positive for COVID. The January 2026 employee illness log showed multiple staff call-ins for symptoms including sore throat, headache, congestion, dizziness, lightheadedness, diarrhea, vomiting, fever, sinus congestion, and cough, but the logs were not completed fully and the date returned to work was left blank each time. The infection preventionist stated she had been in the role for less than a year, worked infection control only 4 to 5 hours per week depending on staffing, and transferred staff illness information from the business office into the employee illness logs. She said staff were to be off work for at least 24 hours after vomiting, fever, or diarrhea resolved, but she had not thoroughly completed the surveillance logs or looked for trends or patterns. The DON stated she reviewed the IP's monthly data before QAPI meetings but had not been reviewing the surveillance logs since the new IP started. The facility's infection control and surveillance policies described monitoring infections for trends and managing infections through education and record keeping, and the return-to-work policy included guidance for suspected or confirmed COVID, but the report states there was no indication this return-to-work process followed CDC guidance.
Infection Preventionist Oversight and Employee Illness Log Deficiencies
Penalty
Summary
The facility failed to ensure its infection preventionist had appropriate time dedicated to oversight of the infection prevention and control program. The infection preventionist stated she had been in the role for less than a year and that her time for infection control depended on staffing needs because she also worked on the floor as a charge nurse. She reported that she typically spent only 4 to 5 hours per week on infection control duties and that she attempted to review infection control information at least weekly, but this was dependent on staffing and whether she had to work on the floor. She also stated she had not really looked for trends or patterns since starting in the role. Review of the January 2026 employee illness log showed multiple staff illness entries, including reports of sore throat, headache, congestion, dizziness, lightheadedness, diarrhea, vomiting, fever, sinus congestion, and cough. The monthly employee illness logs were not completed fully, and the date returned to work was left blank each time. There was also no indication that staff who became symptomatic during a COVID outbreak had been tested for COVID or vetted before returning to work according to CDC guidance. The DON stated she reviewed the infection preventionist's monthly data before QAPI meetings but had not been reviewing the surveillance logs since the new infection preventionist started.
Failure to Timely Notify Physician for Worsening Cough
Penalty
Summary
The facility failed to timely notify the physician when a resident with intact cognition and diagnoses including edema, heart failure, hypertension, premature ventricular contractions, and tricuspid regurgitation developed a worsening cough that did not improve. The resident’s quarterly MDS showed she required moderate assistance with transfers, dressing, and hygiene. After a clinic visit, she returned with orders for comfort care only, including do not hospitalize, stopping metolazone, increasing Lasix to 80 mg twice daily, and discontinuing labs per family request. The physician’s note described chronic fluid retention, weight gain, generalized edema, decreased strength, occasional shortness of breath, and a persistent cough, with the family choosing comfort care after discussion of prognosis and limited benefit of further hospitalization. Nursing notes showed the resident continued to cough chronically and was not resting well. Staff administered PRN morphine in an attempt to relieve discomfort from the cough related to fluid overload, but the medication was ineffective and the resident reported severe pain rated 8 out of 10 with no relief from the cough or discomfort. The care plan addressed diuretic therapy and monitoring for side effects, but it did not include the comfort care orders, the do not hospitalize direction, discontinuation of labs, or instructions for maintaining comfort if the resident’s condition changed. Interviews with the RN and DON confirmed they were aware of the resident’s coughing and believed it was related to fluid retention. The DON stated the facility had received the order not to send the resident to the hospital and agreed the care plan should have included comfort measures. The record also showed staff faxed the physician for guidance but did not receive a response, and the DON stated they could not call the doctor during clinic hours and had been advised to fax instead. The physician was not contacted until the on-call MD later ordered increased PRN morphine frequency for pain, shortness of breath, or cough.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to accurately code medication on the Minimum Data Set (MDS) assessment for 1 resident who was reported to be receiving insulin. The resident had a diagnosis of diabetes, and the quarterly MDS assessments accepted on 2/3/26 and 4/15/26 identified that the resident received an insulin injection 1 time during the last 7 days. However, the resident’s current physician orders showed no insulin orders. Instead, the orders included semaglutide, with instructions for a weekly subcutaneous injection on Wednesdays for diabetes with hyperglycemia, beginning at 0.25 mg and then increasing to 0.5 mg. During interview, the resident stated she did not receive insulin and instead received a weekly GLP-1 injection on Wednesdays. The RN confirmed she had incorrectly coded both quarterly MDS assessments as the resident receiving no insulin and stated she would need to complete and submit a modification of the assessment. The DON stated she would expect the MDS to be accurate and reflect each resident’s status.
Failure to Care Plan Fall Risk for a Resident With Severe Vision Impairment
Penalty
Summary
The facility failed to develop a care plan for 1 of 13 residents, R15, who was identified as being at risk for falls upon admission. R15’s comprehensive MDS assessment accepted on 12/22/25 identified that the CAA for falls would be addressed on the care plan, with staff to monitor for fall risks related to medication, new surroundings, and adjustment due to vision and hearing deficits. The assessment also directed staff to ensure the call light was within reach, make sure R15 knew where it was located, and attach it so it would not slide away because of her vision impairment. R15’s quarterly MDS assessment accepted on 3/20/26 identified intact cognition, severely impaired vision, and the need for moderate assistance of one staff for transfers, dressing, and hygiene. Interview with R15’s family member identified that R15 recently had a fall after falling asleep while sitting in her wheelchair and falling face forward out of the chair, hitting her face on the nightstand and sustaining facial bruising. The nursing progress note dated 5/1/26 documented an unwitnessed fall in R15’s room after she forgot to lock her wheelchair brakes, fell asleep, leaned too far forward, and tipped out of the chair, resulting in a facial bump and bruise and a skin tear on her right ring finger. Review of R15’s current undated care plan showed no mention that she was at risk for falls and no information describing what staff were to do to minimize her fall risk. The MDS nurse stated that if a resident was identified as being at risk for falls upon admission but had no history of falls, that was not always added to the care plan regardless of the CAA findings. The DON stated it was her expectation that any resident assessed to be at risk for falls would have a care plan section alerting staff to those risks and how to provide care and minimize injury.
Failure to Update Care Plans for Comfort Care and Pressure Ulcers
Penalty
Summary
The facility failed to revise the care plan for a resident who was changed to comfort care only after a clinic visit identified worsening fluid retention, weight gain, generalized swelling, decreased strength, occasional shortness of breath, and a persistent cough. The physician ordered that the resident not be hospitalized, that metolazone be stopped, Lasix be increased to 80 mg twice daily, and that labs be discontinued per family request. The current care plan addressed diuretic therapy and a goal for the resident to be free of discomfort, but it did not include the comfort care status, the order not to hospitalize, the discontinuation of lab draws, or instructions for maintaining comfort if the resident’s condition worsened. Nursing notes showed the resident remained in her room in a recliner and was heard coughing continuously, with the cough worsening. Staff administered PRN morphine for chronic cough related to fluid overload, but it was ineffective and the resident reported severe pain and no relief from the cough and discomfort. Additional notes documented continued coughing, shortness of breath, and little relief after cough syrup and morphine were given. The DON acknowledged the care plan should have been revised to identify what staff were to do to provide comfort if the resident’s condition worsened. The facility also failed to revise the care plan for another resident who developed pressure ulcers. The resident’s comprehensive MDS identified four Stage II pressure ulcers, and the CAA directed staff to address the wounds on the care plan with daily treatment, weekly and as-needed monitoring, physician notification for decline or signs of infection, and goals to slow or minimize decline and provide symptom relief or palliative measures. However, the current care plan only identified the resident as at risk for skin integrity impairment and included general measures such as nutrition, moisture control, skin care, and barrier cream use; it did not identify the actual pressure ulcers or include interventions to promote healing or reduce infection or discomfort. The MDS nurse stated she missed revising the care plan to include the pressure ulcers, and the DON stated it was her expectation that a pressure ulcer be identified on the care plan with appropriate goals and interventions.
Failure to Complete Antibiotic Time-Out Review
Penalty
Summary
The facility failed to complete a comprehensive assessment for continued antibiotic use for 2 of 3 sampled residents reviewed for antibiotic stewardship. Review of the CDC Core Elements of Antibiotic Stewardship for Nursing Homes identified that residents should be evaluated for clinical signs and symptoms when first suspected of having an infection and then comprehensively reviewed within 48-72 hours after starting an antibiotic to determine whether the medication is effective. The facility’s monthly antibiotic surveillance reports from January 2026 through April 2026 included fields for symptoms, diagnostic testing, antibiotic start and end dates, and antibiotic reassessment time out, but the documentation for two residents did not show a complete review of whether treatment was working. For R19, the surveillance report identified nasal congestion and a diagnosis of sinus infection. R19 was started on doxycycline 100 mg orally twice a day for 7 days, and an antibiotic time-out was documented as completed. However, the report did not include information in the date symptoms resolved column to show whether treatment was successful or whether the antibiotic needed to be changed or continued. Progress notes showed that R19 was seen by the facility doctor and started on doxycycline, and later staff documented continued sinus symptoms with thick mucus while also noting that R19 reported feeling better. The note did not identify that the doctor was notified or reviewed the information to make an informed decision about continuing, changing, or discontinuing the antibiotic. For R22, the surveillance report identified redness, warmth, and swelling with a diagnosis of cellulitis. R22 was started on doxycycline 100 mg orally twice a day for 7 days, and an antibiotic time-out was documented as completed. The report did not include information in the date symptoms resolved column to show whether treatment was successful or whether the antibiotic needed to be changed or continued. Progress notes showed that R22 continued to have redness, slight swelling, and warmth to the right lower extremity, and staff noted increased confusion with minimal, if any, improvement from the antibiotic. The note did not identify that the doctor was notified or reviewed the information to make an informed decision about continuing, changing, or discontinuing the antibiotic. The DON, IP, and administrator interviews confirmed that the facility documented the time-out in progress notes, did not communicate the assessment information to the prescribing provider, and relied on whether symptoms improved to determine if the antibiotic was working.
Kitchen Exhaust Vent Found with Heavy Grease and Dirt Accumulation
Penalty
Summary
During an observation and interview in the facility kitchen, surveyors identified a large rectangular exhaust vent above the gas stove that was covered with a black, thick grease-like substance. The certified dietary manager (CDM) acknowledged the vent's condition, stating it had been cleaned by maintenance a couple of months prior and believed the buildup was likely rust and dust, but admitted she had not noticed its current appearance and agreed it needed cleaning. The maintenance supervisor reported that the vent had been replaced a couple of months ago due to rust and paint chipping, but was unaware of the extent of dirt and grease accumulation since then. He stated that the black buildup could not be wiped off and required a heavy degreaser for removal. Additionally, when requested, the facility was unable to provide a policy on cleaning vents and equipment in the kitchen. This deficiency had the potential to affect all 28 residents who received food prepared in the facility kitchen, as the vent's condition could contaminate food being prepared and served.
Unattended Hot Coffee Warmer Poses Burn Hazard in Dining Room
Penalty
Summary
A Bunn brand double element coffee warmer was observed in the dining room, switched on by a dietary staff member prior to meal service. The coffee warmer, along with glass coffee pots containing hot coffee, was placed on a counter within easy reach of residents, including those walking or using wheelchairs. The surface of the warmer was noted to be very hot, and there was no consistent staff presence in the dining room to monitor the coffee or prevent residents from attempting to serve themselves. Interviews with the certified dietary manager and the administrator confirmed that the coffee warmer was routinely used in this manner and acknowledged the potential for burns if a resident touched the hot surface or attempted to self-serve. The facility did not provide a policy for safety in the dining room when requested during the survey.
Failure to Follow Infection Control Practices During Insulin Administration and Equipment Use
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during blood glucose testing and insulin administration for two residents. An LPN was observed performing blood glucose monitoring and insulin injections without wearing gloves or performing hand hygiene. The LPN handled blood-contaminated items, such as lancets and cotton balls, with bare hands and placed these items, along with the insulin pen, into her scrub pocket. After administering insulin, the LPN disposed of the used items and cleaned the blood glucose meter only after completing the procedures, rather than between residents. The LPN acknowledged she should have worn gloves and performed hand hygiene but stated she forgot due to being nervous while observed. The DON confirmed that staff are expected to use appropriate PPE and follow infection control measures, especially when contact with blood is involved. Additionally, the facility failed to ensure mechanical lifts were cleaned and disinfected between resident use. A CNA in training was observed moving a mechanical lift from one resident's room to another without cleaning it in between. The CNA stated he was trained to clean lifts at the end of each shift, not between residents, and believed this was the facility's policy. The DON clarified that lifts are to be cleaned and disinfected after each use, regardless of the resident's precaution status, and that new staff are trained accordingly. Facility policy also requires cleaning and disinfection of reusable medical equipment between residents.
Failure to Assess and Accommodate Resident's Wheelchair Needs
Penalty
Summary
The facility failed to ensure that a resident with severe morbid obesity, arthritis, reduced mobility, and a stage II pressure ulcer was appropriately assessed by therapy for a properly fitting wheelchair. The resident, who required extensive assistance with activities of daily living and experienced pain that interfered with her daily activities, reported significant discomfort when using her wheelchair, which led her to remain in her room and avoid activities. Multiple staff members, including an activity aide and a nursing assistant, were aware that the resident was refusing to leave her room due to pain associated with her wheelchair and had reported this to the director of nursing. However, there was no documentation that the resident had been assessed for wheelchair fit or that therapy had been notified to evaluate her needs. The resident's care plan identified risks related to impaired mobility, pain, skin integrity, and limited activity involvement, with interventions to monitor and address pain and discomfort. Despite these care plan directives, the medical record and progress notes lacked evidence that the underlying cause of the resident's refusals—her discomfort in the wheelchair—had been investigated or addressed. Interviews with nursing staff and the administrator confirmed that no referral to therapy or physician notification had occurred to assess the resident for an appropriate wheelchair, and no interventions were documented to improve her comfort while seated.
Failure to Integrate Hospice and Facility Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for two residents who were receiving hospice services. For one resident with severe cognitive impairment, multiple chronic conditions, and a life expectancy of less than six months, the care plan only indicated that hospice visits would occur but did not specify when these visits would take place or delineate which services were to be provided by the facility versus hospice. Similarly, for another resident admitted with a cancer diagnosis and a focus on comfort care, the care plan did not clarify the division of responsibilities between the hospice agency and facility staff. During interviews, the hospice registered nurse reported communication issues with facility staff, including confusion about the roles of hospice and facility aides during bathing and assistance with positioning and dressing. The facility's policy requires care plans to describe all services provided, incorporate resident wishes and goals, and identify which professional services are responsible for each aspect of care. However, the care plans reviewed did not meet these requirements, as they lacked clear delineation of services and responsibilities between the facility and hospice agency.
Inadequate Training for Whirlpool Tub Cleaning
Penalty
Summary
The facility failed to ensure that all 25 nurse aides responsible for bathing residents were appropriately trained and deemed competent in the cleaning and disinfection of the whirlpool tub according to the manufacturer's instructions. Observations and interviews revealed that nurse aides were not following the correct procedures for cleaning and disinfecting the whirlpool tub. For instance, NA-B was observed using a Clorox Fuzion cleaner/disinfectant spray and a brush to clean the tub, but she was unaware of the correct disinfecting time or whether the disinfectant solution was coming out of the jets. Additionally, NA-B did not wear any personal protective equipment (PPE) while performing the task. Further observations and interviews with other nurse aides, such as NA-C, indicated similar issues. NA-C used a Triforce bleach solution with an overpowering smell and was unsure if it was appropriate for the whirlpool tub. She also received training from a colleague who no longer worked at the facility and was unaware of any specific training checklist or competencies for the whirlpool. NA-D and NA-E also expressed uncertainty about the training they received, with NA-E mentioning that the online courses provided were not specific to the tub used at the facility. The Director of Nursing (DON) confirmed that the facility lacked a formal checklist for training nurse aides on whirlpool cleaning and disinfection. There were no accessible records of employee training or competencies completed, and training was conducted on the job alongside colleagues. The facility's training policy from 2020 indicated that initial orientation and yearly online training would be provided, but there was no indication that the training was specific to the facility's equipment.
Failure to Implement Facility-Wide Assessment Protocol
Penalty
Summary
The facility failed to implement a comprehensive facility-wide assessment protocol to ensure staff competencies were identified and completed according to their duties. During an interview, the administrator admitted to having just discussed the facility assessment with the Director of Nursing (DON) and revealed that the assessment had only been recently updated. The administrator was unable to locate the previous assessment and had to start a new one. This indicates a lack of continuity and oversight in maintaining up-to-date assessments. Further interviews revealed that the nursing assistant (NA) reported no direct review of skills or competencies, although online training was completed. The DON acknowledged that department heads had not been completing annual evaluations, and she had not conducted any skills training or competencies with the staff, except for an annual session on mechanical lifts. The facility assessment tool reviewed on 6/24/24 identified necessary staff education and competencies, including infection control procedures, but these were not being adequately addressed or implemented.
Deficiency in QAPI Data Analysis and Documentation
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance Performance Improvement (QAPI) committee was properly analyzed and documented. This deficiency was identified during a review of QAPI minutes from a meeting, which revealed a lack of documentation regarding facility goals and analysis. There was no response on how the facility would meet its goals, nor was there an evaluation of whether previous goals were met or if new processes had been identified. An interview with the Director of Nursing confirmed the absence of data analysis, measurable goals, and actions to meet those goals. Additionally, there was no formal process for staff, residents, or their families to provide feedback to improve areas identified in QAPI. The QAPI Plan policy, which was undated, provided guidance for quality improvement but lacked mention of measurable goals or data analysis. There was also no evidence that the plan had been reviewed to ensure it included all required regulatory elements.
Lack of Performance Improvement Project in QAPI Program
Penalty
Summary
The facility failed to provide evidence of a Performance Improvement Project (PIP) focusing on high-risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a review of QAPI minutes from a meeting held on June 14, 2024, which showed no PIP projects were noted. An interview with the Director of Nursing (DON) on June 25, 2024, revealed that the facility had not conducted a PIP project because the new administrator chose not to participate in such projects. The DON acknowledged the importance of PIP projects in identifying high-level areas of concern to ensure the highest care possible for residents. Additionally, the facility's QAPI Plan policy, which was undated, lacked clear guidance on how PIP projects would be identified, educated to staff and residents, and measured for goal accomplishment and compliance. There was also no evidence that the QAPI Plan had been reviewed to ensure it included all required regulatory elements.
Failure to Reconcile Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that staff followed protocols for verifying controlled medication counts, which could potentially lead to medication diversion. During an observation and interview, a registered nurse (RN) was unable to find documentation that the emergency kit (Ekit) containing controlled medications had been reconciled. The RN confirmed that without reconciling the Ekit controlled medication tag number each shift, it would be impossible to know if the Ekit had been tampered with. A licensed practical nurse (LPN) also revealed that nurses did not reconcile the Ekit controlled medications stored in the locked box within the medication cart. The LPN was unable to verify the tag number on the Ekit controlled medication box, indicating a lack of proper documentation and monitoring. The director of nursing (DON) confirmed that the Ekit controlled medication tag should be monitored and documented each shift, but was unable to find any documentation of this in the narcotic book. The DON discovered that the Ekit tag number had been transferred to a new non-narcotic book without proper documentation or signatures. The DON acknowledged that the tag numbers for the Ekit controlled medication had not been monitored or documented in the non-narcotic book either. A review of the Ekit controlled medication list showed several medications, including morphine sulfate and lorazepam, but the last documented removal was several months prior, with no policy on controlled medications provided.
Inadequate Cleaning and Disinfection of Whirlpool Tub
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a whirlpool tub, affecting two residents who used it for bathing. Observations revealed that two nurse aides, NA-B and NA-C, did not follow the manufacturer's guidelines for cleaning the tub. NA-B used a Clorox Fuzion cleaner/disinfectant spray and scrubbed the tub without wearing personal protective equipment (PPE). She was unaware of the correct disinfecting procedure and whether the solution was effective. NA-C used a Triforce bleach solution, which had an overpowering smell, and was also unaware of the correct cleaning procedure. The facility's housekeeping supervisor and director of nursing (DON) confirmed that the correct disinfectant solution was not being used due to a water heater blocking access to the compartment where the solution should be added. The maintenance director acknowledged that the disinfectant solution had expired and was not being used, leading to only water being dispensed when the DISINFECT button was pressed. The DON admitted that there was no formal training or documentation for staff on the proper use and cleaning of the whirlpool tub. The facility's policies and training materials were outdated and not specific to the current equipment and procedures. The Triforce solution used was not intended for whirlpool tubs and required a different application method than what was being practiced. The lack of proper training and adherence to manufacturer guidelines resulted in inadequate cleaning and disinfection of the whirlpool tub, potentially compromising infection control measures.
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A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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