Pioneer Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fergus Falls, Minnesota.
- Location
- 1131 South Mabelle Avenue, Fergus Falls, Minnesota 56537
- CMS Provider Number
- 245463
- Inspections on file
- 24
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Pioneer Care Center during CMS and state inspections, most recent first.
Surveyors found that multiple medications, including eye drops, insulin pens, inhalers, and nitroglycerin, were not properly labeled or dated, and some were missing administration instructions or resident identifiers. Staff often relied on the EMAR for directions instead of ensuring medication containers were labeled, and medications brought in by families frequently lacked pharmacy labels. These deficiencies were confirmed through staff interviews and observations, revealing a failure to follow facility policy for medication labeling and storage.
Surveyors identified that food items in the kitchen refrigerators and freezers were not consistently labeled with opened dates or expiration dates, and some items were not discarded by their expiration dates. Both the cook and dietary manager confirmed that these practices did not meet facility policy, which requires all opened food to be dated and discarded appropriately.
The facility did not properly implement self-administration of medication assessments and procedures for two residents. One resident had lidocaine patches left unsecured in their room despite not being able to apply them independently, while another had topical antifungal medications left at the bedside without authorization for self-administration. Staff and pharmacy consultants confirmed that medications should have been secured and that proper assessments were not followed.
A resident with severe cognitive impairment and a history of falls was placed in a low bed to prevent further falls, but staff did not complete a restraint assessment or identify the low bed as a potential restraint. Interviews and observations showed that the low bed restricted the resident's ability to stand independently, and staff were uncertain about its classification as a restraint, despite facility policy requiring assessment.
A resident with complex medical needs and a history of falls was not accurately coded on the MDS for the use of bed and chair alarms, despite care plans, physician orders, and staff observations confirming their use. The MDS coordinator did not perform a visual assessment or fully review care documentation, resulting in the omission of this critical information from the assessment.
A resident did not receive appropriate care to maintain or improve ROM and mobility, and the facility did not ensure that necessary interventions were provided or documented, except when decline was medically unavoidable.
The facility did not consistently post up-to-date nurse staffing information as required, with outdated postings and incorrect resident census numbers observed. The DON and scheduler confirmed that postings were often prepared in advance and not always updated to reflect current census or staffing changes, leading to inaccurate information being displayed.
A resident with severe cognitive impairment was found with multiple bruises of unknown origin on her inner thighs and knee. Although the administrator and DON were notified, the physician was not informed until five days later, contrary to facility expectations for immediate notification. This delay prevented timely medical evaluation and intervention.
A resident with severe cognitive impairment and high care needs was found with multiple unexplained bruises on her inner thighs and knees, described as fingerprint-sized and in a straight line. The facility's investigation did not include comprehensive staff interviews about possible abuse or suspicious behavior, and staff who observed the bruising were not questioned about abuse. Leadership acknowledged that the investigation did not follow policy requirements for injuries of unknown origin.
A resident with severe cognitive impairment and multiple medical conditions developed several greenish, fingerprint-sized bruises on the inner thighs. Although there was an order to monitor the bruises, it lacked clear instructions and was not entered into the TAR, resulting in inconsistent monitoring and missing documentation over several days. Staff interviews confirmed a lack of awareness and follow-through regarding the monitoring order, and the medical provider was not notified at the time of the incident.
A resident with cognitive impairment and limited mobility was left unsupervised on a secured outdoor patio for several hours in hot weather, without access to water or sun protection. Staff failed to provide adequate supervision or communicate the resident's status during shift changes, resulting in the resident being found unresponsive and requiring emergency treatment for heat exhaustion and dehydration.
A resident with COPD was allowed to self-administer nebulizer medication without a proper assessment or order in place. The facility's staff, including a TMA and RN, failed to follow the process for evaluating and documenting the resident's ability to self-administer medication safely. The resident's care plan and electronic health record lacked necessary documentation, and the pharmacy consultant expected these assessments and orders to be completed to ensure safe medication administration.
A resident with severe cognitive impairment and a preference for no facial hair was not assisted with facial hair removal, despite requiring substantial assistance with hygiene. Observations showed the resident had facial hair, and interviews revealed staff failed to follow the facility's policy of offering daily assistance for facial hair removal to maintain dignity.
A resident with severe cognitive impairment developed a stage two pressure ulcer behind the left ear due to nasal cannula tubing. The facility failed to assess, document, and implement interventions for the ulcer, despite the resident being at moderate risk. Nursing staff were unaware of the ulcer, and required procedures for pressure ulcer management were not followed, leading to inadequate care.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of medications for nine residents. Medications, including eye drops, insulin pens, inhalers, and nitroglycerin, were found without proper labeling, such as missing resident names, administration directions, or dates of opening. In several cases, medications brought in by families lacked pharmacy labels, and staff relied on electronic medication administration records (EMAR) for instructions rather than ensuring the medication containers themselves were properly labeled. Some medications, such as eye drops and insulin pens, were not dated when opened, making it difficult to determine if they were still within the manufacturer’s recommended usage period. Observations revealed that staff did not consistently follow procedures for labeling medications upon opening or for maintaining medications in their original packaging with pharmacy labels. For example, eye drops and insulin pens were found undated, and some medications were stored outside of their labeled boxes, resulting in missing instructions and resident identifiers. Staff interviews confirmed that the expectation was to label medications with the date opened and to dispose of them after the recommended period, but this was not consistently practiced. In some instances, staff removed and destroyed improperly labeled or expired medications during the survey. The facility’s own policy required that all medications be labeled with the medication name, prescribed dose, strength, expiration date, resident’s name, route of administration, and instructions. However, the survey found that this policy was not followed for several medications, including those for dry eyes, glaucoma, diabetes, and chest pain. The lack of proper labeling and storage was confirmed by nursing staff, the clinical coordinator manager, the consultant pharmacist, and the director of nursing during interviews and observations.
Improper Food Labeling and Storage in Kitchen Refrigerators and Freezers
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and discarding of food items stored in the kitchen refrigerators and freezers. During a kitchen tour, it was found that a half container of sour cream in the walk-in cooler lacked an opened date and had an expiration date that had already passed. In the kitchen fridge, a quarter container of mustard was found with an expired date, and a half bottle of barbeque sauce was missing both an opened date and an expiration date. The cook confirmed these findings and stated that all opened food should be dated and discarded by the expiration date. The dietary manager also confirmed that food should be dated when opened and discarded after the shelf life or expiration date. Facility policy requires leftover foods to be stored in covered containers, clearly labeled, dated, and monitored to ensure consumption by safe use-by dates or frozen.
Failure to Implement and Secure Self-Administration of Medication Procedures
Penalty
Summary
The facility failed to properly implement self-administration of medication (SAM) assessments and procedures for two residents. One resident, who was cognitively intact and had diagnoses including diabetes, heart failure, and arthritis, had a physician's order for a lidocaine patch to be applied at bedtime and removed in the morning. Although the SAM assessment indicated the resident could self-administer medications after nurse setup, observations showed that nursing staff applied and removed the patch daily, and left an open box of lidocaine patches unsecured on the resident's dresser. Staff confirmed that the patches should have been secured in a locked medication drawer and that the resident was not able to apply the patch independently, only remove it. The pharmacy consultant and clinical coordinator both stated that only one patch should be left out at a time and that medications should be stored securely according to the SAM assessment. Another resident, with mild cognitive impairment and diagnoses including an indwelling urinary catheter, heart failure, and hypertension, had orders for topical antifungal medications. The care plan and SAM assessment indicated the resident was not able to self-administer medications. However, observations revealed that tubes of Clotrimazole cream and Nystatin powder were left on the nightstand in the resident's room. The resident reported that staff left the medications out for application, and if not left out, staff would not apply them as only one person could access the locked medications. Staff confirmed there was no order for self-administration and subsequently locked the medications away. Facility policy required that the interdisciplinary team assess each resident's cognitive and physical abilities to determine if self-administration is safe and appropriate, and that self-administered medications be stored securely. The policy also stated that any medications found at the bedside without authorization for self-administration should be turned over to the nurse in charge. The facility did not follow these procedures, resulting in unsecured medications at residents' bedsides and improper implementation of SAM assessments.
Failure to Assess Low Bed as Potential Physical Restraint
Penalty
Summary
The facility failed to comprehensively assess the use of a low bed as a potential physical restraint for a resident with severe cognitive impairment, Parkinson's disease, hypertension, arthritis, and a history of falls. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, and toileting, and used a wheelchair for mobility. Despite the resident's ability to stand independently, staff placed the bed in the lowest position as an intervention following a fall, with the intention of preventing further falls. However, there was no documentation of a restraint assessment being completed prior to implementing this intervention, and the resident's care plan and assessments did not identify the low bed as a restraint. Observations and staff interviews revealed that the low bed made it difficult for the resident to stand up independently, and staff were unsure whether the low bed constituted a restraint. The facility's policy defined a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, the low bed was not evaluated as a potential restraint, and the required assessment was not performed before its use. The director of nursing confirmed that a restraint assessment should have been completed but was not done in this case.
Failure to Accurately Code MDS for Resident Safety Alarms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded to reflect the use of safety alarms for a resident with medically complex conditions, including hypertension, anxiety, and depression, who required extensive assistance with activities of daily living. Despite the resident's care plan and physician orders indicating the use of bed, recliner, and wheelchair alarms as fall interventions, the MDS assessment did not document the presence of these alarms. Multiple observations confirmed the resident was consistently using bed and chair alarms, and staff interviews verified that these alarms had been in place for an extended period. The MDS coordinator acknowledged that the alarms were not coded on the MDS and stated that the standard process involved reviewing assessments, care plans, and care conference notes, but a visual assessment was not performed for this resident at the time of the MDS completion. Both the MDS coordinator and nursing staff confirmed that the alarms should have been included in the MDS coding. The facility's policy required that MDS assessments consistently reflect information from progress notes, care plans, and resident observations, which was not followed in this instance.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care and services were provided to prevent avoidable decline in ROM or mobility, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve the resident's physical abilities were not implemented or documented as required.
Failure to Consistently Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post required nurse staffing information on a daily basis as mandated. On the day of observation, the staff posting displayed was outdated, showing information from two days prior and an incorrect resident census. The current day's posting was found behind previous days' postings and also contained an incorrect census. The DON confirmed these discrepancies and explained that the process was to update the nurse staff posting daily, with the scheduler responsible for creating the postings and the charge nurse responsible for updating them with census or staffing changes. Interviews revealed that the scheduler typically prepares postings for upcoming days in advance, especially before weekends, and places them behind the current posting. Updates to the census or staffing changes occurring on weekends are expected to be made by the charge nurse. However, the process did not ensure that the most current and accurate information was consistently displayed, as required by facility policy. The policy specifies that daily postings must include the facility name, current date, resident census at the beginning of the shift, shift schedule, type and category of nursing staff, actual time worked, and totals for licensed and non-licensed staff.
Failure to Timely Notify Physician of Resident Injury
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a change in condition for a resident who was found with multiple bruises of unknown origin on her inner thighs and knee. The resident had severely impaired cognition, inattention, and disorganized thinking, making her unable to communicate how the bruises occurred or whether she felt safe. Documentation showed that the incident was discovered by staff in the morning, and while the administrator and DON were notified, the section of the incident report regarding physician notification was left blank. Progress notes indicated that the resident's family was informed, but there was no documentation of immediate provider notification. The physician was not notified until five days after the bruises were discovered, via fax, and was unaware of the incident during a routine visit that occurred in the interim. Interviews with staff confirmed that the expectation was for immediate provider notification, especially given the potential for abuse or injury. The lack of timely communication prevented the physician from evaluating the resident promptly and determining if further medical assessment or interventions were necessary.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source for a resident with severe cognitive impairment and multiple physical dependencies. The resident, who had diagnoses including Parkinson's disease, dementia, and anxiety, was non-ambulatory, required substantial to maximal assistance with all activities of daily living, and was unable to communicate about her safety or the cause of her injuries. On assessment, staff identified multiple bruises of varying sizes and colors on the resident's inner thighs and knees, which were described as fingerprint-sized and arranged in a straight line. The resident's care plan directed staff to use caution during transfers and to monitor and report any suspected abuse or neglect, but the source of the bruising was not observed, and the resident could not explain the injuries. The facility's documentation and investigation into the incident were incomplete. Progress notes indicated that the resource manager was notified and the resident's family was informed, but did not specify what actions were taken. The state agency report and facility records showed that previous skin assessments did not note any discoloration or bruising, and that the bruising could have been related to the process of changing the resident's brief. However, there was no evidence that staff interviews included questions about possible abuse, aggressive care, or suspicious behavior by staff or other residents. Staff who discovered or observed the bruising confirmed they were not interviewed about abuse or the incident itself. Interviews with facility leadership and the medical director confirmed that the investigation did not follow policy requirements for injuries of unknown origin, which called for comprehensive interviews with all staff who had contact with the resident during the relevant period, including questions about abuse. The director of nursing acknowledged that staff were only asked about skin changes, difficulties with repositioning, and care challenges, and not about abuse. The medical director stated that he was not notified of the incident and would have expected a more thorough investigation, including an examination to determine if the injuries were suspicious.
Failure to Monitor and Document Bruising for Cognitively Impaired Resident
Penalty
Summary
The facility failed to properly assess and monitor bruises for a resident with severely impaired cognition, Parkinson's disease, dementia, and significant physical limitations. The resident was dependent on staff for all activities of daily living and had an order for weekly skin monitoring, as well as a specific order to monitor bruising to the inner thighs after staff observed multiple greenish, fingerprint-sized bruises. Documentation showed that the order to monitor the bruises lacked clear directions and frequency, and was not entered into the Treatment Administration Record (TAR), resulting in inconsistent monitoring and documentation. Progress notes were missing for several days following the discovery of the bruises, and staff interviews confirmed a lack of awareness and follow-through regarding the monitoring order. The incident report and progress notes indicated that the medical provider was not notified at the time of the incident, and the order to monitor the bruises was not effectively communicated or implemented among nursing staff. The DON and other staff acknowledged that the order should have been placed in the TAR with a specified frequency to ensure consistent monitoring, but this was not done. As a result, there was no documented evidence that the resident's bruises were assessed every shift or daily as would have been expected, leading to a failure in providing appropriate treatment and care according to orders and the resident's needs.
Resident Left Unsupervised Outdoors Resulting in Heat Exhaustion
Penalty
Summary
A deficiency occurred when a resident with mild neurocognitive disorder, impaired mobility, and a history of delusions and agitation was left unsupervised on an outdoor patio. The resident was dependent on staff for transfers, had impaired balance, and required supervision with all decision-making. According to the care plan, the resident was at risk for falls and required prompt response to requests for assistance, as well as supervision when outside. Despite these needs, the resident was brought outside by staff and left alone for an extended period in hot weather, without access to water or sun protection. Staff interviews and documentation revealed that the resident was placed on the patio around early afternoon and checked on intermittently. Multiple staff members noted that the resident refused to return inside when offered, but she was not provided with water or adequate sun protection, and there was no way for her to independently alert staff if she needed help. The patio door required a code to re-enter the building, which the resident could not operate due to her physical limitations. Staff were unclear about the frequency of required checks and did not consistently communicate the resident's location or status during shift changes. The resident was found unresponsive after being left outside for several hours in temperatures reaching 90 degrees Fahrenheit. She exhibited signs of heat exhaustion and dehydration, including confusion, elevated vital signs, and sunburn. Emergency services were called, and the resident was treated in the emergency department for heat exposure, dehydration, and hyperkalemia before being returned to the facility. The facility's policy required supervision based on individual assessment and environmental hazards, but staff failed to provide adequate supervision and did not follow established procedures for monitoring residents outside.
Failure to Ensure Safe Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to ensure the safe administration of nebulizer medication for a resident who was observed to self-administer without being assessed as safe to do so. The resident, who was cognitively intact and had diagnoses including COPD, heart failure, and anxiety disorder, required assistance with activities of daily living. Despite this, the resident's care plan did not include interventions for self-administration of medication, and there was no documented self-administration medication (SAM) assessment or order for the resident to self-administer the nebulizer medication. During observations, a trained medication aide set up the nebulizer for the resident and left the room, allowing the resident to self-administer the medication unsupervised. The aide assumed the resident had been assessed for self-administration, but upon review, it was confirmed that no such assessment or order existed. Interviews with the unit manager RN and the DON revealed that the facility's process for SAM assessments and obtaining orders was not followed, and the resident's care plan and electronic health record lacked the necessary documentation. The pharmacy consultant also expected a SAM assessment and order to be in place to ensure safe medication administration.
Failure to Assist Resident with Facial Hair Removal
Penalty
Summary
The facility failed to ensure that a resident, who required assistance with hygiene, had her facial hair removed, despite her preference for no facial hair. The resident, who was severely cognitively impaired with diagnoses including dementia, coronary artery disease, and hypertension, required substantial assistance with bathing and dressing but was noted to be independent with personal hygiene. However, observations revealed that the resident had multiple white facial hairs on her cheeks, chin, and around her mouth, which she was unable to remove herself. Interviews with nursing assistants and the clinical manager revealed that the usual practice was to assist residents with facial hair removal to maintain their dignity. However, the staff failed to check and assist the resident with facial hair removal as per her care plan and facility policy. The director of nursing confirmed that staff were expected to offer facial hair removal daily and document any refusals. A family member also confirmed the resident's preference for no facial hair. The facility's policy emphasized promoting cleanliness and skin care, yet the staff did not adhere to these guidelines, leading to the deficiency.
Failure to Assess and Manage Pressure Ulcer
Penalty
Summary
The facility failed to comprehensively assess, monitor, and implement interventions for a resident with a stage two pressure ulcer. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, developed a pressure ulcer behind the left ear due to nasal cannula tubing. Despite being at moderate risk for pressure ulcer development, the resident's care plan and assessments lacked documentation of the pressure ulcer, and no interventions were implemented to prevent further skin breakdown. Observations and interviews revealed that nursing staff were unaware of the pressure ulcer and had not completed necessary assessments or documentation. A registered nurse discovered the ulcer during an observation and noted that it had not been assessed or measured previously. The facility's policy required a wound checklist to be completed when a new pressure ulcer was identified, but this was not done, leading to a lack of monitoring and intervention. Interviews with nursing staff and the director of nursing confirmed that the facility's procedures for pressure ulcer management were not followed. The resident's care plan was not updated to reflect the presence of the ulcer, and the necessary steps to promote healing and prevent further deterioration were not taken. The facility's policies on skin assessment and wound treatment documentation were not adhered to, resulting in inadequate care for the resident's pressure ulcer.
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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