St Clare Living Community Of Mora
Inspection history, citations, penalties and survey trends for this long-term care facility in Mora, Minnesota.
- Location
- 110 North 7th Street, Mora, Minnesota 55051
- CMS Provider Number
- 245291
- Inspections on file
- 25
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at St Clare Living Community Of Mora during CMS and state inspections, most recent first.
Code Alert System Failed to Prevent Resident Elopement: The facility failed to keep the code alert system functioning as intended and did not follow the manufacturer’s weekly testing and inspection guidance. Two residents with significant cognitive impairment were able to get through the main doors, and one resident exited the building before staff followed outside. The report also states that multiple residents with code alert devices did not have adequate elopement or wandering assessments and care plan interventions, and several attempts to leave were not documented in the record.
A facility failed to accurately code MDS assessments for code alert device use for multiple residents identified as at risk for elopement and wandering. Although a wander guard log showed several residents had code alert devices, the MDS often stated the devices were not in use and did not reflect wandering behavior. Several care plans also lacked elopement or wandering interventions, and staff interviews confirmed the MDS should reflect code alert placement because it drives the care plan.
A facility failed to include individualized care plan interventions for multiple residents with elopement and wandering risk, despite MDS findings of significant cognitive impairment and use of code alert devices. Staff stated these risks should be in the care plan and reassessed after changes, but several care plans lacked device location and resident-specific interventions. The facility also omitted care planning for a resident receiving trazodone for sleep, a resident who smoked and had COPD/Alzheimer’s disease, and a resident on dialysis who should have had EBP documented.
Failure to perform hand hygiene and use proper ice handling during the snack pass. An NA entered resident rooms without gloves, used a plastic water glass to scoop ice from over-sized pitchers, returned the glass to the ice, handled food and drinks, and repeatedly exited rooms without hand hygiene. The DON stated hand hygiene was expected before entering and after exiting resident rooms, and the facility policy required hand hygiene before and after handling food and soiled utensils or equipment.
Failure to honor a resident’s request for nail care. A resident with dementia, renal insufficiency, HTN, and depression had long fingernails beyond the fingertips and stated staff had not trimmed them despite repeated requests. Staff said nail care was usually done on shower days, but also stated that if a resident asked for nail trimming, an NA, wellness staff, or an LPN/RN could complete it and the resident should not have to wait until the next bath day.
The facility failed to monitor orthostatic blood pressures for residents on antipsychotic medications, did not obtain signed consent for an antidepressant, and did not implement non-pharmacological interventions before initiating antipsychotic medication. These deficiencies were observed in several residents, with staff confirming the lack of consistent monitoring and consent procedures. The facility also did not establish appropriate target behaviors for monitoring the effectiveness of psychotropic medications.
The facility failed to ensure proper use of PPE to prevent COVID-19 spread, with staff reusing N95 masks and goggles despite having adequate supplies. Additionally, the infection control program lacked comprehensive surveillance, only tracking infections treated with antibiotics and not including viral, fungal, or yeast infections. The facility's policies did not adequately address PPE use or infection tracking, contributing to potential infection spread.
Two residents with moderate cognitive impairment were found self-administering medications without proper assessment or physician orders. One resident was observed using a nebulizer independently, while the other self-administered muscle rub and eye drops. The facility's policy requires comprehensive assessments for self-administration, which were not adequately conducted or documented.
A resident with a history of smoking was not provided opportunities to smoke, despite having intact cognition and expressing a strong desire to continue the habit. The facility's non-smoking policy and lack of a tailored care plan led to repeated incidents of the resident expressing anger and frustration. Staff confirmed that the resident's behaviors were linked to nicotine withdrawal and the facility's failure to accommodate her smoking preference.
The facility failed to complete neurological assessments for two residents after unwitnessed falls, with assessments left incomplete or not initiated. Additionally, a resident did not receive bowel management medications as ordered, leading to prolonged constipation. The facility also failed to monitor vital signs as per physician's orders after a medication change. Staff interviews revealed non-compliance with protocols, and the facility's policy for processing orders was not provided.
A resident with moderate cognitive impairment and hearing difficulties did not receive proper audiology services as outlined in their care plan. Despite the resident's expressed difficulty in hearing and lack of hearing aids, the facility failed to offer an audiology appointment or document any discussion of such services. Interviews with staff confirmed the resident's hearing challenges and the absence of hearing aids, highlighting a lapse in following the facility's policy to assist hearing-impaired residents.
The facility failed to implement care plan interventions for a resident at high risk for pressure ulcers by not using pressure-relieving boots as required. Another resident with a stage four pressure ulcer was not repositioned every two hours as per their care plan, remaining in a wheelchair for over four hours without repositioning. Staff interviews confirmed the expectations for both residents' care plans were not met.
A facility failed to assess and supervise a resident with a history of smoking, despite being a non-smoking facility. The resident, with a diagnosis of dementia and other health conditions, was observed smoking outside multiple times without a smoking assessment being conducted. Staff interviews confirmed the resident's smoking habit, and the facility's policy requiring residents to leave the property to smoke was not enforced.
Two residents in the facility were administered digoxin without appropriate pulse monitoring. One resident with intact cognition and multiple diagnoses, including atrial flutter, and another with severe cognitive impairment and paroxysmal atrial fibrillation, received digoxin without parameters for heart rate monitoring. Staff interviews revealed no orders for pulse checks prior to administration, despite facility policy requiring it. The deficiency was identified through observations and staff interviews.
A resident was not offered the PCV20 vaccine as recommended by the CDC, despite having received previous pneumococcal vaccines. The infection preventionist confirmed the oversight, and the facility's policy did not address the administration of PCV20 with shared decision-making.
The facility failed to manage the bowel and constipation needs of a resident with Alzheimer's Disease and severely impaired cognition. Despite a care plan goal of having a bowel movement (BM) every three days, multiple periods showed no BM documentation and no evidence of the facility's Bowel Movement Protocol being implemented. Staff interviews revealed a lack of awareness and documentation regarding the resident's constipation issues.
A resident with Alzheimer's Disease and severely impaired cognition experienced two unwitnessed falls without new interventions being implemented to prevent reoccurrence. Despite being identified as at risk for falls and having a care plan in place, the facility failed to follow its policy requiring additional interventions after repeated falls.
Code Alert System Failed to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the code alert system used for residents at risk for elopement was functioning properly and failed to follow the manufacturer’s recommendations for weekly testing and inspection. The report states that the immediate jeopardy began when R12 was able to exit the building after the main entrance code alert system malfunctioned, and that R19 was also able to get through the main doors because the doors did not lock as required by the system. The manufacturer’s binder in the facility called for weekly testing of the code alert units, regular testing of each detection zone, and quarterly service inspections, but the facility’s logs showed the doors were being tested monthly instead of weekly. R19 was severely cognitively impaired with Alzheimer’s disease. The resident’s assessment identified low elopement risk, and the care plan lacked interventions for elopement and wandering. During observation, R19 wheeled to the main entrance, went through the first door into the vestibule, and the alarm sounded, but the door did not lock. A nursing assistant responded and redirected R19 back to the central TV area. The resident’s progress note did not include the attempt to leave the building. R12 was severely cognitively impaired with non-Alzheimer’s dementia and anxiety. The resident had repeated attempts to leave the facility, but the care plan lacked elopement and wandering interventions, and the most recent assessment also identified low elopement risk with the door alarm band not selected. During observations, R12 repeatedly approached the main entrance, triggered the alarm, and was able to get through the first door into the vestibule; on one occasion R12 exited the building before being followed outside by staff. The report also states that R12’s record lacked documentation of the successful exit and other attempts to leave. In addition, the facility failed to adequately assess and develop care plans for multiple other residents assigned code alert devices, including residents with severe or moderate cognitive impairment and diagnoses such as dementia and Alzheimer’s disease, whose care plans did not include elopement or wandering interventions or, in some cases, the location of the device.
Inaccurate MDS Coding for Code Alert Devices
Penalty
Summary
The facility failed to ensure accurate MDS coding for the use of code alert devices for 14 of 14 residents identified as at risk for elopement and wandering. The code alert system log titled Wander Guard Monitor for 4/2026 identified residents R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46 as having a code alert device in use, but their MDS assessments did not consistently reflect that information in Section P. Instead, the assessments frequently indicated that a wander guard alarm was not in use and that the residents had not exhibited wandering behavior. Several resident records also lacked corresponding care plan interventions for elopement and wandering. R3, R4, R18, R22, R28, R32, R34, R37, and R46 had care plans that did not include elopement or wandering interventions, and R22's care plan did not identify the placement location of the code alert device. R37's problem area for elopement was not initiated until 5/1/26. R46 was discharged on 4/20/26, and the care plan was requested but not received. R19's most recent elopement assessment identified low risk and included clothing labeled with identification and an identification band, but did not select the door alarm band applied as an intervention. R12's assessments similarly identified low risk and listed clothing labeling and an identification band, but did not select the door alarm band applied. The record also showed inconsistencies between assessments, documentation, and staff statements. R13 and R17 had elopement assessments completed on 5/1/26 and their code alert devices were removed, while R19's EMR lacked evidence that elopement assessments were completed quarterly. R12's EMR lacked evidence of quarterly elopement assessments, and progress notes stated the assessments were reviewed with no change despite later documentation of a successful exit of the building and attempts to exit. During interviews, staff stated that residents with wandering or elopement risks should be identified on the care plan, that code alert devices were kept in a book at the main entrance desk, and that the MDS should be coded to reflect code alert placement because it drives care and the care plan.
Incomplete Care Plans for Elopement, Smoking, EBP, and Medication Needs
Penalty
Summary
The facility failed to develop comprehensive care plans with individualized elopement and wandering interventions for 14 residents who were identified as at risk for elopement and wandering. For multiple residents, quarterly, annual, or significant change MDS assessments documented severe or significant cognitive impairment, dementia, Alzheimer’s disease, vascular dementia, anxiety, or other neurocognitive disorders, yet the care plans did not include elopement or wandering interventions. Several of these residents also had code alert devices or wander guard alarms referenced in the record, but the care plans did not identify the device placement or include resident-specific interventions. In some cases, elopement assessments were completed and identified residents as low risk, but the care plans still lacked corresponding interventions or were not updated after later status changes. Specific examples included residents whose MDS assessments indicated cognitive impairment and no wandering behavior, while the care plans remained without elopement-related interventions. One resident’s elopement assessment was completed after a change in status and the code alert device was removed, but the care plan had not been revised to reflect the change. Another resident had a low-risk elopement assessment with interventions such as labeled clothing and an identification band, but the door alarm band was not selected. A resident with a code alert device on an assistive device had no care plan documentation identifying the device location. The facility’s own staff stated that wandering and elopement risks should be added to the care plan, that residents with code alert devices should be watched closely, and that assessments should be redone after events or changes, but this was not consistently done. The facility also failed to care plan other resident-specific needs for three residents. One resident’s care plan did not address sleep disturbance or antidepressant use despite receiving trazodone nightly for sleep. Another resident who smoked and had COPD, heart failure, Alzheimer’s disease, chronic cough, and emphysema was observed smoking outside the front door, but the care plan and nursing assistant group sheet did not identify smoking. A third resident receiving dialysis had no enhanced barrier precautions documented in the care plan or safety sheet, despite staff and the infection preventionist stating that such precautions were expected for residents with certain indwelling medical devices. The DON stated that care plans should include information about smoking, wanderguard use, enhanced barrier precautions, and medication use, but these items were not included for the residents reviewed.
Failure to Perform Hand Hygiene and Use Proper Ice Handling During Snack Pass
Penalty
Summary
The facility failed to ensure proper hand hygiene and proper use of an ice scoop during the snack pass. During an observation on 4/29/26 at 1:56 p.m., NA-A had a snack cart with two over-sized plastic pitchers filled with ice and stopped outside of R29's room. NA-A was not wearing gloves, entered the room, brought out the water cup, filled it with ice using a plastic water glass, returned the plastic glass to the over-sized pitcher with ice, exited the room, and did not perform hand hygiene. NA-A then went to R7's room without performing hand hygiene, entered the room, filled the water cup with ice using the plastic water glass resting on top of the ice, poured juice into a cup, and brought the items into the room. NA-A again exited without hand hygiene. NA-A then went to R30's room, exited with a plate of food, discarded it in the garbage bag attached to the snack cart, did not perform hand hygiene, picked up a banana, and brought it into the room before exiting again without hand hygiene. During interview, NA-A stated the snack cart was taken around to rooms twice daily and verified that the plastic water glass was put back into the over-sized pitcher with ice because it "doesn't touch anything." NA-A also verified that hand hygiene was not performed before or after exiting resident rooms or after disposing of uneaten food from R30's room. The residents involved had documented diagnoses including heart disease, hypertension, hyperlipidemia, GERD, heart failure, diabetes mellitus, and depression, and were described in their MDS assessments as moderately cognitively intact. The DON stated she would expect staff to perform hand hygiene before entering and after exiting a resident room and identified the use of a plastic water glass to fill resident water cups and then returning it to the ice pitcher as an infection control concern. The facility hand hygiene policy dated 6/2019 stated all employees would be trained on hand hygiene practices and that hand hygiene would be performed before and after handling food and after handling soiled utensils or equipment.
Failure to Honor Resident Request for Nail Care
Penalty
Summary
The facility failed to honor a resident’s preference for nail care and did not ensure the resident’s nails were trimmed when requested. The resident had an annual MDS assessment showing moderate cognitive impairment and diagnoses including non-Alzheimer’s dementia, renal insufficiency, hypertension, and depression. The care plan noted limited range of motion in the upper extremities and assistance needs for bathing, showers, grooming, oral care, and dressing. Progress notes showed the resident’s last shower on 4/3/26, but nail care was not addressed in the notes. During observation, the resident was seated in a wheelchair with long fingernails extending beyond the fingertips and stated the nails were too long and that staff had not trimmed them despite requests. A nail clipper was kept on the bedside table because the resident wanted the nails trimmed. On later interviews, the resident again stated the nails had not yet been trimmed and that it bothered them. Staff interviews showed nail care was typically done on shower days, but multiple staff members stated that if a resident requested nail trimming, either nursing assistants, wellness staff, or the nurse could do it, and the DON stated residents should not have to wait until the next bath day for nail trimming.
Deficiencies in Monitoring and Consent for Psychotropic Medications
Penalty
Summary
The facility failed to monitor orthostatic blood pressures for residents on antipsychotic medications, which is crucial due to the risk of orthostatic hypotension. This deficiency was observed in four residents, who were receiving medications such as quetiapine and Zyprexa. Despite physician orders to monitor orthostatic blood pressures monthly, the facility's records lacked evidence of these measurements being taken. Interviews with staff, including the Director of Nursing (DON), confirmed that orthostatic blood pressures were not consistently monitored, which could increase the risk of falls due to medication side effects. Additionally, the facility did not obtain signed consent for the use of an antidepressant medication for one resident. The resident was prescribed Lexapro for major depressive disorder, but the medical record did not contain any evidence of signed consent. The DON acknowledged that consents should be obtained for all mood-altering medications to ensure residents are informed about their treatment and potential side effects. The facility also failed to implement non-pharmacological interventions before initiating antipsychotic medication for one resident. The resident's medical record did not indicate any attempts to address behavioral symptoms through other means before prescribing quetiapine. Furthermore, the facility did not establish appropriate target behaviors for monitoring the effectiveness of psychotropic medications. For instance, one resident's target behavior was listed as sleeping six to eight hours, which the DON identified as a goal rather than a behavior. These deficiencies highlight a lack of adherence to policies regarding the use of psychotropic medications and monitoring of their side effects.
Improper PPE Use and Inadequate Infection Control Program
Penalty
Summary
The facility failed to ensure the correct use of personal protective equipment (PPE) to prevent the spread of COVID-19, affecting all residents, visitors, and staff in the short-term stay unit. Observations revealed that registered nurse (RN)-A reused N95 masks and goggles stored in paper bags, a practice that was common in the facility. Despite having an adequate supply of PPE, staff continued to reuse masks and goggles, which were stored in paper bags labeled with staff names. The infection preventionist (IP) and director of nursing (DON) acknowledged that new surgical masks should have been used to reduce the risk of spreading COVID-19. The facility also failed to develop and implement a comprehensive infection control program that included surveillance of infections not treated with antibiotics. The infection control logs from October to December 2024 only documented infections treated with antibiotics, such as urinary tract infections and cellulitis, but did not include viral, fungal, or yeast infections. The IP admitted that there was no tracking of infection symptoms or COVID-19 infections on spreadsheets, as they were not prescribed antibiotic therapy. The DON confirmed that tracking should include all residents with symptoms of illness, not just those prescribed antibiotics. The facility's policy on airborne precautions did not address the use of PPE, and the surveillance policy was not effectively implemented to identify conditions that increase the risk of infections. The lack of comprehensive infection tracking and the improper use of PPE contributed to the potential spread of infections within the facility. The IP and DON recognized the need for improved tracking and use of PPE to prevent the spread of COVID-19 and other infections among residents and staff.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were comprehensively assessed for self-administration of medications, as evidenced by the cases of two residents, R3 and R10. R3, who had moderate cognitive impairment and required assistance with all activities of daily living, was observed self-administering nebulizer treatments without staff supervision. Despite a previous assessment indicating R3 was not appropriate for self-administration, R3 was found using the nebulizer independently on multiple occasions. R10, also with moderate cognitive impairment and requiring assistance with most activities of daily living, was found with muscle rub cream and eye drops in his room, which he self-administered without a physician's order. Although R10 expressed a desire to self-administer medications, the assessment did not specify which medications he could self-administer, and it was determined he was not appropriate for self-administration. Despite this, R10 continued to self-administer the muscle rub and eye drops, and his nebulizer treatment was not completed as prescribed. The facility's policy requires a comprehensive assessment to determine if self-administration is clinically appropriate and safe, considering factors such as cognitive and physical abilities. However, the assessments for R3 and R10 were not adequately conducted or documented, leading to unsupervised self-administration of medications. The Director of Nursing confirmed that assessments should be completed at admission, quarterly, or with significant changes in status, and that a provider's order is necessary for self-administration, which was not obtained in these cases.
Failure to Support Resident Smoking Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination and choice by not providing opportunities for smoking, which was a significant aspect of the resident's quality of life. The resident, identified as R13, had a history of smoking and expressed a strong desire to continue this habit. Despite having intact cognition and being capable of making her own decisions, the facility did not assess or address her smoking preferences in her care plan. This oversight led to repeated incidents where R13 expressed anger and frustration due to the inability to smoke, as documented in multiple progress notes. R13's electronic health record lacked evidence of any assessment regarding her smoking habits, and her care plan did not address her wish to smoke. The facility's policy required residents who wished to smoke to leave the property, but R13 was not supported in doing so. This resulted in numerous documented instances of R13 attempting to smoke on the premises, asking staff for cigarettes, and expressing anger when her requests were denied. Staff interviews confirmed that R13's behaviors, including verbal aggression, were linked to nicotine withdrawal and the facility's failure to accommodate her smoking preference. The facility's non-smoking policy and lack of a tailored care plan for R13's smoking needs contributed to ongoing behavioral issues. Staff members reported that R13's aggressive behaviors were primarily verbal and stemmed from her inability to smoke. Despite the facility's recognition of resident rights to self-determination, the failure to facilitate R13's smoking preference led to repeated conflicts and dissatisfaction, impacting her quality of life and well-being.
Failure to Complete Neurological Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to complete neurological assessments following unwitnessed falls for two residents, R7 and R25. R7 experienced multiple unwitnessed falls, with one incident on 6/5/24 where a bump was noted on her forehead, yet the neurological assessment was incomplete with several time slots left blank or marked as 'sleeping.' Similarly, on 12/13/24, R7 had two unwitnessed falls, but there was no evidence of neurological assessments being completed. R25 also had an unwitnessed fall on 1/7/25, resulting in a large bump above her right eye, but the neurological assessment was not thoroughly completed, with time slots left blank or marked as 'eating.' Interviews with staff revealed a lack of adherence to the facility's fall protocol, which required waking residents to complete assessments. The facility also failed to administer medications per physician's orders for resident R30, who was reviewed for bowel management. R30 had not had a bowel movement in six days, and the electronic health record lacked evidence that as-needed medications for constipation were provided. Despite R30's complaints of constipation due to dialysis, fluid restriction, and pain medication, the facility did not follow the bowel protocol, which included administering prune juice, senna, suppositories, and enemas on specific days without a bowel movement. Additionally, the facility failed to obtain vital signs per physician's orders for R30. After the discontinuation of carvedilol on 2/4/25, there was an order to monitor R30's heart rate closely, but the last recorded pulse was on 2/1/25. The Director of Nursing confirmed that the order for regular pulse checks was not followed, which was crucial for R30's health. The facility's policy for processing physician's orders was requested but not provided, indicating a potential gap in ensuring compliance with medical directives.
Failure to Provide Audiology Services for Hearing-Impaired Resident
Penalty
Summary
The facility failed to ensure proper treatment was provided to maintain hearing for a resident with moderate cognitive impairment who required assistance with most activities of daily living (ADLs). The resident's care plan indicated that qualified nursing staff would monitor for changes in communication abilities and offer to arrange a hearing evaluation as needed. However, the resident's electronic health record lacked evidence that an audiology appointment was offered. During multiple observations, the resident was noted to be without hearing aids and expressed difficulty hearing, stating that the facility had not discussed audiology services with him. Interviews with nursing assistants and the clinical manager confirmed that the resident was very hard of hearing and did not wear hearing aids. The clinical manager acknowledged the absence of documentation indicating that audiology services were discussed with the resident. The Director of Nursing stated that if staff noticed a progression in hearing loss, the facility should offer audiology services and check for wax buildup. The facility's policy indicated that staff would assist hearing-impaired residents in maintaining effective communication and arranging necessary services, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention and Repositioning Interventions
Penalty
Summary
The facility failed to implement care plan interventions to prevent pressure ulcers for a resident who was at high risk due to severe cognitive impairment and dependency on staff for care. The resident's care plan included the use of pressure-relieving boots while in bed, but observations on multiple occasions showed the boots were not on the resident's feet while in bed. Interviews with staff confirmed that the boots were supposed to be used during all bedtimes, including naps, but were not consistently applied as required by the care plan. Additionally, the facility did not provide timely assistance with repositioning for another resident with a stage four pressure ulcer and severe cognitive impairment. The care plan required repositioning every two hours, but observations indicated the resident remained in a wheelchair for over four hours without repositioning. Interviews with staff confirmed the expectation to reposition the resident every two hours, which was not adhered to, despite the resident's high risk for skin integrity issues due to existing conditions and severe malnutrition.
Failure to Assess and Supervise Resident Smoking in Non-Smoking Facility
Penalty
Summary
The facility failed to comprehensively assess and ensure the safety of a resident, R13, who was smoking outside the facility, despite being a non-smoking facility. R13's medical records indicated a history of tobacco use, dementia, and other health conditions, but there was no evidence of a smoking assessment in her electronic health record. The facility's staff, including the administrator and clinical manager, initially stated that there were no residents who smoked. However, multiple progress notes documented instances where R13 attempted to smoke outside, sometimes with the assistance of staff, and at other times by herself. These incidents included R13 attempting to light a match on the building, hiding cigarettes, and demanding them back from staff who confiscated them. Interviews with various staff members, including nursing assistants, a registered nurse, and the director of nursing, confirmed that R13 was known to smoke outside frequently, despite the facility's non-smoking policy. The facility's Tobacco/Smoke Free policy required residents who wished to continue smoking to sign out and leave the property, but this was not enforced for R13. The director of nursing acknowledged that a smoking assessment should have been completed when R13 was first observed smoking, but confirmed that no such assessment had been conducted. This oversight led to a failure in adequately supervising and ensuring the safety of R13 in relation to her smoking habit.
Failure to Monitor Pulse Before Administering Digoxin
Penalty
Summary
The facility failed to ensure the development and implementation of parameters for administering heart rate control medication, specifically digoxin, for two residents, R13 and R40. Both residents were receiving digoxin for heart rate control without appropriate monitoring of their pulse prior to administration. R13, who had intact cognition and multiple diagnoses including atrial flutter, was receiving digoxin without any parameters indicating when the medication should be held based on heart rate. The Medication Administration Record (MAR) for R13 did not include pulse measurements before digoxin administration, and only three pulse measurements were recorded over a period of more than a month. Similarly, R40, who had severe cognitive impairment and multiple diagnoses including paroxysmal atrial fibrillation, was also receiving digoxin without parameters for heart rate monitoring. The MAR for R40 did not include pulse measurements before digoxin administration, and only 12 pulse measurements were recorded over a similar period. During an observation, a trained medication aide administered medications to R40 without checking the pulse, and the aide confirmed that there were no vitals obtained prior to medication administration. Interviews with staff, including a registered nurse and the director of nursing, revealed that there were no orders in place for pulse checks prior to administering digoxin for either resident. The director of nursing and consultant pharmacist both stated that it was standard practice to obtain a pulse before administering digoxin, and the facility's policy indicated that an apical pulse should be obtained prior to administration. However, this practice was not being followed, leading to the deficiency in medication administration for R13 and R40.
Failure to Offer PCV20 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was offered and/or provided the pneumococcal vaccine series as recommended by the CDC. R30, who was over the age of 65, had received the PPSV23 vaccine on two occasions and the PCV13 vaccine once. However, there was no evidence in the records of shared clinical decision-making with a physician regarding the administration of the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. The absence of this documentation indicates that R30 was neither offered nor received the PCV20 vaccine. During an interview, the infection preventionist acknowledged that R30 was not listed for the PCV20 vaccine on the tracking worksheet, despite the last pneumococcal vaccine being administered over six years prior. The facility's policy on pneumococcal vaccines, last reviewed in October 2022, did not address the administration or offering of the PCV20 vaccine with shared decision-making with a provider. This oversight in policy and practice contributed to the deficiency identified in the report.
Failure to Manage Bowel and Constipation Needs
Penalty
Summary
The facility failed to manage the bowel and constipation needs of a resident (R2) who had diagnoses including Alzheimer's Disease, constipation, and severely impaired cognition. R2's care plan indicated a goal of having a bowel movement (BM) at least every three days, with interventions such as monitoring BM status daily and administering medications as ordered. However, the medical record showed multiple periods where no BM was documented, specifically from 12/29/23 through 1/4/24, 2/4/24 through 2/9/24, 2/14/24 through 2/17/24, and 2/23/24 through 2/28/24. During these periods, there was no evidence that the facility's Bowel Movement Protocol was implemented, which included steps like administering Milk of Magnesia, Bisacodyl suppository, or a fleet enema, and contacting the provider for further orders if no BM occurred by day three. Interviews with staff, including LPN-A, RN-A, RN-B, and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding R2's constipation issues. LPN-A mentioned that Milk of Magnesia or MiraLAX was effective for R2's constipation, but there was no documentation of these interventions during the specified periods. RN-A and RN-B were not aware of any constipation concerns for R2, and the DON confirmed the lack of evidence in the medical record for both BM documentation and the implementation of the Bowel Movement Protocol. The facility's Bowel Protocol directed staff to review bowel reports daily and take specific actions if no BM occurred, but these steps were not followed for R2 during the documented periods.
Failure to Implement New Interventions After Resident Falls
Penalty
Summary
The facility failed to assess and implement new interventions to prevent future falls for a resident with Alzheimer's Disease and severely impaired cognition. The resident had a history of falls, with two unwitnessed falls occurring within a short period. Despite the resident's care plan identifying them as at risk for falls and listing several interventions, no new interventions were implemented following the falls to prevent reoccurrence. The resident's medical record lacked evidence of new interventions after each fall, even though the interdisciplinary team reviewed the incidents and ruled out abuse and neglect. Interviews with staff confirmed that the resident was at risk for falls due to impulsive behavior and poor safety awareness. Staff were directed to visually check on the resident frequently, keep the bed in the lowest position, and ensure the resident wore gripper socks or shoes. However, the registered nurse and director of nursing acknowledged that no new interventions were implemented following the falls, despite the facility's policy requiring additional or different interventions if falls reoccur. The failure to implement new interventions was noted, even though the falls occurred around the time the resident typically went to bed, indicating a potential pattern that was not addressed.
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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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