St Crispin Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Red Wing, Minnesota.
- Location
- 213 Pioneer Road, Red Wing, Minnesota 55066
- CMS Provider Number
- 245449
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at St Crispin Living Community during CMS and state inspections, most recent first.
A resident with chronic pain, an amputation, and PTSD was ordered morphine IR 15 mg QID with PRN 7.5 mg doses, but staff failed to secure a timely refill when the supply ran low, resulting in multiple missed scheduled doses and only a single partial PRN dose over roughly a day. A day‑shift RN recognized the impending shortage but did not obtain a new prescription, and an on‑call NP later signed an electronic order without confirming pharmacy receipt, declined to resend it that night, and did not order alternative pain control or monitoring for opioid withdrawal. The resident reported 10/10 pain, remained in bed, had decreased appetite, and increased anxiety, while his spouse observed sweating, confusion, and functional decline, and documentation showed no comprehensive assessment for withdrawal. Review of narcotic records revealed incomplete controlled substance sheets lacking RX numbers, prescriber names, and directions, and discrepancies between documented quantities received and pharmacy packing slips for morphine, compromising accurate tracking and availability of the opioid.
A resident with chronic pain syndrome had scheduled morphine IR 15 mg ordered four times daily, but multiple doses were missed when the medication ran out and was not available. Nursing staff contacted the on-call NP and pharmacy several times, but the NP did not resend the prescription that evening, did not order alternative pain management, and did not direct monitoring for withdrawal or increased pain. The resident reported severe pain, decreased mobility, poor appetite, and increased anxiety during the period without scheduled morphine. The pharmacy later confirmed it had not received the NP’s prescription that night and stated that an emergency verbal order process existed and that the lack of medication constituted an omission medication error, while facility policy required timely practitioner orders and 24-hour physician services for immediate care needs.
A resident with chronic pain had scheduled Morphine IR doses ordered four times daily, along with a PRN Morphine order, but multiple scheduled doses were not administered because the medication was not available, and one dose was given late. Progress notes showed staff repeatedly contacted the on-call provider, triage RN, and pharmacy about the missing prescription, and the NP declined to fax the order until a later time. The DON later acknowledged that the missed doses constituted an allegation of neglect but was unaware of the situation at the time, and the event was not reported to the State Agency as required by the facility’s Abuse Prevention Plan policy.
A resident with chronic pain syndrome, amputation, shrapnel‑related osteoarthritis, and PTSD was on scheduled morphine IR with a PRN order. Staff failed to timely re‑order and ensure availability of the scheduled morphine, resulting in four missed doses and a prolonged gap in full opioid coverage. During this period, the resident reported pain escalating from a baseline 5/10 to 10/10, remained in bed, had decreased appetite, increased anxiety, sweating, and confusion, while his spouse observed him quiet, diaphoretic, and unable to operate the TV remote. Nursing documentation between the missed doses lacked comprehensive pain assessments with pain characteristics, non‑pharmacologic interventions, increased monitoring for escalating pain or opioid withdrawal, or consideration of emergency transfer. One RN recognized in advance that the morphine supply would be insufficient but did not contact the provider due to time constraints, subsequent nurses confirmed the missed doses and significant pain, and the DON was not notified and did not become aware until later. The NP did not verify that the prescription reached the pharmacy, did not provide alternate pain management orders, and did not direct staff to monitor for withdrawal. The facility’s pain management policy required ongoing assessment and reassessment but did not specify when to complete comprehensive assessments, how to document baseline pain, or what steps to take when scheduled pain medications are missed or unavailable, contributing to the deficient pain management.
The facility failed to maintain kitchen equipment, specifically a hotbox used to keep food warm, leading to food being served at unsafe temperatures. The hotbox's top compartment lacked a working thermometer and displayed an error code, which the culinary director could not explain. The environmental services manager found no maintenance records, and the administrator was unaware of the issue, highlighting a lack of oversight and documentation.
The facility failed to properly manage contaminated linen in the 300-unit laundry room, where a yellow-stained bed sheet was left unbagged on the floor beneath clean resident laundry. The room was dirty, with lint scraps and a mildew smell. Staff interviews revealed that NAs were responsible for maintaining cleanliness, but the room remained unclean. The DON and RRN confirmed the issues, and the IP acknowledged that soiled linens sometimes get mixed with residents' clothing, contrary to facility policy.
A resident admitted with multiple fractures and a surgical wound in the left groin area was not properly assessed or treated according to physician orders. The facility failed to transcribe the discharge instructions into the resident's records, leading to a lack of monitoring and documentation of the surgical wound. This oversight resulted in the wound dehiscing and becoming infected, necessitating a five-day hospital stay for surgical intervention and antibiotic therapy.
Failure to Maintain Opioid Availability and Controlled Substance Accountability
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective pharmacy services and continuous availability of prescribed opioid pain medication for a resident with chronic pain and long-term morphine therapy. The resident had diagnoses including chronic pain syndrome, an above-the-knee amputation, post‑traumatic osteoarthritis with contracture, and PTSD, and was cognitively intact but dependent on staff for transfers and toileting. He had MD orders for morphine IR 15 mg four times daily on a scheduled regimen and morphine IR 7.5 mg twice daily PRN. On one day, the day‑shift RN recognized that the resident’s supply of scheduled morphine IR 15 mg tablets would be insufficient but did not contact the provider for a new prescription before the end of the shift, citing time constraints, and only verbally informed the oncoming nurse without verifying that a prescription was obtained. Later that day, the scheduled afternoon and evening 15 mg morphine doses were not administered because the drug was not available, and only a single 7.5 mg PRN dose was given in place of a full scheduled dose. The evening RN attempted multiple times to reach the on‑call NP through a triage nurse and was told by the NP later that she had signed the order in the electronic system but did not verify that the prescription reached the pharmacy and refused to resend it that night, stating she would address it in the morning. The NP did not provide alternative pain management orders, did not order monitoring for opioid withdrawal symptoms, and did not inquire whether doses had already been missed. Pharmacy records confirmed that no morphine prescription from the NP was received that day, and the pharmacy indicated that no calls from the facility were logged during the reported time frame, despite staff documentation that the pharmacy had been contacted multiple times. The following morning, the resident’s early scheduled morphine dose was again not administered due to lack of medication, and the day‑shift RN was not informed by night staff that multiple doses had been missed. She did not contact the on‑call provider until after mid‑morning, when she discovered the resident was out of morphine, at which time the triage RN and a PA became involved to send a new prescription and authorize use of the e‑kit. The resident reported that during the period without his scheduled morphine he experienced pain at 10/10, could not get out of bed, had decreased appetite, and his anxiety worsened; his spouse observed him sweating, unusually quiet, confused, and unable to operate the TV remote as usual. Documentation showed that the resident went approximately 24 hours without a full scheduled 15 mg dose and about 20.5 hours with only a partial 7.5 mg PRN dose instead of his ordered regimen, with no comprehensive assessment for opioid withdrawal symptoms and no enhanced monitoring for increased pain. In addition to the failure to maintain medication availability, the facility failed to ensure proper reconciliation, transcription, and accountability of controlled substances for the same resident’s morphine. Review of the controlled substance book and medication cart revealed incomplete documentation and discrepancies between the narcotic record, bubble packs, and pharmacy packing slips. One controlled substance sheet documented receipt of 24 tablets of morphine 15 mg without listing the RX number, prescriber name, or directions, and the corresponding bubble pack was no longer present for verification. Another sheet documented receipt of 12 tablets for PRN morphine, while the pharmacy packing slip for the same RX and label indicated delivery of only 6 tablets, and the controlled substance sheet again lacked RX number, prescriber, and directions. These inconsistencies and omissions compromised the facility’s ability to accurately track, verify, and ensure availability of the resident’s ordered controlled substances. The DON stated she was unaware that the resident had missed multiple scheduled morphine doses and acknowledged that this represented a significant medication error that could place the resident at risk for acute withdrawal and significant pain. She confirmed that the provider had not been notified about the missed doses at the time, that no medication error report had been completed, and that there were no orders in place during the gap to control the resident’s pain or to monitor for withdrawal symptoms. The consultant pharmacist and medical director both confirmed, based on record review and interviews, that the resident went without morphine for an extended period, that there were no comprehensive assessments or monitoring for pain or acute opioid withdrawal during that time, and that missing scheduled doses of IR morphine would be expected to result in increased pain and potential withdrawal signs such as sweating and nausea. The surveyors determined that these failures in ordering, communication, monitoring, and controlled substance documentation resulted in severe unmanaged pain and possible early opioid withdrawal symptoms for the resident and constituted immediate jeopardy beginning when the facility first failed to ensure the resident’s prescribed morphine was available for administration.
Failure to Obtain Timely Practitioner Orders and Morphine Refill for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely practitioner orders and provision of prescribed narcotic pain medication when a resident’s scheduled morphine was not available. The resident had an order dated 11/28/23 for morphine IR 15 mg to be administered four times daily for chronic pain syndrome at 6:30 a.m., 11:30 a.m., 4:00 p.m., and 8:00 p.m. The February 2026 MAR showed that on 2/2/26 the 4:00 p.m. and 8:00 p.m. scheduled doses were not administered because the medication was not available, and only a single 7.5 mg PRN dose was given at 5:03 p.m. On 2/3/26, the 6:30 a.m. scheduled dose was not administered and the 11:30 a.m. dose was given late at 1:36 p.m., again due to unavailability of the ordered morphine. Progress notes and interviews documented repeated but unsuccessful efforts by nursing staff to obtain a new prescription and supply of morphine. On the evening of 2/2/26, staff contacted the on-call provider and pharmacy multiple times and documented that the medication was not available. The nurse practitioner reported she had sent the morphine prescription to the pharmacy at 7:00 p.m., but the pharmacy could not locate it, and she declined to fax or resend the prescription that night, stating she might do so the following morning. She did not provide alternative pain management orders, did not give instructions to monitor for opioid withdrawal symptoms, and did not direct staff on how to address increased pain. The charge RN confirmed she attempted to reach the NP multiple times between mid-afternoon and late evening, could not use the MAR reorder function because a new prescription was required, and identified the failure to obtain a timely prescription as the root cause of the missed doses. The resident reported that after running out of morphine in the afternoon, he did not receive his scheduled doses for almost a full day, during which he experienced pain rated 10/10, inability to get out of bed, decreased appetite, and worsened anxiety with difficulty swallowing. The pharmacist stated the pharmacy did not receive a morphine prescription from the NP on 2/2/26 and only received a new prescription from a certified physician assistant the following day, which included authorization to obtain a dose from the e-kit. The pharmacist explained that after-hours procedures allowed for emergency verbal prescriptions for controlled substances and characterized the lack of medication in this situation as an omission medication error. The facility’s Physician Services policy required that a physician, NP, or PA provide orders for residents’ immediate care needs, ensure 24-hour availability of physician services in case of emergency, and maintain residents under physician care with timely communication and documentation of orders, which was not met in this case when timely orders and medication were not secured for the resident’s pain management.
Failure to Timely Report Alleged Neglect Related to Missed Pain Medication Doses
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency within the required timeframe after a resident missed multiple scheduled doses of prescribed pain medication. The resident had physician orders for Morphine IR 15 mg four times daily for chronic pain syndrome and an additional PRN order for Morphine IR 7.5 mg twice daily for pain. The February 2026 MAR showed that the 4:00 p.m. and 8:00 p.m. scheduled doses on 2/2/26 and the 6:30 a.m. scheduled dose on 2/3/26 were not administered because the medication was not available in the facility, and the 11:30 a.m. dose on 2/3/26 was administered late at 1:36 p.m. Progress notes documented that staff contacted the on-call provider and pharmacy multiple times regarding the morphine prescription, that the pharmacy had not received or located the prescription, and that the NP declined to fax the prescription that evening, indicating it might be sent the following morning. Further progress notes indicated continued unavailability of the scheduled morphine dose the following morning and additional contacts with the triage RN on-call, who reported sending a renewed order to the pharmacy and contacting an on-call certified physician assistant. During an interview, the DON stated she was not aware that the resident had missed multiple scheduled doses of morphine due to the medication not being available and confirmed that this constituted an allegation of neglect that had not been reported to the State Agency. The facility’s Abuse Prevention Plan policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required immediate reporting of suspected abuse or neglect to the Executive Director or designee and to the Minnesota Department of Health via the online reporting system in accordance with legal timeframes. Despite these policy requirements, the allegation of neglect related to the missed morphine doses was not reported as required.
Failure to Maintain Scheduled Opioid Therapy and Comprehensive Pain Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s scheduled opioid pain medication was re-ordered, available, and administered as ordered, and to provide comprehensive pain assessment and monitoring when doses were missed. The resident had chronic pain syndrome, an above-the-knee amputation of the left leg, post‑traumatic osteoarthritis with contracture of the left hand from shrapnel injury, and PTSD. His MDS showed intact cognition, dependence on staff for transfers and toileting, use of a motorized scooter, and a scheduled pain regimen without PRN or non‑pharmacological pain interventions. The CAA documented frequent moderate pain over five days and directed staff to assess pain each shift, notify the provider of unrelieved pain, and use pharmacologic and non‑pharmacologic interventions. However, the care plan problem statement for pain was left blank, lacked a documented baseline pain level, and did not provide clear guidance for managing chronic pain, scheduled opioid administration, or monitoring when medications were unavailable, despite an intervention requiring a pain scale each shift. The resident had physician orders for morphine IR 15 mg four times daily for chronic pain and morphine IR 7.5 mg twice daily PRN. The MAR showed that on one day the 4:00 p.m. and 8:00 p.m. scheduled 15 mg doses were not administered because the medication was not available, and a 7.5 mg PRN dose was given at 5:03 p.m. as a substitute. The following morning, the 6:30 a.m. scheduled dose was not administered, and the 11:30 a.m. dose was given late at 1:36 p.m., resulting in four missed scheduled doses and a prolonged gap in full opioid coverage. Progress notes documented repeated contacts with the on‑call provider and pharmacy about the morphine prescription and that the medication was not available. The NP reported having sent a prescription to the pharmacy but did not fax it to the facility that evening and did not provide alternate pain management orders or instructions to monitor for increased pain or withdrawal. A triage RN later reported sending a renewed order to the pharmacy and contacting an on‑call PA. The vitals and intake records for the two days of missed doses showed no documented food intake, with improved intake afterward, and resident and family interviews described decreased appetite during the medication gap. During this period, the record lacked comprehensive pain assessments that included pain characteristics, documentation of non‑pharmacological interventions attempted or offered, increased monitoring for escalating pain or opioid withdrawal symptoms, or any offer or suggestion of emergency transfer for pain management. The resident reported that when he receives all scheduled morphine doses his baseline pain is 5/10, but during the gap he experienced pain at 10/10, could not get out of bed, had decreased appetite, and increased anxiety with difficulty swallowing. He stated he tends to shut down and not ask for medication when in severe pain and that staff only asked for a numerical pain rating without exploring specifics. His spouse described him as stoic, noted that he was sweating, quiet, confused, and unable to operate the TV remote, and confirmed that he did not call her as he usually did. Multiple nurses described him as stoic and requiring prodding to report pain; one nurse identified in advance that the morphine supply would be insufficient but did not contact the provider due to time constraints, and subsequent nurses confirmed the missed doses and significant pain. The DON acknowledged unawareness of the missed doses, agreed this represented a significant medication error with no provider notification, no monitoring for withdrawal, and no alternative pain management, and confirmed that the facility’s pain management policy did not specify when to complete comprehensive pain assessments, how to document baseline pain, or what steps to follow when scheduled pain medications are missed or unavailable. The pharmacist and medical director characterized the situation as emergent, explained the pharmacology of IR morphine, and stated that even one missed dose should trigger assessment and monitoring for escalating pain and acute opioid withdrawal, underscoring that the clinical team was responsible for ensuring communication, medication availability, and monitoring when a scheduled opioid dose was missed. The facility’s written pain management policy required evaluation, documentation, and reassessment of pain at regular intervals, with each new report of pain, and after interventions, using an interdisciplinary approach and involving the resident and responsible party. However, the policy did not specify when or where a comprehensive pain assessment must be completed, did not provide guidance for documenting baseline pain, and did not outline steps to follow when scheduled pain medications are missed or unavailable. This lack of detailed procedural guidance, combined with staff failures to timely re‑order morphine, ensure its availability, notify providers of missed doses, and conduct comprehensive assessments and monitoring during the medication gap, led to the resident experiencing unmanaged severe pain, decreased appetite, sweating, confusion, and anxiety during the period when his scheduled opioid therapy was interrupted.
Failure to Maintain Kitchen Equipment for Safe Food Temperatures
Penalty
Summary
The facility failed to maintain kitchen equipment used to keep food warm prior to serving, as observed during a survey. The culinary director (CD) was found using a hotbox with a malfunctioning top compartment that lacked an internal thermometer and displayed an error code 'E00' on the external display. The CD was unable to clarify the meaning of the error code and was uncertain about the last service date of the hotbox. During a meal service, egg rolls stored in the hotbox were found to have an internal temperature of 120 degrees, which was below the safe serving temperature. The CD acknowledged that improper food temperatures could increase the risk of foodborne illness and stated that staff should monitor and log food temperatures, and report malfunctioning equipment to supervisors or maintenance. Further investigation revealed that the environmental services manager (ESM) could not find any service slips or maintenance requests for the hotbox since January. The ESM mentioned that parts from a second hotbox had been used to fix the current one, but could not verify when this occurred. The facility administrator was unaware of the equipment issue and stated that malfunctioning equipment should be taken out of service until repaired. Maintenance logs and equipment information were requested but not provided, indicating a lack of documentation and oversight in maintaining essential kitchen equipment.
Improper Management of Contaminated Linen in Laundry Room
Penalty
Summary
The facility failed to properly manage and contain contaminated linen in the 300-unit laundry room, which had the potential to affect all 15 residents on the unit. During a tour, it was observed that a yellow-stained contaminated bed sheet was left unbagged on the floor, with clean resident laundry placed in a basket on wheels above it. The laundry room was found to be dirty, with used lint scraps, a used paper towel, and a mildew smell present. The detergent compartment on the washer was also dirty with lint scraps and old soap. Interviews with staff revealed that nursing assistants (NAs) were responsible for keeping the laundry room tidy, but the room remained unclean and the contaminated sheet was not properly bagged and removed. The director of nursing (DON) and regional registered nurse (RRN) confirmed the presence of the unbagged contaminated linen and the mildew smell during their observation. The infection preventionist (IP) stated that soiled linens should be bagged at the point of care and taken to the soiled utility room, but acknowledged that sometimes soiled facility linens get mixed up with residents' personal clothing. The facility's policy dated 5/15/24 also stated that dirty linens should be bagged at the point of use and kept separate from clean laundry, which was not adhered to in this instance.
Failure to Monitor and Treat Surgical Wound Leads to Hospitalization
Penalty
Summary
The facility failed to assess, monitor, and treat a surgical wound according to physician orders for a resident who was admitted with multiple fractures and a surgical wound in the left groin area. Upon admission, the facility did not comprehensively assess the surgical wound or transcribe the physician's orders for its monitoring and treatment into the resident's electronic health record. This oversight resulted in the wound dehiscing and becoming infected, leading to a five-day hospital admission for surgical intervention, antibiotic therapy, and wound vacuum-assisted closure. The resident's hospital discharge summary included specific instructions for the care of the left groin incision, which were not transcribed into the facility's records. The facility's staff failed to document the presence, absence, or removal of the Mepilex Ag dressing that was ordered to be in place over the incision. Progress notes and skin assessments did not identify or monitor the left groin incision, and the baseline care plan was incomplete, lacking specific interventions for the resident's surgical wound. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's surgical incision. Staff members, including licensed practical nurses and registered nurses, did not recall seeing or assessing the incision, and there was no evidence of a comprehensive skin assessment being conducted. The facility's director of nursing and medical director acknowledged the discrepancies in documentation and the failure to follow physician orders, which contributed to the resident's wound dehiscence and subsequent hospitalization.
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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