St Williams Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkers Prairie, Minnesota.
- Location
- 212 West Soo Street, Box 30, Parkers Prairie, Minnesota 56361
- CMS Provider Number
- 245588
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at St Williams Living Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and on anticoagulant therapy developed increased right hip pain and extensive bruising of unknown origin. Staff noted and treated the symptoms but did not promptly notify the physician or the resident's family, despite facility policy requiring such notifications for unexplained bruising and changes in condition. The physician and family only became aware after the resident was sent to the ER, resulting in a deficiency for delayed communication.
A resident with severe cognitive impairment and on anticoagulant therapy developed significant bruising and pain of unknown origin. Multiple staff observed and documented the injuries over several days, but failed to promptly notify the DON, administrator, or state authorities as required by policy. The delay in reporting and investigation did not meet regulatory requirements for timely response to potential abuse or neglect.
A resident with severe cognitive impairment and on anticoagulant therapy developed significant bruising and hip pain of unknown origin. Despite multiple staff observations and documentation of pain and bruising, there was a delay in reporting the injury to authorities and initiating an investigation. Staff interviews revealed incomplete documentation and lack of timely communication with the provider and DON, resulting in a deficiency for failure to respond appropriately to an alleged violation.
A resident with multiple medical conditions who required assistance with bed mobility became trapped between a newly installed air mattress and bed side rail after staff failed to assess entrapment zones as required by facility policy. The omission occurred when staff replaced the mattress but did not check for gaps, resulting in the resident sustaining injuries and requiring assistance to be freed.
The facility's infection control program was found deficient due to incomplete surveillance logs from September to December 2024. The logs lacked critical data such as signs and symptoms of infections, antibiotic start and stop dates, and antibiotic timeouts. Interviews with the IP and DON confirmed these deficiencies, which did not meet national standards for infection prevention and control.
The facility exhibited deficiencies in food handling and sanitation, including improper glove use by a dietary aide, unsanitary conditions of the ice machine, and failure to maintain proper food temperatures. These practices could potentially lead to foodborne illness among residents.
Failure to Notify Physician and Family of Resident's Increased Pain and Bruising
Penalty
Summary
The facility failed to ensure timely notification of a physician and a resident's representative regarding increased right hip pain and significant bruising in a resident with severe cognitive impairment and multiple comorbidities, including atrial fibrillation and use of anticoagulant medication. The resident, who was dependent for transfers and had a history of falls, began experiencing right hip pain and was observed with bruising of unknown origin. Documentation shows that pain and bruising were noted and treated with Tylenol, but there was a delay in reporting these changes to the physician and family. Staff interviews revealed that bruising was first identified and reported among staff, but not immediately communicated to the physician or family, and the size and extent of the bruising were not consistently documented at the time of discovery. Progress notes and staff interviews indicate that the resident's pain increased over several days, with pain scores reaching as high as eight or nine out of ten, and the bruising expanded in size and severity. Despite these changes, the physician was not notified until after the resident was sent to the emergency room at the request of the family, who was also not informed of the situation until the evening the resident was transferred. The medical director confirmed that he was not made aware of the bruising or pain until a follow-up visit days later, and the family expressed concern that they would have requested medical evaluation sooner had they been notified earlier. Facility policy required staff to notify the physician and family of unexplained bruising or changes in condition, especially for residents on anticoagulants. However, staff interviews and documentation review confirmed that these notifications did not occur promptly. The delay in communication and incomplete documentation of the resident's condition led to a deficiency in ensuring that significant changes in the resident's health status were reported as required.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of potential abuse within the required two-hour timeframe for a resident with an injury of unknown origin. The resident, who was severely cognitively impaired and required substantial assistance for transfers, was observed to have multiple bruises and a scabbed scratch on the right hip and lower extremities over several days. Despite ongoing documentation of pain, bruising, and changes in condition, the initial bruising was not reported to the state agency as required, and an investigation was not promptly initiated. The resident had a complex medical history, including atrial fibrillation managed with anticoagulant therapy, dementia, arthritis, and a history of falls. Staff documented increasing right hip pain, grimacing, and significant bruising that expanded over time. Multiple staff members, including nursing assistants and LPNs, observed and documented the bruising and pain, but there was a delay in notifying the Director of Nursing, administrator, and state authorities. The resident was unable to recall the cause of the injuries due to cognitive impairment, and staff interviews confirmed that the bruises were of unknown origin and should have been reported immediately. Facility policy required that all allegations of abuse, neglect, or injuries of unknown origin be reported to the appropriate authorities within two hours. However, the report to the state agency was not made until several days after the initial identification of the bruising. Interviews with staff and review of documentation revealed that the required notifications and investigation were not initiated in a timely manner, resulting in a failure to protect the resident as outlined in facility policy and regulatory requirements.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential resident abuse for a resident who was found to have an injury of unknown origin. The resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, developed significant bruising and right hip pain over several days. Despite multiple observations and documentation of pain and bruising by nursing staff, there was a delay in reporting the injury to the appropriate authorities and in initiating an investigation into the cause of the bruising. Staff interviews revealed that bruising was observed and reported to nurses, but the injury was not measured, and documentation was incomplete. The resident's pain increased, and the bruising expanded before the incident was reported to the state and an investigation was started. The resident's medical history included atrial fibrillation, dementia, arthritis, and use of an anticoagulant, which increased the risk of bruising. Staff documented ongoing pain and bruising, with the resident at times unable to recall how the injury occurred. Despite these findings, there was a lack of timely communication with the medical provider, and the director of nursing was not notified promptly when the bruising and pain worsened. The facility's policy required immediate investigation and reporting of suspected abuse or unexplained injuries, but this was not followed in this case. Interviews with staff and the medical director confirmed that the resident's cognitive impairment made it difficult to obtain an accurate history, but staff were expected to report and investigate unexplained injuries immediately. The delay in reporting, incomplete documentation, and failure to initiate an immediate investigation resulted in a deficiency related to the facility's response to an alleged violation and potential abuse.
Failure to Assess Bed Rail Entrapment Risk After Mattress Replacement
Penalty
Summary
Facility staff failed to properly assess and ensure the safe use of bed rails for a resident who required assistance with bed mobility. The resident, who had diagnoses including wheezing, pneumonia, sleep apnea, and weakness, was assessed to use double half side rails for mobility and was able to use the rails to assist with turning and repositioning. However, the resident also required partial to moderate assistance to roll and extensive assistance from staff for bed mobility, as documented in the care plan. On the night of the incident, staff replaced the resident's mattress with an alternating pressure air mattress due to the previous mattress not holding air. The new mattress was installed on a bed with side rails attached, but staff did not assess the entrapment zones between the mattress and the side rails after the replacement. This omission was contrary to facility policy, which required assessment of bed rail and mattress compatibility to prevent gaps that could entrap a resident. The facility's policy also specifically prohibited the use of side rails with air mattresses due to entrapment risk. As a result of the failure to assess the entrapment zones, the resident was found with his head trapped between the mattress and the side rail, unable to free himself and experiencing pain and skin tears. Staff had difficulty removing the resident's head from the gap, and the incident was later confirmed by a bed rail gap test, which the bed did not pass. The entrapment assessment had not been performed when the mattress was swapped, leading directly to the resident's injury.
Removal Plan
- Updated policy to include side rails will not be used with air mattresses
- Licensed nurses were educated on the side rail policy, Side Rail Assessment, Bed Rail/Mattress Safety Assessment including how to measure for gaps that may cause entrapment
Inadequate Infection Control Surveillance
Penalty
Summary
The facility failed to establish an ongoing infection control program that included comprehensive surveillance of resident infections. The infection control surveillance log from September to December 2024 lacked critical data such as signs and symptoms for each infection, dates when cultures were obtained, and start and stop dates for antibiotics. This deficiency was identified through a review of the facility's infection control surveillance log, which showed incomplete documentation for various infections, including urinary tract infections, tooth infections, and respiratory conditions. During interviews, both the infection preventionist (IP) and the director of nursing (DON) confirmed the deficiencies in the surveillance log. The IP, responsible for overseeing the infection control program, acknowledged that the log did not include necessary data such as signs and symptoms, antibiotic timeouts, and resolution dates. The DON also confirmed these omissions and stated that the expectation was for the surveillance log to be completed according to national standards to prevent the spread of infectious diseases. The facility's infection prevention and control manual outlined essential elements of a surveillance system, including standardized definitions and symptoms of infections based on national standards. However, the facility's current practices did not align with these guidelines. The infection preventionist was expected to collect and review data on an ongoing basis, including signs and symptoms of infections, culture results, and antibiotic orders, but the surveillance log did not reflect this comprehensive data collection.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility was observed to have several deficiencies in food service practices, which could potentially lead to foodborne illness among residents. During a dining service observation, a dietary aide was seen handling food items such as buns and baked potatoes with the same pair of gloves after touching non-food items like an iPad and kitchen drawers. The aide did not wash hands or change gloves between these actions, which was confirmed during an interview. The dietary manager verified that the expectation was for staff to wash hands and change gloves when touching non-food items to prevent the spread of germs. The ice machine in the north kitchen area was found to be unsanitary, with a white powder substance present on the spouts and drain plate. The dietary manager and maintenance staff confirmed the presence of the substance and acknowledged that there was no cleaning process in place for the ice machine. The maintenance staff mentioned that the machine was cleaned every three months, but no log was kept to verify this. The white powder substance was identified as potentially containing bacteria, which could lead to illness in residents. Additionally, the facility failed to maintain proper holding temperatures for cold food items. Egg salad sandwiches were observed to be at temperatures above the recommended safe range, with one sandwich measured at 55.7 degrees Fahrenheit. The cook confirmed that cold sandwiches were not placed on ice and that the holding temperature should be under 41 degrees Fahrenheit to prevent illness. The dietary manager and dietician both confirmed the importance of maintaining proper food temperatures to prevent foodborne illness and ensure food quality for residents.
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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