Sunnyside Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Park, Minnesota.
- Location
- 16561 Us Highway 10, Lake Park, Minnesota 56554
- CMS Provider Number
- 245597
- Inspections on file
- 17
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sunnyside Care Center during CMS and state inspections, most recent first.
A dependent, cognitively impaired resident with hemiplegia and contractures was being transferred by two NAs using a full‑body mechanical lift with a medium sling when the resident fell from the sling, sustaining a scalp laceration with hematoma, a tiny SAH, and a right elbow skin tear with soft tissue swelling. Staff placed the sling with the top several inches below the shoulders and the bottom under the resident’s buttocks, contrary to expectations that it extend from the shoulders to below the tailbone, and one NA reported double‑looping the upper sling straps on the lift bar. Both NAs heard a popping or adjusting sound from the sling during the lift, visually rechecked the loops, then continued the transfer; as the lift was moved away from the bed and the resident’s feet were swung off the mattress, the sling rotated and the resident fell out of the top right side while his legs remained in the sling. Interviews with the DON, RN, and lift manufacturer’s representative confirmed that only one correctly selected loop per side should be attached and that improper sling positioning and/or loop attachment could allow a resident to fall, and the facility’s investigation concluded the cause was inconclusive but may have involved human error.
A resident with severe cognitive impairment, MDRO, a G-tube, a suprapubic catheter, and a head wound was on Enhanced Barrier Precautions (EBP) requiring gown and gloves for high-contact care, device care, and wound care, as indicated by the care plan, facility policy, and a CDC EBP sign on the door. Surveyors observed a PTA and a NA transferring the resident with a full body lift without gown or gloves, and later two NAs performing high-contact care (rolling, checking a brief, boosting in bed, and positioning with boots, wedge, and pillows) wearing only gloves and no gowns. An RN administered medications via G-tube after entering the room without PPE and used only gloves, and another RN performed wound care on the resident’s head, initially handling the old dressing without gloves and then exiting the room without hand hygiene. In interviews, NAs and RNs described expectations to use gowns and gloves for residents on EBP and acknowledged they had not followed or had misunderstood these requirements.
A resident with multiple sclerosis and persistent pain was prescribed and administered oxycodone without being provided education or informed consent regarding the risks and benefits of opioid use. Staff and leadership confirmed that the required education was not completed, despite facility policy mandating such education for high-risk medications.
A resident with hemiparesis and multiple sclerosis, who required extensive assistance and used a motorized wheelchair, was observed with a seatbelt fastened around her waist that she could not remove independently. Staff confirmed the seatbelt was used to prevent falls, but there was no assessment, physician order, or care plan documentation identifying the seatbelt as a restraint, despite facility policy requiring such assessment.
A resident's MDS assessment was inaccurately coded, recording only one fall without injury when documentation showed two unwitnessed falls occurred during the assessment period. The acting DON confirmed the discrepancy, and facility policy requires accurate completion and attestation of MDS entries.
Two residents at high risk for falls did not receive adequate supervision or safe handling as required by their care plans and facility policy. One resident was routinely transported while seated on a four-wheeled walker, contrary to manufacturer warnings, and another resident's walker was repeatedly left out of reach despite a history of falls and care plan interventions. Staff interviews confirmed these unsafe practices and lack of awareness regarding proper procedures.
Two residents with grab bars on their beds did not receive comprehensive assessments or have alternatives attempted prior to the use of bed rails. Staff and residents confirmed that grab bars were installed without documented evaluation of safety, alternatives, or compatibility, and care plans did not reflect their use. Facility policy requiring assessment and proper installation was not followed, resulting in a deficiency.
Improper Mechanical Lift Sling Use Leads to Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement safe mechanical lift transfer practices for a dependent resident, resulting in a fall from a full‑body lift. The resident had a history of CVA with hemiplegia, severe cognitive impairment, expressive aphasia, contractures of multiple extremities, and was dependent on staff for all ADLs and transfers, using a wheelchair for mobility. The care plan directed staff to transfer the resident with a Hoyer‑type full body mechanical lift using a medium sling, with assist of two staff, and to use safe transfer techniques and caution during transfers to prevent striking body parts on hard surfaces. The resident was assessed as a moderate fall risk related to poor communication/comprehension, unawareness of safety needs, and impaired mobility. On the day of the incident, two NAs assisted the resident with a transfer from bed to wheelchair after a bath. A medium cream‑colored sling with dark tan trim was placed under the resident. One NA reported positioning the top of the sling approximately five inches below the resident’s shoulders so that the bottom of the sling covered his bottom, and then crisscrossing the sling between his legs. This placement was later contrasted with the manufacturer’s and facility expectations that the top of the sling be at shoulder level and the bottom approximately two inches below the tailbone so the resident would not sit on the sling. The NAs attached the sling loops to the lift bar; one NA described placing the short black upper loop on the bar and then placing the longer tan loop on top of the black loop (double‑looping), while the other NA described attaching the lower long tan loops and the upper short black loops, using the same color and length on each side. Both NAs reported hearing a “pop” or adjustment sound from the sling while the resident was being raised and stated they stopped and visually rechecked the loops, believing all were attached. The resident was then lifted off the bed with his feet still on the mattress while the lift was pulled back from the bed. One NA moved to the foot of the bed, swung the resident’s feet off the mattress, and supported them as they came off the edge. As the lift was moved away, the sling rotated so that the resident’s back faced the lift and his front faced the window. One NA reported seeing the resident’s weight shift and then observed him fall out of the top right side of the sling, with his upper body and head striking the floor while his legs remained in the sling. The resident sustained a laceration and hematoma to the posterior scalp and a right elbow skin tear with prominent soft tissue swelling, and imaging showed a tiny subarachnoid hemorrhage about the left frontal lobe and contusion/laceration over the right parietal/occipital area without fracture. Interviews with the DON, an RN, and the lift manufacturer’s representative confirmed that correct practice required the sling to be positioned with the top at the shoulders, the bottom below the tailbone, and only one loop of the same color and length attached on each side, and that incorrect sling placement and/or loop attachment could allow a resident to fall from the sling. The facility’s investigation could not conclusively determine the exact mechanism of the fall but acknowledged that human error related to sling placement and/or loop attachment may have contributed.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident on EBP with indwelling devices and an open wound. The resident had multiple diagnoses including CVA, neurogenic bladder, MDRO, aphasia, and had a G-tube and suprapubic catheter. The care plan and facility EBP policy required staff to use gown and gloves for high-contact resident care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care (urinary catheter, feeding tube), and wound care. An EBP sign from CDC was posted on the resident’s door, instructing that everyone must clean their hands before entering and when leaving the room, and that providers and staff must wear gloves and gown for high-contact resident care activities. Surveyors observed multiple instances where staff did not follow these EBP and hand hygiene requirements. A PTA and a nursing assistant transferred the resident from wheelchair to bed using a full body lift without donning gown or gloves, despite the EBP sign and PPE cart at the door. Later, two nursing assistants entered and provided high-contact care, including rolling the resident, checking the brief, boosting the resident in bed, and applying pressure-relieving boots, wedge, and pillows. They wore gloves but did not wear gowns as required for high-contact care under EBP. Although they removed gloves and sanitized their hands before leaving, the lack of gowns during these high-contact activities was inconsistent with the posted EBP instructions and facility policy. Additional observations showed registered nurses also failed to comply with EBP and hand hygiene requirements. One RN entered the room without gown or gloves to administer medications via G-tube, only applying gloves after entering and raising the resident’s shirt to access the tube, without using a gown as required for device care. Another RN entered without gown or gloves, removed and replaced a dressing on the back of the resident’s head, and handled wound care supplies; she initially handled the old dressing without gloves, then applied clean gloves to place a new dressing and wrap, and exited the room without washing or sanitizing her hands. In interviews, multiple staff, including nursing assistants and RNs, acknowledged that gowns and gloves were expected for high-contact care and device care for residents on EBP, and some admitted they had not followed these requirements or had misunderstood when gowns were required, despite the EBP sign and facility policy.
Failure to Provide Informed Consent and Education on Opioid Medication
Penalty
Summary
The facility failed to obtain informed consent and provide education to a resident or their representative regarding the risks and benefits of opioid medication use. The resident, who had intact cognition and diagnoses including anemia, hemiparesis, and multiple sclerosis, was experiencing persistent pain and was prescribed oxycodone as part of their pain management regimen. Documentation showed that the resident received oxycodone on several occasions, but there was no evidence in the medical record that education about the risks and benefits of the opioid medication was provided to the resident or their representative. Interviews with the resident, nursing staff, the acting DON, and the pharmacist consultant confirmed that no education regarding the risks and benefits of the opioid medication had been conducted prior to administration. The facility's policy on high-risk medications required that residents and/or their representatives be educated on the use and risks/benefits of such medications, including opioids. Despite this policy, the process in place only ensured education for psychotropic medications, not opioids, resulting in the deficiency.
Failure to Assess and Document Use of Wheelchair Seatbelt as a Restraint
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for a resident with intact cognition and diagnoses including anemia, hemiparesis, and multiple sclerosis. The resident required extensive assistance with activities of daily living, used a wheelchair for mobility, and had a high risk for falls. Despite documentation in the Minimum Data Set, Care Area Assessment, and care plan indicating no use of restraints, observations revealed the resident was consistently seated in a motorized wheelchair with a seatbelt fastened around her waist. The resident was unable to remove the seatbelt independently and stated it made movement difficult, while staff confirmed the seatbelt was used to prevent her from sliding or falling out of the wheelchair. Interviews with nursing staff and the acting director of nursing confirmed that the seatbelt restricted the resident's movement and that she could not remove it herself, meeting the facility's own definition of a physical restraint. However, there was no evidence in the medical record of a restraint assessment, physician order, or care plan documentation regarding the seatbelt's use as a restraint. The facility's policy required assessment of any device that could be considered a restraint, but this was not completed for the resident in question.
Inaccurate MDS Coding of Resident Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in an incorrect assessment record. According to the CMS RAI 3.0 User's Manual, Section J1800 and J1900 require that all falls since the last assessment be documented, including the number and whether injuries occurred. For the resident in question, the quarterly MDS indicated only one fall without injury since the last assessment. However, a review of the resident's progress notes revealed two unwitnessed falls without injury during the relevant period. During an interview, the acting DON confirmed that there were two falls and acknowledged that the MDS should have been coded to reflect both incidents. Facility policy requires accurate and comprehensive assessment documentation, with staff attesting to the accuracy of their entries.
Failure to Prevent Accident Hazards and Ensure Safe Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and that adequate supervision and assistance were provided to prevent accidents for two residents identified as being at high risk for falls. One resident, who was cognitively intact and had diagnoses including heart failure, arthritis, and chronic obstructive pulmonary disease, required supervision or assistance for mobility and transfers. Despite being assessed as high risk for falls and having a care plan specifying the need for safe transfer and supervision, this resident was observed being transported by a nursing assistant while seated on a four-wheeled walker, which was used as a transportation device against manufacturer warnings. The nursing assistant admitted to routinely transporting the resident in this manner and was unaware that this practice was unsafe and not permitted. Another resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, had a history of multiple falls in the facility. The resident's care plan included specific interventions such as ensuring the walker was within reach at all times to prevent self-transfers and falls. However, during multiple observations, the resident's walker was found out of reach, positioned several feet away from the resident while seated in a recliner. Staff interviews confirmed that the walker should have been within reach, and the resident was at continued risk for falls due to this oversight. Facility policies required individualized fall risk assessments and implementation of care plan interventions to minimize fall risk, as well as safe handling and transfer procedures. Despite these policies, the facility did not consistently implement or monitor the required interventions for residents at high risk for falls, resulting in unsafe practices and failure to provide adequate supervision and accident prevention.
Failure to Assess and Attempt Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and attempt alternatives prior to the use of bed rails for two residents who were observed to have grab bars installed on their beds. Both residents were cognitively intact and had varying degrees of independence with activities of daily living, but their care plans did not identify the presence of grab bars. Documentation in their medical records lacked a comprehensive assessment regarding the appropriate use of bed rails, safety measurements, and any attempted alternatives before the installation of the bed rails. Observations revealed that both residents had double-sized standard beds with black grab bars attached, which were used to assist with positioning and transfers. Interviews with the residents indicated that the grab bars were either brought in by family members or were present when the residents arrived at the facility. Neither resident was aware of any staff assessment of the grab bars. Staff interviews confirmed that the usual practice was to obtain a consent form for bed rail use and review it annually, but staff were not aware of any alternatives being tried prior to installation. The acting DON confirmed that the facility had not completed assessments of the grab bars and did not have the manufacturer's instructions for the devices in use. The facility's policy required a person-centered approach, including the assessment of alternatives, evaluation of risks such as entrapment, and assurance of correct installation and maintenance. However, these steps were not documented or completed for the two residents, resulting in a deficiency related to the use of bed rails without comprehensive assessment and consideration of alternatives.
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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