The Emeralds At Faribault Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Faribault, Minnesota.
- Location
- 500 Southeast First Street, Faribault, Minnesota 55021
- CMS Provider Number
- 245067
- Inspections on file
- 40
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Emeralds At Faribault Llc during CMS and state inspections, most recent first.
A resident with extensive cardiac history and long-term warfarin therapy had a care plan that lacked individualized cardiac management interventions and detailed monitoring for anticoagulant-related bleeding, despite physician orders specifying signs and symptoms to observe. The Kardex and NA care guides did not indicate that the resident was on blood thinners or list bleeding signs to monitor, and NAs reported they did not know which residents were on anticoagulants, were unfamiliar with terms like "tarry stool," and did not consistently report bruising or other potential bleeding indicators. Facility leadership confirmed that the care guides, which serve as the primary tool for directing daily care, omitted anticoagulant monitoring instructions and that the resident’s care plan did not include individualized interventions for recognizing and responding to cardiac symptoms such as chest pain and SOB.
A resident with extensive cardiac history experienced sudden severe left-sided chest pain radiating to the left arm, shortness of breath, nausea, and anxiety, reported that it felt like a heart attack, and repeatedly requested transfer to the ED. Staff checked basic vital signs but did not complete or document a comprehensive cardiac assessment, did not initially honor the resident’s repeated requests for EMS activation, and were unaware of a specific cardiac assessment policy. The resident continued to call a family member, who contacted the administrator about staff allegedly refusing to send the resident out, and only after this escalation were the NP notified and EMS called. Documentation showed that only vital signs and pain scores were recorded, with no detailed cardiac assessment, and the resident was ultimately transported by EMS and diagnosed in the ED with NSTEMI, severe anemia, and GI hemorrhage.
A resident with extensive cardiac history experienced sudden left-sided chest pain radiating down the left arm, with shortness of breath and nausea, and repeatedly told staff he believed he was having a heart attack and wanted to go to the ED. A NA reported the resident said he might be having a heart attack and appeared very worried, repeatedly using the call light to ask when an ambulance was coming. The assigned RN stated he attempted a cardiac assessment but was unaware of the resident’s cardiac history, could not describe the assessment performed, and admitted he did not document the cardiac assessment or the resident’s requests for ED transfer. Progress notes only reflected vital signs and hospital transfer for 10/10 chest pain later that evening, and record review confirmed there was no documentation of a comprehensive cardiac assessment or of the resident’s repeated requests for emergent evaluation. The DON confirmed the lack of required documentation, and the facility did not provide a policy outlining expectations for complete, accurate, and timely medical record documentation.
A newly hired NAIT was allowed to work full-time across all units without a completed pre-employment background screening, as required by facility policy and state regulations. The NAIT had not completed the fingerprinting process, resulting in no background clearance, and this oversight was not identified by facility leadership until the time of the survey. This failure had the potential to affect all residents in the facility.
The facility did not protect a resident from the wrongful use of their belongings or money, resulting in a deficiency related to safeguarding personal property and financial resources.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not accurately post the actual hours worked by RNs, LPNs, and CNAs on the daily nurse staffing form, instead only listing the number of staff and total hours per role. The DON confirmed that actual hours worked were only available in staff schedules at nursing stations, not in the required public posting, affecting all residents and visitors seeking this information.
Surveyors found that staff did not follow proper sanitization procedures in the kitchen, using Dawn dish detergent instead of required chemical sanitizers in the three-compartment sink and failing to send all items through the dishwasher. Additionally, staff with beards were not wearing beard restraints as required by facility policy. These deficiencies had the potential to affect all residents receiving meals from the main kitchen.
Soiled personal laundry and linens were observed being transported loosely in bins without being bagged at the point-of-use, both in the main laundry washroom and in two units. The housekeeper and interim DON confirmed that items should have been bagged to prevent cross-contamination, but this was not consistently done. Facility audits did not include soiled utility rooms, and there was no policy addressing soiled linen handling or transportation.
Two residents with indwelling urinary catheters were observed with uncovered urine drainage bags visible to others, both in their rooms and in common areas. Staff, including nursing personnel, acknowledged that catheter bags should be covered for dignity, but did not act to address the issue. One resident reported never being asked about covering the bag, and both staff and residents expressed discomfort with the lack of privacy.
A resident who was cognitively intact reported an incident involving a nursing assistant and filed a grievance, requesting the assistant not return to her unit. The facility did not document the grievance, failed to provide follow-up or resolution to the resident, and could not locate any records of the grievance, despite policy requiring documentation and retention of such records.
A resident with nicotine dependence, emphysema, and CHF was identified as a current smoker through multiple assessments and staff interviews, but her care plan did not reflect her smoking status or include safety interventions such as removal of oxygen during smoking. Staff confirmed the omission, and the care plan was not updated until after the survey process began.
A resident who completed OT for left wrist weakness and was discharged with a wrist brace and independent ambulation was not properly care planned for these changes. The care plan continued to require staff assist for walking and did not mention the brace, despite staff confirming the resident's independence and the need to monitor for skin integrity.
A resident with Parkinson's Disease and a history of constipation experienced prolonged periods without bowel movements despite being on scheduled laxatives. Staff failed to reassess the resident's bowel regimen or document interventions, and there was no clear tracking or consistent management of the resident's constipation, resulting in inadequate care.
A resident with sensorineural hearing loss experienced ongoing difficulty communicating needs due to the facility's failure to follow up on and document the use of hearing aids, despite physician notes and resident requests. Care plans and treatment records did not reflect hearing aid use, and staff were unaware or lacked updated information regarding the resident's adaptive equipment, resulting in the resident not receiving appropriate hearing support.
A resident with multiple medical conditions and an existing stage IV pressure ulcer developed a new stage III pressure injury, but the facility did not comprehensively reassess the resident or update interventions in the medical record. Staff interviews indicated the resident was resistant to care and the required skin evaluation was left incomplete, with care plan updates only occurring after the survey began. The facility's policy lacked clear guidance on documenting comprehensive reassessments after significant changes.
A resident with limited mobility and multiple medical conditions did not receive recommended physical therapy or restorative nursing services to maintain or improve range of motion, despite medical orders and ongoing mobility limitations. The care plan lacked evidence of restorative interventions, and staff confirmed that the resident was not reassessed for therapy after discharge, resulting in a failure to provide necessary contracture care.
A resident with moderate cognitive impairment and an indwelling catheter did not have documented ongoing medical justification for catheter use, and no attempts were made to remove the catheter or reassess the need for it. The medical record lacked evidence of assessment for urine retention or follow-up on a urology recommendation for a suprapubic catheter, and the facility's policy only addressed catheter care, not ongoing evaluation.
A resident with chronic pain was not comprehensively reassessed for pain following a hospitalization and changes to her pain medications. Despite ongoing reports of severe pain and frequent use of PRN pain medications, no updated pain assessment was documented, and staff confirmed that a reassessment should have occurred after the change in condition.
A resident who receives all nutrition via a PEG tube was found to have tube feeding equipment and a pole coated with dried feeding solution and greasy smears, with multiple observations confirming the lack of cleaning. Nursing staff acknowledged responsibility for cleaning the equipment but admitted it was not being done, and both the resident and their spouse reported the equipment was always dirty. The DON confirmed staff were expected to clean the equipment and recognized the issue as a concern for infection control and dignity.
Staff left care sheets containing private resident information exposed and unattended on medication carts in hallways and near common areas. Multiple staff, including an LPN, RN, and TMA, acknowledged the care sheets should not have been left out, and the DON confirmed this was a HIPAA violation and against facility policy.
A resident with multiple health issues experienced a change in condition, but the facility delayed assessing her and contacting EMS. The LPN noticed the change at 8:00 a.m., but vital signs were not taken until 10:30 a.m., and EMS was called at 11:33 a.m. The resident had unstable vital signs and was unresponsive, yet there was a delay in providing necessary medical intervention.
A resident with chronic respiratory conditions and dependence on supplemental oxygen was admitted to the facility without a documented physician's order for continuous oxygen therapy. Despite the resident's medical history indicating the need for oxygen, the facility's MAR and TAR lacked the necessary order, leading to a deficiency in care. Interviews revealed that the oxygen orders were not included in the discharge orders but were found in the history and physical documentation, resulting in a failure to ensure proper management of the resident's oxygen therapy.
A resident with narcolepsy did not receive their prescribed methylphenidate, as indicated by a negative urine drug screen. Despite awareness of potential drug diversion, the LTC facility failed to report the incident to the state agency as required by policy. The administrator acknowledged the deficiency in reporting and investigation.
A facility failed to investigate an alleged drug diversion involving a resident with narcolepsy. Despite hospital findings indicating the absence of prescribed medication in the resident's system, the facility did not implement a protection plan or conduct a thorough investigation. The facility's policy required immediate reporting and investigation, but these actions were not taken, leaving the resident vulnerable to further incidents.
A facility failed to coordinate hospice services for a resident with cancer, malnutrition, and depression, resulting in missing documentation such as a medication list and care plan. The hospice nurse did not provide comprehensive assessments to the facility, and communication issues persisted despite attempts to obtain necessary documentation. The facility's policy and hospice contract required coordination and communication, which were not effectively followed.
A resident reported being sexually abused by a nurse, but the allegation was not reported to the State Agency immediately as required. The incident was later disclosed to law enforcement during a hospital transfer, prompting a report to the facility administrator. The administrator acknowledged the delay in reporting, which violated the facility's policy.
A resident with chronic kidney disease and a history of falls reported being sexually abused by a nurse, but the LTC facility failed to investigate the allegation. Despite the resident's intact cognition and communication of the incident to staff, the facility's records showed no evidence of an investigation, violating their abuse policy.
A resident with a history of heart disease, morbid obesity, and type 2 diabetes was found with multiple oral medications in their room without a self-administration order. The resident admitted to forgetting to take the medications despite reminders from a nurse. The facility's policy requires physician authorization and observation to ensure medication ingestion, which was not followed in this case.
A resident with a history of respiratory and circulatory issues was left unsupervised during nebulizer treatment, and necessary assessments were not conducted. Additionally, the facility failed to apply compression stockings as ordered, despite the resident's swollen legs and expressed concerns. The DON acknowledged the need for staff supervision during treatments and accurate documentation.
A resident with a history of intestinal issues did not receive scheduled acetaminophen via PEG tube, leading to uncontrolled pain and the need for narcotic medication. A trained medication assistant improperly set up medications for another staff member to administer, violating facility policy. The resident experienced severe pain and distress due to the delay in receiving pain relief.
A resident with a history of hemiplegia and chronic kidney disease experienced a delay in the collection of a urine analysis with urine culture (UA/UC) despite a provider order due to dysuria. The order was documented from 6/14 to 6/17, but the sample was not collected until 6/18. Interviews with staff revealed a lack of documentation and timely action, with the resident continuing to experience symptoms.
Failure to Individualize and Communicate Anticoagulant and Cardiac Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, individualized care plan addressing anticoagulant therapy and cardiac management for a resident with extensive cardiac history and long-term anticoagulation. The resident had diagnoses including acute diastolic congestive heart failure, prior TIA, cerebral infarction, atrial fibrillation, coronary artery disease, ischemic cardiomyopathy, prior STEMI, and long-term anticoagulation. Physician orders included warfarin 2 mg nightly and specific monitoring for signs and symptoms of bleeding such as discolored urine, black tarry stools, sudden severe headache, nausea, vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, and nosebleeds. The comprehensive care plan, reviewed on 3/9/26, lacked individualized cardiac management interventions and goals, and only contained a generic problem for potential alteration in blood formation and coagulation related to anticoagulant use, without detailed, individualized cardiac monitoring interventions. The facility also failed to ensure that care plan interventions related to anticoagulant therapy were effectively communicated to direct care staff. The resident’s Kardex and nursing assistant care guide sheets did not include interventions or instructions for monitoring or reporting signs and symptoms of bleeding or indicate that the resident was on blood-thinning medication. Nursing assistants reported they were unaware which residents were on anticoagulants and did not know the specific signs and symptoms of bleeding they should observe and report. One nursing assistant stated she did not know what a tarry stool was and did not report every bruise, assuming nursing staff could see them, and another stated she might delay reporting bruising or weakness until the end of the shift because she did not recognize them as significant. Events preceding the deficiency included the resident’s hospitalization for gastrointestinal bleeding, with an ED note identifying a suspected GI source of anemia and reference to dark stools that the resident himself did not witness because he used a bedpan managed by staff. The resident reported that a male staff member had informed him of dark stools a couple of days before hospitalization and that he assumed staff were monitoring this condition. Facility leadership, including the nurse manager and DON, confirmed that the Kardex and care guides did not contain instructions for monitoring or reporting bleeding for residents on anticoagulants and that the resident’s care plan lacked individualized interventions for monitoring and responding to cardiac symptoms such as chest pain and shortness of breath. The facility’s own care planning policy required a person-centered, individualized comprehensive care plan used by staff to guide daily care and updated as the resident’s condition changed, which was not met in this case.
Failure to Perform Timely Cardiac Assessment and Honor Resident’s Requests for ED Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, comprehensive cardiac assessment and response for a resident with extensive cardiac history who reported acute chest pain and requested emergency evaluation. The resident had multiple serious cardiac diagnoses, including acute diastolic CHF, prior TIAs and stroke, atrial fibrillation on warfarin, prior CABG, multiple stents, prior MIs, ischemic cardiomyopathy, and atherosclerotic heart disease. Despite this history, the resident’s care plan did not include a cardiac-focused problem or individualized interventions to guide staff in monitoring and responding to changes in cardiac status. On the day of the incident, the resident reported sudden, severe left-sided chest pain radiating down the left arm, shortness of breath, nausea, and anxiety, and stated that the pain felt like a heart attack. The resident activated the call light and initially spoke with a female staff member, telling her he was having chest pain that felt like a heart attack and wanted to go to the ED. A male nurse then came to the room; the resident reported telling him he was having chest pain radiating down his left arm, believed he was having a heart attack, and wanted to be sent to the ED. According to the resident, the nurse refused to call an ambulance, stating that the resident’s vital signs were fine and he did not need to go, and only checked blood pressure, pulse oximetry, and temperature without auscultating heart or lungs or performing a more detailed cardiac assessment. The resident stated he repeatedly requested transfer, attempted unsuccessfully to call 911 himself, and felt frantic and unsafe due to the delay. A nursing assistant later reported that the resident told her he might be having a heart attack, described severe left arm pain and prior heart attacks, and that she immediately notified the RN. She observed that it took a significant amount of time before the resident was transported, that this did not occur until after supper, and that during this period the resident was visibly distressed, repeatedly pressing the call light and asking when the ambulance was coming. The resident’s family member reported receiving four frantic calls from the resident over a period of time, during which the resident stated he was having chest pain radiating down his left arm, believed he was having a heart attack, and that staff would not send him to the ED despite his requests. The family member contacted the administrator by text and phone, reporting that staff were refusing to send the resident despite his extensive cardiac history. The administrator confirmed receiving these messages and that the family member relayed the resident’s complaints of chest and arm pain and his belief he was having a cardiac episode. The nurse assigned to the resident stated he was unaware of the resident’s extensive cardiac history, was not aware of a specific facility policy for assessing cardiac symptoms, and could not clearly describe or document a comprehensive cardiac assessment or the resident’s request to go to the ED. The nurse manager later assessed the resident after being alerted that staff were reportedly refusing to send him, found the resident upset with left-sided chest pain and a history of multiple cardiac events, and obtained vital signs that were within normal limits. He stated that vital signs can be normal during a heart attack and that the resident wanted to go to the hospital immediately. Facility documentation showed that the resident was ultimately transferred to the hospital for chest pain rated 10/10, with EMS called after 6:00 p.m. EMS records indicated they received an emergent call for chest pain, found the resident reporting crushing chest pain radiating down the left arm for approximately 30 minutes, and provided aspirin, nitroglycerin, and oxygen before transport. Facility progress notes documented vital signs and pain assessment but did not include a comprehensive cardiac assessment or detailed clinical evaluation of the reported chest pain. The ED record documented that the resident reported chest pain beginning around 5:00 p.m., similar to prior heart attacks, and that he stated it took staff a while to call EMS. The ED identified NSTEMI, severe anemia with hemoglobin 5.7, GI hemorrhage, hypoxia, and other conditions. The DON confirmed that no comprehensive cardiac assessment was documented, that staff had not received written education or competency testing on cardiac assessment and monitoring, and that the facility lacked a comprehensive cardiac assessment and monitoring policy, which was requested but not provided.
Failure to Document Cardiac Assessment and Resident Requests for ED Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate medical record documentation for a resident with extensive cardiac history who experienced acute chest pain. The resident’s diagnoses included acute diastolic congestive heart failure, prior TIA, cerebral infarction, atrial fibrillation, prior CABG, hypertension, ischemic cardiomyopathy, atherosclerotic heart disease, and prior STEMI. On the evening in question, the resident reported sudden left-sided chest pain radiating down the left arm, accompanied by shortness of breath and nausea, and believed he was having a heart attack. He activated his call light, informed staff of his symptoms, and requested to be sent to the ED. According to the resident and his family member, the resident repeatedly requested hospital evaluation and contacted his son multiple times, stating that staff were refusing to send him to the ED. A nursing assistant reported that the resident told her he might be having a heart attack and had severe left arm pain; she immediately notified the RN. The nursing assistant observed that the resident appeared very worried and repeatedly used the call light asking when the ambulance was coming, and estimated that the incident began around 5:00 p.m., with transport occurring after supper around 6:00 p.m. Progress notes later documented transfer to the hospital for chest pain rated 10/10, with vital signs recorded shortly after 6:00 p.m., and EMS activation and transport documented between approximately 6:03 p.m. and 6:34 p.m. The RN assigned to the resident stated he was informed by a nursing assistant that the resident wanted to see him and that the resident reported chest pain and appeared agitated. The RN stated he was unaware of the resident’s cardiac history and reported that he attempted to perform a cardiac assessment, but he could not describe what the assessment included and acknowledged that he did not document the cardiac assessment or the resident’s requests to go to the ED in the medical record. Review of the medical record confirmed there was no documentation of a comprehensive cardiac assessment or of the resident’s repeated requests for hospital evaluation at the onset of symptoms. The nurse manager and DON confirmed that the RN failed to document the cardiac assessment and the resident’s requests for emergent care, and that this information should have been documented. Requested facility policy on resident-identifiable records and documentation expectations was not provided.
Failure to Complete Pre-Employment Background Screening for Staff Member
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of property, by not completing pre-employment background screening for a newly hired nursing assistant in training (NAIT). Documentation review revealed that the NAIT began working in the facility without a completed criminal background study, as required by both facility policy and state regulations. The NAIT worked full-time across all units in the facility for several months, and the required background clearance was not present in the employee file. The NAIT had completed the background study form online but did not complete the fingerprinting process, resulting in no background clearance being issued. Interviews with facility staff, including the DON and the administrator, confirmed that the background screening process was not completed prior to the NAIT starting work, contrary to facility policy. The administrator was unaware of the missing background clearance until the time of the survey. Facility policies reviewed specified that employees may not begin working until background study results are received and confirm the applicant is not disqualified. The failure to complete the required background screening had the potential to affect all 71 residents in the facility, as the NAIT worked on all units.
Failure to Protect Residents' Belongings and Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report documents that the facility failed to ensure that each resident was safeguarded against unauthorized or improper use of their personal property or financial resources. Specific details about the actions or inactions that led to this deficiency, as well as information about the residents involved or their medical history, are not provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Accurately Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to post accurate daily nurse staffing information as required. On the date of observation, the nurse staff posting form was found at the front desk and included the daily resident census, total number of nursing staff hours, and breakdowns by unit and shift for various nursing roles. However, the posting did not specify the actual hours worked by each category of nursing staff. Instead, it only indicated the number of staff in each role and the total hours for those roles, without detailing the actual hours worked by individual staff members. During an interview, the DON confirmed that the actual hours worked were only reflected in staff schedules posted at the nursing stations, not in the daily nurse staff posting accessible to residents and visitors. The facility's own policy required the posting to include the total number and actual hours worked by RNs, LPNs, and CNAs per shift, in accordance with federal law. This deficiency had the potential to affect all 71 residents and their visitors who may wish to review the staffing information.
Improper Kitchen Sanitization and Lack of Beard Restraints
Penalty
Summary
The facility failed to ensure proper sanitization procedures were followed in the main kitchen, specifically regarding the use of the three-compartment sink. Surveyors observed that the bottles for quaternary sanitizer and pot/pan detergent above the sink were empty, and staff were using Dawn dish detergent instead of the required chemical sanitizing solutions. Staff confirmed that pots, pans, and kitchen utensils were hand washed with Dawn and water, and these items were not always sent through the dishwasher for proper sanitization, contrary to facility policy. Additionally, there was no thermometer available to check water temperature, and items were rinsed for less than 30 seconds before being set to dry, which does not meet the required sanitization standards outlined in facility policy. The facility also failed to ensure that employees wore appropriate beard restraints while preparing food. Observations revealed that a cook with a beard was not wearing a beard cover, and beard restraints were not available at the kitchen entrance or in the office. Interviews with dietary staff and directors confirmed that beard covers were required for beards longer than a specified length, but staff were not consistently following this policy. These failures had the potential to affect all 76 residents who received meals from the main kitchen.
Failure to Bag Soiled Laundry and Linens at Point-of-Use
Penalty
Summary
The facility failed to ensure that soiled personal laundry and linens were properly bagged at the point-of-use and transported in a manner that would reduce the risk of cross-contamination and infectious spread. During a tour of the main laundry washroom and two units, it was observed that soiled linens and personal clothing were placed loosely in mobile bins without being bagged, causing items to touch each other. The housekeeper confirmed that these items should have been bagged prior to transport and acknowledged that this issue had occurred before. In the soiled utility rooms of both units, similar practices were observed, with soiled laundry not being bagged and, in one instance, biohazard-marked bags were placed on top of uncovered soiled laundry. Review of facility documentation revealed that monthly audits of laundry and linen areas did not include the soiled utility rooms where soiled linens were kept before transport. The facility's infection prevention and control program policy did not address soiled linen handling or transportation, and the only related protocol provided was specific to isolation rooms. The interim DON, who also served as the infection preventionist, confirmed that staff had been educated on the need to bag soiled items at the point-of-use, but acknowledged the ongoing issue. No facility policy on soiled laundry handling and transportation was provided.
Failure to Maintain Dignity for Residents with Urinary Catheters
Penalty
Summary
The facility failed to maintain the dignity of two residents who utilized indwelling urinary catheters. Both residents were observed with uncovered urine drainage bags that were visible to others, either from the hallway or in common areas. Staff members, including nursing staff, walked past the rooms or observed the residents with uncovered bags but did not take action to cover them. One resident reported that staff had never asked if they wanted a cover on their urine bag and expressed discomfort at the idea of others seeing the contents. Another resident was seen moving around the hallway and dining area with an uncovered urine drainage bag attached to their wheelchair, visible to other residents and staff. Interviews with staff, including an RN, LPN, and the DON, confirmed that catheter bags should be covered for reasons of dignity and decency. The DON also noted concerns regarding infection control and dignity related to uncovered catheter bags. Despite requests, the facility's policy on dignity was not provided for review. The observations and interviews demonstrate that the facility did not ensure the residents' right to a dignified existence was upheld in relation to the management of urinary catheter drainage bags.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to sufficiently act upon a grievance filed by a cognitively intact resident regarding an incident with a nursing assistant. The resident reported that a nursing assistant entered her room during an evening shift and attempted to change an incontinent brief, despite her not wearing them, and was unkind during the encounter. The resident reported the incident to staff the following morning and subsequently filed a grievance, requesting that the nursing assistant not return to her unit. However, there was no follow-up from the facility regarding the outcome of her grievance, and the nursing assistant continued to work on the unit. A review of the facility's grievance records and the resident's progress notes revealed no documentation of the incident or the grievance. Interviews with staff indicated that grievances should be documented, investigated, and resolved using both hard copy forms and an electronic system, but no record of the resident's grievance could be found. The administrator confirmed that the incident was known and addressed with the nursing assistant, but no written resolution or follow-up was provided to the resident, and the grievance form was missing. The facility's policy requires all grievances to be documented and retained for at least three years, which was not followed in this case.
Failure to Include Smoking Status and Safety Interventions in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and maintain a comprehensive care plan for a resident who was a current smoker. The resident, who had diagnoses including nicotine dependence, emphysema, and congestive heart failure, was assessed multiple times as a smoker and reported to staff that she smoked cigarettes and used oxygen at night only, ensuring she did not wear oxygen while smoking. Despite these assessments and the resident's disclosure, her care plan did not reflect her smoking status or include necessary safety interventions related to smoking, such as ensuring oxygen was removed during smoking. Interviews with nursing staff and review of the electronic medical record confirmed that the resident's smoking status was known to staff and documented in smoking assessments, but this information was not incorporated into the care plan until after the survey process began. The facility's policy required that care plans be used to guide daily care routines, but the omission of the resident's smoking status and related safety measures from the care plan resulted in a lack of comprehensive planning for her care needs.
Failure to Update Care Plan for Resident's Mobility and Brace Use
Penalty
Summary
The facility failed to update and revise the care plan to reflect current interventions for a resident who had recently completed occupational therapy for left wrist weakness and joint pain. The resident was provided with a wrist brace and discharged from therapy with instructions to use the brace as tolerated and to walk independently with a walker. Despite these changes, the care plan continued to list a walking program requiring staff assistance and did not mention the use of the wrist brace. Interviews with therapy and nursing staff confirmed that the care plan was outdated and did not reflect the resident's current level of independence or the use of the brace. Additionally, the care plan lacked documentation regarding the monitoring of the wrist brace for potential skin integrity issues, as noted by a registered nurse who stated that all braces and splints should be care planned to ensure proper monitoring. The facility's policy required care plans to be updated as the resident's condition and care needs changed, but this was not done in this case. The deficiency was identified through observation, interviews, and document review, which showed a disconnect between the resident's current needs and the interventions documented in the care plan.
Failure to Reassess and Intervene for Resident with Chronic Constipation
Penalty
Summary
The facility failed to reassess and implement new interventions for a resident with a known history of constipation, despite clear evidence of ongoing issues. The resident, who was cognitively intact and had Parkinson's Disease—a condition commonly associated with constipation—was frequently incontinent of bowel and required significant assistance with toileting. Documentation showed the resident often went several days without a bowel movement, including a period of ten days without one, and had only minimal bowel movements over the course of the month. Although the resident was on scheduled medications for constipation, there was no recent bowel evaluation that assessed her typical patterns, what was normal or abnormal for her, or what interventions had been attempted or were in place to prevent constipation. Progress notes for the relevant period lacked documentation of the resident's constipation or any interventions used to promote bowel movements until after the resident reported constipation and discomfort. Interviews with staff revealed inconsistent practices and expectations regarding bowel movement tracking and intervention, with some staff unsure of what actions were being taken to manage the resident's constipation. The facility was unable to provide a policy on constipation management when requested. These actions and omissions resulted in a failure to provide appropriate treatment and care according to the resident's needs and medical condition.
Failure to Implement and Document Hearing Aid Use for Resident with Hearing Loss
Penalty
Summary
The facility failed to follow up and implement appropriate treatment for a resident with documented hearing loss. The resident was identified as having highly impaired hearing and a diagnosis of unspecified sensorineural hearing loss, with care plans indicating the use of a pocket talker but omitting any mention of hearing aids. Despite a physician's note stating the resident wore hearing aids, multiple assessments and care documents, including the treatment administration record and care sheets used by nursing assistants, did not reflect the use or management of hearing aids. The resident repeatedly expressed difficulty hearing and a desire for assistance with hearing aids, but was observed without them, and staff interviews confirmed that care documentation was not updated to include hearing aids or their management. Further review revealed inconsistencies and lack of communication among staff regarding the resident's use of hearing aids. Nursing assistants and the activities director noted the resident had hearing aids available but had not worn them regularly, and only after new batteries were provided did the resident begin to use them again. The registered nurse responsible for the resident's hearing assessment confirmed moderate hearing difficulty but did not find hearing aids in use at the time and noted a previous refusal for a referral for hearing aids. The facility's medication and treatment policy did not specifically address adaptive devices such as hearing aids, contributing to the lack of consistent follow-up and documentation.
Failure to Reassess and Update Interventions After New Pressure Injury
Penalty
Summary
The facility failed to comprehensively reassess and develop proactive interventions after a new pressure injury was identified in a resident with multiple medical conditions, including heart failure, hypertension, and multiple sclerosis. The resident was already at risk for pressure injuries and had an existing stage IV pressure ulcer that developed after admission. Despite the development of a new stage III pressure injury, there was no documented evidence of a comprehensive reassessment or updated interventions in the medical record. The care plan and interventions were not revised until after the survey began, and the required skin evaluation form was left incomplete. Interviews with staff revealed that the resident was largely independent in her care decisions, often refusing repositioning and other recommended interventions. Staff described the resident as dismissive and resistant to care, with a preference for remaining in bed and limited time spent in her wheelchair. Although the interdisciplinary team (IDT) discussed the resident's wounds and care plan, there was a lack of documentation regarding what interventions were considered, offered, or refused, especially after the new wound developed. The IDT notes provided were undated and lacked specific details about the reassessment process or any new interventions implemented. The facility's policy required a pressure ulcer risk assessment and completion of a skin evaluation form upon significant change, but the policy did not provide clear guidance on how a comprehensive reassessment should be conducted or documented. The director of nursing acknowledged that the medical record lacked evidence of a comprehensive reassessment and that proper documentation was important for continuity of care. The absence of a thorough reassessment and documentation following the development of a new pressure injury constituted the deficiency identified by surveyors.
Failure to Provide Range of Motion and Contracture Care
Penalty
Summary
A deficiency was identified when a resident with limited mobility and multiple diagnoses, including chronic pain, muscle weakness, and spinal cord disease, did not receive appropriate services to maintain or prevent loss of range of motion (ROM) and contracture care. The resident, who was dependent on staff for lower body dressing and transfers and used a wheelchair for mobility, reported not receiving physical therapy (PT) or occupational therapy (OT) for at least two weeks. The resident expressed frustration, stating that therapy was the primary reason for their stay and that nursing staff were not performing recommended leg exercises in bed. The resident also noted a decline in the ability to straighten her left leg, which she could do prior to admission, and was currently using a Hoyer lift for transfers. Review of the resident's medical record revealed external facility orders recommending daily PT participation while maintaining non-weight bearing status to the left heel, with toe-touch transfers allowed. Despite these recommendations, the resident's care plan lacked evidence of a restorative nursing program or recent PT assessments. Interviews with nursing and therapy staff confirmed that the resident had been discharged from OT and PT and was not receiving any restorative nursing services. Staff also verified that the resident had not been reassessed for PT services after discharge, despite the presence of new orders and ongoing mobility limitations. Further interviews with facility leadership, including the RN manager, director of therapy, and DON, confirmed that communication lapses occurred regarding therapy reassessment and implementation of restorative care. The director of therapy acknowledged that a PT assessment should have been completed, and the DON stated the importance of working with therapy and restorative nursing to prevent unnecessary decline. The facility's policy required timely transcription of treatment orders, but this was not followed, resulting in the resident not receiving necessary services to maintain or improve ROM.
Failure to Ensure Ongoing Medical Justification and Assessment for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had ongoing medical justification for its use and did not attempt a trial removal as recommended. The resident, who had moderate cognitive impairment and required assistance with toileting and bathing, was admitted with a catheter in place. Although the resident's diagnoses included several conditions that could potentially justify catheter use, the electronic medical record did not document the duration of urinary retention, any attempts to manage the condition without a catheter, or clear medical justification for continued catheterization. There was also no evidence of post void residual measurements to assess the extent of urine retention. Additionally, a urology note indicated a plan for a suprapubic catheter placement, but the record lacked follow-up on this order. Interviews with the resident and nursing staff revealed that the catheter had been in place since admission, primarily to prevent urine leakage during travel, and that no attempts had been made to remove it or reassess the need for ongoing catheterization. The facility's policy addressed catheter care procedures but did not address the need for ongoing assessment or justification for continued use.
Failure to Reassess Pain After Hospitalization and Medication Changes
Penalty
Summary
The facility failed to comprehensively reassess a resident for pain management following a hospitalization related to concerns with her pain medication regimen and subsequent medication changes. The resident, who was cognitively intact and independent with most ADLs, had a history of chronic pain and was receiving multiple pain medications, including Buprenorphine, Oxycodone, Pregabalin, and Acetaminophen. Despite these interventions, the resident continued to report almost constant, severe pain that affected her sleep and daily activities. Documentation showed frequent use of PRN pain medications, and the most recent comprehensive pain assessment was dated over two months prior to the hospitalization and medication changes. After the resident's hospitalization for over-sedation and subsequent adjustments to her pain medications, there was no evidence in the electronic medical record of a comprehensive pain reassessment to evaluate the effectiveness of the new regimen or to consider additional interventions. Observations and interviews confirmed the resident continued to experience significant pain, and staff interviews indicated that comprehensive pain assessments were expected after a change in condition, such as hospitalization. However, the required reassessment was not completed, and the facility was unable to provide a policy on pain management when requested.
Failure to Maintain Clean and Sanitary Tube Feeding Equipment
Penalty
Summary
A deficiency was identified when a resident's tube feeding (TF) pole and equipment were observed to be coated with a dried white substance and greasy smears, indicating a lack of proper cleaning and maintenance. The resident, who has intact cognition and a history of depression, anxiety, chronic respiratory failure requiring oxygen, and head and neck cancer with all nutrition provided via a PEG tube, was found to have TF equipment that was visibly soiled on multiple occasions. Observations revealed the dried substance on the entire surface of the pole and all five legs of the base, as well as greasy smears on the front programming screen of the TF machine. Interviews with nursing staff, including an LPN and an RN, confirmed that it was the responsibility of nursing staff to clean the TF equipment if spills or visible soil were present. Both staff members acknowledged the equipment was not being cleaned as expected, with the RN describing the condition as 'horrible' and attributing the residue to TF solution not wiped up after use. The resident and their spouse also reported that the equipment was consistently dirty and that they had never seen staff clean it. The DON confirmed the expectation for staff to clean the equipment and recognized the issue as a concern for infection control and resident dignity. The facility's policy on environmental cleaning of patient care equipment was requested but not provided.
Failure to Secure Resident Care Sheets and Maintain Confidentiality
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of residents' personal and medical records by leaving care sheets containing private information exposed and unattended on medication carts in accessible areas. On multiple occasions, staff members, including an LPN, RN, and TMA, left care sheets with sensitive information for multiple residents visible on top of medication carts in hallways and near common areas. These unattended documents were observed by surveyors as staff and residents passed by, with the information remaining exposed for several minutes each time. Interviews with the involved staff confirmed that the care sheets contained private patient information and should not have been left unattended or exposed. The DON acknowledged that leaving such documents out in the open constituted a HIPAA violation and compromised resident dignity and privacy. Facility policy also explicitly prohibits leaving care sheets or other client-identifying papers unattended or visible.
Delayed Response to Change in Resident's Condition
Penalty
Summary
The facility failed to immediately assess a resident after a change in condition was noted. A Licensed Practical Nurse (LPN) observed a change in the resident's condition at 8:00 a.m., but vital signs were not taken until 10:30 a.m., and Emergency Medical Services (EMS) were not called until 11:33 a.m. The resident, who had a history of acute cystitis with hematuria, chronic obstructive pulmonary disease, acute kidney failure, and other significant health issues, was noted to have unstable vital signs and was unresponsive to stimuli. Despite these observations, there was a delay in contacting EMS and providing necessary medical intervention. The resident's care plan required daily monitoring of skin integrity and reporting any changes to the provider. On the day of the incident, the resident's vital signs were unstable, with low blood pressure and oxygen saturation levels, and she was not responding to verbal commands or sternal rubs. The nursing staff increased the resident's oxygen levels, but her condition did not improve significantly. The family member present at the facility initially instructed the staff not to send the resident to the emergency department, as they were planning to discharge her home with hospice services. However, the family member later approved the transfer to the emergency department after arriving at the facility. Interviews with facility staff revealed that there was a lack of immediate action following the observed change in the resident's condition. The LPN and other nursing staff did not promptly notify the provider or perform a thorough assessment. The Director of Nursing and other staff members acknowledged that the delay in assessing the resident's condition and notifying the provider was inappropriate. The facility's policy required immediate assessment and notification of changes in a resident's condition, which was not followed in this case.
Failure to Obtain Physician's Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen for a resident who was on continuous oxygen therapy. The resident, who was admitted with a primary diagnosis of acute cystitis with hematuria and additional diagnoses including chronic obstructive pulmonary disease, COVID-19, and chronic respiratory failure, required supplemental oxygen as part of their home regimen. Despite the resident's medical records indicating the need for oxygen therapy, the facility did not have an order for supplemental oxygen documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February and March 2025. Interviews with the Director of Nursing (DON) and a registered nurse (RN) revealed that the oxygen orders were not included in the discharge orders but were instead found in the history and physical documentation from the provider. This oversight resulted in the orders not being translated into the resident's MAR and TAR. The RN stated that he would typically rely on the MAR and TAR to determine if a resident required supplemental oxygen and would apply it based on standing orders if necessary. However, in this case, the lack of a documented order led to a failure in ensuring the resident's continuous oxygen therapy was properly managed.
Failure to Report Potential Drug Diversion
Penalty
Summary
The facility failed to recognize and report a potential drug diversion involving a resident's medication to the state agency. The resident, who was diagnosed with narcolepsy, was prescribed methylphenidate to manage their condition. However, a series of events indicated that the resident might not have been receiving their medication as prescribed. The resident experienced episodes of unresponsiveness and was taken to the emergency department, where a urine drug screen showed no presence of amphetamines, which was unexpected given the medication regimen documented in the facility's records. Interviews and record reviews revealed that the facility staff, including nurses and the interim director of nursing, were aware of the negative drug screen results and the potential for drug diversion. Despite this, the incident was not reported to the state agency as required by the facility's policy. The facility's policy mandates that any suspected misappropriation of resident property, including medication, should be reported to the Minnesota Department of Health within 24 hours if it did not result in serious bodily injury. The failure to report the potential drug diversion was acknowledged by the facility's administrator, who stated that the incident should have been reported immediately to the director of nursing or themselves and subsequently to the state agency. The lack of timely reporting and investigation into the potential drug diversion represents a deficiency in the facility's adherence to its abuse prohibition and vulnerable adult policy.
Failure to Investigate Alleged Drug Diversion
Penalty
Summary
The facility failed to implement a protection plan and conduct a thorough investigation following an allegation of drug diversion involving a resident with narcolepsy. The resident, who was prescribed methylphenidate for narcolepsy, experienced episodes of unresponsiveness and was taken to the emergency department (ED) on multiple occasions. During one of these visits, a urine drug screen revealed no presence of amphetamines, raising concerns about potential drug diversion, as the medication was reportedly administered according to the facility's records. Despite the hospital's notification to the facility about the negative drug screen and the suspicion of drug diversion, the facility did not take immediate action to protect the resident or investigate the matter thoroughly. Interviews with staff revealed that the information was communicated to the facility's director of nursing (DON) and administrator, but no protection plan was put in place, and the investigation was not initiated promptly. The facility's policy required immediate reporting and investigation of such incidents, but this protocol was not followed. The facility's failure to respond appropriately to the alleged drug diversion and to protect the resident from potential harm constitutes a deficiency. The lack of a timely investigation and protection plan left the resident vulnerable to further incidents, and the facility did not comply with its own policies regarding the reporting and handling of such allegations.
Lack of Coordination in Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for a resident receiving hospice care. The resident, who had intact cognition and was diagnosed with cancer, malnutrition, and depression, required assistance with daily activities and was at risk for pressure ulcers. Despite being on hospice, the resident's medical record lacked essential documentation, including a current medication list, hospice care plan, goals for care, hospice certification, and hospice orders. The hospice nurse admitted to not providing comprehensive assessments to the facility, as she was unaware of the requirement, and did not have access to the facility's electronic medical record. Interviews with the Director of Nursing (DON) and the Administrator revealed ongoing communication issues between the facility and the hospice agency. The facility had attempted to obtain the necessary hospice documentation through various means but faced challenges in receiving timely updates. The facility's policy and hospice contract outlined the responsibilities of both parties in coordinating care, including the development of an integrated care plan and regular communication. However, these protocols were not effectively followed, leading to a lack of coordination and communication regarding the resident's hospice care.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse immediately to the State Agency as required. A resident, who had a history of falling and chronic kidney disease, reported being sexually abused by a female nurse on a specific date. The resident informed the nurse manager and later the social worker about the incident. However, the social worker did not report the allegation to the State Agency immediately, as required by the facility's policy. The incident was further brought to light when the resident mentioned the abuse to law enforcement and emergency medical services during a hospital transfer. The registered nurse who was informed by law enforcement reported the allegation to the facility administrator. The administrator acknowledged that the allegation was not reported within the required two-hour timeframe, which is a violation of the facility's Abuse Prohibition/Vulnerable Adult policy.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse and provide adequate resident protection for a resident who reported being inappropriately touched by a nurse. The resident, who had a history of falling, chronic kidney disease, and required extensive assistance with activities of daily living, reported the incident to the nurse manager and social worker. Despite the resident's intact cognition and clear communication of the incident, the facility's medical records lacked evidence of an investigation. The facility's administrator acknowledged that the allegation was not investigated, despite being informed of the incident by a registered nurse. The facility's policy on Abuse Prohibition/Vulnerable Adult Abuse required prompt reporting, documentation, and investigation of all alleged or suspected abuse incidents. However, the facility did not adhere to these procedures, resulting in a failure to ensure the safety and protection of the resident involved.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, who was observed to have medications in their room, was appropriately assessed and deemed safe to self-administer medications. The resident, who had a history of heart disease, morbid obesity, and type 2 diabetes, was cognitively intact and dependent on staff for most activities of daily living. The resident's care plan indicated that medications should be administered as ordered, and there was a specific order allowing the resident to keep inhalers at the bedside. However, there was no documentation of assessments for safe self-administration of oral medications. During an observation, multiple oral medications were found in the resident's room, and the resident admitted to forgetting to take them despite being reminded by a nurse. The trained medication aide confirmed that the resident did not have a self-administration order for oral medications, and the director of nursing stated that visual observation of medication ingestion is expected unless a self-administration order is in place. The facility policy requires that residents can only self-administer medications when authorized by the attending physician and that they must be observed to ensure the dose is ingested.
Failure to Supervise Nebulizer Treatment and Apply Compression Stockings
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of nebulizer treatment and the application of compression stockings for a resident. The resident, who had a history of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and pulmonary embolism, was observed receiving nebulizer treatment without proper supervision. The trained medication assistant left the resident unsupervised during the treatment and did not perform necessary assessments such as checking lung sounds, heart rate, oxygen saturation, or pulse after the treatment. Additionally, the facility did not follow the physician's order to apply compression stockings daily for the resident. The resident was observed with swollen lower extremities and no compression stockings or wraps were applied, despite the resident's care plan indicating the need for assistance with putting on compression stockings. The resident reported to staff multiple times about the inability to put on the stockings and expressed concerns about skin splitting open due to swelling, yet no action was taken. The Director of Nursing acknowledged the expectations for staff to remain with residents during nebulizer treatments and to document the application of compression stockings accurately. The facility's policy for oral inhalation administration included specific instructions for monitoring and documenting the resident's condition during and after nebulizer treatments, which were not followed in this case.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, resulting in the resident experiencing uncontrolled pain and requiring narcotic pain medication. The resident, who had a history of intestinal perforation and required medication via a PEG tube, did not receive her scheduled acetaminophen dose. The medication administration record indicated that the resident was supposed to receive acetaminophen every six hours for pain management. However, during an observation, a trained medication assistant was seen setting up medications for another staff member to administer, which is against facility policy. The facility's policy requires that the person who prepares the medication is the one who administers it, ensuring the five rights of medication administration are followed. Despite this, the trained medication assistant set up medications for a nurse who was on break, leading to a delay in the resident receiving her pain medication. The resident expressed severe pain and distress, having requested pain relief since noon without receiving it. The registered nurse on duty later administered PRN oxycodone for the resident's pain, as per the resident's request and physician orders. Interviews with staff, including the director of nursing, confirmed that the facility's policy was not followed, contributing to the resident's unmanaged pain.
Failure to Timely Collect Urine Sample for Resident
Penalty
Summary
The facility failed to ensure a timely collection of a urine analysis with urine culture (UA/UC) and sensitivity for a resident who was experiencing a change in condition. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, and chronic kidney disease, was cognitively intact and able to communicate effectively. On 6/13/24, a provider ordered a UA/UC due to the resident's symptoms of dysuria and facial tingling. However, the urine sample was not collected until 6/18/24, despite the order being documented in the medication administration record (MAR) and treatment administration record (TAR) from 6/14/24 to 6/17/24, with no documentation for the day shift. Interviews with the resident, a licensed practical nurse (LPN), the nurse practitioner (NP), and the director of nursing (DON) revealed that the facility staff failed to collect the urine specimen in a timely manner. The resident expressed concern about not receiving the test results and continued to experience symptoms. The LPN acknowledged the lack of documentation indicating the completion of the order and the NP emphasized the importance of timely specimen collection to prevent further complications. The DON confirmed that the expectation was for the specimen to be collected as soon as possible. The facility did not provide a procedure or process for lab collection when requested.
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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