The Emeralds At Grand Rapids Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Rapids, Minnesota.
- Location
- 2801 South Highway 169, Grand Rapids, Minnesota 55744
- CMS Provider Number
- 245495
- Inspections on file
- 34
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Emeralds At Grand Rapids Llc during CMS and state inspections, most recent first.
The facility did not ensure accurate reconciliation and secure destruction of controlled substances, resulting in the diversion of narcotic medications by a former employee. Staff interviews revealed that medication destruction logs were incomplete or missing, and required witnessing and documentation procedures were not consistently followed, allowing for the loss of medications prescribed to multiple discharged residents.
The facility failed to follow provider orders for fluid restrictions and weight monitoring for two residents, did not consistently notify providers of significant weight changes, and did not address elevated blood glucose levels for a resident with diabetes. Additionally, a resident began using a walker without a required PT/OT assessment or education, despite repeated requests. Documentation and adherence to care plans and provider orders were lacking in all cases.
A unit refrigerator was found to be operating at 50°F, above the facility's policy for safe food storage. Multiple food items inside were either expired, lacked proper opened-on dates, or were labeled for residents no longer present. Staff confirmed the unsafe temperature and acknowledged that no maintenance request had been made to address the issue, and that food labeling did not meet policy requirements.
Surveyors identified failures in infection prevention and control, including improper cleaning and storage of nebulizer equipment for two residents, inadequate dating and drying of tube feeding supplies for another resident, and a missing PICC line cap for a fourth resident. Staff did not consistently follow facility policies or physician orders regarding equipment care, and some staff lacked training in PICC line management.
Two residents were allowed to keep and self-administer medications at bedside without the required self-administration assessments or provider orders. An LPN and the DON confirmed that facility policy mandates these steps before medications can be left at bedside, but neither resident had the necessary documentation. Both residents were cognitively intact and had medications such as diclofenac cream and nebulizer solutions left in their rooms, contrary to policy.
A resident with multiple medical conditions had a POLST indicating DNR status, but the EMR order and banner incorrectly listed CPR. Staff interviews confirmed reliance on the EMR banner for code status decisions, and the inconsistency between the POLST and EMR was not identified until after review. The facility's process and policy required matching documentation, but the resident's wishes were not accurately reflected in the chart.
A resident who transitioned from Medicare Part A to hospice private pay was not provided with the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) after their Medicare coverage ended. Although the Notice of Medicare Non-Coverage (CMS-10123) was issued, the facility did not follow its policy to inform the resident of potential financial liability for continued stay, as confirmed by both the business office manager and the administrator.
A resident with an unhealed pressure ulcer did not consistently receive prescribed dressing changes as ordered, with multiple missed or undocumented treatments over several days. Staff interviews revealed confusion about responsibility for dressing changes and inconsistent documentation, making it unclear whether care was provided as required.
A resident with end stage renal disease and a newly placed AV fistula for dialysis did not have their fistula consistently monitored for bruit and thrill as required. The care plan lacked details about the fistula, and staff interviews revealed that assessments for bruit and thrill were not performed or initiated, with uncertainty among staff about monitoring frequency. Orders did not specify this monitoring, and the facility's dialysis policy was not available.
A resident with a PICC line for IV medication did not have their care plan updated to include PICC management, and their line was found without a lumen cap for several days. The resident experienced air being withdrawn from the line, and staff interviews revealed a lack of formal training or competency checks for PICC and IV care. Facility policies and documentation did not adequately address these procedures, leading to improper care and documentation lapses.
Pharmacy recommendations for two residents regarding antipsychotic use and incomplete medication orders were not addressed or documented in a timely manner, despite expectations for provider response within 30 days. The consultant pharmacist's recommendations were repeated without provider action, and the facility's policy on pharmacist services was not provided upon request.
A resident with a history of kidney transplant was prescribed Tacrolimus, an antirejection drug, with the diagnosis listed as 'health maintenance' rather than the specific indication of post-transplant status. The consultant pharmacist identified the discrepancy, noting the need for an accurate diagnosis, and the DON confirmed that all medications should have appropriate diagnoses assigned.
A resident's diclofenac sodium topical gel was found in their room without any labeling to indicate the resident's name, dosage, or administration frequency. Staff confirmed that medications left at the bedside should be properly labeled, and facility policy requires this information. The absence of labeling meant that staff and residents did not have clear instructions for the medication's use.
A resident at risk for falls due to medical conditions fell during a transfer because the bed wheel locks failed to hold, despite appearing secure. The nursing assistant reported the issue, but there was confusion about formal reporting. Maintenance confirmed the bed's brakes were faulty, despite passing inspection. The facility's administrator was unaware of the issue, indicating a lapse in communication and maintenance oversight.
A facility failed to timely execute physician orders for a BMP and UA/UC for a resident with vascular dementia and severely impaired cognition, leading to a delay in diagnosing a UTI. The physician ordered the tests on 6/3/24, but they were not signed until 6/7/24, and the resident was diagnosed with acute cystitis after an emergency room visit. The delay was due to a lack of follow-up on verbal orders and failure to record them in the resident's chart.
A resident with severe cognitive impairment and a history of wandering was able to leave a facility unnoticed due to a malfunctioning WanderGuard system on a courtyard door. Despite being at high risk for falls and elopement, the resident exited the building and fell in a secured courtyard. The facility's logbook showed inconsistencies in door monitor checks, and staff interviews revealed a lack of effective supervision, contributing to the resident's elopement and fall.
A resident was discharged without a complete discharge summary, lacking details of their stay and current condition, including recent injuries from a fall. The receiving facility was not informed of the resident's condition due to missing documentation and a nurse-to-nurse report. Staff interviews revealed a lack of adherence to discharge procedures, with a new RN unaware of the policy and the DON confirming the deficiencies.
A resident with a recent amputation fell while attempting to stand independently, resulting in a forehead laceration. Initial first aid was provided, but the facility failed to monitor the injury's healing process. Staff interviews revealed a lack of adherence to the facility's protocol for post-fall injury monitoring, and the DON confirmed the absence of required documentation and follow-up.
A resident with dysphagia and severe cognitive impairment experienced a choking incident after being served chopped chicken strips instead of the physician-ordered ground texture. The incident, observed by a nursing assistant, resulted in the resident requiring the Heimlich Maneuver and subsequent hospitalization due to aspiration and respiratory failure. The culinary director confirmed the meal preparation did not follow the specified diet order, highlighting a communication breakdown between culinary and nursing staff.
A resident with dysphagia was not re-assessed for supervision with eating following a diet change order, leading to a choking incident that required emergency intervention and hospitalization. Staff interviews revealed inconsistencies in understanding and implementing the resident's supervision needs, and the facility failed to re-evaluate the need for supervision after a speech-language pathologist's evaluation.
Failure to Accurately Reconcile and Destroy Controlled Substances
Penalty
Summary
The facility failed to ensure accurate reconciliation and secure destruction of controlled substances for six residents, resulting in the loss and diversion of narcotic medications. A police report indicated that a former employee was found in possession of medications and empty packages that had been prescribed to multiple discharged residents, including hydrocodone, clonazepam, gabapentin, lorazepam, oxycodone, and morphine. Facility records showed that destruction logs for these medications were missing for several months, and the logs that were available did not contain the required details such as resident names and correlating medications. Interviews with facility staff revealed inconsistencies and lapses in the medication destruction process. The DON stated that medication destruction was supposed to be performed weekly with a log maintained, and that both the facility and pharmacy had keys to the disposal system. However, the DON also acknowledged that the pharmacy did not reconcile medications with facility staff during destruction. A trained medication aide admitted to signing off on narcotic logs without always witnessing the destruction, especially during busy periods. Facility policy required that controlled substances be destroyed in the presence of two licensed nurses, with detailed documentation including the resident's name, medication, and prescription number. Despite this, the facility's destruction records lacked this information, and there was no evidence that the required procedures were consistently followed. This failure in process and documentation allowed for the diversion of controlled substances by a former employee.
Failure to Follow Provider Orders and Ensure Timely Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to provider orders and residents' needs in several instances. For one resident with diagnoses including anemia, coronary artery disease, and renal failure, the facility did not consistently monitor or document adherence to fluid restriction orders, with records showing multiple occasions where fluid intake exceeded the prescribed limits and documentation was incomplete. Additionally, the facility did not notify the provider as ordered when the resident experienced a significant weight increase. Another resident with heart failure and a history of kidney transplant also had fluid restriction and daily weight monitoring orders, but the facility failed to document fluid intake monitoring and missed several daily weights. Provider notification was not documented when the resident experienced weight gains that met the threshold for required notification. A third resident with diabetes, multiple chronic conditions, and on steroid therapy experienced repeated episodes of elevated blood glucose levels, including multiple readings over 400 mg/dl. The facility's records lacked evidence of consistent provider notification for these high readings or for the trend of increasing blood glucose values. The resident's care plan and orders did not include specific parameters for provider notification or interventions for hyperglycemia or hypoglycemia, nor did they address the impact of steroid use on blood glucose management. Interviews confirmed that the resident expressed concern about their blood sugar levels and requested to see a provider, but there was no documentation of a provider visit or comprehensive intervention during the period of elevated readings. In another case, a resident with mobility limitations requested to use a walker and to be evaluated by physical therapy (PT). Despite repeated requests and the delivery of a walker by the resident's family, there was no evidence of a timely PT/OT assessment or completion of a risk versus benefit form prior to the resident's use of the walker. The resident began using the walker without assessment or education from nursing or therapy staff, and staff interviews confirmed that the required evaluation and documentation had not occurred. Facility policy for PT/OT evaluation and treatment was requested but not provided.
Improper Food Storage Temperatures and Labeling in Unit Refrigerator
Penalty
Summary
Surveyors observed that the unit refrigerator on wing 3 was consistently operating at 50 degrees Fahrenheit, as confirmed by two internal thermometers during multiple checks. This temperature is above the facility's policy range of 35 to 40 degrees for safe food storage. The refrigerator contained several food items, including a container of french onion dip with an expired date, packages of sliced cheese and deli meat labeled with resident names but lacking opened-on dates, and a large bottle of Pedialyte labeled with an open date and the name of a resident who had already been discharged. Staff interviews confirmed that the temperature was too high for safe food storage and that perishable foods would need to be discarded. Further interviews revealed that staff had not made a maintenance request to address the high temperature of the refrigerator. The facility's policy requires immediate action by a supervisor if temperatures are out of range and mandates that all food be properly dated. The failure to maintain proper refrigerator temperatures and to ensure food items were correctly labeled and dated constituted a deficiency in food storage practices, with the potential to affect all residents and visitors using the unit refrigerator.
Infection Control Failures in Nebulizer, Tube Feeding, and PICC Line Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for multiple residents in several areas. For two residents receiving nebulizer treatments, staff did not follow protocols for cleaning, drying, and storing nebulizer equipment. In one case, a resident was observed with a nebulizer canister containing liquid that had been left sitting for over an hour before use, and staff confirmed that the medication was not administered at the documented time. The facility's policy required medication to be given immediately after setup and the equipment to be rinsed and air-dried after use, but these steps were not followed. Additionally, nebulizer equipment was found stored directly on bedding, with moisture remaining in the medication cup and tubing not dated, contrary to policy and physician orders. For a resident with a PEG tube, the facility did not ensure that the syringe and graduated cylinder used for tube feeding flushes were properly dated, rinsed, dried, and stored. Observations revealed that the syringe was left undated and sitting in water in the graduated cylinder on the resident's nightstand for multiple days, despite policy requiring daily changes and air drying of equipment. Interviews with staff and review of the resident's care plan and orders confirmed that these infection control practices were not being followed. In another instance, a resident with a PICC line did not have a lumen cap in place for an extended period, as observed by surveyors and confirmed by the resident and staff. The resident reported that the cap had been missing for a couple of days, and staff interviews revealed a lack of training and competency in PICC line care among some staff members. The facility's expectation was that the PICC line should always have a cap to prevent infection, but this was not maintained.
Failure to Complete Self-Administration Assessments and Obtain Provider Orders for Bedside Medications
Penalty
Summary
The facility failed to perform required self-administration of medication (SAM) assessments and obtain provider orders before allowing two residents to have medications left at their bedside. One resident, with diagnoses including heart failure, hypertension, and renal insufficiency, was observed with a tube of diclofenac cream left on a shelf in her room. The resident stated that staff left the cream available for use, but there was no SAM assessment or provider order documented to permit this practice. Another resident, diagnosed with anxiety, depression, and post-traumatic stress disorder, was observed with a nebulizer canister containing medication at his bedside. The resident self-administered the nebulizer medication without staff present, and documentation did not match the actual time of administration. There was no SAM assessment or provider order allowing this medication to be kept at bedside. Interviews with staff, including an LPN and the DON, confirmed that facility policy requires a SAM assessment and provider order before medications can be left at bedside for self-administration. Both residents involved were cognitively intact according to their MDS assessments, but the required assessments and orders were not completed. The facility's policy, last revised in February, states that safety for self-administration must be determined through assessment forms and provider orders, which was not followed in these cases.
Failure to Accurately Reflect Advanced Directives in Medical Chart
Penalty
Summary
The facility failed to ensure that a resident's advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart. The resident, who was cognitively intact and had diagnoses including congestive heart failure, diabetes, and respiratory failure, had a POLST (Physician Orders for Life Sustaining Treatment) indicating Do Not Resuscitate (DNR) status. However, the electronic medical record (EMR) contained conflicting information, with the order and banner indicating Cardiopulmonary Resuscitation (CPR) instead of DNR. Multiple staff interviews revealed that nurses and LPNs relied on the EMR banner or facesheet to determine code status in an emergency, and would have initiated CPR based on the incorrect information displayed. Staff confirmed that the process involved reviewing the POLST and entering the code status into the EMR, but in this case, the POLST and EMR entries did not match. The discrepancy was not identified until after staff reviewed the records and discussed the issue. The facility's policy required that the POLST and code status orders be consistent and that routine audits be conducted to ensure accuracy. Despite this, the resident's wishes as documented in the POLST were not accurately reflected in the EMR, creating a situation where the resident's preferences for emergency treatment would not have been honored if an event had occurred prior to the correction.
Failure to Provide Required SNFABN Form After Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to a resident whose Medicare Part A coverage ended while remaining in the facility. Documentation showed that the resident's last day of skilled services under Medicare Part A was due to transitioning to hospice services, and a Notice of Medicare Non-Coverage (CMS-10123) was issued and signed. However, there was no evidence in the medical record that the CMS-10055 form, which informs residents of their potential financial liability for services not covered by Medicare, was reviewed with or provided to the resident prior to the end of Medicare coverage. The business office manager confirmed during an interview that the CMS-10055 form had not been issued, despite the resident staying in the facility for one day after Medicare A coverage ended and changing to hospice private pay. The administrator also acknowledged that the form should have been provided to any resident remaining in the facility after Medicare Part A coverage ceased. Facility policy required issuance of the SNFABN (CMS-10055) in such circumstances, but this was not followed in the resident's case.
Failure to Complete and Document Pressure Ulcer Dressing Changes
Penalty
Summary
The facility failed to perform prescribed dressing changes to a pressure ulcer as ordered for one resident who was at risk for pressure ulcers and had an unhealed, unstageable pressure ulcer. The resident's medical record indicated orders for twice-daily dressing changes, including cleansing the ulcer, packing, and covering with a bordered foam dressing. However, documentation in the Medication Administration Record (MAR) showed that dressing changes were not completed or not documented on multiple specified days and shifts. Progress notes for the same period lacked any explanation for missed dressing changes or evidence that the responsibility was passed to the next shift. Interviews with the resident and staff confirmed that several dressing changes were missed, and there was uncertainty among staff about when or if the dressing changes were completed. Staff described a process where nurses from other hallways would assist with dressing changes when a nurse was not assigned, but acknowledged that sometimes these were not done and should have been documented in the MAR. The registered nurse and director of nursing both confirmed that, based on the documentation, it was not possible to verify if the dressing changes were completed as ordered.
Failure to Monitor Dialysis Fistula for Bruit and Thrill
Penalty
Summary
A deficiency was identified regarding the monitoring of a resident's dialysis access site. The resident, who had diagnoses including anemia, end stage renal disease, and diabetes, had a right upper extremity arteriovenous (AV) fistula placed for dialysis. The care plan referenced a dialysis port in the right chest but did not include information about the AV fistula in the right arm. Physician orders required monitoring of the chest port post-dialysis and specified no blood draws or blood pressures on the right arm, as well as monitoring the dialysis site for bleeding. However, the orders did not include instructions to monitor the fistula for bruit and thrill, which are important indicators of fistula function. Interviews with facility staff revealed that the AV fistula was not being consistently monitored for bruit and thrill after its placement. Staff members, including an LPN, a trained medication aide, and an RN, indicated that assessments of the fistula were either not performed or not started, and there was uncertainty about the required frequency of monitoring. The dialysis clinical manager confirmed that monitoring for bruit and thrill should have begun daily after the fistula was placed. The director of nursing also stated that such monitoring should occur per facility policy, but the facility's dialysis policy was not provided for review.
Failure to Ensure Staff Competency in PICC Line and IV Medication Management
Penalty
Summary
The facility failed to ensure that licensed staff were properly educated and competent in the administration of intravenous (IV) medications and the management of peripherally inserted central catheters (PICC) for a resident with significant medical needs. The resident, who was cognitively intact and had diagnoses including congestive heart failure, diabetes, and respiratory failure, had a PICC line for medication administration. The resident's care plan did not include the PICC line or any related goals and interventions, despite active orders for PICC line care and IV medication administration. Observations revealed that the resident's PICC line was missing a lumen cap, which the resident reported had been off for several days. The resident also described an incident where a nurse withdrew multiple syringes of air from the PICC line, causing the resident distress and concern for their safety. Interviews with staff confirmed that the missing cap was an infection control issue and that air in the PICC line was a serious concern. Documentation of these events, including notification of the provider and progress notes, was lacking at the time of the incident. Further investigation found that several licensed staff, including LPNs and RNs, had not received specific training or competency assessments related to PICC line management, IV medication administration, blood draws, or dressing changes. Facility policies did not specifically address cap changes or the management of air in a PICC line. Competency checklists and orientation materials provided by the facility did not include these critical skills, and staff reported receiving only minimal or on-the-spot training. This lack of structured education and competency verification contributed to improper PICC line care and documentation lapses.
Failure to Address Pharmacy Recommendations for Medication Orders
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely manner for two of five residents reviewed for unnecessary medications. For one resident with diagnoses including heart failure, hypertension, and renal failure, the consultant pharmacist recommended that the facility address the diagnosis for Quetiapine Fumarate, as the documented diagnosis of 'other specified anxiety disorders' was not an FDA-approved indication for antipsychotic use per CMS guidance. This recommendation, documented in the pharmacist's review, was not addressed or signed as completed in the resident's medical record. For another resident with multiple diagnoses including sequelae of cerebral infarction, PTSD, and psychosis, the consultant pharmacist twice recommended that the provider specify the frequency for a polyvinyl alcohol ophthalmic solution order to complete the medication order. Both recommendations, made in consecutive monthly reviews, were not addressed in the resident's medical record. Interviews with the consultant pharmacist and the DON confirmed that the expectation was for providers to respond to pharmacist recommendations within 30 days, but this did not occur. The facility's policy on consultant pharmacist services was requested but not provided.
Lack of Appropriate Diagnosis for Antirejection Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not having an appropriate diagnosis documented for the use of Tacrolimus, an antirejection medication. The resident in question had intact cognition and a medical history including heart failure, hypertension, renal failure, and a post kidney transplant. The medication order summary listed Tacrolimus as being prescribed for 'health maintenance,' but during an interview, the consultant pharmacist clarified that Tacrolimus is specifically indicated for transplant rejection prevention and that 'post kidney transplant' would have been the appropriate diagnosis. The DON confirmed that all medications should have appropriate diagnoses assigned, but the facility did not provide a medication policy for review.
Unlabeled Medication Left at Bedside
Penalty
Summary
A deficiency was identified when a resident's medication, specifically diclofenac sodium topical gel, was found in the resident's room without proper labeling. Observations on two separate occasions revealed that both the box and tube of the medication lacked any label indicating the resident's name, medication dosage, or administration times. The resident confirmed that staff used the cream and left it on the shelf for convenience. Review of the resident's medical orders showed that the medication was prescribed to be applied four times daily, but this information was not present on the medication packaging in the resident's room. Interviews with facility staff, including an LPN and the DON, confirmed that any medication left at a resident's bedside should be labeled with at least the resident's name, dosage, and frequency of administration. The facility's own policy also requires that all ordered medications and treatments include specific identifying and administration information. The lack of labeling on the medication meant that staff and residents would not have clear information about the correct dosage or whether the medication was appropriately ordered for the resident.
Failure to Maintain Bed Wheel Locks Leads to Resident Fall
Penalty
Summary
The facility failed to maintain the bed wheel locks properly, leading to a fall incident involving a resident identified as R2. R2, who was at risk for falls due to various medical conditions including hepatic encephalopathy, urea cycle metabolism disorder, and a history of stroke, required substantial assistance for mobility and transfers. During a transfer attempt from bed to toilet, the bed moved because the wheel locks did not hold, causing R2 to slide off the bed and fall, resulting in a hospital visit for evaluation. The nursing assistant involved in the incident reported that the bed's wheel locks did not stay locked, despite appearing to be secure initially. This issue had been communicated to other staff members, but there was confusion about how to report it formally. The maintenance assistant later confirmed that the bed's brakes were not functioning properly, despite having passed a recent inspection. The maintenance director acknowledged that the older beds in the facility had a history of premature brake failure and that the inspection process might not have been thorough enough to catch the issue. The facility's administrator was unaware of the bed brake issue until after the incident, indicating a lapse in communication and maintenance oversight. The maintenance team had been tasked with inspecting all beds following the incident, but the inspection process was found to be inadequate as R2's bed was initially marked as having passed the inspection. This deficiency highlights a significant gap in the facility's maintenance and safety protocols, particularly concerning the upkeep of older equipment.
Failure to Timely Execute Physician Orders for UTI Diagnosis
Penalty
Summary
The facility failed to ensure timely execution of physician orders for a Basic Metabolic Panel (BMP) and Urine Analysis (UA)/Urine Culture (UC) with susceptibility and sensitivity for a resident diagnosed with a urinary tract infection (UTI). The resident, who had vascular dementia and severely impaired cognition, was evaluated by a physician due to agitation, behaviors, and multiple falls. The physician ordered the BMP and UA/UC on 6/3/24, but the order was not signed until 6/7/24. The resident was later diagnosed with acute cystitis with hematuria after an emergency room visit on 6/8/24. The delay in obtaining the necessary tests was attributed to a lack of follow-up on verbal orders communicated by the nurse practitioner to the registered nurse. The registered nurse confirmed that the orders were not recorded in the resident's chart, and the director of nursing was unaware that the tests were not completed. The facility's policy required verbal orders to be recorded in the resident's chart, but this was not done, leading to a delay in diagnosis and treatment of the UTI.
Inadequate Supervision and Faulty WanderGuard System Lead to Resident Elopement and Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was cognitively impaired and at high risk for falls and elopement. The resident, diagnosed with vascular dementia and anxiety, had a history of wandering and elopement. Despite having a WanderGuard in place, the resident was able to leave the building without staff's knowledge and entered a secured courtyard, resulting in a fall. The facility's care plan for the resident included monitoring exit-seeking behaviors and ensuring the WanderGuard was functioning properly, but these measures were not effectively implemented. The facility's logbook documentation revealed inconsistencies in the operation checks of door monitors and the patient wandering system. The door leading to the courtyard, identified as E9, had failed inspections and was marked as not applicable on several occasions. The maintenance director confirmed that the WanderGuard system on the courtyard door had been broken for over a month, and no alternative alarm was placed. This lack of functioning alarm allowed the resident to exit the building without staff being alerted, leading to the resident's fall and subsequent exit through a gap in the courtyard fence. Interviews with staff and family members highlighted the resident's frequent wandering behaviors and the need for close supervision. Staff were directed to visually check on the resident every 15 minutes, but the resident was still able to leave the facility unnoticed. The facility's failure to ensure the proper functioning of the WanderGuard system and to adequately supervise the resident contributed to the incidents of elopement and falls, demonstrating a lack of adherence to the facility's elopement policy and fall prevention measures.
Failure to Provide Complete Discharge Summary and Communication
Penalty
Summary
The facility failed to meet discharge summary requirements for a resident who was discharged to an assisted living facility. The discharge summary lacked a recapitulation of the resident's stay and a final summary of the resident's status, including details about the resident's physical functioning, structural problems, skin condition, and special treatments. The resident had a history of falls, including one with injury, and had sustained a laceration and bruising from a fall prior to discharge. However, these injuries were not documented in the discharge summary, nor was the receiving facility informed of the resident's condition through paperwork or a nurse-to-nurse report. Interviews with staff revealed a lack of communication and documentation regarding the resident's discharge. A registered nurse who was new to the facility was unsure of the discharge policy and did not complete a nurse-to-nurse report. Another nurse, who was not present on the day of discharge, confirmed that the resident's medical record lacked necessary documentation, including a recapitulation of the stay and a final summary of the resident's status. The director of nursing confirmed these deficiencies and stated that the expected procedures, including a nurse-to-nurse report and signed discharge instructions, were not completed as required by the facility's policy.
Failure to Monitor Resident's Injury Post-Fall
Penalty
Summary
The facility failed to monitor the healing of injuries sustained by a resident following a fall. The resident, who had a recent right below-the-knee amputation and a history of falls, attempted to stand independently and fell, resulting in a 2-centimeter laceration on the forehead. Initial first aid was provided, including cleaning the laceration, applying steri strips, and using an ice pack. However, subsequent documentation and monitoring of the injury's healing process were lacking in the resident's medical record. Interviews with staff revealed a lack of awareness and adherence to the facility's protocol for monitoring injuries post-fall. The registered nurses involved did not ensure that the provider was notified for further orders on monitoring the wound, nor was there any follow-up documentation in the resident's electronic medical record. The Director of Nursing confirmed the absence of monitoring for the resident's injuries, which was contrary to the facility's policy on fall prevention and management. The policy required documentation of any signs of pain, swelling, bruising, and other symptoms, as well as follow-up monitoring, which was not conducted in this case.
Non-Adherence to Textured Diet Order Leads to Choking Incident
Penalty
Summary
The facility failed to provide the physician-ordered textured diet for a resident (R1) with a history of dysphagia and severe cognitive impairment. Despite R1's documented need for a mechanically altered diet, the facility served chopped chicken strips instead of ground, leading to a choking incident that required the resident to undergo the Heimlich Maneuver and subsequent hospitalization due to aspiration and respiratory failure. The incident occurred in the common area of the unit, where a nursing assistant (NA-A) observed R1 gasping for air after a meal. The culinary director confirmed that the chicken strips were not prepared according to the diet order, as they were chopped instead of ground as directed. The deficiency was identified through interviews and document reviews, highlighting a breakdown in communication and adherence to dietary orders between the culinary and nursing staff. Despite R1's care plan clearly indicating the need for a specific textured diet, the incorrect meal was served, resulting in a serious adverse event. The facility's failure to ensure proper menu preparation and adherence to physician orders for residents with specialized dietary needs led to an immediate jeopardy situation for R1, emphasizing the critical importance of accurate meal planning and service in long-term care settings.
Failure to Re-Assess Resident for Supervision with Eating
Penalty
Summary
The facility failed to re-assess a resident (R1) for supervision with eating following a diet change order. R1 was admitted with a diagnosis of dysphagia and required supervision or touching assistance to eat, as indicated in her care plan. Despite this, the care plan was updated to resolve the supervision requirement without a proper re-evaluation. On 3/9/24, R1 experienced a choking incident that required emergency intervention and hospitalization due to aspiration, highlighting the lack of adequate supervision during meals. Interviews with staff revealed inconsistencies in the understanding and implementation of R1's supervision needs. The certified occupational therapy assistant (COTA) and licensed practical nurse (LPN) indicated that close supervision meant staff should be sitting with R1 to ensure she was clearing her mouth and taking sips of liquids between bites. However, the director of nursing (DON) described the supervision as checking frequently and offering bites, which was insufficient. The speech-language pathologist (SLP) who assessed R1 on 3/20/24 recommended close supervision due to the recent choking episode and inconsistencies in previous assessments. The administrator acknowledged that R1's care plan for close supervision should have been discontinued based on the updated diet orders but admitted that the facility failed to re-evaluate R1's need for supervision following the SLP evaluation. This lack of re-assessment and proper supervision led to R1's choking incident, which could have been prevented with appropriate care and monitoring during meals.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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