The Estates At Bloomington Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Minnesota.
- Location
- 9200 Nicollet Avenue South, Bloomington, Minnesota 55420
- CMS Provider Number
- 245324
- Inspections on file
- 29
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at The Estates At Bloomington Llc during CMS and state inspections, most recent first.
Failure to respect resident dignity occurred when staff entered a shared room without knocking, introducing themselves, or waiting for permission. Two NAs entered the room of a resident with dementia, psychosis, total care needs, and hospice enrollment, as well as a cognitively intact resident with fibromyalgia, anxiety, depression, and chronic pain, and later re-entered without knocking. The cognitively intact resident reported that staff often entered without permission and described an incident where a staff member looked in while she was naked.
Call Light Not Kept Within Reach: A resident with impaired cognition, dementia, and hospice status was observed without a call light within reach. A NA wheeled the resident into the middle of the room and left without placing the call light nearby, and later the call light was found attached under a pillow and out of sight while the resident was in bed. The NA and DON both stated call lights should be within reach, and facility policy required communication devices to be placed within reach of each resident.
A resident with impaired cognition, hemiplegia, diabetes, and anxiety was transferred to the ER for diarrhea, but the facility did not provide or document a written transfer notice or bed-hold notice. The RN said he believed he left a message with the guardian but did not document it, and the DON verified the EMR lacked the required forms and follow-up.
Failure to develop and implement a comprehensive, person-centered care plan for a resident with polydipsia and severe cognitive impairment. The resident repeatedly sought fluids, tried to get drinks from other residents, and drank water from the bathroom sink. Staff used an 1800 mL fluid restriction, thickened liquids, redirection, a closed bathroom door, and a commode, but the care plan and TAR lacked resident-specific interventions to guide management of the ongoing fluid-seeking behavior.
Incomplete BIPAP Orders and Missing Respiratory Settings Documentation: A resident with intact cognition and use of a non-invasive ventilator had BIPAP orders for bedtime use, daily water changes, and weekly cleaning, but the orders did not include specific settings or clear direction to verify or maintain them. Staff stated BIPAP units were typically pre-set by a respiratory company and nurses checked them, but the resident’s record lacked documentation of the respiratory company setup and the specific BIPAP settings.
Failure to document non-pharmacological pain interventions before PRN medication administration. Two residents with intact cognition received repeated PRN opioid and muscle relaxant doses for pain, but the MAR/TAR, progress notes, and medical record lacked evidence that non-medication measures such as repositioning, rest, massage, or other comfort measures were offered or attempted before the medications were given. Although care plans referenced non-medicinal pain relief, staff interviews confirmed the expectation to offer and document these interventions, and the DON acknowledged the missing documentation for one resident.
Failure to maintain bedroom ceiling lights for two residents. One resident had impaired cognition, dementia, and was enrolled in hospice, while the other had intact cognition and diagnoses including fibromyalgia, anxiety, depression, and chronic pain. The second resident reported a flickering ceiling light that had not worked for a long time, caused headaches, and left the room dark unless she used the pull-string light. Staff said maintenance requests were supposed to be entered in TELS, but the DON and MT-D confirmed no request had been submitted for the issue.
The facility failed to properly clean and disinfect community-use glucometers between uses, affecting nine diabetic residents. Staff did not follow the manufacturer's instructions, using hand sanitizer instead of EPA-registered wipes and not adhering to required contact times. Additionally, residents' fingers were not washed with soap and water before testing. Interviews revealed inconsistencies in staff knowledge and implementation of proper procedures, and the facility's policy on cleaning medical equipment was not provided.
Two residents shared a room with an unfinished wall, which had been left unsanded and unpainted since October 2024. Despite the residents' complaints about the unhomelike environment, staff failed to notice or report the issue for maintenance. The maintenance director cited logistical challenges in completing the repair, and the facility's maintenance policy was not provided.
A resident with severe cognitive impairment was not provided with dentures, which were necessary for safe and independent eating. Despite having a care plan indicating the use of dentures, staff were unaware of their presence and did not offer them during morning care. The interim DON confirmed that refusals were not documented, leading to a failure in providing appropriate care.
A resident in a LTC facility did not receive routine nail care despite needing assistance with ADLs. The resident had long, yellow fingernails and a cracked toenail, and expressed dissatisfaction with the lack of assistance. Staff were responsible for trimming nails on bath days, but assessments inaccurately indicated no need for trimming. The facility's policy emphasized necessary services for grooming, which was not followed.
The facility failed to assess and address poor wheelchair posture for a resident with severe cognitive impairment and functional limitations, as well as to provide necessary interventions for another resident with limited ROM. Observations showed inadequate wheelchair positioning and lack of protective devices, with staff unaware of required interventions. The facility's policies lacked guidance on therapy referrals, leading to deficiencies in resident care.
A resident with worsening hearing loss did not receive a timely audiology consult despite a provider's order. The Health Information Manager confirmed the appointment was not scheduled, leading to the resident's social withdrawal. A policy on audiology services was requested but not provided.
A resident with intact cognition and mobility independence was found with an unsecured mattress hanging over the bed frame, lacking a footboard or retainer bar. Despite staff awareness, no documentation or alternatives were provided to address the safety risk. The facility's bed safety policy was not available.
A facility failed to monitor and document the oxygen use for a resident with COPD and respiratory failure, leading to a deficiency in care. The resident's oxygen saturation levels were recorded without noting the liters per minute (LPM) of oxygen administered, despite an order to maintain saturation above 92 percent. The resident experienced worsening shortness of breath and was hospitalized, while the facility's system did not allow for proper documentation of oxygen dosage.
A facility failed to ensure the safety of a resident's bed rails, leading to a deficiency. The resident, who required assistance for bed mobility, had a loose side rail that increased the risk of injury. Despite the resident's concerns, staff did not take corrective action, and the facility's documentation lacked comprehensive assessment and maintenance of the side rails. Interviews revealed a lack of communication and follow-up regarding the issue, and the facility did not have a policy on side rail evaluation and maintenance.
A facility failed to address consulting pharmacist recommendations for a resident on multiple psychotropic medications. The pharmacist recommended reviewing the lowest effective doses, but no response was documented. Interviews revealed a lack of evidence of provider response, and the interim DON was unsure if recommendations were sent to the correct psychiatrist due to recent changes.
A facility failed to document symptoms and non-pharmacological interventions before administering PRN psychotropic medication to a resident with severe cognitive impairment and on hospice care. The resident's records showed multiple administrations of lorazepam without supporting documentation, and staff interviews revealed inconsistent documentation practices. The facility's policy required such documentation to ensure the medication's necessity and efficacy, but this was not adhered to, highlighting a gap in care.
A resident with cellulitis and other conditions did not receive prescribed wound care due to the facility's failure to verify and implement orders from a nurse practitioner. The orders for daily cleaning and Betadine application were not reflected in the treatment records, and staff did not clarify the orders with the provider. The facility lacked a treatment order policy, indicating a procedural gap.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain resident dignity for 2 of 2 residents reviewed when staff did not knock, introduce themselves, or wait for permission before entering resident rooms. R9’s quarterly MDS identified dementia, psychosis, dependence on staff for all cares, and hospice enrollment. R13’s quarterly MDS identified cognitive intactness along with fibromyalgia, anxiety, depression, and chronic pain. During observation and interview, a nursing assistant entered the shared room occupied by R9 and R13 without knocking or announcing herself, wheeled R9 into the middle of the room, and left without speaking. The same two nursing assistants later entered the room again without knocking. Both staff members confirmed they did not knock, introduce themselves, or wait for permission to enter. R13 stated that most staff failed to knock and wait to enter her room and described an incident where a staff member looked into the room while she was naked without knocking or introducing herself. The DON stated the expectation was for all staff to knock and wait for permission before entering any resident room.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences by not ensuring a call light was accessible for one resident reviewed for call lights. The resident had impaired cognition, no limitation in upper extremity range of motion, and was dependent on staff for turning, repositioning, transfers, and all personal care. The resident’s diagnoses included dementia, and the resident was enrolled in hospice. During observation, a nursing assistant wheeled the resident into the middle of the room and left without placing the call light within reach or speaking to the resident. On another observation, the resident was lying in bed with the head of the bed elevated and pillows positioned around the body, while the call light was attached to the bed sheet under a pillow, hanging down to the bed frame and out of sight. The nursing assistant stated the resident was able to use the call light and acknowledged that call lights should be in reach of residents if they need assistance. The DON stated every resident should have a call light in reach and that it is their lifeline to ask for help if needed. Facility policy stated call cords, buttons, or other communication devices must be placed where they are within reach of each resident.
Failure to Provide Transfer Notice and Bed-Hold Information
Penalty
Summary
The facility failed to provide a written transfer notice and notice of bed hold for 1 resident who was transferred to the emergency room for diarrhea. The resident’s admission MDS identified impaired cognition, need for assistance with all personal cares, and diagnoses of hemiplegia, diabetes, and anxiety. The resident’s EMR progress notes did not show a hospitalization or emergency room visit since admission, although a hospital after-visit summary dated 4/14/26 identified the transfer to the ER for diarrhea. During interviews, the resident could not recall whether a transfer form or bed hold notice was offered or provided at the time of the ER visit. The RN who sent the resident to the hospital stated he believed he had called and left a message with the guardian but did not document it. Facility staff stated the nurse was expected to offer and provide a signed transfer form and bed hold notice, document that in the EMR, and follow up until contact was made. The DON verified the resident’s EMR did not contain a transfer form or bed hold notice and that the facility failed to follow up on obtaining it. The facility policy titled Bed-Holds and Returns required written information be given prior to transfer explaining bed-hold rights and limitations, reserve bed payment policy, per diem rate requirements, and transfer details.
Failure to Care Plan Polydipsia and Fluid-Seeking Behaviors
Penalty
Summary
The facility failed to develop and implement, or revise as needed, a comprehensive, person-centered care plan with individualized interventions for a resident with polydipsia and ongoing fluid-seeking behaviors. The resident had severe cognitive impairment and a diagnosis of polydipsia. The care plan, dated 10/29/24, noted that a risk versus benefit form was completed for not following the recommended diet related to polydipsia and documented that the resident was observed trying to get drinks from other residents and drinking water from the bathroom sink. It also included an 1800 milliliter fluid restriction and instructions to offer fluids and snacks between meals, but it lacked updated, resident-specific interventions to reduce fluid-seeking behaviors and increase comfort related to polydipsia despite continued repeated attempts to obtain more fluids. Record review and staff interviews showed the resident's April 2026 TAR tracked fluid intake and fluid-seeking behaviors but did not include resident-specific interventions. During observation, the resident was pacing between the room and hallway and asking to get into the bathroom, while a sign on the door directed staff to keep the door closed and not allow access to the bathroom. Staff stated the bathroom door remained locked to prevent the resident from drinking from the sink, and one staff member said the resident needed more reminders. Nursing staff reported the resident frequently requested fluids, was given thickened liquids in small cups, and was managed with frequent redirection, pudding, ice cream, supplements, one water jug per shift, a closed bathroom door, and a commode. The nurse manager and DON acknowledged that the resident's polydipsia was not specifically care planned, and that interventions such as lemon oral swabs had not been trialed, while the behavior was only documented in the nutrition section of the record.
Incomplete BIPAP Orders and Missing Respiratory Settings Documentation
Penalty
Summary
The facility failed to ensure accurate and complete respiratory care documentation and resident-specific ordered settings for the use and management of a BIPAP device for one resident. The resident’s quarterly MDS indicated intact cognition with a BIMS score of 14 and use of a non-invasive mechanical ventilator. Physician orders directed the BIPAP to be applied at bedtime, remain on during nocturnal hours, and be removed in the morning, along with daily water changes and weekly cleaning of the water chamber, mask, and tubing. However, the orders did not include specific BIPAP settings or clear direction for staff to verify or maintain the prescribed settings. During interviews, an RN stated that BIPAP machines typically arrived pre-set and staff were instructed not to adjust settings unless there was a malfunction, while nurses checked the machine to ensure settings remained as originally set. A nurse manager stated that when a BIPAP was ordered, the facility typically faxed the order to a respiratory company for setup and that staff were expected to have specific settings documented in the orders. She also stated she was unable to locate documentation identifying the respiratory company responsible for setup or the specific BIPAP settings for the resident, and that this resident was the only one for whom this information could not be found.
Failure to Document Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented before administering PRN pain medications for 2 residents, R5 and R28, who were reviewed for unnecessary medication use. For R5, the admission MDS identified intact cognition, no hallucinations, delusions, or behavioral issues, and noted that the resident received scheduled and PRN pain medications without non-medication interventions. R5 reported occasional pain rated 4 out of 10, and the care plan included non-medicinal pain relief such as positioning, rest, and massage, along with pain medication as ordered and documentation of effectiveness. R5’s MAR/TAR showed multiple administrations of hydrocodone-acetaminophen and methocarbamol for pain, with documentation of pain scales and effectiveness, but no documentation that nonpharmacological interventions were offered or attempted before the PRN medications were given. Progress notes and the medical record also lacked evidence of any non-medication interventions prior to the administered doses. During observation, R5 was given hydrocodone-acetaminophen and methocarbamol while lying in bed, and stated that staff sometimes offer alternatives such as placing a pillow underneath him to help reposition him, but this was not documented for the reviewed administrations. For R28, the MDS indicated intact cognition with a BIMS score of 15 and receipt of PRN pain medication, but no non-medication pain interventions. The care plan listed non-pharmacological pain interventions such as positioning, rest, massage, and other comfort measures, yet the record lacked resident-specific documentation of what interventions were attempted, what was effective, or what was ineffective. R28 received multiple doses of methocarbamol in April, and the MAR/TAR contained no corresponding documentation of non-pharmacological interventions before administration. Interviews with nursing staff and the DON confirmed the expectation that non-pharmacological interventions should be offered and documented prior to or with PRN pain medication use, and the facility policy stated nursing would evaluate appropriate non-pharmacological interventions to address pain.
Failure to Maintain Bedroom Ceiling Lights
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for 2 residents whose main bedroom ceiling lights did not function properly. R9’s quarterly MDS identified impaired cognition, no limitation in upper extremity range of motion, and dependence on staff for turning, repositioning, transfers, and all personal care; R9 also had dementia and was enrolled in hospice. R13’s quarterly MDS identified intact cognition and diagnoses of fibromyalgia, anxiety, depression, and chronic pain. During observation, R13 pointed to a flickering ceiling light and stated it had not worked for a long time. R13 said the strobe-like light caused headaches and that she had to use the pull-string light over her bed because the room was otherwise dark. A NA stated staff were expected to use the TELS electronic messaging system to request maintenance repairs and said she was aware that R9 and R13’s ceiling light had not worked for at least a month. The DON and MT-D both stated maintenance requests were to be submitted through TELS, and the MT-D verified that no TELS requests had ever been submitted for the two residents’ ceiling light issue.
Improper Cleaning of Glucometers in LTC Facility
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of community-use glucometers between patient uses, as well as failed to ensure that staff were knowledgeable about the correct procedures for cleaning and disinfecting these devices according to the manufacturer's instructions. This deficiency had the potential to affect nine residents who were diabetic and required blood glucose monitoring using a community glucometer. The manufacturer's instructions for the Arkray Assure Platinum Blood Glucose Monitoring System specify that the device should be cleaned and disinfected with an EPA-registered wipe, such as the Super Sani-Cloth Germicidal Disposable Wipes, which require a contact time of two minutes to be effective. During observations, it was noted that registered nurses and other staff members did not follow the manufacturer's instructions for cleaning and disinfecting the glucometers. For instance, RN-A used hand sanitizer on a facial tissue to clean the glucometer instead of the recommended Saniwipe, and did not allow the device to remain wet for the required contact time. Similarly, RN-C used a Saniwipe but did not adhere to the recommended contact time, and LPN-B incorrectly stated that alcohol wipes could be used for cleaning the glucometer. Additionally, staff did not wash residents' fingers with soap and water before obtaining blood samples, as required by the manufacturer's guidelines. Interviews with various staff members, including the assistant director of nursing and the facility's infection control preventionist, revealed inconsistencies in the understanding and implementation of the correct cleaning procedures. The facility's policy on cleaning and disinfecting medical equipment was requested but not provided, indicating a possible lack of formalized procedures or training. This lack of adherence to proper infection control practices could potentially lead to the transmission of blood-borne pathogens among residents using shared glucometers.
Unfinished Wall Repair in Resident Room
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for two residents sharing a room with an unfinished wall. The wall had a large area of white joint compound that was unsanded and unpainted, which had been in this state since one of the residents moved into the room in October 2024. Both residents expressed dissatisfaction with the appearance of the wall, stating it made the room feel unclean and uncared for. Despite the residents' intact cognition, the issue was not addressed by the staff, who were expected to notify maintenance for repairs. Interviews with various staff members, including registered nurses, nursing assistants, and the maintenance director, revealed that none had noticed the unfinished wall or submitted a maintenance request to complete the repair. The maintenance director acknowledged the patching work but cited a lack of available rooms to relocate the residents temporarily and the absence of matching paint as reasons for the delay in completing the repair. The facility's policy on building maintenance and repair was requested but not provided, indicating a possible lapse in procedural adherence.
Failure to Provide Dentures for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident, identified as R60, was provided with necessary dental appliances to promote safety and independence in eating. R60, who had severe cognitive impairment and was dependent on staff for oral hygiene, was observed without dentures on multiple occasions. Despite having a care plan that indicated the use of dentures, there was no evidence that R60 was offered or refused his dentures during the observed days. Nursing staff, including a nursing assistant and a registered nurse, were unaware of the presence of R60's dentures, which were found in his room, and did not offer them to him during morning care. The interim director of nursing confirmed that R60 had dentures and acknowledged that refusals to wear them were not documented. The facility's policy on maintaining abilities in activities of daily living emphasized the importance of providing necessary care to prevent a decline in residents' abilities unless unavoidable. However, the lack of documentation and awareness among staff regarding R60's dentures led to a failure in providing appropriate care, as dentures were not offered or placed before meals, which is essential for the resident's ability to eat properly.
Failure to Provide Routine Nail Care for Resident
Penalty
Summary
The facility failed to provide routine nail care for a resident who required assistance with activities of daily living (ADLs). The resident, who was cognitively intact and did not refuse care, had long, yellow fingernails with dark orange matter underneath and a cracked toenail with a sharp edge. Despite the resident's need for assistance with personal care, as indicated in their care plan and clinical diagnosis report, the facility did not provide the necessary nail care. The resident expressed dissatisfaction with the lack of assistance, stating that it had been at least a month since staff helped with nail care. Observations and interviews revealed that the facility's staff, including nursing assistants and a nurse manager, were responsible for trimming residents' nails on bath days. However, the resident's weekly skin assessments inaccurately indicated that nail trimming was not needed. The assistant director of nursing acknowledged the importance of nail care for infection control and preventing skin problems, but the facility's failure to provide this care resulted in the deficiency. The facility's policy on activities of daily living emphasized the need for necessary services to maintain grooming and personal hygiene, which was not adhered to in this case.
Failure to Address Wheelchair Posture and ROM Interventions
Penalty
Summary
The facility failed to adequately assess and address the wheelchair posture of a resident with severe cognitive impairment and functional limitations in range of motion. The resident was observed multiple times seated in a standard wheelchair with poor posture, as his arms could not rest on the armrests without hunching his shoulders. The wheelchair was in disrepair, with worn-down wheels exposing the underlying material. Despite these observations, the resident's care plan did not include specific interventions for wheelchair positioning, and there was no evidence of recent evaluation by occupational therapy to address these issues. Another resident with severely impaired cognition and limited range of motion was not provided with the necessary interventions to prevent skin injury and contracture worsening. The resident's care plan included the use of palm protectors and positioning of elbows with towels or pillows, but these interventions were not consistently implemented. Observations revealed the resident lying in bed with hands balled into fists and no protective devices in place. Nursing staff were unaware of the need for these interventions and did not document any refusals or alternative measures. The facility's failure to communicate and implement assessed interventions for both residents highlights a lack of coordination between nursing and therapy services. Staff interviews revealed a lack of awareness and follow-through on necessary interventions, leading to inadequate care for residents with mobility and positioning needs. The facility's policies did not provide clear guidance on when to refer residents to therapy services for ongoing concerns, contributing to the deficiencies observed.
Failure to Schedule Audiology Consult for Resident
Penalty
Summary
The facility failed to act promptly on an order for an audiology referral for a resident who expressed difficulty with hearing. The resident, who had intact cognition and no delusional thinking, was noted in a quarterly Minimum Data Set (MDS) to have adequate hearing and did not use hearing aids. However, a referral form dated February 22, 2024, indicated an order for an audiology consult due to a diagnosis of hearing loss. By July 1, 2024, the resident reported worsening hearing loss, leading to social withdrawal, and the provider's note reiterated the need for an audiology consult. Interviews revealed that the interim Director of Nursing (DON) directed questions about resident appointments to the Health Information Manager (HIM), who confirmed that the audiology appointment had not been scheduled or refused by the resident. The HIM acknowledged the oversight and stated that scheduling the appointment would now take about four months. A policy regarding audiology services was requested but not provided, indicating a lack of documented procedures for ensuring timely access to necessary medical consultations.
Failure to Secure Bed Mattress for Resident
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R59, by not assessing and securing the bed mattress properly. R59, who had intact cognition and was independent in most mobility-related activities, was observed with a mattress that hung over the foot of the bed frame by about 12 inches, lacking a footboard or retainer bar to prevent it from sliding. The resident expressed difficulty in getting on and off the bed and mentioned that the footboard was removed and placed in the closet by staff. Despite being aware of the issue, the maintenance director and nursing staff did not document or offer alternatives to address the overhanging mattress. Interviews with various staff members, including a nursing assistant, RN, LPN, and the assistant director of nursing, revealed a lack of communication and documentation regarding the resident's bed safety. The maintenance director acknowledged the availability of bed extensions and longer mattresses but did not document any efforts to provide these alternatives. The facility's failure to assess and document the appropriateness of the mattress and bed frame for R59, who was at risk for pressure ulcers, was evident. The facility's policy on bed safety was requested but not provided, indicating a potential gap in procedural adherence.
Failure to Monitor and Document Oxygen Use
Penalty
Summary
The facility failed to ensure ongoing monitoring of a resident's oxygen use, which led to a deficiency in respiratory care. The resident, who had intact cognition and was diagnosed with heart failure, kidney failure, COPD, and respiratory failure, was on oxygen therapy and had a care plan indicating the need for monitoring and documentation of her respiratory status. However, the facility's medication and treatment records did not document the liters per minute (LPM) of oxygen being administered, despite an order to maintain oxygen saturation above 92 percent. This lack of documentation made it difficult to correlate the oxygen saturation levels with the oxygen dosage being administered. The resident experienced shortness of breath and was observed receiving oxygen at a rate of four LPM, which was not documented in the medical record. The registered nurse confirmed that the computer system did not allow for documentation of the LPM of oxygen administered, and the interim director of nursing acknowledged that the order for recording the oxygen flow rate had been missed. The resident's condition worsened, leading to hospitalization, and the facility was unable to provide a policy regarding oxygen use when requested.
Failure to Maintain Safe Bed Rails for Resident
Penalty
Summary
The facility failed to accurately assess and maintain the safety of side rails for a resident, identified as R33, who used bilateral quarter-sized side rails on their bed. R33's admission Minimum Data Set (MDS) indicated that the resident had intact cognition and required substantial assistance for bed mobility. During an observation, it was noted that the side rail on the open side of R33's bed was loose, allowing significant movement and increasing the risk of entrapment or injury. Despite R33 expressing concerns about the loose rail to staff, no corrective action was taken, and the resident was not informed of alternative options to assist with bed mobility. The facility's documentation, including the Monarch Healthcare Management (MHM) Bed Mobility Device Evaluation, lacked comprehensive information on the assessment of alternative devices for R33. The evaluation incorrectly identified the use of grab bars instead of side rails and did not specify which devices had been attempted or discussed with the resident. Additionally, R33's care plan did not include any information or direction regarding the use of side rails, despite the resident being at risk of falls and injury due to mobility issues. Interviews with staff revealed a lack of communication and follow-up regarding the maintenance of the side rails. Nursing Assistant (NA)-A acknowledged the loose rail but had not reported it for maintenance. The Director of Maintenance (DOR) confirmed that no maintenance requests had been submitted prior to the surveyor's inquiry. The interim Director of Nursing (DON) admitted that the evaluation was completed in error and that the rented bed limited alternative options. The facility did not have a policy on side rail evaluation and maintenance, contributing to the oversight in ensuring the safety of the resident's bed rails.
Failure to Address Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations were fully addressed or acted upon for a resident reviewed for unnecessary medications. The resident, who had intact cognition, was diagnosed with major depressive disorder, bipolar disorder, and an anxiety disorder. The resident was prescribed multiple psychotropic medications, including quetiapine, bupropion XL, duloxetine, lamotrigine, aripiprazole, melatonin, and buspirone. The consulting pharmacist made recommendations on two occasions, in December and January, for the prescriber to review whether the resident was on the lowest effective doses of these medications. However, the recommendations were left unaddressed, with no signature, date, or prescriber response documented. Interviews with the consulting pharmacist and the interim director of nursing revealed that there was no evidence of a provider response to the pharmacist's recommendations. The consulting pharmacist noted the importance of attempting to reduce psychotropic medication use when possible, and the interim director of nursing confirmed that the recommendations should have been sent to the resident's psychiatrist. However, due to a recent change in psychiatrists and oversight by the previous director of nursing, it was unclear who the recommendations were sent to. The facility's Medication Regimen Review policy required that pharmacist recommendations be acted upon and documented, but this was not followed in this case.
Failure to Document Symptoms and Interventions for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or documented for a resident (R2) before administering as-needed (PRN) psychotropic medication. R2, who had severe cognitive impairment and was on hospice care, was observed to have been administered PRN lorazepam multiple times without documentation of symptoms or behaviors justifying its use, nor any attempts at non-pharmacological interventions. The resident's care plan indicated a history of refusing care and medications, and a risk for adverse reactions to psychotropic medications, yet the facility did not adhere to the outlined protocols. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2025 showed five administrations of PRN lorazepam, each lacking documentation of symptoms or non-pharmacological interventions. Interviews with staff, including a trained medication aide and a registered nurse, revealed that while non-pharmacological interventions were sometimes attempted, they were not consistently documented. The registered nurse acknowledged the absence of recorded symptoms or interventions and suggested that staff might have been administering the medication without proper documentation. Further interviews with the regional nurse consultant and the consulting pharmacist confirmed that the facility's policy required non-pharmacological interventions to be attempted and documented before administering PRN psychotropic medications. However, the resident's medical record lacked the necessary behavior monitoring order set, which should have been used to document interventions and support medication use. The facility's failure to document symptoms and interventions contravened its own policy and highlighted a gap in ensuring the efficacy and necessity of PRN psychotropic medication for the resident.
Failure to Verify and Implement Wound Care Orders
Penalty
Summary
The facility failed to verify and implement wound care orders for a resident with a primary diagnosis of cellulitis of the right lower limb, along with other conditions such as venous insufficiency, muscle weakness, chronic kidney disease stage three, and anemia. The resident's medical records showed that a nurse practitioner had ordered daily cleaning and Betadine application for a vascular ulcer on the resident's right side. However, these orders were not reflected in the treatment administration record for July 2024, indicating a lapse in following the prescribed treatment plan. Interviews with facility staff revealed a breakdown in communication and verification processes. The registered nurse and clinical manager described a procedure where the wound care nurse and clinical manager would update treatment plans based on the wound care provider's notes. However, the clinical manager assumed the orders were a mistake and did not verify them with the nurse practitioner. The nurse practitioner confirmed that the facility staff did not clarify the orders with her, and the administrator stated that her expectation was for staff to follow and clarify orders as needed. The facility did not provide a treatment order policy when requested, highlighting a potential gap in their procedural documentation.
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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