The Estates At Excelsior Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Excelsior, Minnesota.
- Location
- 515 Division Street, Excelsior, Minnesota 55331
- CMS Provider Number
- 245332
- Inspections on file
- 29
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at The Estates At Excelsior Llc during CMS and state inspections, most recent first.
Medication administration records and supporting documentation failed to show clinical indications for several meds, ordered monitoring was not completed or recorded, and PRN psychotropic orders lacked stop dates for multiple residents. One resident had metoprolol ordered with a heart rate hold parameter, but the HR was not monitored, while other residents had orthostatic BP orders that were not consistently documented. Another resident had PRN haloperidol and lorazepam without a 14-day limit or documented stop date.
A resident with moderate cognitive impairment and a foley catheter was observed in a wheelchair with the catheter bag hung uncovered from the armrest and urine visible while being moved from the dining room. The resident said he was embarrassed and did not want the bag displayed in public. An NA stated privacy bags were available and expected to be used whenever the resident left the room, and the DON stated catheter bags were expected to be covered when out in public.
Failure to assess and document safe self-administration of meds affected two residents. One resident with intact cognition and multiple chronic conditions had conflicting orders about self-administration, no current SAM assessment, and was observed self-administering acetaminophen while keeping multiple meds/supplements in the room. Another resident with severe cognitive impairment had Lasix set up at bedside under an order for self-administration, but the EMR lacked a SAM assessment and the care plan had no related interventions; nursing leadership confirmed assessments were not being completed.
A resident with intact cognition and a history of hoarding, trauma, anxiety, and depression had multiple personal belongings removed from her room by the administrator, NM, BOM, and SSD without prior notice. Her care plan required trauma-informed care, a 30-day notice before room cleaning, OOLTC notification, and gradual removal of items per ACP recommendations, but the EMR showed no documentation of the notice or OOLTC notification. The resident became upset and combative, called police, and the ombudsman was not notified of the planned clean-out.
The facility failed to update comprehensive care plans for two residents. One resident with dementia and prior skin issues had care plans that were not revised when MASD resolved and when new stage 3 pressure injuries developed on the coccyx and right lateral midfoot. Another resident’s care plan still listed a hearing amplifier even though the resident did not have or use one, despite documented hearing loss and staff observations confirming no hearing device was in use.
A facility failed to provide needed ADL assistance for two residents. One resident had a care plan and order for staff help with grooming and a knee brace, but was repeatedly observed with visible chin hair and without the brace in place, while staff reported uncertainty about the brace and avoided asking about shaving. Another resident with cognitive impairment and multiple diagnoses was repeatedly observed wearing the same stained clothing over several days, and the EMR did not show evidence that staff offered cueing or assistance with changing clothes or addressed hygiene concerns.
A resident with intact cognition and multiple chronic conditions, including HF, HTN, seizure disorder, COPD, and AFib, was repeatedly transported in a wheelchair without foot pedals while staff pushed him. Observations showed his feet bouncing, sliding, or contacting the floor during transport, and staff interviews confirmed he did not refuse foot pedals and that foot pedals should be used when a resident is being pushed in a wheelchair.
Failure to implement a ROM functional maintenance program for a resident with moderate cognitive impairment, cerebral palsy, hemiplegia, and bilateral lower-extremity contractures. Therapy had established an FMP with complete ROM to both lower extremities 3 times daily, but the EMR showed no evidence the program was started or routinely completed. CNA sheets referenced ROM, yet staff confirmed no ROM exercises were being performed and the RN case manager stated no ROM program was in place.
A resident with intact cognition, significant medical comorbidities, and a history of weakness and self-transferring had repeated falls, including falls while going to or from the bathroom and one fall with head injury and ER transfer. Incident reviews identified factors such as ESRD, fatigue after dialysis, muscle weakness, unlocked wheelchair brakes, refusal to call for help, and self-transferring, but the record showed only existing fall precautions and no consistent root cause analysis, individualized interventions, or care plan updates. Interviews and the facility policy confirmed that post-fall assessment, analysis, and care plan revision were expected but were not consistently completed.
Failure to offer or document pneumococcal vaccination for a resident with intact cognition and multiple chronic diagnoses, including AFib, HF, HTN, renal failure, DM, anxiety, depression, and schizophrenia. The MDS did not show the resident was up to date on pneumococcal immunization, and the EMR lacked documentation of vaccine offer, administration, prior vaccination, contraindication, or refusal. The resident stated she would have been interested in receiving eligible vaccines, and the DON confirmed there was no documentation that the vaccine had been offered or received.
Failure to offer and document COVID-19 booster vaccination for a resident with intact cognition and multiple chronic conditions, including AFib, HF, HTN, renal failure, DM, anxiety, depression, and schizophrenia. The resident’s MDS did not show she was up to date, and the EMR lacked evidence of a booster being offered, administered, or refused. The DON confirmed there was no documentation that the resident had been assessed for eligibility or offered the booster.
The facility did not consistently provide snacks to residents when meals were more than 14 hours apart. A resident with multiple health conditions reported never being offered a snack and was unaware of the option. Staff interviews revealed that snacks were not routinely distributed, and the dietary manager and registered dietitian confirmed the lack of a clear process. The facility's policy did not specify when or how often snacks should be offered, leading to a gap in care.
A staff member was observed eating a sandwich at a food preparation counter in the kitchen, placing the wrapper on the hot holding steam table counter. The dietary manager and registered dietician confirmed that eating in the kitchen is not permitted and constitutes an infection control concern. No relevant policy was provided during the survey.
The facility did not analyze or document data submitted to the QAPI committee, resulting in a lack of oversight for issues such as pressure injuries, falls, psychoactive medication use, increased ADL assistance, infection control, and unplanned hospitalizations. QAPI meeting minutes lacked goals, action plans, and data analysis, contrary to facility policy.
The facility did not document goals, action plans, or data analysis for multiple PIPs, including call light response times, change in condition notifications, enhanced barrier precautions, and air mattress monitoring. QAPI minutes showed repeated lack of detail and no evidence of committee review or project closure decisions, with no additional supporting materials or policies provided.
The facility did not consistently track or document employee illnesses and their clearance to return to work, resulting in incomplete records for staff who reported symptoms such as fever, sore throat, and diarrhea. Logs lacked key information on symptom resolution and test results, and the process for reviewing and clearing staff to return was not reliably followed or documented.
The facility did not consistently post or provide dietary menus to residents, despite repeated concerns raised during resident council meetings and acknowledgment by staff. Residents reported not receiving menus or information about upcoming meals, and observations confirmed menus were not posted as required by facility policy. Staff interviews indicated awareness of the issue but a lack of follow-through to resolve it.
The facility did not notify the Ombudsman of multiple resident transfers to acute care hospitals and failed to provide required bed hold notices or written transfer notifications to residents or their representatives. These deficiencies were identified through record reviews and staff interviews, affecting residents with complex medical needs and resulting in missing documentation and notifications.
Multiple dependent residents did not receive necessary assistance with ADLs, including toileting, repositioning, queuing for meals and fluids, and personal hygiene. One resident with severe cognitive impairment and on hospice was left in bed for long periods without being offered food or fluids, and was frequently found in soiled clothing and bedding with matted hair. Another resident experienced long delays in call light response, leading to incontinence and inadequate hygiene. A third resident was transferred with poor hygiene and reported not having a shower for months. Staff interviews confirmed inconsistent care and lack of oversight.
A resident with documented dementia and cognitive impairment was required to sign a Notice of Medicare Non-Coverage without the involvement of their power of attorney, despite clear evidence of incapacity and a family member acting as decision-maker. The facility did not notify the representative, resulting in the resident being unaware of the coverage change and an outstanding bill, contrary to facility policy and regulatory requirements.
Multiple residents were served meals that did not align with their documented food preferences and dietary restrictions, including a resident with end stage renal disease who received restricted items and disliked foods, and others who were not offered alternatives when served items they disliked. Staff interviews revealed a lack of training and awareness regarding the process for addressing food preferences, resulting in residents not receiving appropriate meal options.
The facility did not ensure that psychotropic medications were prescribed with clearly identified target behaviors or symptoms, nor did staff monitor for these behaviors to assess medication effectiveness. For example, a resident with depression and anxiety received antipsychotic medications without individualized target behaviors documented in the care plan or medical record. Staff, including CNAs, LPNs, and RNs, were unable to identify specific behaviors to monitor, and the facility's policy requiring such documentation was not followed for several residents.
A resident with multiple medical conditions was admitted and required assistance with several activities of daily living. The facility's baseline care plan did not specify the level of assistance or staffing needed, and the resident was not added to care sheets used by nursing assistants. Both an RN and the DON confirmed that the care plan lacked essential information needed to guide care within the required 48-hour timeframe.
A resident with a history of TIA and cerebral infarction, who was moderately cognitively impaired and prescribed clopidogrel for myocardial infarction, did not have a care plan that included interventions or safety precautions for anti-platelet therapy. Nursing staff confirmed the absence of necessary monitoring and interventions in the care plan, despite facility policy requiring individualized and comprehensive care planning.
The facility did not update care plans for two residents to reflect their current care needs. One resident's care plan incorrectly indicated the presence of a Foley catheter, which staff confirmed was not present, while another resident's care plan listed an outdated dialysis transportation schedule. Staff interviews and observations confirmed these discrepancies, and the consulting nurse acknowledged the care plans were not current.
A resident with a pressure ulcer and significant cognitive impairment did not have an individualized turning and repositioning schedule established or documented according to professional standards. Staff reported repositioning every 2 hours, but this was not consistently recorded, and the care plan lacked specific interventions to promote wound healing. The facility's documentation and care planning practices did not ensure appropriate pressure ulcer prevention and care.
A resident with end stage renal disease and a fluid restriction was not consistently provided with the prescribed renal diet, receiving inappropriate foods and insufficient portions despite clear dietary orders and documented preferences. Dietary staff and the RD were unaware of the ongoing issues, and the facility could not provide a relevant policy during the survey.
A resident who was dependent on staff for mobility missed a scheduled dialysis appointment because staff did not ensure timely readiness for transportation, resulting in the ride leaving. When an alternative dialysis appointment was offered, the facility did not pay for the required private transportation, despite a contract stating the facility was responsible for all transportation costs. This led to the resident missing necessary dialysis care.
A resident with severe cognitive impairment and multiple medical conditions, including C-diff, did not receive several prescribed doses of vancomycin due to the facility's failure to ensure medication supply and notify the provider or pharmacy of the shortage. Communication lapses among nursing staff, the provider, and the pharmacy contributed to the missed doses, and required procedures for medication ordering and notification were not followed.
A resident who did not eat toast was not offered an alternative meal item after voicing her preference to a NA, who did not notify the kitchen or return to address the issue. The NA was unaware of an alternate menu and had not received training on handling such situations, and the facility's policy did not specify procedures for offering alternatives when a resident cannot or will not eat a served item.
The facility did not complete comprehensive assessments for continued antibiotic use for two residents, as required by CDC guidelines. Although infection logs tracked basic information, there was no documentation that criteria for ongoing antibiotic therapy were met. The DON acknowledged the lack of an accessible form for staff to document assessment criteria, and the facility's policy requiring use of Mcgreer's criteria was not fully implemented.
A resident with a history of lymphoma, anemia, and dementia was not offered or provided an updated pneumococcal vaccine as required by CDC guidelines, and there was no documentation of vaccine offer or declination in the medical record, despite facility policy and standing orders mandating such actions.
A resident with a history of stroke and peripheral vascular disease, receiving hospice services, was admitted with a non-healing Stage 3 pressure ulcer. Despite physician orders for an air pressure redistribution mattress to aid in pain management and ulcer relief, the facility delayed its implementation for over two weeks. This delay, despite multiple reminders to hospice, contributed to the worsening of the resident's pressure ulcer, contrary to the facility's policy for immediate implementation of medical orders.
A facility failed to implement appropriate PPE for a resident under enhanced barrier precautions (EBP) to prevent infection spread. The resident had multiple medical conditions requiring wound care and antibiotic treatment via a PICC line. Despite signage indicating EBP, nursing assistants were observed performing peri care without gowns, citing time constraints. The facility's policy mandates gown and glove use during high-contact care activities, but staff did not adhere to these guidelines, resulting in a deficiency.
A facility failed to notify a physician about a resident's deteriorating diabetic foot ulcer, despite a nurse practitioner's orders for an X-ray and lab work to rule out osteomyelitis. The resident's care plan required immediate notification for wound complications, but a new RN did not report the concerns to the physician, only informing the DON without mentioning specific orders.
The facility's QAPI committee failed to maintain effective action plans for infection control practices related to Foley catheters, resulting in deficiencies such as improper hand hygiene, PPE use, and catheter care. Despite having a QAPI plan, the facility's audits were insufficient and poorly documented, contributing to the recurrence of these issues.
The facility failed to label insulin pens and eye drops with open dates, as required by policy, for two residents and a previously discharged resident. This oversight was confirmed by interviews with the RN and DON, who acknowledged the importance of labeling to prevent administering expired medications.
The facility failed to adhere to infection control protocols, including the use of PPE and hand hygiene. Staff did not follow enhanced barrier precautions for residents requiring high-contact care, and a nurse neglected hand hygiene during wound care. Additionally, a Foley catheter was improperly managed, with the drainage port not cleaned after emptying.
The facility failed to provide written notification of the bed hold policy to two residents during their hospitalizations. Despite having a policy requiring such notifications, the facility did not provide them to residents with multiple health conditions, as confirmed by staff interviews and record reviews.
A facility failed to ensure a resident received the pneumococcal vaccination as per CDC guidelines. The resident, with a history of chronic health conditions, had previously received PCV-13 and PPSV23 but was not offered or administered the PCV20 vaccination. Facility records lacked evidence of the vaccination, and interviews revealed a deficiency in obtaining shared clinical decision-making and providing the vaccination.
A facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe. A resident, who was mildly cognitively impaired, reported being roughly handled by a nursing assistant. The incident was not reported to the State Agency until the following day, violating the facility's abuse reporting policy.
Medication Documentation and Monitoring Failures
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards of practice for 5 of 6 residents reviewed for unnecessary medications. The report identified failures to document clinical indications for multiple medications, failures to monitor medications as ordered, including ordered heart rate monitoring before metoprolol administration, and failures to ensure PRN psychotropic medications had appropriate stop dates. The residents involved were R2, R5, R6, R16, and R26, each with documented diagnoses and varying levels of cognitive and functional impairment. For R2, the EMR showed calcitriol and gabapentin were administered, but physician orders, progress notes, and care plans did not document the conditions being treated or any clinical indication for either medication. R26 had multiple medications administered without documented diagnoses or clinical indications, including calcium carbonate-vitamin D, diltiazem ER, fluticasone, folic acid, montelukast, and omega-3 fatty acids. Review of R26’s physician orders, progress notes, and care plans also lacked documentation identifying the conditions being treated for these medications. Staff interviews confirmed that diagnoses or indications should be documented so staff understood why each medication was prescribed. The facility also failed to monitor ordered parameters and to document ordered assessments. R5 had an order for metoprolol tartrate with instructions to hold for SBP less than 100 or heart rate less than 55, but the MARs for January through March 2026 did not show heart rate monitoring or recording. RN-C stated the heart rate was not being monitored, and the DON stated nurses were expected to check and record blood pressure and/or heart rate as ordered. R6, R16, and R26 each had orders for orthostatic blood pressures, but the TARs and nursing documentation lacked evidence that orthostatic blood pressures were consistently monitored and documented as ordered. R6 also had PRN haloperidol and lorazepam orders without a 14-day end date or documented stop date, and the record lacked evidence that these orders were time-limited or otherwise justified in the chart.
Uncovered Foley Bag Visible During Transport
Penalty
Summary
The facility failed to ensure a catheter bag containing urine was concealed from public view for 1 of 3 residents reviewed for dignity. The resident had moderate cognitive impairment, required staff assistance with ADLs, and had a care plan addressing a foley catheter with staff monitoring output and providing catheter care per policy. During observation, the resident was in a wheelchair being propelled from the dining room toward his room, and the foley catheter bag was hung from the side of the wheelchair armrest uncovered with urine visible. The resident stated he was embarrassed and preferred the bag not be hung out in the open for everyone to see. A nursing assistant stated blue privacy bags were available and were expected to be used every time the resident came out of the room, but was unsure why the resident did not have one. The DON stated catheter bags were expected to be placed in a privacy bag at all times when out in public for the privacy and dignity of the resident and others in the area.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed and determined safe to self-administer medications, and failed to consistently follow physician orders and its own policy for self-administration of medications for 2 residents. Facility policy dated 2/2024 required the interdisciplinary team to assess each resident’s cognitive and physical abilities, document whether self-administration was safe and clinically appropriate, and record that ability in the medical record and care plan. For one resident, the annual MDS identified intact cognition and need for assistance with ADLs, but the EMR showed the most recent self-administration assessment was dated 7/14/23. There was no evidence of quarterly reassessments or reassessment after changes in physician orders. Orders were conflicting, including orders allowing certain topical medications and supplements to be self-administered, followed by an order on 10/28/25 stating staff were to administer medications and the resident was no longer permitted to self-administer medications. Despite this, the resident was observed self-administering acetaminophen from a medication cup kept in her wheelchair, and multiple bottles of medications/supplements were observed in her room within reach. Staff interviews confirmed the resident was no longer supposed to self-administer medications and that the last assessment had been completed in 2023. For the second resident, the quarterly MDS identified severe cognitive impairment, with diagnoses including hypertension, weakness, moderate intellectual disabilities, and adult failure to thrive. During observation, an RN set up Lasix on the resident’s overbed table and left the room while the resident was in the bathroom, stating the resident had an order for self-administration and would take the medication when done. The EMR lacked evidence of a self-administration assessment, and the care plan lacked documentation or interventions related to self-administration. Interviews with nursing leadership confirmed no self-administration assessments were being completed, and the DON stated she did not believe the resident had the capability to self-administer medications.
Failure to Honor Resident Choice and Personal Possessions During Room Clean-Out
Penalty
Summary
The facility failed to honor a resident’s right to make choices regarding her living environment and personal possessions when staff removed multiple items from her room without prior notice. The resident, R22, had intact cognition on her annual MDS and required assistance with ADLs. Her diagnoses included osteoarthritis of the knee, hypertension, renal insufficiency, diabetes mellitus, anxiety disorder, depression, adjustment disorder with anxiety, and personality disorder. R22’s care plan identified her as at risk for behavioral alterations related to trauma and documented a long-standing history of hoarding behaviors after prior loss of belongings. The care plan included interventions for trauma-informed care, direct communication, avoiding involvement of her brother in cleaning discussions, providing a 30-day notice before assisting with cleaning her room, notifying the OOLTC when notice was provided, and supporting her in expressing needs and engaging with services. ACP recommendations also called for working collaboratively with R22 to gradually remove one to two items per week to reduce distress. The EMR contained no documentation that the required 30-day notice was provided before her room was cleaned, and no documentation that the OOLTC was notified. Progress notes stated that the administrator, NM, BOM, and SSD entered R22’s room and removed multiple belongings, including magazines, bags, and other items, which upset her and led to combative behavior. R22 later called the police, and law enforcement responded. The ombudsman reported no knowledge of R22 or any planned room clean-out, and staff interviews showed the NA was unaware of specific interventions while the administrator acknowledged the clean-out occurred without the required notice and without awareness of the ACP recommendation to remove items gradually.
Failure to Update Comprehensive Care Plans for Skin and Hearing Needs
Penalty
Summary
The facility failed to revise and update the comprehensive care plan for 2 of 5 residents reviewed, including a resident with severe cognitive impairment, dementia, anxiety, hypertension, and a history of a stage 3 sacral pressure ulcer. For this resident, the care plan was revised to include ecchymotic areas and moisture-associated skin damage to the right gluteal area, but it was not updated when the right gluteal MASD was documented as resolved. The care plan also was not revised after new in-house skin issues were documented, including a stage 3 coccyx pressure ulcer/injury and later a stage 3 pressure ulcer/injury to the right lateral midfoot. The nurse manager stated she updated wounds on care plans when informed of a new wound and relied on nurses to tell her directly rather than reviewing progress notes, while the DON stated care plans were expected to identify the skin concern, location, date identified, and interventions/care. The facility also failed to update another resident’s care plan related to communication needs. This resident’s admission MDS indicated cognitive intactness, dependence on staff for ADLs, minimal hearing difficulty, and no hearing aids. The CAA identified minimal hearing loss and noted the resident was at risk for missed messages, isolation, depression, and further hearing loss. The care plan dated 3/9/26 listed an alteration in communication and stated the resident used a hearing amplifier with staff assistance, but the resident did not have a hearing amplifier. During interviews and observations, the resident stated he had difficulty hearing and wanted some type of hearing aid or amplifier, staff confirmed he had no hearing devices, and the DON stated that if a resident was not using or did not have a device listed on the care plan, the care plan should have been updated to reflect the resident’s current status.
Failure to Assist with Grooming, Dressing, and Personal Hygiene
Penalty
Summary
The facility failed to provide assistance and cueing with activities of daily living for 2 residents, including grooming, dressing, and personal hygiene. One resident was cognitively intact and independent with ADLs on the MDS, but the care plan identified a self-care deficit and included interventions for staff assistance with personal hygiene, grooming, hair washing, nail care, and support from one staff member. The resident also had an order for a right knee brace to be applied every morning for pain, yet the brace was repeatedly observed on the bed instead of being worn, and the resident stated staff had not been helping put it on. The resident was also observed multiple times with visible gray chin hair, and staff interviews showed some were unaware of the brace order and others avoided asking about shaving because they believed it might upset the resident. The second resident had moderate cognitive impairment and required assistance with bathing, with diagnoses including polyneuropathy, schizophrenia, muscle weakness, adverse effects of antipsychotic medications, colostomy status, and neuroleptic-induced parkinsonism. Review of the EMR did not identify evidence that staff offered help with changing clothing, provided reminders or cueing to change soiled garments, or addressed hygiene and appearance concerns. Over multiple observations across several days, the resident was seen wearing the same red polo shirt with visible stains, black sweatpants, and yellow gripper socks while in bed, in the dining room, and walking in the hallway. Staff interviews indicated expectations that residents should be prompted to shower, assisted with changing clothing daily, and offered help when wearing the same or soiled clothing. However, one NA stated the resident sometimes preferred to wear the same clothing and that refusals were not documented, while another NA stated the resident was assisted daily. The DON stated that if a resident wore the same clothing for multiple consecutive days, staff should notify the nurse and the nurse should assess and follow up, but the DON was unable to provide evidence that these interventions were implemented for the resident.
Wheelchair Transport Without Foot Pedals
Penalty
Summary
The facility failed to ensure safe mobility and transportation for a resident who had intact cognition and required assistance with ADLs. The resident’s diagnoses included heart failure, hypertension, seizure disorder, anxiety disorder, depression, COPD, paroxysmal atrial fibrillation, paresthesia of the skin, and long-term use of systemic steroids. Review of the resident’s EMR and comprehensive care plan did not identify interventions addressing safe wheelchair positioning or the use of foot pedals during transport. During multiple observations, the resident was transported in a wheelchair without foot pedals while staff pushed the wheelchair, and the resident’s feet were observed bouncing, sliding, or contacting the floor. Staff interviews confirmed the resident did not refuse foot pedals, that the resident’s feet slid on the floor during transport, and that staff repeatedly reminded the resident to lift his feet. RN staff and the DON stated foot pedals should be in place when a resident is being pushed in a wheelchair, and the DON acknowledged that transporting a resident without foot pedals could place the resident at risk for harm.
Failure to Implement ROM Functional Maintenance Program
Penalty
Summary
The facility failed to ensure a functional maintenance program was implemented to maintain a resident’s highest practicable level of functioning, as recommended by therapy services. The resident had moderate cognitive impairment and diagnoses including progressive neurological conditions, cerebral palsy, hemiplegia, malnutrition, gait and mobility abnormalities, thyrotoxicosis, contractures of both lower legs, muscle weakness, and dysphagia. The MDS did not indicate any range of motion exercises. Therapy discharge documentation stated that a functional maintenance program had been established, staff were trained to provide ROM, and the resident was to receive complete ROM exercises to both lower extremities three times daily to reduce the risk of contractures, with an excellent prognosis to maintain current function with consistent staff support. Review of the EMR showed no evidence that the functional maintenance program was implemented after therapy discharge, and there was no documentation that ROM exercises were initiated, scheduled, or routinely completed. The CNA report sheet for the resident’s group included a bolded instruction to perform ROM exercises on the lower extremities, but the EMR did not support that the intervention was carried out. During observations, the resident was seen lying in bed with the left arm and both legs elevated due to contractures, and later was observed with the left wrist contracted at approximately a 90-degree angle and the lower extremities contracted and leaning to the left. Staff interviews confirmed that no ROM exercises were being performed, and the RN case manager stated a ROM program was not in place for the resident.
Failure to complete post-fall analysis and update interventions after repeated falls
Penalty
Summary
The facility failed to complete thorough post-fall assessments, including root cause analyses, and failed to implement individualized interventions after repeated falls for a resident with intact cognition who required assistance with ADLs and had multiple diagnoses including ESRD, anemia, CAD, heart failure, hypertension, diabetes mellitus, CVA, TBI, anxiety, depression, respiratory failure, atrial fibrillation, hypoglycemia, hypokalemia, and cardiomyopathy. The resident’s EMR showed four falls, with incident reviews documenting that contributing factors such as muscle weakness, ESRD, fatigue after dialysis, unlocked wheelchair brakes, refusal to call for assistance, and self-transferring were identified. After the falls, the incident reviews repeatedly reflected only existing measures such as the bed in low position, call light within reach, gripper socks, and a call-for-help sign. In several reviews, possible interventions were noted but not implemented, and in one review the section for possible interventions was left blank. The resident fell while in the bathroom, while ambulating to the bathroom, and while attempting to ambulate independently, and one fall involved striking the head with active bleeding and transfer to the emergency room for evaluation. The resident’s care plan, printed after the repeated falls, still listed a fall-risk problem related to traumatic subdural hemorrhage and included general interventions such as PT/OT instructions, keeping the room free of clutter, ensuring the call light was within reach, and following the facility fall protocol. Interviews with nursing assistants, RNs, the RN case manager, and the DON confirmed the facility expected post-fall assessment, root cause analysis, intervention development, and care plan updates, but acknowledged these steps were not consistently completed for the resident. The facility’s Fall Prevention and Management policy required post-fall assessment, incident review and analysis, individualized interventions, monitoring effectiveness, and care plan updates, but these actions were not consistently followed.
Failure to Offer or Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure pneumococcal immunization was offered and/or administered in accordance with current standards of practice for 1 of 5 residents reviewed for immunizations, R27. A CDC pneumococcal vaccine timing resource dated 3/2025 identified recommended vaccination schedules for adults, including that adults age 50 years and older with no prior pneumococcal vaccination should receive either PCV20 or PCV21, and that additional vaccination with PCV20 may be considered for those who previously received PCV13 and PPSV23 based on shared clinical decision-making. R27's admission MDS identified intact cognition and the ability to make needs known. R27's diagnoses included atrial fibrillation, heart failure, hypertension, renal failure, diabetes mellitus, anxiety disorder, depression, and schizophrenia. The MDS and immunization section did not indicate that R27 was up to date on pneumococcal vaccination, and review of the EMR lacked documentation that a pneumococcal immunization had been offered or administered. There was no evidence of prior vaccination, medical contraindication, or refusal documented in the medical record. R27 stated she would have been interested in receiving any vaccinations for which she was eligible, and the DON confirmed the facility was responsible for assessing pneumococcal vaccination status and offering the vaccine unless previously received, medically contraindicated, or refused, with no documentation that R27 had been offered or received the vaccine.
Failure to Offer and Document COVID-19 Booster Vaccination
Penalty
Summary
The facility failed to ensure COVID-19 immunization was offered and/or administered in accordance with current standards of practice for 1 of 5 residents reviewed for immunizations, R27. CDC COVID-19 vaccination guidance in effect at the time of survey indicated individuals should receive recommended COVID-19 vaccinations, including booster doses, when eligible unless medically contraindicated or refused, and long-term care facilities were responsible for assessing vaccination status and ensuring residents were offered recommended vaccines. R27’s admission MDS identified intact cognition and the ability to make needs known. R27’s diagnoses included atrial fibrillation, heart failure, hypertension, renal failure, diabetes mellitus, anxiety disorder, depression, and schizophrenia. The MDS immunization section did not indicate that R27 was up to date on COVID-19 booster vaccination. Review of R27’s EMR, including immunization records, showed no documentation that a COVID-19 booster had been offered or administered. Physician orders and progress notes also lacked evidence of assessment for booster eligibility, discussion with the resident or representative, or documentation of refusal or contraindication. During interview, R27 stated she would have been interested in receiving any vaccinations for which she was eligible. The DON confirmed the facility was responsible for ensuring residents were assessed for and offered COVID-19 booster vaccinations when eligible and acknowledged there was no documentation that R27 had been offered or received a booster. The facility’s COVID-19 vaccination policy stated residents were to be assessed for vaccination status and eligibility upon admission or within 5 days, offered vaccination within 30 days when indicated, and documented accordingly.
Failure to Routinely Offer Snacks Between Meals
Penalty
Summary
The facility failed to routinely offer snacks to residents when the interval between meals exceeded 14 hours, affecting all 35 residents. One resident, who was cognitively intact and had diagnoses including heart failure, diabetes, and COPD, reported never being offered a snack during her stay and was unaware she could request one. Staff interviews revealed inconsistent practices regarding snack distribution, with some staff noting that snacks were only available if specifically requested from the kitchen and that there was no regular snack cart or routine offering. The dietary manager confirmed that snacks were not consistently provided and was unsure of the established process, while the registered dietitian acknowledged that residents would benefit from snacks and fluids at least once daily but was unfamiliar with the facility's procedures. The administrator agreed that there was a significant gap in the process, noting that there were 15 hours between supper and breakfast without a substantial snack being offered. Review of the facility's snack policy showed that while it described how to assist residents with snacks, it did not specify the timing or frequency for offering them. This lack of routine snack provision and unclear policy contributed to the deficiency identified during the survey.
Staff Consumed Food in Kitchen Food Preparation Area
Penalty
Summary
A deficiency occurred when a staff member, identified as Cook-A, was observed eating a sub sandwich at a food preparation counter in the kitchen, near the microwave, with a plate of food also present on the counter. After finishing her meal, Cook-A placed the sandwich wrapper on the hot holding steam table counter. The dietary manager confirmed that staff are not permitted to eat in the kitchen and noted that Cook-A has physical challenges, with the staff break room located down a flight of stairs in the basement. Cook-A acknowledged she should not have been eating in the kitchen and typically eats in the designated break room. The registered dietician also agreed that eating in the kitchen at the food prep counter is an infection control concern and that all staff should eat only in the designated break room. No relevant policy was provided during the survey period.
Failure to Analyze and Document QAPI Data and Action Plans
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented, resulting in a lack of oversight for identified areas needing improvement. Review of QAPI meeting minutes from March 2025 through May 2025 showed that department heads presented data on several key quality indicators, including pressure injuries above the national average, trends in falls, psychoactive medication use, increased assistance with activities of daily living (ADLs), rising antibiotic use for infection control, and six unplanned hospitalizations. However, there were no documented goals, action plans, or analysis of the data presented for these areas. An interview with the interim administrator confirmed that the QAPI meeting minutes lacked identification of goals, action plans, and data analysis for the issues brought forward. The administrator acknowledged the need for improvement and recognized the deficiencies in the QAPI process. Additionally, the facility's QAPI policy required the committee to oversee improvement areas, develop action plans, and analyze results, but documentation did not reflect these activities. No information was provided regarding the involvement of the medical director, as messages left were not returned.
Lack of Documentation and Data Analysis in QAPI Performance Improvement Projects
Penalty
Summary
The facility failed to provide evidence of a goal, action plan, or analysis of data for its identified Performance Improvement Projects (PIPs) as required by regulatory standards. Review of QAPI minutes from March through May 2025 showed that for several PIPs—including call light response times, notification of change in condition, enhanced barrier precautions, and air mattress monitoring—there was either no goal identified, no documentation of the action plan, or no analysis of data presented to the committee. In multiple instances, the documentation remained unchanged from month to month, and there was no indication that the committee had reviewed or analyzed any data related to these projects. Additionally, the QAPI minutes lacked documentation regarding the decision to end certain PIPs or the analysis of data that would support such decisions. Interviews and email communications confirmed that the facility had no additional material or details about the PIP projects beyond what was recorded in the QAPI minutes. Requests for relevant policies were not fulfilled by the end of the survey, and attempts to contact the medical director for further information were unsuccessful. This deficiency had the potential to affect all 35 residents residing at the facility.
Failure to Accurately Track and Document Employee Illnesses for Return to Work
Penalty
Summary
The facility failed to ensure that employee illnesses were properly tracked and documented to determine when staff could safely return to work, as required by their infection prevention and control program. Review of employee absence and illness logs from February through June 2025 revealed incomplete documentation for three sampled staff members, including missing information on symptom resolution, test results, and clearance for return to work. For example, a housekeeping aide returned to work after reporting a fever, but there was no documentation of symptom resolution. Similarly, a speech therapist returned after a sore throat and COVID testing, but the log lacked evidence of test results. A certified nursing assistant returned to work after experiencing diarrhea, but there was no documentation of symptom resolution or whether the illness was potentially norovirus. Interviews with the administrator confirmed that employees were expected to report symptoms to the DON, who would then review their health status for clearance to return to work. However, the administrator was not aware of the specific illness or treatment for the certified nursing assistant, and the illness logs did not consistently reflect accurate tracking or clearance procedures. Policy review indicated that staff were required to report certain infections to the infection preventionist and to seek evaluation if symptoms persisted or worsened, but these procedures were not consistently followed or documented.
Failure to Post and Provide Dietary Menus to Residents
Penalty
Summary
The facility failed to honor residents' rights to organize and participate in resident/family groups by not acting promptly or providing resolution for concerns related to the posting of dietary menus. Resident council meeting minutes from several months documented repeated complaints from residents that menus were not posted or provided, and that kitchen staff were unable to inform them of upcoming meals. Despite these concerns being raised multiple times and documented in both resident council and QAPI committee minutes, there was no evidence of consistent improvement or effective action taken to resolve the issue. Observations on-site confirmed that menus were not posted in resident areas as required by facility policy. Interviews with facility staff, including the activity director, dietary manager, and administrator, confirmed awareness of the ongoing issue but revealed a lack of follow-through and monitoring to ensure the deficiency was corrected. The dietary manager acknowledged not posting or distributing menus despite having them available, and the administrator was unable to provide documentation of audits or follow-up to verify resolution. The facility's own policy required menus to be written in advance and posted in at least two resident areas, but this was not being followed at the time of the survey.
Failure to Notify Ombudsman and Provide Bed Hold Notices During Resident Hospitalizations
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and discharges, specifically omitting notification to the Ombudsman for several residents who were hospitalized. For example, one resident with diagnoses including ataxia, COPD, chronic back pain, and paranoid schizophrenia was transferred to an acute care hospital after calling 911 due to back pain. The medical record and staff interview confirmed that the Ombudsman was not notified of this transfer. Similar failures to notify the Ombudsman were identified for three other residents who experienced hospitalizations, as evidenced by the absence of these residents on monthly discharge notices and lack of documentation in their records. Additionally, the facility did not ensure that residents or their legal representatives were informed of bed hold rights or provided with written notices of transfer in at least one case. For a resident dependent on staff for transfers and with multiple complex medical conditions, there was no documentation that a bed hold notice was given during a hospital transfer, and the facility confirmed that no bed hold was provided. These deficiencies were identified through review of medical records, facility documentation, and staff interviews, which consistently showed a lack of required notifications and documentation for residents transferred to hospitals.
Failure to Provide Adequate Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several dependent residents, including assistance with toileting, turning and repositioning, queuing for food and hydration, and personal hygiene. One resident with severe cognitive impairment, hemiplegia, and on hospice care was repeatedly observed lying in bed for extended periods without being offered food, fluids, or assistance. Meal trays were left untouched and removed without staff attempting to queue or assist the resident, and her water pitcher was not refreshed. The resident was frequently found in soiled clothing and bedding, with matted hair that eventually required cutting due to lack of care. Multiple interviews with hospice staff, family members, and facility staff confirmed ongoing issues with personal care, hydration, and communication between facility and hospice staff. Another resident, who was cognitively intact but physically dependent, reported frequent delays in staff response to call lights, resulting in episodes of incontinence and feelings of neglect. He stated that staff rarely offered to take him to the toilet and only changed his brief upon request, sometimes after significant delays. Family members corroborated these accounts, describing long waits for assistance and inadequate hygiene care, such as only having his face washed in the morning and infrequent bathing. A third resident, who was transferred to another facility, was found with dried feces on her back, dirty feet, matted hair, and body odor, and reported not having had a shower in three months. Her personal care assistant and family members noted repeated issues with lack of hygiene and long waits for staff assistance. Another dependent resident was observed with visible facial hair that was not addressed by staff, despite family requests and care plan instructions. Staff interviews revealed a lack of clarity and consistency in providing grooming and personal care, with some staff unaware of or not performing required tasks. The facility lacked documented audits or oversight to ensure that ADL care was being provided as required.
Failure to Notify Resident Representative of Medicare Non-Coverage Due to Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) were provided to the appropriate representative for a resident with known cognitive impairment. The resident in question had documented moderate to severe cognitive deficits, as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 and multiple St. Louis University Mental Status Examination (SLUMS) scores indicating dementia. The resident's care plan and provider notes consistently identified cognitive impairment, confusion, and the involvement of a family member as the resident's decision-maker and power of attorney (POA). Despite this, the facility had the resident personally sign the NOMNC form when skilled services were ending, without involving the family member or POA. The business office manager stated that the facility was unaware of the POA status, as there was no documentation of a POA or guardian on file, and the resident was listed as the guarantor on hospital forms. The family member, who had previously handled all paperwork for the resident, was not notified of the coverage termination and only became aware after the resident's status changed to private pay, resulting in an outstanding bill. The facility's policy required that the NOMNC be issued to the resident or legal responsible party, but did not specify procedures for residents with cognitive deficits. The policy also indicated that staff should confirm receipt of the notice and adequately explain it, but in this case, the notice was not communicated to the family or POA, and the resident, due to cognitive impairment, was unable to understand or contest the decision. The deficiency was identified through interviews, document review, and communication with the ombudsman.
Failure to Honor Resident Food Preferences and Dietary Restrictions
Penalty
Summary
The facility failed to honor food preferences and dietary restrictions for multiple residents, as evidenced by direct observations, interviews, and review of dietary documentation. One resident with end stage renal disease and a fluid restriction was served items specifically listed as dislikes and not permitted on his diet slip, including milk and apple juice at dinner, as well as potatoes and broccoli. The resident expressed that he was not supposed to receive milk and did not like several items on his tray, which were clearly documented as dislikes. As a result, the resident did not eat his meal. The resident's care plan and dietary slip outlined specific dietary needs and preferences, which were not followed by staff. Additional observations included a resident being served toast despite a documented dislike, with the nursing assistant failing to offer an alternative or notify the kitchen due to time constraints and lack of training. Another resident reported frustration after being served mushrooms, which were also listed as a dislike, and only received a replacement meal after specifically requesting it from the cook. Staff interviews confirmed a lack of awareness and training regarding alternative food options and the process for addressing resident dislikes. The facility's policy required staff to document and honor food preferences, but this was not consistently implemented for the residents involved.
Failure to Identify and Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to residents had clearly identified target behaviors or symptoms, and did not monitor for these behaviors or symptoms to assess medication effectiveness. For example, one resident with diagnoses of seizures, anxiety, and depression was receiving antipsychotic medications for major depressive disorder, but neither the care plan nor the medical record specified individualized target behaviors to monitor. The care plan only included general interventions such as assessments, redirection, and emotional support, without detailing specific behaviors to track. The director of nursing confirmed that while weekly meetings reviewed nursing progress notes, individualized target behaviors were not documented in the medical record for residents on psychotropic medications. Similarly, another resident with dementia and anxiety was prescribed both antidepressant and antipsychotic medications, but the orders and care plan lacked evidence of specific target behaviors the medications were intended to address. Staff interviews revealed that nursing assistants and nurses were unable to identify or were unaware of any target behaviors for these medications, and this information was not reflected in the medication administration record or care plan. The facility's policy required ongoing documentation of behavioral indicators, symptoms, and monitoring for effectiveness, but this was not followed for multiple residents reviewed.
Failure to Complete 48-Hour Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to complete a 48-hour baseline care plan upon admission for one resident. The resident's admission Minimum Data Set (MDS) assessment indicated she was cognitively intact, experienced depression several days a week, and required assistance with hygiene while being independent with transfers. She had multiple diagnoses, including heart failure, diabetes, COPD, respiratory failure, and atrial fibrillation, and was at risk for pressure ulcers. She was prescribed insulin, an anticoagulant, and a diuretic. The baseline care plan documented that she required assistance with bathing, dressing, hygiene, mobility, and transfers, but did not specify the level of assistance or the number of staff required for these tasks. During interviews, a registered nurse stated that the care plan lacked sufficient detail to determine the resident's care requirements or staffing needs. The director of nursing confirmed that the baseline care plan was missing essential information and acknowledged that the resident had not yet been added to the care sheets used by nursing assistants for guidance on activities of daily living, transfers, diet, and precautions. The facility's policy requires a baseline plan of care to be developed within 48 hours of admission to address immediate needs, but this was not completed for the resident in question.
Failure to Address Anti-Platelet Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident that addressed the use of anti-platelet therapy and associated safety precautions. The resident had a history of transient ischemic attack and cerebral infarction, was moderately cognitively impaired, and required assistance with daily activities. Despite being prescribed clopidogrel bisulfate (Plavix) for myocardial infarction, the resident's care plan did not include interventions or monitoring parameters related to anti-platelet therapy, such as monitoring for signs and symptoms of bleeding or bruising. Interviews with nursing staff confirmed that the care plan lacked necessary identification of interventions and monitoring for the anti-platelet medication, and review of facility policy indicated that care plans should be individualized and comprehensive.
Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to revise and update care plans to reflect the current care needs of two residents. For one resident with severe cognitive deficits and multiple diagnoses, the care plan continued to indicate the presence of a Foley catheter and related enhanced barrier precautions, despite staff observations and interviews confirming that the resident did not have a Foley catheter. Nursing assistants providing care were unaware of any history of a Foley catheter for this resident, and no catheter was observed during care. For another resident with intact cognition and multiple complex medical conditions, including end stage renal disease and a history of lung transplant, the care plan listed an outdated dialysis transportation schedule. The resident reported, and staff confirmed, that the actual pick-up time for dialysis had changed months prior, but the care plan was not updated to reflect this. The consulting nurse acknowledged that both care plans did not accurately represent the residents' current care needs, and the facility's policy requires individualized and current care plans prepared by the interdisciplinary team.
Failure to Individualize and Document Pressure Ulcer Repositioning Interventions
Penalty
Summary
The facility failed to identify and implement an appropriate turning and repositioning schedule for a resident with a pressure ulcer, as well as to document when staff performed repositioning. The resident had a diagnosis of pressure ulcers, diabetes, and neurocognitive disorder with Lewy body dementia, and was identified as severely cognitively impaired and at risk for pressure ulcer development. The care plan indicated the need for turning and repositioning every 2 to 3 hours and as needed, but there was no evidence that a specific, individualized schedule was established or documented in accordance with professional standards of practice. Observations and interviews revealed that staff repositioned the resident, but did not consistently document when repositioning occurred. Nursing staff reported that repositioning was done every 2 hours, but this was not always recorded, and the care plan lacked personalized interventions to promote wound healing. The CNA report sheet did not reflect the required interventions, and staff were not required to use a checklist to document hourly rounding or repositioning. The wound care nurse noted that repositioning every 2 hours was not sufficient to promote wound healing for this resident. The facility's care planning policy required individualized care plans, but the resident's plan did not include specific, personalized interventions for pressure ulcer prevention and care. The lack of documentation and individualized planning contributed to the failure to minimize the risk of further pressure ulcer development and ensure that appropriate interventions were implemented.
Failure to Provide Prescribed Renal Diet and Fluid Restriction
Penalty
Summary
The facility failed to provide a prescribed therapeutic renal diet to a resident with complex medical needs, including end stage renal disease, severe protein-calorie malnutrition, and a fluid restriction. Despite clear dietary orders and documented food preferences, the resident was repeatedly served meals that did not comply with his renal diet or fluid restrictions. On multiple occasions, the resident received items such as milk and apple juice, which were not permitted, and was not provided with double portions as required. The resident also reported receiving foods he disliked and was not supposed to have, such as potatoes and broccoli, and was not offered adequate calorie intake, especially after being away from the facility for medical appointments. Interviews with dietary staff and the registered dietician revealed a lack of awareness and adherence to the resident's prescribed diet. The dietary manager acknowledged that the correct diet was not served on at least two occasions and noted confusion among staff regarding the provision of second helpings. The registered dietician was unaware of the ongoing issues and relied on dietary staff to follow the prescribed orders. The facility was unable to provide a policy related to prescribed diets during the survey, and the resident's care plan clearly outlined the need for increased protein, fluid restriction, and communication with the renal dietician, which was not consistently implemented.
Failure to Arrange and Cover Transportation for Dialysis as Required by Contract
Penalty
Summary
The facility failed to implement its dialysis contract and arrange for appropriate transportation for a resident who required regular dialysis treatments. The resident, who was cognitively intact but physically dependent on staff for transfers and mobility, missed a scheduled dialysis appointment because staff did not ensure he was ready and at the pick-up location on time. The resident had a long-standing schedule for dialysis transportation, but on the day in question, staff reported he refused to get up until the ride arrived, resulting in the transportation service leaving after waiting the required five minutes. Documentation and interviews revealed conflicting accounts, with staff stating the resident was not ready and the resident and his roommate asserting that staff did not get him up in time. Following the missed ride, the facility contacted the dialysis center and was offered an alternative appointment later that day, which required the resident to pay privately for transportation. The resident declined this option, stating he did not have the funds and was unwilling to pay. The facility did not offer to cover the cost, citing that the resident was a member of Metro Mobility and that the facility was not obligated to pay for private transportation. The resident was also offered a dialysis appointment the following morning but refused to reschedule another personal appointment he had at that time. As a result, the resident missed his regular dialysis session and was rescheduled for an additional day later in the week. A review of the facility's contract with the dialysis provider revealed that the facility was responsible for arranging suitable transportation for the resident to and from the dialysis center, including covering all associated costs. Despite this contractual obligation, the facility did not pay for the alternative transportation when the resident missed his scheduled ride, leading to the resident missing his dialysis treatment. Interviews with staff, transportation providers, and the resident confirmed that the facility did not fulfill its responsibility to ensure the resident received timely and appropriate dialysis care as required by the contract.
Failure to Administer and Supply Ordered Antibiotic for C-diff
Penalty
Summary
The facility failed to ensure the timely supply and administration of a prescribed antibiotic medication for a resident with a diagnosis of diabetes mellitus type 2, neuromuscular dysfunction of the bladder, neurogenic bowel, and a terminal diagnosis of CVA. The resident was admitted with septic shock and diarrhea, and had a positive test for clostridium difficile (C-diff), for which vancomycin was ordered. According to the Medication Administration Record, five doses of vancomycin were missed on specific dates, and a Medication Error Incident summary later identified a total of seven missed doses. There was no documentation that the provider or pharmacy was notified about the missed doses or the lack of medication supply. Interviews revealed that the nurse practitioner was unaware of the missed doses and noted ongoing communication challenges with the facility. The DON confirmed that nurses had not notified the physician or pharmacy about the medication shortage, which was expected per facility policy. The pharmacist stated that the pharmacy had not received any request for a refill and that the facility had multiple ways to request additional medication. Facility policy required staff to accurately transcribe medication orders and communicate with the pharmacy as directed, but this was not followed in this case.
Failure to Offer Alternative Meal for Resident Food Preference
Penalty
Summary
A nursing assistant (NA) delivered a breakfast tray to a resident that included toast, which the resident stated she did not eat. The NA did not respond to the resident's comment, did not offer an alternative food item, and did not notify the kitchen of the resident's preference. Instead, the NA continued passing trays to other residents and did not return to address the issue. The NA later confirmed he was unaware of an alternate menu and had not received training on how to handle such situations, typically offering a snack like Jello when a resident disliked a food item. The director of nursing stated that staff are expected to offer an alternative food item with equal nutritional value when a resident voices a dislike for a food item. Review of the facility's Resident Food Preference policy showed that while it required documenting preferences and offering a variety of foods, it did not specify procedures for when a resident receives food they cannot or will not eat. This resulted in the resident not being provided with an appropriate alternative meal option.
Failure to Complete Comprehensive Antibiotic Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for the continued use of antibiotics for two of three sampled residents reviewed for antibiotic stewardship. According to CDC guidelines, residents started on antibiotics should be comprehensively reviewed within 48-72 hours to ensure the medication is effective, which involves evaluating current symptoms and laboratory results. However, review of the facility's infection control logs and medical records for two residents revealed that there was no documentation of an initial comprehensive assessment after antibiotics were prescribed. One resident, admitted with septic shock and diarrhea, was prescribed vancomycin for a C-diff infection, but the medical record lacked evidence of an initial assessment. Another resident, admitted with a duodenal ulcer and hemorrhage, was prescribed metronidazole and tetracycline for H. pylori, but similarly, no initial comprehensive assessment was documented. The facility's infection summary reports and logs included information such as resident names, infection dates, body systems affected, and medications, but did not provide evidence that criteria for continuation of antibiotic use were met. The DON confirmed that while symptoms were assessed and communicated to the physician, and Mcgreer's criteria were referenced, there was no accessible form for staff to document that criteria had been met. Additionally, the facility's policy required the use of Mcgreer's criteria and review of antibiotic therapy for appropriateness, but a copy of the criteria was not provided upon request.
Failure to Offer and Document Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered or provided an updated pneumococcal vaccination in accordance with CDC recommendations. The resident in question was an older adult with a history of non-Hodgkin lymphoma, anemia, and dementia, who had previously received PPSV-23 and PCV-13 vaccines. Despite facility policies requiring assessment of immunization status within five days of admission and offering the vaccine within thirty days if indicated, the medical record did not contain evidence that the resident was offered the updated pneumococcal vaccine or had signed a declination form. Document review showed that standing orders and facility policy aligned with CDC guidelines, mandating documentation of vaccination status, administration details, and periodic audits by the Infection Preventionist. However, the resident's medical record lacked documentation of being offered the vaccine or declining it, and the Minimum Data Set incorrectly indicated that vaccines were up to date. The DON confirmed the expectation that vaccines should be current, highlighting the gap between policy and practice.
Failure to Implement Air Pressure Redistribution Mattress
Penalty
Summary
The facility failed to implement the use of an air pressure redistribution mattress for a resident who was reviewed for pain management and had a history of cerebral infarction, peripheral vascular disease, and was receiving hospice services. The resident was admitted with a non-healing Stage 3 pressure ulcer and required ongoing pain management. Despite physician orders for an air pressure redistribution mattress dated 12/3/24, the mattress was not implemented until after 12/21/24. This delay occurred despite multiple reminders and calls to hospice by the facility staff. The resident's care plan and wound care notes indicated the necessity of the mattress for pressure ulcer relief and pain management. The facility's director of nursing and nurse manager were unaware of the delay in implementation, which was contrary to the facility's policy on immediate implementation of medical provider orders. The delay in providing the air pressure redistribution mattress contributed to the worsening of the resident's pressure ulcer, as noted in progress notes that documented an increase in the size and drainage of the ulcer.
Failure to Implement Proper PPE for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate personal protective equipment (PPE) for a resident under enhanced barrier precautions (EBP) to prevent the spread of infection. The resident, identified as R2, had multiple medical conditions including Clostridioides difficile infection, a nephrostomy tube, and a positive sputum culture for methicillin-susceptible Staphylococcus aureus. R2 required wound care, nephrostomy flushes, and antibiotic treatment via a peripherally inserted central catheter (PICC) line. Despite the presence of signage indicating the need for EBP, nursing assistants were observed performing peri care without wearing gowns, which are required along with gloves and face masks during high-contact resident care activities. The nursing assistant acknowledged the requirement to wear a gown but cited time constraints as a reason for not donning all the necessary PPE. The registered nurse and director of nursing confirmed the need for EBP due to the resident's current infection, PICC line, and open wounds. The facility's policy on enhanced barrier precautions, revised in April 2024, mandates the use of gowns and gloves during specific care activities and requires clear signage to be posted. However, the staff did not adhere to these guidelines, leading to a deficiency in infection control practices.
Failure to Notify Physician of Resident's Wound Deterioration
Penalty
Summary
The facility failed to provide timely notification to the physician regarding a change in condition for a resident with diabetic foot ulcers. The resident's care plan required immediate notification to the provider for any complications such as increased drainage, odor, or changes in the wound. On a specific date, a nurse practitioner observed the resident's right toe wound deteriorating with odorous drainage and ordered an X-ray and lab work to rule out osteomyelitis. Despite these observations and orders, the nurse practitioner expressed concerns to the nurse manager about the resident's discharge to home, but the physician was not notified. A registered nurse, who was new and unsure of the procedure, did not report the nurse practitioner's concerns or the orders for X-ray and lab work to the resident's physician. The nurse did inform the director of nursing but did not receive any feedback and failed to mention the specific orders. The facility's policy required staff to notify the physician immediately of any changes in a resident's condition that might require intervention, which was not followed in this case.
Inadequate Infection Control Practices for Foley Catheters
Penalty
Summary
The facility failed to ensure the effectiveness of its Quality Assurance Process Improvement (QAPI) committee in maintaining appropriate action plans to correct a previously identified quality deficiency related to infection control practices for indwelling Foley catheters. During the survey, deficiencies were identified, including improper hand hygiene during wound care for one resident, improper use of personal protective equipment (PPE) for two residents, and improper placement and cleaning of a Foley catheter bag for another resident. These issues were observed despite the facility's QAPI plan, which included goals to decrease urinary tract infections and ensure proper infection control practices. The facility's QAPI meeting minutes from June 2023 to April 2024 lacked information regarding audits completed for infection control related to catheter care. Although an audit plan was mentioned in the QAPI meeting minutes dated November 28, 2023, the audits conducted were insufficient and lacked detailed documentation. For instance, only a few audits were completed in July 2023, and subsequent months showed a significant decrease in the number of audits, with some months having only one or two audits that did not specify what was audited. Interviews with the facility administrator revealed that the QAPI committee met monthly to discuss problem areas, but there was no evidence of comprehensive audits on catheter care. The administrator acknowledged the lack of documentation in the QAPI minutes for catheter care and confirmed that no additional audits were completed. This lack of effective monitoring and documentation contributed to the recurrence of deficiencies related to infection control practices for Foley catheters.
Failure to Label Insulin Pens and Eye Drops
Penalty
Summary
The facility failed to ensure that insulin pens and eye drops were appropriately labeled with an opened date according to the manufacturer's guidelines and facility policy. During an observation of the north medication cart, it was found that insulin pens for two residents had been opened and used without any labels indicating when they were first removed from the refrigerator and opened. Additionally, three bottles of eye drops, intended for use by two residents and one previously discharged resident, were also found without labels indicating their open dates. Interviews with the registered nurse and the director of nursing confirmed that the facility's practice requires staff to label medications with the date they are opened to prevent the administration of expired medications. The facility's policies, reviewed in May 2022, also mandate that staff check expiration dates and label multi-dose containers with the date opened. The lack of adherence to these procedures led to the potential risk of administering expired medications to residents.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by multiple observations and interviews. For one resident, staff did not adhere to enhanced barrier precautions, which required the use of gowns, masks, and gloves during high-contact activities. Despite signage indicating these precautions, staff were observed entering the resident's room without the necessary protective equipment. This lapse in protocol was confirmed by interviews with nursing staff, who acknowledged the importance of PPE in preventing the spread of infections. Another deficiency was noted in the handling of a resident with an indwelling Foley catheter. The catheter bag was observed on the floor without a barrier, and the drainage port was not cleaned with alcohol after being emptied. This was contrary to the facility's policy, which requires cleaning the port to prevent cross-contamination. The nursing assistant involved admitted to not having the necessary supplies to perform the task correctly, highlighting a gap in resource availability or adherence to protocol. Additionally, a registered nurse failed to perform hand hygiene during wound care for a resident with a stage 3 pressure ulcer. The nurse did not wash hands after removing gloves at various stages of the wound care process, which is a critical step in preventing infection. This oversight was acknowledged by the nurse, who recognized the potential risk of spreading infections within the facility. The facility's wound care procedure explicitly requires hand hygiene after glove removal, indicating a failure to follow established protocols.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to two residents, R1 and R20, during their hospitalizations. R1, who had multiple diagnoses including dysphagia, obesity, and COPD, was hospitalized twice, but there was no evidence in the medical record that a written notification of the bed hold policy was provided to R1 or their representative. Similarly, R20, who had conditions such as immunodeficiency, malnutrition, and end-stage renal disease, was hospitalized, and their medical record also lacked evidence of a written notification of the bed hold policy. Interviews with the facility staff revealed that the responsibility for completing bed holds was unclear, with the director of social services indicating it depended on staff availability, and the DON stating it was the nursing staff's responsibility. The facility's policy, updated in February 2023, required that written information about bed holds be given to residents and their representatives prior to a transfer, but this was not adhered to in the cases of R1 and R20.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered or received the pneumococcal vaccination in accordance with CDC recommendations. The resident, who had intact cognition and was admitted to the facility in January 2024, had a medical history that included acute on chronic diastolic congestive heart failure, chronic kidney disease, and type two diabetes mellitus. Despite having received PCV-13 in 2015 and PPSV23 in 2017, there was no evidence that the resident was offered or administered the PCV20 vaccination, nor was there documentation of shared clinical decision-making regarding this vaccination. The facility's records, including the resident's medication administration record and treatment administration record for January and February 2024, lacked evidence of the PCV20 vaccination being administered. Interviews with the director of nursing and the regional nurse consultant revealed that the facility had a vaccination schedule and procedures in place, but they acknowledged a deficiency in obtaining shared clinical decision-making and providing the PCV20 vaccination to the resident. The facility's policy required assessment of immunization status and offering of the pneumococcal vaccine within 30 days of admission, but this was not adhered to in the case of the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure an allegation of staff-to-resident abuse was reported immediately to the State Agency (SA) for a resident who was mildly cognitively impaired. The incident involved a nursing assistant who allegedly grabbed the resident by the rib cage, picked her up, and threw her onto a wheelchair to assist with a transfer to the bathroom. The resident reported the incident to a registered nurse the following morning, but the nurse did not report it to any other staff, thinking the resident was having a difficult time adjusting to the transitional care unit. The resident's son also reported the incident to another registered nurse, who then attempted to contact the administrator but did not receive a response that evening. The administrator became aware of the incident the following morning and subsequently reported it to the SA. The facility's policy requires suspected abuse to be reported to the SA no later than two hours after forming the suspicion of abuse. The delay in reporting the incident violated this policy, as the initial report was not made until the day after the incident was first reported by the resident.
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.
Trusted by long-term care providers and associations.
