The Estates At Lynnhurst Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 471 Lynnhurst Avenue West, Saint Paul, Minnesota 55104
- CMS Provider Number
- 245394
- Inspections on file
- 35
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Estates At Lynnhurst Llc during CMS and state inspections, most recent first.
A resident with a history of bipolar disorder reported unwanted physical contact from another resident, but staff did not immediately update care plans, initiate safety checks, or begin an investigation as required by policy. The incident was documented, but no immediate protective actions or interviews with other potential witnesses occurred, and monitoring interventions were delayed.
A resident reported an allegation of sexual abuse to an LPN, who then informed the nurse manager. Due to a misunderstanding of the required reporting timeframe, the administrator was not notified until over five hours later, resulting in a failure to report the incident to authorities within the mandated two-hour window as required by facility policy.
A resident with a chronic heel wound and diabetic foot ulcer repeatedly refused to wear physician-ordered heel suspension boots, citing discomfort. The care plan was not updated to address these refusals or to provide alternative interventions, despite staff awareness of the issue and facility policy requiring care plan revisions as resident needs changed.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
The facility did not employ a full-time RD or a qualified DM to oversee food and nutrition services, with the RD only present eight hours per week and the Culinary Director not pursuing required certification, despite administrative expectations.
Dietary staff, including the Culinary Director, were observed preparing food without wearing beard guards, despite having facial hair. The Culinary Director acknowledged not wearing a beard guard and indicated uncertainty about facility requirements and lack of available beard guards. The administrator confirmed that beard guards were expected for infection control, but no related policy was provided.
A resident with heart failure, diabetes, and dementia, who was able to communicate and make daily decisions, was not consistently invited to participate in care conferences, nor was her legal guardian. Documentation for multiple care conferences lacked evidence of invitations or attendance, and staff confirmed the absence of records showing resident or guardian involvement in care planning.
A resident was not given required Medicare Part A coverage termination and appeal rights notices at least two days before the last covered day, as both the NOMNC and SNFABN forms were signed after coverage ended and the SNFABN lacked documentation of the resident's appeal option choice.
A resident who required staff assistance with personal hygiene was exposed to view from the hallway when a nursing assistant failed to fully close the privacy curtain and the room door remained open. The resident's genitals were visible in a wall mirror during incontinence care, contrary to staff expectations for maintaining privacy and dignity.
A resident with cataracts and aphasia did not have their care plan properly reviewed or revised to address vision needs, including follow-up on a cataract extraction referral and a consult for new eyeglasses. The care plan lacked documentation of the use of multiple non-prescription glasses, and there was no evidence that the resident's or representative's input was considered during care planning. Observations and interviews confirmed ongoing vision issues and missing documentation of necessary follow-up actions.
A resident who was dependent on staff for toileting and frequently incontinent was left waiting over an hour in a soiled brief while staff attended to a roommate's wound care and took breaks. Despite the resident's requests for assistance and the presence of a noticeable odor, timely incontinence care was not provided, resulting in the resident remaining wet and soiled until staff were available to assist.
A resident with paraplegia and neurogenic bladder, admitted with a Foley catheter, did not receive a scheduled urology appointment as ordered upon hospital discharge. The HUC failed to arrange the referral, and neither the DON nor nursing staff could find evidence of a completed or scheduled appointment, despite established processes for order verification.
Two residents experienced deficiencies in care when the facility did not follow up on vision consults and failed to ensure the use of assistive hearing devices. One resident with cataracts and impaired vision did not have referrals for cataract extraction or new eyeglasses scheduled or documented, despite multiple orders and requests. Another resident with moderate hearing loss was not consistently provided with a pocket talker as directed in the care plan, and staff were unclear about its use. Staff interviews and record reviews confirmed lapses in communication, documentation, and adherence to care plans.
A resident with diabetes and neuropathy did not receive timely podiatry services or diabetic shoes despite multiple provider orders and documented need. The resident experienced long toenails, dry skin, edema, and foot pain, while staff failed to schedule follow-up appointments or document refusals, and the facility lacked a clear referral policy.
A resident with severe cognitive impairment and right-sided hemiparesis, who was dependent on staff for transfers and had a history of falls, did not have a fall mattress in place next to the bed as required by the care plan. Multiple staff, including an LPN and a nursing assistant, entered and exited the room without ensuring the mattress was replaced after it was moved, leaving the resident without this key fall prevention intervention for an extended period. Staff interviews and facility policy confirmed the intervention should have been in place.
Staff failed to use required PPE while providing direct care to a resident on enhanced barrier precautions for a sacral wound. Despite clear signage and facility policy, staff entered the room, administered medications, and assisted with transfers without donning gowns or gloves, and were unaware of the resident's EBP status.
A resident with severe cognitive and physical impairments had a personal refrigerator in their shared room that was found to be unsanitary, containing multiple unlabeled and undated food items. Temperature logs were incomplete or missing, and staff interviews confirmed that required monitoring and cleaning procedures were not followed, despite facility policy mandating regular checks and cleaning.
A resident reported a loose grab bar in the second-floor shower room, which was not repaired promptly, posing a safety risk. The facility also faced a persistent fly infestation, confirmed by staff and observed in various areas, including a resident's room. Despite contracting a pest control company, the issue persisted due to maintenance scheduling problems and inadequate cleaning practices.
A resident with a history of agitation and behavioral issues was transferred to a locked behavioral unit, but the facility failed to update her care plan to address her specific needs and triggers. Despite being cognitively intact, the resident's care plan lacked interventions for managing her aggression, refusal of care, and known triggers. The Director of Nursing acknowledged the care plan was not comprehensive or specific to the resident's needs.
Failure to Immediately Investigate and Protect After Allegation of Inappropriate Physical Contact
Penalty
Summary
The facility failed to immediately provide protections and initiate an investigation after a resident reported unwanted and inappropriate physical contact from another resident. One resident, with diagnoses including alcohol dependence and bipolar disorder, reported to the social service designee (SSD) and the director of nursing (DON) that another resident sat on his lap and kissed him, despite his request for her to stop. The incident was documented in a progress note, but no immediate changes were made to the care plan, and safety interventions such as 15-minute checks were not implemented until several days later. The resident's care plan did not reflect any updates following the incident, and the resident continued to have direct proximity to the alleged perpetrator. The facility did not initiate an immediate investigation or interview other residents who may have witnessed the event. The SSD and DON did not further discuss the allegation or notify other staff to begin an investigation, contrary to facility policy requiring prompt reporting and investigation of abuse allegations. The alleged perpetrator, who had a history of impulsive and non-consensual touching, did not have her care plan updated until after the incident was reported to police. Documentation of safety checks for both residents was incomplete, and there was a lack of evidence that appropriate monitoring or protective interventions were put in place immediately following the report.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe. The incident occurred when a resident, who did not have impaired cognition but had a history of stroke and metabolic encephalopathy, reported to an LPN that a man had put his fingers in her vagina and was also touching her daughter. The LPN immediately informed the nurse manager, but the nurse manager was unaware of the two-hour reporting requirement and believed the timeframe was 24 hours. As a result, the administrator was not informed of the allegation until approximately 5.5 hours after the initial report was made to staff. The facility's policy required immediate notification of the administrator and/or DON upon learning of an allegation of sexual abuse, as well as prompt reporting to the State Agency. However, the delay in communication among staff led to a failure to meet the mandated reporting timeframe. The administrator acknowledged that the facility did not comply with its own policy or regulatory requirements regarding timely reporting of abuse allegations.
Failure to Revise Care Plan for Pressure Ulcer Intervention Refusals
Penalty
Summary
The facility failed to revise the care plan for a resident with a chronic right heel wound and diabetic foot ulcer who was refusing physician-ordered pressure-relieving interventions. The resident, who had diagnoses including diabetes, heart failure, and a prosthetic heart valve, was cognitively intact and required maximal assistance for personal care and mobility. Despite having orders for the use of heel suspension boots while in bed to address a right heel ulcer, the care plan did not address the resident's refusals to wear the boots or provide alternative interventions. Observations confirmed that the resident was not wearing the boots as ordered and reported only being able to tolerate them for limited periods due to discomfort. Staff interviews revealed that the LPN was aware of the resident's refusals but did not know the reasons or have alternative approaches documented. The care plan and physician orders were reviewed and confirmed to lack documentation regarding the resident's refusals and did not outline specific interventions for such situations. The facility's policy required care plans to be updated as resident needs changed, but this was not done in response to the resident's ongoing refusal of a key pressure-relieving intervention.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Employ Qualified Food and Nutrition Service Staff
Penalty
Summary
The facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to oversee the food and nutrition service since 3/26/24, potentially affecting all 65 residents. The RD reported working full-time across five buildings but only spent eight hours per week at this facility. The Culinary Director (CD), who had been employed for almost a year, had not started training for the Certified Dietary Manager's certificate, despite being asked about it and expressing reluctance to begin. The administrator confirmed that the expectation was for the CD to have the CDM upon hire or within the first three months, but this requirement had not been met.
Failure to Ensure Dietary Staff Wore Beard Guards During Food Preparation
Penalty
Summary
The facility failed to ensure that dietary staff wore beard guards while preparing food, as observed when the Culinary Director, who had a beard, was seen cutting fruit in the kitchen without a beard guard. During interviews, the Culinary Director confirmed he was not wearing a beard guard and stated uncertainty about the facility's requirements, also noting that beard guards were not available for staff use. The administrator later confirmed that dietary staff with beards were expected to wear beard guards for infection control purposes. A policy regarding infection control in the kitchen was requested but was not provided.
Failure to Involve Resident and Guardian in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and her legal guardian were invited to participate in the development and review of her person-centered care plan. Multiple care conferences corresponding to the resident's Minimum Data Set (MDS) assessments, including annual, quarterly, significant change, and admission, lacked documentation showing that either the resident or her guardian were invited or attended. Progress notes and care conference forms did not consistently record invitations or attendance, and in some cases, there was no follow-up after initial outreach attempts. Interviews with staff confirmed the absence of documentation regarding invitations and participation of the resident and her guardian in care conferences. The resident, who had diagnoses of heart failure, diabetes, and dementia, was assessed as able to make herself understood and had modified independence in daily decision-making. She expressed a desire to participate in care conferences and voiced concerns about not being included since the appointment of her legal guardian. The resident also reported unmet personal needs and preferences, such as wanting access to personal belongings and assistive devices. Staff interviews and document reviews confirmed the lack of evidence that the resident or her guardian were involved in care planning as required.
Failure to Timely Provide Medicare Coverage Termination and Appeal Notices
Penalty
Summary
The facility failed to provide timely and complete notification of Medicare Part A coverage termination and associated appeal rights to a resident. Specifically, the resident's last day of covered Medicare Part A skilled services was identified, but both the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) were signed by the resident eight days after coverage ended, rather than at least two days prior as required. Additionally, the SNFABN did not indicate which appeal option the resident had chosen. The facility's policy requires that such notices be given at least two days before the last covered day, but this was not followed in this instance.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
A deficiency occurred when staff failed to maintain the privacy and confidentiality of a resident who required assistance with personal care. The resident, who had intact cognition and was dependent on staff for toileting hygiene and personal hygiene due to conditions such as hemiparesis, chronic lung disease, and COPD, was observed during care with the door to his shared room left open. The privacy curtain was not fully drawn, and a mirror on the wall reflected the resident's exposed genitals as a nursing assistant changed his incontinence brief. This allowed visibility from the hallway, compromising the resident's privacy. Interviews with staff confirmed that facility expectations were to close the door and fully pull the privacy curtain during personal care to protect resident dignity and privacy. The nursing assistant involved acknowledged that the curtain could have been closed further to prevent exposure, and this was demonstrated during the survey. The facility's policy on resident rights and privacy was requested but not provided during the survey.
Failure to Revise Care Plan and Follow Up on Vision Needs
Penalty
Summary
The facility failed to review and revise a resident's care plan with input from the resident to address vision needs, specifically for a resident with a history of cataracts and aphasia. The resident's quarterly MDS indicated moderately impaired cognition, adequate vision, and no use of corrective lenses, despite a diagnosis of bilateral age-related cataracts. The Care Area Assessment (CAA) triggered by the cataracts noted the need to maintain current visual function and referenced a consultation for cataract extraction, which the resident elected to pursue. However, the care plan, last revised several months later, did not document the use of multiple pairs of non-prescription glasses or follow-up on the cataract extraction referral and new eyeglasses order. Review of the resident's electronic health record (EHR) revealed a lack of documentation that the referral to a cataract extraction specialist was followed up, and there was no evidence that the order for a consult to optometry for new eyeglasses was addressed. Observations showed the resident using eyeglasses with a missing left temple, and the resident reported ongoing cataract issues, difficulty seeing without glasses, and a need for a new pair. Interviews with the optometrist confirmed that a referral for cataract extraction had been placed and that the facility was responsible for scheduling, but there was no record of the resident requesting eyeglasses or the facility communicating this need. Further, the care conference documentation did not indicate whether the resident or their representative's input was considered in the care planning process. The DON stated that staff were expected to follow up on appointment referrals and that resident preferences and interventions were discussed during care conferences, but also acknowledged that documentation of the use of over-the-counter non-prescription eyeglasses was lacking. Facility policy required person-centered care planning with resident participation and timely updates as needs changed, but these requirements were not met in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for toileting and frequently incontinent of bowel and bladder was not provided timely incontinence care. The resident, who had diagnoses including COPD, chronic atrial fibrillation, and pancreatitis, was observed waiting in his wheelchair for over an hour to have his soiled brief changed. Staff informed the resident that he needed to wait until his roommate's wound care was completed, which was expected to take 15 minutes but ultimately took longer. During this time, the resident remained in a soiled brief, and there was a noticeable odor of bowel movement. When care was finally provided, the resident was found to be wet with urine that had soaked through his pants, and he had also had a bowel movement. Interviews with staff confirmed that the resident waited an hour to be changed due to the ongoing wound care for his roommate and staff breaks. The nurse manager acknowledged that an hour was too long for a resident to remain in a soiled brief and that the resident should have been changed before wound care began. The DON stated that residents should be changed as soon as possible or within a set timeframe to prevent skin breakdown, and that other staff, such as the nurse manager, could assist if nursing assistants or nurses were busy. Facility policy required assistance with activities of daily living, including toileting and hygiene, for residents unable to perform these tasks independently.
Failure to Follow Up on Urology Referral for Resident with Neurogenic Bladder
Penalty
Summary
The facility failed to follow up on a urology referral for a resident with paraplegia and neurogenic bladder, who was admitted with a Foley catheter and required substantial assistance with mobility and toileting. The resident's care plan included interventions such as monitoring catheter output, changing the catheter monthly, and administering bowel medications as ordered. Hospital discharge orders specifically indicated the need for a urology appointment due to bladder spasms and urine bypassing the Foley catheter. Despite these orders, interviews and document review revealed that the Health Unit Coordinator (HUC) did not schedule the required urology appointment and was unable to provide a reason for this omission. The process for entering and verifying discharge orders involved both the HUC and nursing staff, with responsibilities for comparing and clarifying orders upon admission. However, the Director of Nursing (DON) confirmed that there was no record of a completed or scheduled urology appointment for the resident. A facility policy regarding coordination of care was requested but not provided.
Failure to Follow Up on Vision Consults and Provide Hearing Assistive Devices
Penalty
Summary
The facility failed to follow up on vision-related consults and provide necessary assistive devices for hearing for two residents. One resident with a history of cataracts, hemiplegia, and aphasia had multiple documented orders and recommendations for a cataract extraction consultation and new eyeglasses. Despite repeated documentation from optometry and provider notes indicating the need for a cataract extraction consult and new eyeglasses, there was no evidence in the electronic health record that these referrals were followed up on or scheduled. The resident continued to experience vision difficulties and used broken eyeglasses, with no documentation of timely action taken to address these needs. Interviews with facility staff, including the optometrist, health information management (HIM), LPN, and DON, confirmed that the process for handling referrals and consults was not consistently followed. Orders for vision care were not properly communicated or acted upon, and there was a lack of documentation regarding the status of referrals. The HIM and DON acknowledged that consults should have been forwarded and scheduled, and that there was an expectation for documentation of over-the-counter eyeglasses provided to the resident, which was not present in the record. For another resident with moderate hearing loss, the facility failed to ensure consistent use of an assistive hearing device (pocket talker) as directed in the care plan. Observations showed that staff did not offer or utilize the device during care interactions, and some staff were unaware of its intended use, mistaking it for a music device. Interviews with nursing staff and the DON confirmed that staff were expected to use assistive hearing devices for residents with communication deficits, but there was uncertainty about training and proper implementation. Requested policies related to communication devices and vision treatment were not provided.
Failure to Provide Timely Podiatry Services and Diabetic Footwear
Penalty
Summary
The facility failed to ensure that appropriate podiatry services were obtained for a resident with diabetes and neuropathy. The resident was identified as having a self-care deficit and required ongoing at-risk foot care, as documented in her care plan and podiatry notes. Despite a podiatry visit recommending continued care and a follow-up in nine to twelve weeks, no further podiatry appointments were scheduled for the resident over several months. The resident also reported being promised diabetic shoes, but no follow-up occurred, and her care plan lacked information regarding diabetic shoes or podiatry preferences. Multiple provider notes and orders indicated the need for podiatry referral and diabetic shoes, but these were not acted upon in a timely manner. Observations revealed the resident had long toenails, dry skin, edema, and reported foot pain, stating she could not wear her current shoes. Interviews with staff indicated confusion regarding the scheduling of podiatry appointments, with the health information manager unable to provide documentation of any refusal by the resident and the director of nursing noting a lapse in follow-up due to a change in guardianship. The facility was unable to provide a written policy for referrals, and the process described by the administrator was not followed in this case, resulting in the resident not receiving necessary podiatry care and diabetic shoes as ordered.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement fall prevention interventions as outlined in the comprehensive care plan for a resident with significant fall risk factors. The resident had a history of falls, severe cognitive impairment, right-sided hemiparesis, and was dependent on staff for transfers. The care plan required a fall mattress to be placed next to the bed at all times when the resident was in bed, as he had previously fallen out of bed. Despite this, multiple staff members, including an LPN and a nursing assistant, entered and exited the resident's room without ensuring the fall mattress was in place after it had been moved. The mattress remained out of position for an extended period while the resident was in bed, contrary to the care plan directives. Observations confirmed that the fall mattress was not replaced after staff completed their tasks, and interviews with staff and the DON verified that the intervention should have been in place to prevent injury. The facility's policy required staff to implement and monitor resident-specific fall interventions, but this was not followed in this instance. The deficiency was identified through direct observation, staff interviews, and review of the resident's care plan and facility policy.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident who was on enhanced barrier precautions (EBP) due to a wound on the sacrum. The resident, who was dependent on staff for all activities of daily living and had diagnoses including dementia, seizure disorder, and contractures, was identified as requiring EBP as per the care plan and signage outside the room. Despite this, staff members, including a trained medication assistant and a nursing assistant, entered the resident's room and provided direct care, such as medication administration and transferring the resident using a full body lift, without donning the required PPE. The staff had direct contact with the resident and her bedding during these activities. Interviews revealed that the staff were unaware that the resident was on EBP, even when shown signage and a poster indicating the precautions. There was also no PPE bin directly outside the resident's room, although one was available across the hallway. The facility's policy required the use of gown and gloves during high-contact care for residents with wounds or at increased risk of multidrug-resistant organism (MDRO) acquisition, but this protocol was not followed during the observed care activities.
Failure to Monitor and Maintain Sanitation of Resident's Personal Refrigerator
Penalty
Summary
A deficiency was identified when a personal refrigerator in a resident's shared room was found to be unsanitary and not properly monitored. The resident in question had severe cognitive impairment, required substantial to maximal staff assistance for mobility, and was dependent on staff for transfers. Diagnoses included hemiplegia, stroke, seizure disorder, and malnutrition. During observation, the refrigerator contained multiple unlabeled and undated food items, including plastic bags with unidentified contents, rolled aluminum foil, a cup with white liquid, and various containers. Temperature logs for the refrigerator were incomplete or missing for several dates, and a second refrigerator in the room was found unplugged and empty. A family member expressed concern about the cleanliness of the refrigerator, describing it as "very unsanitary." Interviews with staff revealed that nursing staff were responsible for checking and documenting refrigerator temperatures nightly, and that logs were to be turned in to management. However, the administrator was unable to provide complete temperature logs for the requested period, and the DON confirmed that the refrigerator should have been cleaned and logs updated prior to the survey. Facility policy required weekly temperature checks, removal of expired food, and monthly cleaning, but these procedures were not followed as observed and confirmed during the survey.
Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment when a resident, identified as R23, reported a loose safety grab bar in the second-floor shower room, which was not repaired in a timely manner. R23, who was cognitively intact and had a history of falls, pointed out the loose grab bar during an observation. The grab bar was missing screws, making it unstable and posing a risk to residents who used it for support during showers. Despite a work order being entered on 6/29/24, the issue was not addressed, and the grab bar remained a safety hazard. Additionally, the facility had an ongoing issue with flies throughout the building, including in the second-floor shower room and a resident's room. The presence of flies was confirmed by staff and observed during the survey. The facility had contracted with a pest control company, but the problem persisted due to maintenance scheduling issues and inadequate cleaning practices, particularly in the breakroom where flies were attracted to spilled trash and liquids. The facility's pest control policy, last revised in 2008, was not effectively implemented, as evidenced by the continued presence of flies. The administrator acknowledged the recurring fly problem and the need for targeted pest control measures, including drain cleaning and addressing resident behaviors contributing to the issue. Despite these efforts, the facility failed to maintain a clean and pest-free environment, impacting the quality of care provided to residents.
Failure to Update Care Plan for Resident in Locked Behavioral Unit
Penalty
Summary
The facility failed to revise and update a care plan to ensure it was individualized and comprehensive for a resident who was transferred to a locked behavioral unit. The resident, who was cognitively intact, had a history of agitation and behavioral issues, including involvement in resident-to-resident altercations and refusal of care. Despite these issues, the care plan was not updated to include specific interventions or address the resident's triggers and behaviors. The resident's care plan initially focused on mood and behavior alterations, with interventions such as monitoring mood changes and encouraging participation in therapy. However, after the resident was transferred to the locked unit due to increased agitation and feelings of unsafety, the care plan was not revised to include new interventions or address the resident's specific behaviors and triggers. Interviews with staff revealed that the care plan lacked details on managing the resident's aggression, refusal of care, and known triggers. The Director of Nursing acknowledged that the care plan was not comprehensive or specific to the resident's needs. The facility's policy required person-centered care plans to be developed and updated based on comprehensive assessments, but this was not done for the resident. The care plan did not include interventions for the resident's aggression towards staff, refusal of care, or the need to reapproach her multiple times, nor did it address her preferences regarding roommates and environment.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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