The Shores Of Worthington
Inspection history, citations, penalties and survey trends for this long-term care facility in Worthington, Minnesota.
- Location
- 1307 South Shore Drive, Worthington, Minnesota 56187
- CMS Provider Number
- 245596
- Inspections on file
- 29
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at The Shores Of Worthington during CMS and state inspections, most recent first.
Incomplete TB screening and testing for newly hired staff was cited after surveyors found multiple employees lacked required TB documentation or follow-through on testing. One NA worked with residents before TB testing was completed, one dietary aide had a 2nd-step TB test that was never read, one NA had no TB screening on file, and another NA had no 2nd-step TB test completed. The DON and HR director described the facility’s expected TB testing process, and the policy required screening before employment began.
Meals Served Unattractive and Unpalatable: During an observed meal service, spaghetti noodles became dried and gummy as trays were plated, portions were inconsistent, and the final tray had to be scraped from the steam table pan. Residents were served corroded, spotted silverware and dishes with hard water residue, and a resident reported overcooked, flavorless food, mushy vegetables, and food brought to her room that was never hot. Food committee minutes noted water spotting and menu preferences, but did not address food temp, palatability, consistent portions, or fresh produce.
Kitchen sanitation and glove-use failures were observed during food storage and meal service. Multiple freezers had food residue, soil buildup, and ice accumulation, and one freezer contained opened, undated food items. Several steam table pans and utensils were stored wet or with food residue, and a cook repeatedly handled ready-to-serve foods, containers, and utensils with the same gloves without changing them or performing hand hygiene between tasks.
Failure to notify the Ombudsman of a resident discharge occurred when a resident with intact cognition, a walker, and diagnoses including CHF and COPD was sent to the hospital after worsening COVID-related respiratory symptoms, including cough, wheezing, and SOB. The SSD said she was responsible for the notice but missed this discharge, and the DON stated all discharges were expected to be reported and that a backup plan should have been in place.
Failure to revise a resident's care plan for a new pressure ulcer. A resident with moderately impaired cognition, lower-extremity limitations, and diagnoses including HF, arthritis, and depression developed a stage 2 pressure ulcer on the left 2nd toe. The skin assessment noted the resident was educated to leave the shoe off to relieve pressure, but the care planning section was blank and the care plan did not include that intervention, even though nursing documentation showed the wound was assessed and the care plan was reviewed.
A facility failed to ensure 1 of 5 staff had initial and annual Alzheimer's and dementia training. NA-G's file showed a hire date but no completed training for key topics such as ADL assistance, problem solving with challenging behaviors, or communication skills. The DON could not locate the initial hiring documentation, and the facility's in-service policy required dementia management and behavioral health training before staff provided services, annually, and as needed based on the facility assessment.
A resident with severe cognitive impairment was sexually abused by another resident with a documented history of sexually inappropriate behaviors, including prior breast touching and repeated attempts to touch female residents. Despite referral information and ongoing progress notes describing escalating behaviors such as handholding, rubbing arms and chest, standing over women, and persistent attempts to approach a particular female resident, the facility did not initially incorporate the full sexual behavior history into assessments and care planning, and staff did not consistently prevent physical contact. The abuse occurred when the male resident was found in a common area with his hand under the female resident’s shirt touching her breast while she rested in a recliner, after months of documented, inadequately controlled sexually inappropriate conduct toward female residents.
The facility did not designate a physician to serve as Medical Director after the previous Medical Director retired, leaving the position vacant for an extended period and potentially affecting all 52 residents. The DON reported being solely responsible for reviewing clinical trends and participating in QAPI clinical review, with no physician-level oversight. The Administrator confirmed the ongoing vacancy, noted unsuccessful attempts to secure a contract with local medical groups, and relied on informal conversations with rounding physicians instead of formal Medical Director services. The Administrator also acknowledged uncertainty about how physician-level oversight, contractual obligations, and federal compliance were maintained, despite a written policy that assigns broad clinical and administrative responsibilities to the Medical Director.
The facility did not include a Medical Director on its QAPI committee after the prior Medical Director retired, leaving the position vacant for at least two consecutive quarters. QAPI records showed no Medical Director attendance during this period, and the DON reported being the only person reviewing clinical trends and participating in QAPI clinical review. The Administrator confirmed that the former Medical Director had been a quarterly QAPI attendee and acknowledged uncertainty about how physician-level oversight and regulatory compliance were maintained in the absence of a Medical Director, affecting all residents in the facility.
A resident with diabetes and obesity, requiring extensive hygiene assistance, did not receive prescribed skin treatments for acute dermatitis as ordered. Nursing staff failed to document or report significant skin redness and moisture, and a nursing assistant independently applied antifungal cream without notifying licensed staff or following physician orders. The facility's wound care procedures for assessment, reporting, and documentation were not followed.
A resident with a history of pressure ulcers and moderate risk for skin breakdown did not receive comprehensive skin assessments or physician-ordered wound treatments as prescribed. Staff failed to document wound assessments, did not apply treatments according to orders, and were inconsistent in monitoring the resident's skin condition, leading to inadequate prevention and management of pressure ulcers.
A resident with an indwelling urinary catheter and a history of incontinence experienced repeated UTIs due to improper perineal and catheter care by staff. Observations showed staff using contaminated washcloths and failing to perform hand hygiene or change gloves between tasks, contrary to infection control guidelines. No surveillance or staff education on catheter care was conducted, and the facility's policy for clean technique was not followed.
Staff failed to consistently perform proper hand hygiene during personal care for multiple residents requiring extensive assistance, including those with fractures, intellectual disabilities, and parkinsonism. Observations showed that staff did not always wash or sanitize hands between glove changes or after removing gloves, and sometimes used the same gloves or cleaning utensils for both front and back perineal care. Interviews revealed inconsistent understanding of hand hygiene protocols among staff, despite facility policies requiring these practices.
Surveyors found that the facility did not create or update individualized care plans for several residents with complex medical needs, resulting in missing or inadequate instructions for staff on managing behaviors, monitoring for medication side effects, providing wound and catheter care, and responding to refusals of care. Staff interviews and observations confirmed that care plans were often generic and not revised to reflect changes in residents' conditions or new provider recommendations.
Surveyors identified unsanitary conditions in the kitchen, including dirty food prep surfaces, improper storage of food items, and staff using personal cell phones and sitting on food storage equipment. The ice machine was found with visible mineral and grime buildup, and cleaning logs were not maintained as required by policy and manufacturer guidelines. The dietary manager and registered dietitian acknowledged gaps in cleaning oversight and auditing.
The governing body did not provide adequate oversight to ensure correction of previously identified deficiencies, as QAPI meetings lacked measurable goals, thorough data analysis, and actionable plans for issues such as pressure ulcers, falls, infection control, psychotropic medication use, staffing shortages, and grievances. The facility failed to assign responsibility for follow-up actions, did not ensure staff competency or education on QAPI initiatives, and did not monitor the effectiveness of corrective actions, resulting in ongoing noncompliance.
The facility did not implement its assessment protocol to ensure staff competencies were identified and completed according to their duties, particularly following a merger that brought additional challenges. Leadership had not updated or implemented the facility assessment or related staff education, impacting the ability to provide competent care for all residents during daily operations and emergencies.
The facility did not analyze or document QAPI data with measurable goals or benchmarks, despite department heads presenting data on key areas such as infection control and falls. Interviews confirmed the absence of a formal process to set or monitor goals, and review of policy showed required steps were not being followed.
The QAPI committee did not identify or address facility-specific concerns, failed to implement action plans for identified issues, and did not ensure oversight of systems to maintain quality of care. Despite initiating a PIP for abuse allegations, there was no documentation of goal-setting, progress monitoring, or evaluation of compliance, and no active PIPs were in place during a period of organizational change.
A resident with Hepatitis C was not included in the facility's infection control surveillance, and the care plan did not mention the diagnosis. During the absence of the infection preventionist, no staff member was assigned to oversee the infection control program, and the RN who was supposed to cover was not informed. Infection tracking for staff illnesses was incomplete, with missing return-to-work data, and there was no policy for infection control oversight.
The facility did not ensure proper oversight of its infection control program, failing to track and monitor a resident with chronic Hepatitis C and omitting staff illness return-to-work data from surveillance records. When the infection preventionist went on leave, no qualified staff member was assigned to oversee the program, and key personnel were unaware of their responsibilities or the absence of oversight.
The facility did not provide mandatory training on its QAPI program to staff, as confirmed by interviews with RNs, an LPN, and a nursing assistant who were unaware of QAPI meetings or goals. The DON confirmed no formal QAPI education was provided, and documentation of such training was not available during the survey.
The facility did not consistently include dialysis communication reports in the medical records for two residents receiving hemodialysis and failed to update care plans with necessary dialysis information. Additionally, a resident's new physician orders after a medical appointment were not transcribed or implemented promptly, with some directions missing from the records. Staff interviews indicated that the lack of a medical records staff member contributed to these documentation and communication lapses.
A resident who was cognitively alert and required significant assistance with ADLs was admitted with multiple diagnoses, including malnutrition and diabetes. The facility did not ensure the resident's POLST was signed by a physician after admission, and staff interviews confirmed the required process was not followed according to policy.
A resident with a complex medical and behavioral history persistently refused all care, assessments, and medications, resulting in staff being unable to complete required evaluations. Despite this, staff documented assessment data in the MDS and other records based on assumptions or outdated information rather than direct observation, leading to incomplete and inaccurate documentation.
A resident with severe cognitive impairment and a diagnosis of PTSD was not thoroughly assessed for trauma history or potential triggers, as the facility stopped the PTSD screening after an initial negative response and did not seek further information from family or previous staff. The care plan addressed aggressive behaviors but did not reference the PTSD diagnosis or include interventions specific to trauma-related needs. No documentation or policy was provided to show appropriate assessment or care planning for PTSD.
A resident with major neurocognitive disorder, recent inpatient psychiatric care, and ongoing behavioral issues was admitted without the facility notifying the State Mental Health Authority or coordinating a PASARR Level II assessment. The resident exhibited repeated refusals of care, delusions, and aggressive behaviors, yet the facility relied on an outdated PASARR Level I from a previous facility and did not initiate the required mental health evaluation.
Two residents did not have their care plans updated after new physician orders were received, resulting in staff not consistently implementing required interventions such as leg elevation, compression wrapping, and scheduled repositioning. Staff interviews and observations confirmed a lack of awareness and follow-through on the new care requirements, and the care plans did not reflect the updated orders as required by facility policy.
A resident with multiple chronic conditions did not receive timely and complete implementation of physician orders, including delayed transcription of orders for diuretics, leg wraps, and antifungal powder. Staff were unaware of some new orders, and there was a lack of clear communication and documentation processes, resulting in missed treatments and incomplete care.
A resident with multiple pressure ulcers and intact cognition experienced significant unplanned weight loss, but staff failed to assess the cause or notify the provider as required. Despite electronic alerts and documentation, there was no evidence of timely dietician assessment or interdisciplinary team discussion, and communication lapses between dietary, nursing, and contracted staff contributed to the deficiency.
Two residents requiring dialysis were not consistently monitored or assessed for complications following their treatments. Care plans and order summaries lacked critical information such as dialysis access site location, monitoring instructions, and dialysis schedules. Nursing staff confirmed that pre- and post-dialysis assessments were often incomplete, and access site documentation was missing, making it difficult for staff to provide appropriate care.
A resident with a complex psychiatric and medical history persistently refused care, medications, and assessments, yet staff did not notify the medical director or implement additional interventions to address the resident's mental health needs and questionable capacity to refuse care. Documentation showed that the resident received minimal assessment and care over several months, and the care plan lacked specific strategies for managing ongoing refusals. The medical director was unaware of the situation, and the facility's behavioral health policy did not guide staff on how to proceed when interventions were ineffective.
Controlled medications in the emergency kit refrigerator, specifically Lorazepam, were not reconciled or documented at each shift change as required by facility policy. Nursing staff confirmed that the red tag number and quantity were not being checked or recorded, and the DON and medical director stated that such monitoring was expected to prevent diversion.
A resident with chronic kidney disease, diabetes, and other conditions was admitted with orders for a renal consistent carbohydrate diet, but the facility failed to provide the prescribed therapeutic diet. Staff were unaware of renal diet requirements, and the resident was served standard meals with only portion adjustments for diabetes, not renal needs. On dialysis days, the resident's daughter brought in food, and the facility did not provide or document appropriate meals, resulting in the resident not receiving the ordered renal diet.
A facility failed to implement effective infection control measures, resulting in an RSV outbreak affecting multiple residents. Despite symptoms like coughing and shortness of breath, the facility did not consistently isolate affected residents or enforce PPE use. Residents with underlying health conditions were not adequately monitored, and staff were unaware of necessary precautions. This led to the spread of RSV among residents, highlighting significant lapses in infection control practices.
Two residents in the facility experienced multiple falls due to the lack of comprehensive fall analyses and individualized interventions. Despite being identified as at risk for falls, their care plans were not updated to include specific fall prevention measures. This oversight resulted in one resident sustaining a fracture requiring surgery. The facility's policy on fall management was not followed, leading to deficiencies in care.
The facility failed to ensure that four nursing assistants were deemed competent to provide care, potentially affecting all 45 residents. Employee records lacked documentation of completed orientation and competency training. Interviews revealed that NAs were assisting residents without being signed off for skills competencies. The DON stated that competency records were missing, and the facility's training program requirements were not provided.
The facility failed to report alleged abuse and neglect for two residents in a timely manner. A hospice nurse found a resident in a neglected state but did not report it. Another resident experienced falls resulting in a serious injury that was not reported. The facility's reporting policy was inconsistent with federal standards.
The facility failed to accurately assess and manage pressure ulcers for two residents, leading to inadequate interventions and deterioration of existing wounds. One resident had multiple stage 3 pressure ulcers upon admission, with inconsistent wound assessments and care plans not reflecting necessary interventions. Another resident developed a wound misidentified as MASD, with care plans not updated with current interventions. Staff interviews revealed limitations in care plan individualization and inconsistent monitoring, contributing to the deficiencies.
A facility failed to ensure clear communication between hospice and facility staff for a resident receiving hospice care. The hospice nurse communicated care plan changes to an unidentified nursing assistant instead of the nurse on duty, leading to a lack of documentation in the electronic health record. Interviews revealed no designated staff for coordinating hospice communication, contrary to the facility's policy.
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene for residents requiring such measures. A resident with diabetes and cellulitis received IV antibiotics without the administering RN wearing a gown, despite signage indicating the need for EBP. Additionally, another resident with dementia did not receive proper hand hygiene care during peri care, as the RN did not perform hand hygiene before or after glove use.
A resident fell from a mechanical lift due to improper use, resulting in spinal fractures. The facility failed to ensure correct sling sizes and safety checks for multiple residents, leading to discrepancies between care plans and actual practices. Staff were unaware of proper procedures, increasing the risk of injury.
A resident with severe cognitive impairment and a history of exit-seeking behaviors managed to elope from the facility and drive around the city for 1.5 hours due to inadequate supervision and delayed response to the WanderGuard alarm. The facility failed to implement necessary interventions and revise the care plan despite multiple documented exit attempts.
A resident with severe cognitive impairment and multiple medical conditions was transferred to another facility without the required 30-day notice. The family was not given the opportunity to appeal the discharge, and the Ombudsman was not notified in writing. The facility staff admitted to not following the discharge policy, citing safety concerns.
Incomplete TB Screening and Testing for Newly Hired Staff
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors found the facility failed to ensure tuberculosis (TB) screening and testing were completed upon hire for 4 of 5 sampled staff members. Review of employee health files showed NA-E, hired 2/4/26, had a TB screening completed on 3/13/26 but no TB testing completed, and time punches showed NA-E had worked 12 days since hire. DA-B, hired 3/2/26, had an undated TB screening, a 1st step TB test given on 2/9/26 and read on 2/11/26, but the 2nd step TB test given on 2/23/26 was never read. NA-M, hired 1/21/26, had no TB screening completed, although the 1st and 2nd step TB tests were done and read. NA-F, hired 3/17/26, had an undated TB screening and a 1st TB test given on 3/23/26 and read on 3/26/26, but no 2nd step TB test was completed. The DON stated staff should have TB testing completed, with the first step done upon hire before working with residents and the second step about 2 weeks later. The HR director stated the usual process was to complete a TB test on day one, follow up for the Mantoux reading, notify staff when the second TB test was due, and file the completed TB form in the personnel record. The facility policy stated newly hired employees would be screened for LTBI and TB disease before beginning employment.
Meals Served Unattractive and Unpalatable
Penalty
Summary
The facility failed to provide meals that were attractive and palatable during one observed meal service. During observation of the lower-level dementia unit meal service, spaghetti with meatballs and sauce, garlic toast, lettuce salad, mashed potatoes and gravy, and canned pears were prepared and plated. The noodles were served in inconsistent portions, and as the meal service continued they became dried and gummy in appearance; the final tray required scraping noodles from the bottom of the steam table pan. The only vegetable offered for residents on altered texture diets was mashed potatoes and gravy served with the spaghetti. Red plate covers had dried white hard water residue, and silverware had a dull gray, spotted, corroded appearance with white residue visible on observation. A resident reported that food was overcooked, lacked flavor, and that seasonings were not provided to add to food served. She stated she often ate soup because of the overcooked foods offered, that vegetables were served pooled in liquid and cooked to mush, and that fresh vegetables were not offered. She also reported that food brought to her room was never hot and that dishes and utensils were unappetizing because of heavy water spots and discoloration. Food committee minutes reviewed by surveyors discussed water spotting on dishes and silverware, differences in preparation of menu items, and menu likes and dislikes, but did not address food temperature, palatability, consistent serving sizes, or availability of fresh fruits and vegetables. The dietary manager acknowledged the noodles had become overcooked by the end of meal service and should not have been served, and both the maintenance supervisor and registered dietitian identified hard water residue as an ongoing problem affecting the appearance of meal service.
Kitchen sanitation and glove-use failures during food storage and meal service
Penalty
Summary
The facility failed to maintain and clean 4 of 4 freezers in the kitchen. During observation with the dietary manager, an upright freezer used for soups had food particles, white residue, soil buildup on the door hinges, shelves, floor, handles, and door edges, along with ice buildup on the shelves and walls. A freezer used for ice cream products contained an opened undated package of French toast slices and an open undated package of pancakes, which the dietary manager removed because he did not know when they had been opened or last used. The freezer also had spilled food particles on the floor and shelves and a soiled door surface. A large chest freezer behind the steam table and beside the cook top had soiled lid edges, a buildup of food particles in the lid seal, and a large amount of ice on the walls and boxes. An upright freezer used for vegetables had food particles on the floor and shelves, a brown substance running down the base, and residue on the door edges and handle. The facility also failed to ensure food preparation equipment was properly cleaned and dried before storage. In the storage area for scoops, spoons, spatulas, pans, skillets, and steam table pans, multiple quarter, half, small square, and full-size steam table pans were observed stacked while still wet, and several contained food residue on the interior surfaces. The drawer holding serving spoons, scoops, and spatulas contained a wet spatula and scoop with food residue. The dietary manager confirmed the pans had not been adequately washed and should have been allowed to air dry before being stacked for storage. He also stated the items were returned to the dishwashing area to be rewashed and sanitized, and that food storage equipment was expected to be cleaned daily with spills and buildup removed. During lunch meal preparation and service, a cook repeatedly handled food and equipment with the same gloves without changing them or performing hand hygiene between tasks. He carried boiling spaghetti to the sink, sprayed and drained it, then continued preparing food while opening drawers, retrieving scoops, and entering the walk-in cooler with gloved hands to handle containers of lettuce, cheese, and chicken salad. He used the same gloves to remove covers, place utensils in containers, assemble sandwiches, butter bread, and continue plating meals. He also used a gloved hand to push noodles back onto a plate and later handled jelly, peanut butter, and bread without glove changes or hand hygiene after leaving and returning to the steam table. The dietary manager confirmed the cook should have changed gloves and performed hand hygiene between tasks and should have used a serving utensil rather than a gloved hand to adjust food on a plate.
Failure to Notify Ombudsman of Hospital Discharge
Penalty
Summary
The facility failed to notify the Office of the Ombudsman of a resident discharge to the hospital for one of two sampled residents. The resident returned to the facility after a short-term general hospital stay and had a significant change in status MDS assessment showing intact cognition, use of a walker, independence with all care with some set-up assistance or supervision, and diagnoses including anemia, heart failure, high blood pressure, thyroid disorder, and COPD. Progress notes showed the resident tested positive for COVID and was placed on isolation, then developed a worsening cough, diminished lung sounds, wheezing, and shortness of breath. The resident received nebulizer treatments, cough medicine, and an order for a chest X-ray, and was transported by ambulance to the hospital due to worsening cough and shortness of breath. The resident was admitted to the hospital for shortness of breath and weakness and later returned to the facility. The social service designee stated she was responsible for notifying the Ombudsman of resident discharges and sent notices monthly, but the hospital discharge notice for this resident was not completed. The director of nursing stated the social service designee was responsible for the notification and that the facility should have had a backup plan when she was on vacation.
Failure to Revise Care Plan for New Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident with a newly identified pressure ulcer. The resident's 4/9/26 MDS assessment showed moderately impaired cognition, limitations on one side of the lower extremity, partial to substantial assistance needed for cares and transfers, and risk for pressure ulcers with use of a pressure relieving device for the wheelchair and bed. During the assessment period, the resident received an antibiotic and a diuretic and had diagnoses of heart failure, arthritis, and depression. On 4/21/26, a skin issues assessment identified a new stage 2 pressure ulcer on the left dorsum 2nd toe that developed at the facility and measured 0.26 cm by 0.25 cm by 0.1 cm. Bacitracin and a band aid were applied per physician orders, and the resident was educated to leave the shoe off due to pressure to the toes and agreed. However, the care planning section of the assessment was blank, and there were no further interventions or indication that the care plan would be revised after the new pressure ulcer was identified. Although a nursing progress note documented a wound assessment, enhanced barrier precautions, and that the care plan was reviewed, the resident's care plan lacked the intervention to leave the shoe off as tolerated to relieve pressure to the toes, which the DON confirmed was not added to the care plan.
Missing Required Alzheimer's and Dementia Training
Penalty
Summary
The facility failed to ensure 1 of 5 staff had initial and annual Alzheimer's and dementia training. Review of nursing assistant (NA)-G's employee file showed a hire date of 1/10/25, but her Alzheimer's Disease or Related Disorder Training record did not show completion of training on an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. A follow-up email reply from the DON stated the facility was unable to locate NA-G's initial hiring documentation, and no additional information was provided by the end of the survey period regarding the expectation for completion of initial Alzheimer's training. The facility's undated In-Service Training policy required staff to participate in regular in-service education, including effective communication with residents and families, resident rights, preventing abuse, dementia management, and behavioral health, with training completed prior to providing services, annually, and as necessary based on the facility assessment.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Known Sexually Inappropriate Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired female resident from sexual abuse by a male resident with a known history of sexually inappropriate behaviors. Prior to admission, referral documents from a previous facility clearly identified that the male resident had engaged in public urination, following female residents, rubbing their shoulders and arms, and an incident involving touching a woman’s breast, which had been serious enough to be reported to the State Agency. That prior facility had revised his care plan to include 1:1 supervision to prevent further sexually inappropriate behavior, and progress notes documented that while on 1:1 supervision he had no further incidents of touching female residents. Despite receiving these records, the admitting facility did not initially incorporate this history of sexually inappropriate behaviors into his vulnerability assessment or care plan. After admission, the male resident’s behaviors toward female residents, particularly one female resident with severe cognitive impairment, escalated over several months. Progress notes documented repeated episodes of him holding and rubbing female residents’ hands, rubbing or attempting to touch their arms and chest, standing over or very close to them, staring at them, and attempting to touch their breasts. Staff repeatedly redirected him, but the behaviors persisted and often required frequent or constant redirection. Although the care plan was eventually updated to address “touching of other residents” and directed staff not to allow physical contact, progress notes showed that staff did not consistently prevent physical contact, and the male resident continued to approach and touch female residents, including the cognitively impaired female resident who became the primary focus of his attention. On the day of the abuse incident, a nursing assistant observed the male resident standing over the cognitively impaired female resident, who was resting in a recliner, with his hand under her shirt touching her breast. Another resident pointed toward them, prompting the assistant to intervene, tell him to stop, and direct him away. The female resident, who had severe cognitive impairment and required extensive assistance with ADLs, awoke and questioned what he was doing, indicating she was unable to independently protect herself from the unwanted sexual contact. This event occurred in the context of documented ongoing and escalating sexually inappropriate behaviors by the male resident toward female residents, including this particular resident, and despite prior knowledge from referral records, guardian reports, and internal documentation that he had a pattern of progressing from seeking proximity and handholding to touching women’s breasts.
Failure to Designate a Medical Director for Resident Care Oversight
Penalty
Summary
The facility failed to designate a physician to serve as Medical Director responsible for implementation of resident care policies and coordination of medical care, affecting all 52 residents in the facility. The DON reported that the former Medical Director retired in June or July and that the position had not been filled since that time. The Administrator confirmed that the Medical Director position had been vacant since July 2025 and that the local medical physician group would not contract with the facility. The facility had attempted to contract with two other medical groups and was in ongoing contract negotiations with a physician from one of those groups, but no formal appointment had been made. During interviews, the DON stated she was the only person reviewing clinical trends and participating in QAPI clinical review, indicating that physician-level oversight of these functions was not in place. The Administrator stated that, in the absence of a Medical Director, they had informal conversations with physicians when they rounded at the facility, but there was no formal notification to the Governing Body regarding the vacancy, although ownership was verbally informed in daily conversations. The Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements had been achieved since July 2025. This situation existed despite a written Medical Director policy, last reviewed on 3/2/25, that outlined extensive responsibilities for the Medical Director, including implementation of resident care policies, coordination of medical care, evaluation of staff adequacy, review of incidents and accidents, and participation in QAPI meetings.
Lack of Medical Director Participation in QAPI Committee
Penalty
Summary
The facility failed to include a Medical Director as a required member of the Quality Assurance Performance Improvement (QAPI) committee, resulting in noncompliance with the requirement that the Quality Assessment and Assurance group have the required members and meet at least quarterly. Review of QAPI documentation from July 2025 through January 2026 showed no Medical Director attendance at QAPI meetings during that period. The facility’s QAPI plan states that the program is to be an ongoing, facility-wide plan to monitor and evaluate the quality and safety of resident care, resolve identified problems, and coordinate quality-related activities across departments and services. Interviews with facility leadership confirmed that the Medical Director position had been vacant since approximately June or July 2025, when the former Medical Director retired, and that no replacement had been appointed. The DON reported that she was the only person reviewing clinical trends and participating in QAPI clinical review during this time. The Administrator stated that the former Medical Director had been a quarterly attendee at QAPI and last attended in June 2025, and acknowledged that this was the second quarter without a Medical Director participating. The Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements were being achieved since the Medical Director position became vacant. All 52 residents residing in the facility were subject to this deficient practice.
Failure to Assess and Treat Impaired Skin Integrity
Penalty
Summary
The facility failed to comprehensively assess and treat impaired skin integrity for a resident with acute dermatitis. The resident, who had diagnoses including type two diabetes and obesity, was admitted with a history of frequent incontinence and required extensive assistance with personal hygiene and toileting. Hospital discharge orders included specific topical treatments and interventions for skin care, but review of the medication administration record showed no indication that these treatments were applied. The initial skin assessment did not identify issues, but subsequent progress notes and observations revealed persistent redness and moisture under abdominal folds and in the groin area. During care observations, a nursing assistant noted significant redness and soreness in the resident's abdominal fold and groin but did not report these findings to the nurse. Instead, the nursing assistant independently applied antifungal cream without notifying licensed staff or ensuring physician orders were followed. The infection preventionist later confirmed the presence of red and moist skin areas and stated that the issue should have been reported to the nurse and physician for appropriate intervention. The resident reported a history of similar skin issues and described more frequent hygiene interventions at a previous facility, which were not provided at the current facility due to the resident's condition. Interviews with nursing staff and the director of nursing revealed a lack of documentation regarding the skin condition and a reliance on nursing assistants to report new skin issues. The director of nursing acknowledged that it was outside the scope of practice for a nursing assistant to choose and apply treatment products without nurse or physician involvement. The facility's wound care procedure required verification of physician orders and documentation of wound care, which was not followed in this case.
Failure to Provide Comprehensive Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to monitor and complete comprehensive skin assessments, evaluate the effectiveness of interventions, and provide physician-ordered treatments as prescribed for a resident at risk for pressure ulcers with a history of such ulcers. The resident, who was obese, dependent on staff for lower body care, had an indwelling urinary catheter, and was always incontinent of bowels, was identified as having a healed stage III pressure ulcer and a moderate risk for pressure ulcers according to the Braden scale. The care plan included interventions for behavior management and pressure ulcer prevention, but the resident frequently refused care and preferred to sleep in a recliner rather than a bed. Between early March and early April, the treatment administration record indicated that a prescribed mixture of calmoseptime ointment and collagen fibers was applied to the resident's buttocks twice daily. However, there was no corresponding documentation of skin assessments or monitoring of the treated area during this period. During an observed care episode, staff did not follow the physician's order to mix the cream with collagen, nor did they measure or assess the affected areas. The nurse present was not comfortable with wound staging and deferred to the DON for assessment, and staff reported that the resident's behaviors often led to rushed care and missed steps. Interviews with staff revealed inconsistent wound care practices, lack of proper documentation, and uncertainty regarding wound assessment and treatment. The infection preventionist and DON confirmed that the current wound treatment was not appropriate and that staff were expected to document wound conditions daily and seek guidance if unsure. Facility protocols required verification of physician orders and documentation of wound care and assessments, but these were not consistently followed, resulting in a failure to prevent new ulcers and properly manage existing skin breakdown.
Failure to Provide Proper Catheter and Perineal Care Resulting in Repeated UTIs
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident had a history of overactive bladder, benign prostatic hyperplasia, and was always incontinent of bowels, requiring total assistance with lower body care. The care plan included monitoring for urinary complaints, pain, urine characteristics, and cognitive changes, with orders for monthly catheter changes and evaluation for signs and symptoms of UTI. Despite these interventions, the resident experienced multiple UTIs, as documented by positive urine cultures and symptoms such as hematuria and hallucinations. Direct observation of care revealed improper perineal and catheter care practices by staff. Nursing assistants used the same washcloth to clean areas contaminated with stool and then proceeded to clean the catheter area without changing cloths or gloves, and without performing hand hygiene between tasks. Staff also failed to change gloves or sanitize hands before applying barrier cream after handling the catheter and perineal area. These actions were inconsistent with infection control guidelines and increased the risk of introducing bacteria to the urinary tract. Interviews with the infection preventionist and director of nursing confirmed that there had been no surveillance or analysis of catheter-related infections, and no audits or education had been conducted to address proper catheter and perineal care. The facility's policy required clean technique when handling catheters, but this was not followed during observed care, contributing to repeated UTIs in the resident.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during personal care for four residents. Observations revealed that nursing assistants did not consistently perform hand hygiene between glove changes or after removing gloves, particularly during perineal care and when cleaning residents after bowel movements. In several instances, staff used the same gloves or cleaning utensils to clean both the front and back perineal areas, and in some cases, failed to sanitize or wash hands before donning new gloves or after completing care tasks. Residents involved had significant care needs, including assistance with hygiene due to conditions such as fractures, intellectual disabilities, and parkinsonism. Staff were observed providing extensive assistance, including the use of mechanical lifts and enhanced barrier precautions. Despite these measures, lapses in infection control were noted, such as using contaminated washcloths, not changing gloves between different care tasks, and not performing hand hygiene at appropriate times during and after care. Interviews with staff indicated inconsistent understanding and application of hand hygiene protocols. Some staff believed handwashing was only necessary between residents or after particularly messy care, while others were unaware of the need to perform hand hygiene between glove changes. Facility leadership acknowledged the importance of proper hand hygiene and recognized that current practices did not meet expected standards, as confirmed by the facility's own infection prevention policies.
Failure to Develop and Implement Individualized, Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for multiple residents, as required. Surveyors found that care plans were often generic, lacking specific interventions tailored to each resident's diagnoses, behaviors, and care needs. For example, one resident with multiple complex diagnoses, including hypoparathyroidism, chronic hepatitis C, and behavioral issues, had a care plan that did not address recent behavioral changes or new medical conditions identified by the primary care provider. Staff interviews confirmed that the care plans were difficult to individualize due to the use of pre-programmed templates, resulting in missing or inadequate interventions for new or evolving resident needs. Several residents with significant medical conditions, such as diabetes, chronic kidney disease, pressure ulcers, and use of anticoagulants, had care plans that omitted critical information. For instance, residents on blood thinners did not have care plans instructing staff to monitor for signs of bleeding or when to notify a provider. Residents with pressure ulcers or at risk for skin breakdown lacked scheduled repositioning regimens or instructions for staff on how to respond to refusals of care. In some cases, care plans failed to specify the frequency or method of essential care, such as catheter care or wound treatment protocols, despite these being required by facility policy and resident condition. Direct observations and staff interviews further revealed that staff were often unaware of specific care needs or protocols due to these care plan deficiencies. For example, one resident with pressure ulcers was observed sitting in a wheelchair for extended periods without repositioning, and staff were unsure how often repositioning should occur. Another resident with a Foley catheter had no care plan guidance on catheter care frequency. The facility's own policy required care plans to be person-centered and updated as resident conditions changed, but surveyors found that care plans were not consistently revised to reflect new diagnoses, changes in condition, or provider recommendations.
Sanitation Deficiencies in Kitchen and Ice Machine
Penalty
Summary
Surveyors observed multiple sanitation deficiencies in the facility's kitchen and food preparation areas. A stainless-steel food prep counter had a lower shelf with a dry black/brown substance, a brown liquid covering a large area, and a greasy, sticky buildup with dirt and grime. A plastic container on the shelf, used for condiment cups, was visibly dirty with an unknown brown substance and food crumbs. Staff were observed sitting on the freezer, which is sometimes used to set food on, and using a cell phone in the kitchen, both of which were acknowledged by staff as inappropriate and potential sources of cross-contamination. The dietary manager confirmed that staff were signing off on cleaning tasks, but acknowledged the need for more specific cleaning logs and possible retraining. The registered dietitian stated she had not conducted visual audits of the kitchen and was unaware of the cleanliness issues, expecting the dietary manager to perform regular audits. Additionally, the ice machine located in a hallway was found to have a white crusty buildup resembling mineral deposits and a black/gray/brown spotty buildup inside the door above the ice bin. Some of this buildup was removable with a dry paper towel. The maintenance director reported that he does not keep a log of cleaning and de-scaling the ice machine, performing these tasks approximately every six months, with a deep clean about once a year. Manufacturer guidelines recommend cleaning and sanitizing the ice machine every six months. The facility's own policy requires a written cleaning schedule, assignment of tasks, and staff initials and dates upon completion, but these procedures were not being adequately followed.
Governing Body Failed to Ensure Oversight and Correction of Deficient Practices
Penalty
Summary
The governing body failed to provide appropriate oversight to ensure that previously identified deficient practices were corrected and compliance was achieved. QAPI meeting minutes revealed that while various quality issues such as pressure ulcers, falls, infection control, psychotropic medication use, staffing shortages, and grievances were discussed, there was a lack of measurable goals, thorough data analysis, and actionable plans. For example, the facility did not document current rates for pressure ulcers or falls, nor did they analyze contributing factors or trends. Infection control discussions lacked benchmarks and did not address how the infection preventionist would complete required training or who would oversee the program in the interim. Similarly, open staff positions and their impact on care were not analyzed, and grievances related to call light response, care, and dietary issues were not thoroughly investigated or linked to potential systemic causes. The QAPI committee did not assign responsibility for follow-up actions, nor did it ensure that staff were educated on new QAPI plans or performance improvement projects. There was no evidence of staff competency checks following education, and the facility did not ensure that staff understood or implemented the QAPI program's requirements. The administrator acknowledged a lack of direct oversight and was unaware of gaps in infection control training and supervision. The facility's QAPI policy required the governing body to establish and implement plans to correct deficiencies and monitor their effects, but these steps were not adequately carried out. Additionally, the facility did not ensure that audits and monitoring were effectively implemented to address previous deficiencies, such as those related to psychotropic medication diagnoses and documentation. The absence of clear goals, designated oversight, and comprehensive analysis of data contributed to the ongoing noncompliance. The administrator relied on external consultants for plan of correction development and did not ensure that internal leadership provided the necessary oversight to achieve compliance.
Failure to Implement Facility Assessment Protocol for Staff Competencies
Penalty
Summary
The facility failed to implement its facility assessment protocol to ensure that staff competencies were identified and completed according to the duties performed. During interviews, the medical director confirmed that the facility was responsible for reviewing, identifying, and determining appropriate interventions and oversight of outcomes. The administrator acknowledged that the recent merger of two nursing homes, which included both residents and staff, created additional challenges. He also stated that updates to the facility assessment, including staff education, had not yet been implemented, despite decisions being made regarding resident care, resources, and services. A review of the facility's August 2024 Facility Assessment Tool showed that the leadership team planned to discuss goals to ensure direct care staff were trained to provide necessary services. The assessment identified the need for staff education, training, certifications, testing, and policies to support resident care. The facility also intended to gather input from residents, family members, and staff to address concerns and expectations. However, the report indicates that the facility had not yet updated or implemented these assessments and related staff education, affecting the ability to ensure competent care for all 56 residents during both routine operations and emergencies.
Failure to Analyze and Document QAPI Data with Measurable Goals
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance 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 over a one-year period showed that department heads brought forward data on topics such as infection control, falls, incident reports, and vaccinations. However, there was no documentation of benchmarks or measurable goals for these areas, nor evidence of ongoing monitoring to determine if goals were met or if continued QAPI oversight was necessary. Interviews with the medical director and administrator confirmed that the facility did not have a formalized process for setting or tracking measurable goals within QAPI activities. The administrator acknowledged that the recent merger of two nursing homes had introduced additional challenges, and that the QAPI committee had not established a process to identify or document improvements. Review of the facility's QAPI policy indicated that benchmarks and data analysis were required, but these steps were not being followed in practice.
Failure of QAPI Committee to Identify and Address Facility-Specific Concerns
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility-specific concerns, implement an action plan to address identified issues, or ensure committee participation in the development and oversight of systems to maintain quality of life and care for all residents. Review of QAPI meeting minutes over a one-year period revealed that, although a performance improvement project (PIP) related to abuse allegations was initiated, there was no documentation on how goals would be met, progress monitored, or current measures evaluated for compliance. Interviews with the medical director and administrator confirmed that the facility was expected to review, identify, and determine appropriate interventions and oversight for outcomes, but these steps were not taken. The administrator acknowledged that the recent merger of two nursing homes introduced additional challenges, including the need to streamline resident care, resources, and services, but also stated that no PIPs were currently in place. Review of the facility's QAPI policy indicated that the committee was responsible for establishing benchmarks, analyzing data, and determining root causes, but these processes were not followed.
Failure to Monitor Infectious Disease and Maintain Infection Control Oversight
Penalty
Summary
The facility failed to ensure that a resident with a highly infectious disease, Hepatitis C, was included in the infection control (IC) surveillance data for monitoring. The resident, who had a history of multiple medical conditions and was admitted from a now-closed sister facility, was not listed in the facility's infection tracking system despite a physician's note identifying the diagnosis. Additionally, the resident's care plan did not mention the Hepatitis C diagnosis. This omission occurred even though the facility had previously contracted with a consultant infection preventionist (CIP) to assist with infection control oversight following a prior deficiency. Further review revealed that the facility did not maintain adequate oversight of the IC program, as there was no designated staff member actively managing the program during the infection preventionist's medical leave. The registered nurse who was supposed to oversee the program was not informed of this responsibility and had no knowledge of the infection tracking process. Surveillance records for staff illnesses were incomplete, with missing information on symptoms resolution and return-to-work dates. The director of nursing acknowledged these gaps and confirmed that all relevant data should have been entered to ensure proper tracking and staff management. There was also no policy provided regarding oversight of the IC program.
Failure to Maintain Infection Control Oversight and Surveillance
Penalty
Summary
The facility failed to maintain oversight of its infection control (IC) program, resulting in inadequate tracking, trending, and analysis of infection data. Specifically, the facility did not include a resident with a diagnosis of chronic Hepatitis C in its IC surveillance system, despite the resident's recent hospital stay and documented diagnosis. The resident's care plan also lacked any mention of the Hepatitis C diagnosis. Additionally, the facility's infection surveillance records for staff illnesses were incomplete, with missing information regarding symptoms resolution and return-to-work dates for staff who had reported illnesses. Oversight of the IC program was further compromised when the designated infection preventionist (IP) went on medical leave, and no qualified staff member was assigned to oversee the program in her absence. Interviews revealed that the registered nurse who was supposed to cover the IP's duties was not informed of this responsibility and had no knowledge of the infection tracking process. The contracted infection preventionist had not yet begun providing assistance, and the medical director was unaware that there was no active IP or designated replacement. The facility also lacked a policy related to oversight of the IC program.
Lack of Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training to staff on its Quality Assurance and Performance Improvement (QAPI) Program. Multiple staff members, including RNs, an LPN, and a nursing assistant, reported during interviews that they were either unaware of QAPI meetings, had not attended them, or did not know the specific goals or performance improvement projects of the facility. While some staff mentioned attending meetings if their schedules allowed, none could identify current QAPI goals or describe their roles in the program. The admission coordinator was aware of a plan to prevent infection control outbreaks but did not reference formal QAPI training or goals. A review of email correspondence with the director of nursing confirmed that there was no formal QAPI education provided to employees. The administrator stated that QAPI education was given upon employment but acknowledged the need to formalize requirements for all staff. The facility's QAPI policy outlined processes for identifying and addressing areas for improvement, but documentation of employee QAPI training was requested and not provided during the survey. This deficiency had the potential to affect all 57 residents in the facility.
Failure to Maintain Complete Medical Records and Timely Transcription of Physician Orders
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents receiving dialysis and did not ensure timely transcription and implementation of physician orders following a medical appointment. For two residents with end-stage renal disease and chronic kidney disease, the facility's electronic medical records lacked consistent documentation of dialysis run/communication reports, with only a few reports present and several missing. Additionally, the care plans for these residents did not include essential information such as dialysis schedules, access site details, or monitoring instructions, despite the residents' ongoing need for hemodialysis. Interviews with facility staff revealed that contracted nurses were unable to access hospital records, and the facility no longer employed a medical records staff member responsible for obtaining and scanning external documents into the residents' records. This resulted in incomplete communication between the dialysis center and the facility, contrary to the facility's own policies and agreements, which required sharing of dialysis summaries, complication reports, and care recommendations. In a separate incident, a resident with multiple comorbidities, including heart failure and renal insufficiency, had new physician orders following an appointment that were not transcribed or implemented in a timely manner. Orders for leg wraps, compression stockings, and medication adjustments were delayed by several days, and some directions, such as elevating lower extremities and applying antifungal powder, were not entered into the medication or treatment administration records. Staff interviews confirmed that the process for handling new orders was inconsistent and hampered by the absence of a dedicated medical records staff member, leading to delays and incomplete documentation.
Failure to Obtain Physician Signature on POLST Upon Admission
Penalty
Summary
The facility failed to ensure that a physician signed the Provider Order for Life-Sustaining Treatment (POLST) for one resident following admission. The resident was cognitively alert and required substantial to maximal assistance with activities of daily living, and had diagnoses including malnutrition, anxiety, diabetes, and cirrhosis. The resident's POLST, dated prior to admission, indicated full code status, but there was no documentation that the resident's wishes were communicated to the primary physician, nor was the POLST signed by the physician within 30 days of admission. Interviews with facility staff, including an RN, the DON, and the admission coordinator, confirmed that the process for obtaining and documenting the POLST was not followed as per facility policy. The staff acknowledged that the POLST should have been completed and signed by the physician upon admission, and that this omission was not acceptable practice. Review of the facility's Advance Directive Policy further indicated that the resident's status on the POLST should be obtained and documented upon admission, and the document should be accessible in the medical record.
Failure to Accurately Assess Resident Due to Persistent Refusals
Penalty
Summary
The facility failed to accurately and comprehensively assess a resident who exhibited ongoing refusal of all cares, medications, treatments, and evaluations. Upon admission and throughout the resident's stay, staff were unable to complete required assessments due to the resident's persistent refusals and behaviors, such as not allowing staff entry into the room, refusing to communicate, and declining all personal care and medical interventions. Despite these refusals, staff documented assessment data in the Minimum Data Set (MDS) and other records, often based on assumptions or outdated information, rather than direct observation or current evaluation. For example, vital signs and weights were only recorded at admission and then repeated without new measurements, and staff marked the resident as independent in personal hygiene and continence without being able to verify these statuses. The resident had a complex medical history, including hypoparathyroidism, multiple fractures, hypothyroidism, generalized anxiety disorder, and a history of behavioral health issues. The resident was noted to have delusions, social isolation, and a pattern of refusing all care, including medications and assessments. Staff and the MDS nurse acknowledged that they could not perform comprehensive assessments, and the MDS data submitted was not based on actual, current assessments. The medical director was unaware of the extent of the resident's refusals and the lack of skilled nursing care, and staff interviews confirmed that no direct care, assessments, or treatments had been provided for an extended period. Documentation in the resident's records, including progress notes, MDS assessments, and care tasks, reflected incomplete or inaccurate information due to the inability to assess the resident. Staff entered data into the electronic system to fulfill submission requirements, despite knowing the information was not accurate or current. The facility's failure to ensure a comprehensive and accurate assessment process, as required by federal regulations, was evident in the lack of direct observation, incomplete documentation, and reliance on assumptions or outdated data for the resident who persistently refused care.
Failure to Accurately Assess and Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to accurately and thoroughly assess a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD). The resident, who had severely impaired cognition and was dependent on staff for all activities of daily living, was identified as feeling down or hopeless several days a week and exhibited verbal behaviors such as screaming, threatening, or cursing. Despite having a diagnosis of PTSD, the facility's PTSD Resident Screening assessment was stopped after the resident answered 'no' to the initial trauma question, and no further attempts were made to gather information from the resident's emergency contact, family, or previous facility staff regarding the cause of the PTSD or potential triggers. The resident's care plan addressed her aggressive behaviors during bathing and included interventions such as administering medications, encouraging verbalization, using diversion techniques, and allowing personal space. However, the care plan did not mention her PTSD diagnosis or any history of trauma, nor did it include strategies specific to managing PTSD-related triggers. The social service designee who completed the trauma assessment could not recall reaching out for additional information and confirmed that no documentation existed regarding assessment for triggers or appropriate care related to the PTSD diagnosis. No relevant policy was provided by the facility during the survey.
Failure to Notify State Mental Health Authority and Complete PASARR Level II Assessment
Penalty
Summary
The facility failed to notify the State Mental Health Authority for a resident with a diagnosis of major neurocognitive disorder, known behavioral issues, and a recent inpatient psychiatric stay prior to admission. Upon review, it was found that the resident had a history of significant mental health concerns, including catatonia, delusions, and repeated refusals of care, medication, and assessments. Despite these ongoing issues, the facility did not coordinate a new PASARR Level II assessment upon the resident's transfer from a now-closed sister facility, relying instead on an outdated Level I screening that did not reflect the resident's current mental health status or recent psychiatric hospitalization. The resident exhibited multiple concerning behaviors after admission, such as chronic refusal of care, delusional statements, fasting due to religious delusions, and aggressive responses to staff interventions. Staff and the primary care provider repeatedly documented the resident's refusals and behavioral health needs, including the administration of antipsychotic medications and attempted transfers to behavioral health services. Despite these interventions and ongoing behavioral health concerns, there was no evidence that the facility referred the resident for a PASARR Level II evaluation or notified the appropriate mental health authorities as required for individuals with significant mental health diagnoses and recent psychiatric treatment. Interviews and documentation confirmed that facility leadership was aware of the resident's refusals and mental health history. The director of nursing acknowledged that, although state law did not require a new PASARR Level I for transfers from the sister facility, staff should have initiated a Level II assessment due to the resident's mental health diagnosis and recent inpatient psychiatric care. No policy or documentation was provided to show that the facility had procedures in place to ensure compliance with PASARR requirements in such cases.
Failure to Revise Care Plans After New Physician Orders
Penalty
Summary
The facility failed to revise the care plans for two residents after receiving new physician orders that required changes in their care. One resident, who had diagnoses including atrial fibrillation, heart failure, renal insufficiency, dementia, and morbid obesity, was ordered to have her lower extremities wrapped daily, compression stockings applied, and her legs elevated as much as possible. Despite these orders, her care plan did not reflect these interventions, and staff were not consistently aware of or implementing the new orders. Observations showed the resident seated in a wheelchair with her legs down and not elevated, and staff interviews revealed a lack of communication regarding the new care requirements. Another resident, with diagnoses including diabetes, dementia, depression, and multiple pressure ulcers, was ordered by a wound consultant to be repositioned every two hours. However, her care plan did not specify the frequency of repositioning, and staff were unsure of how often this should occur. Observations over a two-hour period showed the resident remained in the same position in her wheelchair without being repositioned, despite staff being present and interacting with her. The care plan only mentioned encouraging the resident to shift weight as she allows, without scheduled repositioning. The facility's own policies require that care plans be updated to reflect changes in residents' conditions and new orders, and that interventions be consistent with professional standards of practice. Interviews with staff and the medical director confirmed the expectation that care plans should be revised as residents' needs change. In both cases, the failure to update the care plans resulted in staff not consistently providing the care as ordered by physicians and consultants.
Failure to Timely Implement and Communicate Physician Orders
Penalty
Summary
The facility failed to implement physician orders for a resident with multiple complex medical conditions, including atrial fibrillation, heart failure, renal insufficiency, dementia, anxiety, depression, and morbid obesity. The resident required extensive assistance with activities of daily living and had recently been seen by a physician due to increased swelling in her lower legs. The physician ordered the addition of a diuretic (Lasix), daily application of compression stockings or ace wraps, elevation of the lower extremities as much as possible, and application of antifungal powder under abdominal folds. However, there were delays and omissions in transcribing and implementing these orders. The order for ace wraps was transcribed eight days after receipt, and the increased Lasix dosage was transcribed two days after the order was received. The medication and treatment administration records did not include directions for staff to elevate the resident's lower extremities or to apply antifungal powder as ordered. Observations and staff interviews revealed that the resident was not consistently receiving the ordered treatments. On one occasion, the resident was observed without leg wraps, and staff were unaware of the new orders. Nursing assistants reported that information about new orders was not always communicated during shift reports, and there was confusion regarding the application of antifungal powder. Additionally, the facility lacked a designated medical records person, resulting in delays in scanning and processing physician orders. The original physician order was found unscanned in a pile of papers, and the facility was unable to provide a policy for order transcription and implementation during the survey.
Failure to Assess and Address Significant Weight Loss
Penalty
Summary
The facility failed to properly assess and address significant weight loss in a resident who was identified as having intact cognition, being independent with eating, and having multiple pressure ulcers and venous ulcers. The resident experienced a weight loss of more than 10% over six months, which was not part of a physician-prescribed weight-loss regimen. Despite electronic medical record alerts and documentation of the weight loss, there was no evidence that the provider was notified, and the dietician had not assessed the resident in response to the weight change. The resident was on a regular diet and received Arginade for wound healing, but there was no documentation of additional nutritional interventions specifically for the weight loss. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's weight loss. The dietary manager was aware of the weight loss alerts in the electronic system but did not confirm whether the provider had been notified or if the dietician had assessed the resident. The dietician only visited monthly and was not made aware of the resident's weight loss, relying on the dietary manager to provide updates. Nursing staff also did not notify the provider, and there was confusion about which department was responsible for monitoring and reporting weight changes. The registered nurse confirmed that the weight loss should have been investigated, and the registered dietician expected to be notified of such changes to perform an assessment. The facility's policy required immediate re-weighing and notification of the dietician for any weight change of 5% or more, with the dietician expected to respond within 24 hours. However, this protocol was not followed, and the interdisciplinary team did not discuss or address the resident's weight loss in a timely manner. The lack of communication and failure to follow established procedures resulted in the resident's significant weight loss not being properly assessed or managed.
Failure to Consistently Monitor and Assess Dialysis Residents Post-Treatment
Penalty
Summary
The facility failed to consistently monitor and assess residents for potential complications related to dialysis treatment post-treatment for two residents with end-stage renal disease. One resident, admitted with chronic kidney disease stage 5 and other comorbidities, had a dialysis port in the right upper chest and was on a renal and consistent carbohydrate diet. The resident's order summary did not mention monitoring the access site for infection, the location of the access site, or the dialysis schedule. The care plan lacked identification and location of the access site, dialysis schedule, and the dialysis provider. Pre- and post-dialysis evaluation assessments were inconsistently completed, with only a portion of required assessments documented over two months. Another resident with end-stage renal disease and multiple comorbidities had a care plan that did not identify dialysis status, access site location, necessary precautions, or monitoring requirements. The order summary also lacked information on access site monitoring and dialysis schedule. Interviews with nursing staff confirmed that pre- and post-dialysis assessments were not consistently completed and that access site locations were not documented, making it difficult for staff, especially contracted nurses, to provide appropriate care. Facility policies and agreements required assessment of dialysis access sites and monitoring for complications, but these were not consistently followed.
Failure to Notify Medical Director and Provide Appropriate Mental Health Services
Penalty
Summary
The facility failed to notify the medical director and provide appropriate treatment and services to a resident who exhibited ongoing mental health and behavioral issues, including repeated refusals of care, medication, and assessments. The resident, who had a complex medical and psychiatric history including major neurocognitive disorder, catatonia, and recent behavioral health hospitalizations, consistently refused all care, medications, and personal hygiene assistance shortly after admission. Despite these ongoing refusals and the resident's questionable capacity to make informed decisions, staff did not implement additional interventions or seek timely guidance from the medical director regarding the resident's ability to refuse care and the risks associated with not receiving necessary services. Documentation and interviews revealed that staff were unable to perform comprehensive assessments, obtain vital signs, or provide basic care such as bathing and laundry for the resident over several months. Progress notes indicated that the resident was largely unassessed, with only minimal documentation of vital signs and weights, and staff often recorded the resident as independent in personal hygiene without direct observation or assessment. The care plan lacked specific interventions for managing the resident's repeated refusals, and staff primarily relied on offering care and notifying the family, without escalating concerns to the medical director or ensuring a formal evaluation of the resident's decision-making capacity. Interviews with nursing staff, the DON, and the medical director confirmed that the medical director was not informed of the resident's ongoing refusals and lack of care. The medical director stated he would have expected to be notified, especially given the resident's inability to make safe decisions regarding his health and safety. The facility's behavioral health policy did not provide clear guidance for staff on how to proceed when current interventions were ineffective, and there was no evidence that the interdisciplinary team took further steps to address the resident's needs or ensure his health and safety in light of his persistent refusals and compromised mental status.
Failure to Reconcile and Document Emergency Kit Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications, specifically Lorazepam stored in the emergency kit refrigerator, were reconciled according to facility protocol. During an observation with an RN, it was found that the Lorazepam vials were not being checked or documented at each shift change as required. The RN was unable to locate documentation of reconciliation in the narcotic logbook, and confirmed that the emergency Lorazepam had not been checked at shift change. Both the RN and an LPN acknowledged that the red tag number and the amount of Lorazepam should be monitored and documented at each shift change to prevent diversion. Further interviews with the DON and the medical director confirmed that the expectation was for nursing staff to monitor and document controlled medications each shift. Review of the facility's Controlled Substances policy indicated that reconciliation of controlled medications should occur upon receipt, administration, disposition, and at the end of each shift, with both incoming and outgoing nurses participating in the count. The policy also required documentation and reporting of discrepancies, as well as periodic review by the DON. Despite these protocols, the required monitoring and documentation for the emergency Lorazepam was not being performed.
Failure to Provide Ordered Renal Diet for Resident with Complex Medical Needs
Penalty
Summary
A resident with chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency was admitted to the facility with physician orders for a renal consistent carbohydrate diet. The resident's care plan did not mention nutritional status or specify the diet to be provided, despite the resident's complex medical needs and dialysis attendance. The dietary department's records and diet slip only indicated a diabetic diet, with no mention of renal-specific restrictions or foods to avoid. Interviews with facility staff revealed a lack of understanding and implementation of the prescribed renal diet. The dietary aide was unaware of what a renal diet entailed, and the cook and dietary manager both reported that the resident received the same meals as other residents, but in smaller portions, based on a diabetic diet. The dietary manager and cook also confirmed that no special renal diet modifications were made, and potassium-rich foods were not specifically avoided. On dialysis days, the resident's daughter frequently brought in outside food, and the facility did not provide a meal tray or document meal intake for those occasions. The registered dietician confirmed that the dietary department should have been knowledgeable about renal diets and that the resident should have been served appropriate meals with limited potassium and other necessary restrictions. The medical director expected the dietary department to provide the prescribed diet as ordered. The facility failed to ensure that the resident received the ordered therapeutic diet, and staff did not consistently communicate or implement the dietary orders, resulting in the resident not receiving the required renal diet.
Inadequate Infection Control Measures Lead to RSV Outbreak
Penalty
Summary
The facility failed to implement effective infection control strategies to mitigate the spread of Respiratory Syncytial Virus (RSV), resulting in an outbreak affecting multiple residents. The initial case was identified on December 28, 2024, but the facility did not adequately isolate affected residents or enforce the use of personal protective equipment (PPE) such as masks and gowns. Observations revealed that residents were not wearing masks in communal areas, and staff were not consistently using PPE when interacting with residents who had tested positive for RSV. Several residents, including those with underlying health conditions such as congestive heart failure, diabetes, and chronic obstructive pulmonary disease, tested positive for RSV. Despite the presence of symptoms like coughing, shortness of breath, and wheezing, the facility did not consistently implement transmission-based precautions or conduct regular respiratory assessments. In some cases, residents were transported to external appointments without masks, and there was no documentation of communication with external facilities regarding the residents' RSV status. The facility's infection preventionist and nursing staff were not fully aware of the RSV test results or the necessary precautions to be implemented. This lack of communication and documentation led to a delay in placing residents on appropriate isolation precautions. The facility's failure to monitor and document symptoms consistently, along with inadequate staff training on infection control measures, contributed to the spread of RSV among residents.
Failure to Prevent Recurrent Falls and Implement Individualized Interventions
Penalty
Summary
The facility failed to conduct comprehensive fall analyses and implement individualized interventions to prevent recurrent falls and mitigate the risk of falls with major injury for two residents. Resident R7, who had severe cognitive impairment and was wheelchair-bound, experienced multiple falls over a period of several months. Despite being identified as at risk for falls, R7's care plan did not include specific interventions to address this risk. The fall incident reports for R7 consistently lacked comprehensive fall analyses and did not result in revisions to the care plan to include immediate fall prevention interventions. This oversight led to R7 sustaining a left tibial fracture that required surgical repair. Resident R5, who also had severe cognitive impairment and was dependent on staff for transfers, experienced multiple falls as well. The fall incident reports for R5 similarly lacked comprehensive analyses, and the care plan was not revised to address the falls. The facility's policy required causal analysis and care plan revisions after falls, but these were not completed, as confirmed by the Director of Nursing during an interview. The facility's failure to adhere to its policy on fall management and prevention resulted in actual harm to R7 and posed a risk to R5. The lack of comprehensive fall analyses and individualized interventions in the care plans for these residents contributed to the recurrence of falls and the potential for further injury. The facility's policy outlined the need for cause identification and treatment management, but these steps were not adequately followed, leading to deficiencies in the care provided to the residents.
Failure to Ensure Competency of Nursing Assistants
Penalty
Summary
The facility failed to ensure that four nursing assistants (NAs) were deemed competent to provide care to residents, which could potentially affect all 45 residents in the facility. The job description for Non-Certified Nursing Assistants (NAs) requires them to complete competency training for resident lifts, transfers, and activities of daily living (ADLs) with the assistance of a Certified Nurse Aide (CNA). However, the employee records for NA-T, NA-D, NA-G, and NA-U lacked documentation of completed orientation and competency training. Interviews with the NAs revealed that they were assisting residents with various tasks, such as dressing, toileting, and transfers, without having been signed off for skills competencies. The Director of Nursing (DON) stated that the Assistant Director of Nursing (ADON) was responsible for performing competencies for all new employees before they worked on the floor. However, the competency records were not found in the employee files, and the DON was unsure of their location. The facility's training program requirements were requested but not received, indicating a lack of proper documentation and oversight in ensuring that nursing assistants were adequately trained and competent to perform their duties.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse and neglect to the State Agency in a timely manner for two residents. One resident, identified as R5, was severely cognitively impaired and receiving hospice care. During a visit, a hospice registered nurse found R5 in a concerning state, with matted eyes, dark material around the mouth, and heavily soiled linens, suggesting neglect. However, the nurse did not report these concerns to the facility staff due to being upset. The facility's Director of Nursing (DON) and Administrator expected hospice staff to report such concerns to the nurse on duty and the DON, but this did not occur. Another resident, R7, who had severe cognitive impairment and was at risk for falls, experienced two unwitnessed falls. After the second fall, R7 was sent to the emergency room and later diagnosed with a left tibia fracture, cellulitis, and an abscess, requiring surgery. The DON acknowledged that the fracture was a serious injury and should have been reported, but it was not. The facility's policy required immediate reporting of suspected abuse, neglect, or injury of unknown source, but this was not adhered to. Additionally, the facility's agreement with the hospice agency had inconsistent reporting requirements compared to federal standards.
Inadequate Pressure Ulcer Assessment and Intervention
Penalty
Summary
The facility failed to accurately and comprehensively assess pressure ulcers for two residents, leading to inadequate individualized interventions to prevent new pressure ulcers and deterioration of existing ones. One resident, who was at risk for pressure ulcers, had multiple stage 3 pressure ulcers upon admission. The care plan for this resident was not consistently evaluated or revised to include necessary pressure-relieving interventions. The wound assessments were inconsistent and not comprehensive, with discrepancies between the evaluations and corresponding photos. The resident's care plan did not reflect the interventions needed to prevent further deterioration, and the resident's refusal of certain treatments was not adequately addressed. Another resident, who was at risk for pressure ulcers but had none initially, developed a wound that was misidentified as moisture-associated skin damage (MASD) rather than a stage 2 pressure ulcer. The care plan for this resident was not updated with current interventions, and the facility's documentation did not accurately reflect the resident's condition. The facility's policies on pressure injuries and wound care did not provide comprehensive guidelines for assessment or interventions, contributing to the deficiencies in care. Interviews with facility staff revealed that the care plans were not individualized due to limitations in the facility's software, and there was a lack of consistent monitoring and updating of care plans. The Director of Nursing acknowledged the inconsistencies in wound assessments and the failure to implement new interventions for deteriorating wounds. The facility's policies did not adequately address the necessary components of a comprehensive assessment or pressure-relieving interventions, leading to the deficiencies observed in the care of the residents.
Failure in Communication Between Hospice and Facility Staff
Penalty
Summary
The facility failed to establish a clear communication process between hospice and the facility staff regarding changes in hospice services for a resident receiving hospice care. The resident, identified with severe cognitive impairment and dependent on assistance for daily activities, was admitted to hospice with a diagnosis of malnutrition. During a hospice nurse's visit, changes to the resident's care plan, including repositioning and oral care every two hours, were communicated to an unidentified nursing assistant instead of the nurse on duty. This lack of direct communication with the appropriate staff led to the changes not being documented in the facility's electronic health record. Interviews with facility staff, including registered nurses and the director of nursing, revealed that there was no designated staff member responsible for coordinating communication with hospice. The hospice nurse did not follow the expected protocol of reporting changes to the nurse on duty, resulting in a failure to update the resident's care plan with the necessary interventions. The facility's Hospice Program Policy emphasized the responsibility of the facility to communicate with hospice providers to ensure resident needs are met, highlighting a gap in the implementation of this policy.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene for residents requiring such measures. One resident, diagnosed with diabetes mellitus type 2 and cellulitis, was observed receiving intravenous (IV) antibiotics without the administering registered nurse (RN) wearing a gown, despite signage indicating the need for EBP. The RN only wore gloves and did not perform hand hygiene after removing them. The director of nursing confirmed that EBP should be used for residents with IVs, urinary catheters, or wounds, and the facility's policy indicated that EBP is required for residents needing device care. Additionally, another resident, diagnosed with dementia and dependent on staff for mobility, grooming, and hygiene, did not receive proper hand hygiene care from the nursing staff. During peri care for an incontinent bowel movement, the registered nurse did not perform hand hygiene before or after glove use. The nurse acknowledged the lapse in hand hygiene, which is contrary to the facility's policy requiring hand hygiene before moving from a contaminated body site to a clean one during resident care.
Improper Use of Mechanical Lifts Leads to Resident Injury
Penalty
Summary
The facility failed to safely use a mechanical lift according to the manufacturer's recommendations, resulting in a resident falling from the lift and sustaining three fractures to the thoracic and lumbar spine. The incident occurred when staff did not ensure the lift sling was properly secured before transferring the resident, who was severely cognitively impaired and required a mechanical lift for transfers. The resident's care plan indicated the need for a large sling and two staff assistance, but the staff involved were unsure of the sling size and did not check the care plan or the tension of the straps during the transfer. The facility also failed to ensure comprehensive assessments for sling size and care plan development for multiple residents requiring full body mechanical lifts. Observations revealed discrepancies between the sling sizes used and those documented in care plans or required by the residents' conditions. For instance, several residents were observed being transferred with medium slings when their care plans specified large slings, and staff often relied solely on weight to determine sling size without considering other factors such as height and girth. Interviews with staff and the director of nursing highlighted a lack of awareness and adherence to proper procedures for sling sizing and safety checks. Staff admitted to not verifying sling sizes or performing necessary safety checks, increasing the risk of residents falling from lifts. The facility's policy on mechanical lifts emphasized the importance of using the correct sling size and performing safety checks, but these procedures were not consistently followed, leading to the deficiency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to comprehensively assess and implement interventions to provide adequate supervision for a resident with a history of exit-seeking behaviors. The resident, diagnosed with Alzheimer's, dementia, and senile degeneration of the brain, had severe cognitive impairment and daily wandering behaviors. Despite being identified as a high risk for elopement, the resident's care plan did not include all necessary interventions, such as frequent monitoring. The resident had multiple documented occurrences of attempting to leave the facility without further assessment and revisions to the care plan to manage these behaviors effectively. On the day of the incident, the resident attempted to leave the building twice and was given antipsychotic medications to calm him. However, the resident managed to exit the facility, triggering the WanderGuard alarm. Staff did not respond timely to the alarm, and the resident got into an unlocked vehicle and drove around the city for 1.5 hours until the police stopped him. The facility's staff, including the Director of Nursing and Assistant Director of Nursing, were aware of the resident's exit-seeking behaviors but did not implement adequate measures to prevent the elopement. Interviews with staff revealed that the resident was frequently wandering and exit-seeking, and staff had to always watch him. However, there was not enough staff scheduled to provide 1:1 supervision, and the WanderGuard system did not lock the doors. The facility's policies on wander management and elopement were not effectively followed, leading to the resident's elopement and subsequent driving incident. The facility's failure to provide adequate supervision and timely response to the WanderGuard alarm resulted in the resident's elopement and immediate jeopardy.
Removal Plan
- discharged R1 to a secured memory care facility
- The facility developed a new protocol to have staff always present in the area of the door leading out of the facility
- The facility re-educated staff on response time to the door alarms, and providing adequate supervision for wandering residents
Failure to Provide Timely Discharge Notification
Penalty
Summary
The facility failed to provide timely discharge notification in writing to the resident, the resident's representative, and the Ombudsman. The resident, who had severe cognitive impairment and multiple medical conditions including Alzheimer's, dementia, and was on hospice, was transferred to another facility without the required 30-day notice. The resident's family was not given the opportunity to appeal the discharge prior to the transfer. The facility's Director of Nursing and Social Service Director admitted that they did not follow the 30-day discharge notice policy, citing the resident's safety as the reason for the immediate transfer. The Ombudsman confirmed that the facility did not notify her of the discharge in writing and that the family was opposed to the transfer. The facility's policy requires a post-discharge plan to be developed and reviewed with the resident and family at least 24 hours before discharge, which was not followed in this case. The facility staff acknowledged that they were usually able to manage residents with similar needs through redirection and distraction, but did not provide a specific care plan to address the resident's safety concerns prior to the transfer.
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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