The Villas At New Brighton
Inspection history, citations, penalties and survey trends for this long-term care facility in New Brighton, Minnesota.
- Location
- 825 First Avenue Northwest, New Brighton, Minnesota 55112
- CMS Provider Number
- 245164
- Inspections on file
- 44
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at The Villas At New Brighton during CMS and state inspections, most recent first.
Walk-In Freezer Not Maintained: The facility failed to keep the walk-in freezer free of water drippings and ice build-up. During kitchen observation, the freezer ceiling had numerous frozen water drops and the floor had three frozen areas about 12 inches in diameter. The CD said the condition had been present for a couple of weeks and that the frozen water on the floor was a safety hazard. The CD could not find a work order, and the DM said he was not aware of the current build-up.
The facility failed to submit accurate and complete PBJ staffing data to CMS for a quarter in which the PBJ report showed excessively low weekend staffing. The staffing coordinator stated weekend coverage was scheduled with at least one RN per shift and that the charge nurse found replacements for call-ins, while the administrator stated the low staffing was identified on the first weekend in November and that inaccurate reporting occurred. A requested PBJ policy was not provided.
Unattended medication carts were repeatedly observed unlocked on the LTC and respiratory care units while residents, NAs, housekeeping staff, and other staff passed by. An LPN, RN, and LPN trainee each confirmed the carts had been left unlocked, and the DON stated carts should be locked whenever a nurse is outside arm's length and that no audits had been done. The RN also walked away from an unlocked cart to find another nurse to complete narcotic reconciliation.
Failure to Honor Resident Preferences and Maintain Dignity: A cognitively intact resident with MS, neurogenic bladder, and quadriplegia was repeatedly gotten up before her preferred time, left in a soiled brief for long periods, and at times placed back in bed in a hospital gown after urine soaked her clothing and wheelchair. The resident reported feeling humiliated and said staff did not follow her care plan for incontinent care or showers; observations showed a damp, urine-smelling wheelchair cushion and severely oily, flaky hair with buildup on her shoulders and wheelchair.
A resident with MS, neuromuscular dysfunction of the bladder, and quadriplegia was cognitively intact and dependent on staff for ADLs, with a care plan preference not to be gotten up into a w/c until after 11:00 a.m. The resident stated staff repeatedly dressed and transferred the resident earlier than requested, and during observation the resident was already dressed and seated in an electric w/c after being gotten up at 9:30 a.m. A NA said she did not reference the care guide for the resident's preferred time, while the DON stated staff were expected to honor the preference and that it should have been listed on the daily NAR guide.
A resident with CAD, DM, morbid obesity, and debility was not told before taking an LOA that it would end his Medicare Part A coverage. After the resident returned, the MDS nurse issued a NOMNC and therapy services ended because he no longer qualified for skilled coverage. The DRS said he learned of the discharge after the LOA had already occurred, and the resident stated he had only been given medication instructions and meds for the trip, not notice that the LOA would affect coverage.
The facility failed to provide needed ADL assistance for two residents. One resident with MS and quadriplegia was supposed to receive showers with staff help, but records showed repeated bed baths instead, and observation found oily, heavily flaked hair and buildup on the scalp and wheelchair. Another resident with severe cognitive impairment asked for toenail care and podiatry, but her toenails were long and thickened, she was not on the podiatry list, and weekly assessments did not document needed nail care.
A facility failed to follow up on a consultant pharmacist’s recommendation for one resident during monthly drug regimen review. The resident had multiple diagnoses, and the pharmacist recommended reviewing the concurrent use of Omeprazole and Sucralfate to avoid potentially unnecessary medications, but the DON confirmed the recommendation was not addressed. The facility policy stated that all pharmacist recommendations are to be acted upon and documented by staff and/or the prescriber.
A resident with severe cognitive impairment, on hospice, and dependent for all transfers was care planned to receive two-person assistance with a mechanical lift, with a low bed and floor mat as fall interventions. Video showed two NAs manually dragging and repositioning the resident from a floor mattress to the bed by pulling on the gown and manipulating the resident’s limbs, leaving the resident prone and partially exposed without undergarments, instead of using the ordered mechanical lift. Staff later acknowledged they knew the lift was required but had repeatedly used similar manual methods due to perceived space limitations in the room and did not report these difficulties or their deviation from the care plan to nursing leadership, resulting in psychosocial harm as determined under the reasonable person concept.
A resident with heart and respiratory failure, severe cognitive impairment, and dependence for all ADLs was care planned as a fall risk with a floor mat and need for extensive assistance, but no care conference was ever held to involve the resident or representative in person-centered care planning despite facility policy and staff statements that such conferences should occur shortly after admission and quarterly. Surveyors observed the resident eating breakfast from a tray placed on a floor mattress, leaning on one elbow with food falling onto the mattress, while staff reported she often crawled onto the floor, was only placed in a wheelchair when family were present, and routinely received bed baths instead of showers. The social services director, LPN, DON, and administrator confirmed that a care conference should have occurred to address preferences and needs, and a family member reported never being offered a conference, disagreed with the resident being left on the floor for hours, preferred toileting and showers, and stated that eating on the floor was not consistent with their culture.
Staff failed to follow infection control practices when a nursing assistant performed incontinence care for a resident with heart failure, respiratory failure, severe cognitive impairment, and frequent incontinence. After removing a soiled brief and wiping the perineal area, the NA did not change gloves or perform hand hygiene before proceeding with clean tasks, including applying barrier cream, repositioning the resident, adjusting bedding and the call light, and handling the resident’s oxygen tubing. A family member reported similar observations via a room camera, and a grievance documented that an LPN had been informed that staff were not changing gloves between peri care and oxygen tubing adjustment. Facility staff interviews and the written handwashing policy confirmed that gloves should be changed between dirty and clean tasks and that hand hygiene should be performed before and after glove use and after changing incontinent products.
Surveyors found that the facility failed to develop and update care plans to address repeated bath/shower refusals and assistance needs for two residents. One resident with stroke-related paralysis and total dependence for bathing frequently refused showers over several weeks, yet the care plan lacked interventions for refusals, did not document offering alternate times, and did not include the resident’s preference for certain staff. Another resident with traumatic brain injury, seizure disorder, heart and lung disease, and weakness was care planned as independent with bathing despite needing supervision or touch assistance and refusing showers for multiple consecutive weeks. This resident appeared disheveled with body odor and reported not bathing weekly and not being offered help, while nursing staff acknowledged missed baths, lack of documented independent showers, and absence of care plan interventions to address refusals or promote regular bathing, contrary to the facility’s stated expectations and care planning policy.
A resident with multiple medical conditions fell and sustained a femur fracture during a transfer with a full body mechanical lift when staff failed to attach the sling correctly, placing a strap at the top instead of the bottom of the hook. Despite staff believing they knew the correct procedure, the improper attachment led to the sling detaching and the resident falling, requiring surgical intervention.
A resident with intact cognition and multiple diagnoses was found with several medications at her bedside without completed self-administration assessment or provider orders. Staff interviews confirmed that the required process for self-administration and secure medication storage was not followed, and facility policy regarding safe storage was not adhered to.
A resident with multiple medical conditions suffered a femur fracture after falling from a full mechanical lift during a transfer, due to staff not following manufacturer instructions for sling attachment. The incident, which resulted in hospitalization and surgery, was not reported to the State Agency as required by facility policy, despite being a serious injury.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not submit accurate and complete staffing data to CMS for a reviewed quarter, as PBJ data showed low weekend staffing while daily schedules indicated adequate coverage. The regional director of operations was unsure of the cause for the discrepancy, and the facility's policy was not provided when requested.
A resident with anxiety, mood disorder, and a surgical wound reported multiple grievances about inadequate pain management and staff response, stating her complaints were not followed up on or resolved. Documentation showed delays and discrepancies in pain medication administration and incomplete wound care, while grievance forms lacked evidence of proper investigation or resolution, contrary to facility policy.
A resident with multiple risk factors for skin breakdown developed severe pressure ulcers due to failures in assessment, documentation, and communication among staff. Despite being dependent on staff for repositioning and care, the resident's wounds were not promptly identified or reported, and appropriate interventions were not consistently implemented. The resident was ultimately hospitalized with multiple advanced pressure ulcers and wound infections, which were determined to have developed over several weeks prior to admission.
A resident with multiple comorbidities and a g-tube did not receive comprehensive assessment and monitoring of the g-tube site, as staff failed to consistently perform head-to-toe skin checks and document findings. Nursing staff sometimes relied on nursing assistants for skin observations and did not always remove clothing for full assessments. The resident was later hospitalized with infection and skin breakdown at the g-tube site, which had not been properly documented or reported.
Nursing staff failed to perform thorough weekly skin assessments for a high-risk resident, relying on incomplete visual checks and aide reports rather than direct inspection. As a result, extensive pressure wounds and skin breakdown went undocumented and unreported until hospital admission, where multiple severe wounds were discovered. The nurse involved lacked specific training on skin assessments, and facility policy for documentation and communication was not followed.
A nursing assistant failed to wear a gown and did not consistently follow proper PPE and hand hygiene protocols while emptying the urinary catheter bag of a resident on enhanced barrier precautions due to an indwelling device and history of infections. The assistant struggled with the catheter spout, resulting in urine splashing, and handled contaminated items without appropriate glove changes or use of alcohol swabs, despite facility policy and posted signage requiring both gown and gloves for such care.
A resident with respiratory and cardiac diagnoses, who was cognitively intact, repeatedly smoked on the designated patio while using oxygen, despite a care plan and signed contract requiring oxygen to be left inside. The facility did not provide direct staff supervision of the smoking area, lacked follow-up assessments, and did not enforce the smoking contract, resulting in ongoing unsafe smoking practices.
A facility failed to prevent medication diversion, resulting in the misappropriation of controlled substances for 30 residents. A TMA improperly signed out narcotics without proper documentation, leading to significant discrepancies between doses signed out and those administered. Residents with various medical conditions were affected, and the TMA was found to be performing tasks outside their scope of practice, including administering G-tube medications.
A facility failed to secure narcotics and properly label and store insulin pens, affecting medication safety. A resident's discontinued oxycodone was still signed out, raising diversion concerns. Insulin pens lacked proper labeling and storage, risking contamination and errors. Staff confirmed these deficiencies, and the facility's policy for medication checks was not consistently followed.
The facility did not post daily nurse staffing information as required, with outdated postings observed on three occasions. This failure potentially affected all 57 residents and their visitors, as the information was not readily accessible as per the facility's policy.
A resident with severe cognitive impairment and hemiplegia was repeatedly observed in a hospital gown in public areas, despite her preference for her own clothing. The facility staff cited issues with the resident's clothes ripping, but the care plan did not reflect a preference for a hospital gown, and there was a lack of communication with the resident's guardian regarding clothing options.
A resident, who was cognitively intact and had diagnoses of CHF and diabetes, was found with medications on his dresser without a proper assessment of his ability to self-administer. Despite a previous evaluation indicating he was unsafe to do so, the facility failed to include this in his care plan and did not follow their policy requiring a comprehensive assessment.
A facility failed to report an allegation of sexual abuse involving a resident to the state agency and law enforcement. The resident, who was cognitively intact and dependent on staff, was allegedly abused by a CNA. Despite being informed, the administrator and other staff did not report the incident, as required by facility policy. The resident expressed fear due to the CNA's continued presence, indicating a failure to ensure her safety.
A resident, who was cognitively intact and dependent on staff, reported an alleged sexual abuse incident involving a CNA. The facility failed to thoroughly investigate the allegation, as the administrator did not interview the resident or staff and did not report the incident to the State Agency or police. The CNA continued to work with the resident without suspension. The facility's policy required immediate investigation and reporting, which was not followed, leading to a deficiency.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked critical dialysis information, such as the use of an AV fistula and related care instructions. Another resident's care plan did not include passive range of motion exercises or document her clothing preferences, impacting her dignity. Staff were unaware of these omissions, highlighting deficiencies in care planning and communication.
A facility failed to provide a resident with prescribed passive range of motion (PROM) exercises following a stroke, as indicated in the occupational therapy discharge summary. The resident, who was severely cognitively impaired and had functional limitations due to hemiplegia, did not have PROM exercises included in their care plan. Staff interviews revealed a lack of communication and documentation regarding the resident's refusal of the ROM program, which could lead to decreased mobility and contractures.
A facility failed to properly assess and monitor a resident receiving dialysis through an AV fistula. The care plan inaccurately reflected the dialysis access method, and staff were unaware of the need to remove a pressure dressing within four hours, risking complications. Blood pressure readings were incorrectly taken on the access arm, and documentation was not updated to reflect the use of the fistula, contrary to facility policy.
The facility had an 8% medication error rate, exceeding the acceptable 5% threshold. Two residents were involved in errors during medication passes. One resident received metoprolol tartrate despite a low pulse, and another was nearly given an incorrect dose of quetiapine fumarate. LPNs acknowledged the errors, and the DON emphasized the need for adherence to medication administration policies.
The facility failed to ensure safe storage of medications, with instances of unlocked and unattended medication carts and medications left unattended in a resident's room. Staff acknowledged the errors, and the DON emphasized the importance of keeping medication carts locked and medications attended.
The facility failed to perform proper hand hygiene during tracheostomy care for a resident, as staff did not wash hands between glove changes. Additionally, a resident's catheter drainage bag was repeatedly found on the floor, and the spout was not cleaned with an alcohol wipe before being secured. These actions were contrary to the facility's policies on handwashing and catheter care.
A resident with severe cognitive impairment and cardiac conditions received metoprolol tartrate despite a physician's order to hold the medication if the pulse was below 60 beats per minute. An LPN administered the medication after recording a pulse of 55, and medication records showed repeated instances where the medication was not held as ordered, with no documentation to indicate otherwise. Staff interviews and facility policy confirmed the requirement to follow such parameters.
A resident with a history of acute embolism and thrombosis was mistakenly given Buprenorphine HCL Buccal Film instead of the prescribed sublingual tablets for pain. The error occurred because an LPN could not find the sublingual medication and assumed the film could be used as a substitute. The resident, who was aware of the error, attempted to inform the LPN, but was not believed. The sublingual tablets were available in the facility, and the LPN failed to perform necessary safety checks or contact the provider as required by facility policy.
A facility failed to make a psychiatric referral for a resident with bipolar disorder and malnutrition, as ordered by a physician. The resident was not currently receiving services from the Associated Clinic of Psychology (ACP) despite a physician's order due to a lack of communication and awareness among staff. The LPN and social services staff were unaware of the referral order, and no policy was in place to ensure such orders were processed.
A resident with severe cognitive impairment and multiple health issues developed a left toe ulcer that led to an amputation. The facility failed to notify the resident's family about the wound's progression, despite regular monitoring and treatment. Interviews revealed that the family was unaware of the condition until the resident was hospitalized. Facility staff showed inconsistency in following notification policies, leading to a significant communication oversight.
A resident with a full code status was found unresponsive in a LTC facility, but CPR was not initiated, leading to the resident's death. Despite being trained and certified in CPR, staff failed to follow the protocol, resulting in a critical deficiency.
A facility failed to properly manage methadone treatment for a resident with opioid dependence, leading to missed doses and unauthorized tapering. The facility did not coordinate with the methadone clinic, resulting in withdrawal symptoms for the resident. Additionally, there were significant lapses in narcotic documentation and waste procedures, with incomplete records and improper handling of methadone doses.
Walk-In Freezer Not Maintained
Penalty
Summary
The facility failed to ensure the walk-in freezer was maintained so that water drippings and ice build-up would not affect frozen food storage. During an observation of the kitchen, the walk-in freezer ceiling had numerous frozen water drops extending into the middle of the freezer across from the two fans on the left side, and the floor had three frozen areas approximately 12 inches in diameter. The culinary director stated the freezer had been in that condition for a couple of weeks and that the regional person had come out and de iced it, and also stated the frozen water on the floor was a safety hazard. The culinary director was unable to find a work order for the de icing. The director of maintenance stated there had been a work order for ice build-up on the freezer and that he had defrosted it and replaced a door gasket on a prior occasion, but he was not aware of the current build-up. He also stated any staff could place a work order or notify a manager. A policy for maintaining equipment was requested but was not received.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate and/or complete direct care staffing information to CMS based on payroll and other verifiable and auditable data during Quarter 1 of fiscal year 2026. The PBJ staffing data report showed excessively low weekend staffing for the quarter covering October 1 through December 31, 2025. During an interview, the staffing coordinator stated she was responsible for nurse staff schedules, that at least one RN was scheduled per shift, and that weekends were covered, with the charge nurse responsible for finding replacements when staff called in. During a later interview, the administrator stated the low staffing was found on the first weekend in November 2025 and that the PBJ report was submitted after corporate pulled and reviewed the information; the administrator also stated there was inaccurate reporting. A requested facility policy for PBJ was not provided.
Unattended medication carts left unlocked
Penalty
Summary
The facility failed to ensure safe storage of medication when medication carts were left unlocked and unattended on multiple occasions. During observation on 4/20/26, a medication cart on the LTC unit was unlocked without a nurse in eye sight while a nursing assistant, a housekeeper, a maintenance worker, and four residents passed by it before LPN-A and then CC-A acknowledged the cart had been left unlocked. LPN-A stated he was unsure how long it had been unlocked but estimated 5-10 minutes. On 4/21/26, a medication cart in the respiratory care unit was observed unlocked with no nurse in eye sight while a nursing assistant, residents in wheelchairs, and staff passed by; LPN-B later locked the cart and stated she had just noticed it was unlocked and had not been in eye sight of it the whole time. On 4/22/26, one medication cart on the LTC unit was unlocked with a resident sitting next to it while staff were at the nurses station, and RN-A stated he had received the cart keys from LPN-C and walked away from the unlocked cart to find her so they could complete narcotic reconciliation. Later that day, another RCU medication cart was observed unlocked while two NAs, RN-A, housekeeping staff, and a resident passed by; LPN-D later locked it and stated she was on day 2 of training and forgot to lock the cart. The DON confirmed medication carts should be locked whenever a nurse is outside arm's length, stated no audits had been done, and acknowledged awareness of prior survey concerns about medication storage.
Failure to Honor Resident Preferences and Maintain Dignity
Penalty
Summary
The facility failed to maintain resident rights related to dignity and self-determination for one resident who was cognitively intact and dependent on staff for ADLs, with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and quadriplegia. The resident’s care plan indicated staff were to assist with incontinent care upon rising, before or after meals, at bedtime, and twice overnight, and that she was not to be gotten up into her wheelchair until after 11:00 a.m. per her preference. The resident stated staff repeatedly got her up earlier than requested, dressed her, and transferred her to her wheelchair before 11:00 a.m., despite her requests to wait, and she became tearful while describing feeling humiliated and saying she had given up asking for help because staff told her they were too busy. The resident also stated she remained in the same brief all day after being placed in her wheelchair in the morning, and that by afternoon urine had soaked through her clothing and onto her wheelchair. She stated that when her wheelchair became soiled, staff changed her into a hospital gown and placed her back in bed until the next morning, and that brief changes typically occurred at 8:00 p.m. and 5:00 a.m. During observation, she was seen in bed wearing a hospital gown, and her wheelchair cushion appeared damp and smelled of urine. On another observation, her hair was oily, clumped, and covered with large thick yellow-white flakes, with flakes also on her shoulders and wheelchair, and she stated staff had not washed her hair since admission. The DON stated staff were expected to provide incontinence care every 2 to 3 hours and as needed, keep residents clean and dry, follow the care plan, honor resident preferences, and provide regular showers for dignity and health.
Failure to Honor Resident Preference for Morning Care Timing
Penalty
Summary
The facility failed to honor a resident's right to make choices about aspects of care for 1 of 2 residents reviewed for self-determination. The resident was cognitively intact per the comprehensive MDS, had clear speech, could make self understood, and could understand others. The resident's diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder, and quadriplegia, and the resident was dependent on staff for ADLs. The care plan indicated the resident required assistance of two with Hoyer transfers, assistance of one with ADLs, and that the resident should not be gotten up into a wheelchair until after 11:00 a.m. per preference. During interview, the resident stated that several times requested to get up after 11:00 a.m. but staff consistently dressed and transferred the resident to the wheelchair earlier in the morning. The resident became tearful and stated, "makes me feel I'm in the land of misfit toys." During observation, the resident was dressed and seated in an electric wheelchair, and the bed was made; the resident stated two aides got the resident up at 9:30 a.m. and basically said it was "now or never." A NA stated the care guides indicated resident preferences and care needs, but did not usually work with the resident and did not reference the care guide for the resident's preferred time request. The DON stated the care plan reflected the resident's preference not to get up until 11:00 a.m. and expected staff to honor it, and stated the preference should have been listed on the daily NAR guide. The resident's NAR guide stated, "Don't get up the pt before 11 AM."
Failure to Notify Resident of Medicare Part A Coverage Ending Before LOA
Penalty
Summary
The facility failed to notify a resident, the resident’s doctor, and a family member that the resident’s Medicare Part A coverage would end before the resident went on a leave of absence (LOA). R11 was admitted with coronary artery disease, diabetes mellitus, morbid obesity, and debility, and was cognitively intact. R11 stated he told facility staff he planned to leave for the Easter holiday and needed medications for two days, and on 4/5/26 the nurse reviewed his medication instructions and provided medications through the morning of 4/7/26. R11 stated he was not told before leaving that the LOA would result in termination of his Medicare Part A covered services. After R11 returned from the LOA, the MDS nurse informed him that the LOA violated his ability to continue receiving Medicare Part A covered services and issued a NOMNC with a therapy end date of 4/10/26. The Director of Rehab Services stated he first learned on 4/8/26 that R11 had to be discharged from PT and OT because he had taken a LOA and no longer qualified for Medicare Part A coverage. The MDS nurse stated she issued the NOMNC after learning R11 had been on LOA from 4/5/26 through 4/7/26 and stated she had been previously instructed that residents on skilled services were not allowed to take a LOA. The resident’s progress note documented the LOA request, medication provision, and that the on-call nurse and provider were updated per facility protocol.
Failure to Provide Needed ADL Assistance
Penalty
Summary
The facility failed to provide ADL assistance for two dependent residents. One resident, who had multiple sclerosis and quadriplegia and was cognitively intact, required total assistance with bathing and had a care plan calling for a shower with assistance of one staff member. Weekly skin inspection forms showed repeated bed baths instead of showers over several months, with only two showers documented and one refusal. During observation, the resident’s hair was oily, clumped, stringy, and heavily flaked with yellow-white buildup on the scalp, shoulders, and wheelchair, and the resident stated staff had told her she could not have showers because she could not hold herself upright in the shower chair and that her hair had not been washed since admission. Staff later stated shower chairs with straps were available, and the DON stated the resident should have been given showers with hair-washing according to her preference. Another resident with severe cognitive impairment and diagnoses including heart failure, bipolar disorder, and schizophrenia stated she wanted help cutting her toenails and needed to see a podiatrist. During observation, her toenails were long, with some thickening, and one big toenail extended at least 1/2 inch past the toe. Weekly skin assessments documented either that nail trimming was not necessary or that the resident refused, but staff confirmed there were no recent notes documenting refusal and that she was not on the podiatry list. Staff stated nails should be assessed weekly during bath time and that residents with long, thick, or otherwise unmanageable toenails should be referred to podiatry. The DON confirmed nail care should be completed as needed and that residents needing it could be placed on the podiatry list.
Failure to Address Consultant Pharmacist Recommendation
Penalty
Summary
The facility failed to follow up on a consultant pharmacist’s recommendation for one resident reviewed for monthly pharmacist reviews. The resident had a quarterly MDS showing cognitive intactness and diagnoses including heart failure, diabetes mellitus, depression, respiratory failure, and anemia. The EMR showed multiple pharmacist recommendations to the facility, including a 12/15/25 recommendation to review the concurrent use of Omeprazole 40 mg and Sucralfate 1 mg to avoid potentially unnecessary medications. During interview, the DON stated she received the monthly pharmacy recommendations by email and distributed them for response, but confirmed the December recommendation for this resident was not addressed. The facility policy for consultant pharmacist reports stated that all recommendations are to be acted upon and documented by facility staff and/or the prescriber.
Improper Manual Transfer and Handling Causing Psychosocial Harm
Penalty
Summary
The deficiency involves staff failing to provide care and transfers in accordance with the resident’s care plan, professional standards, and facility policy for a resident with severe cognitive impairment who frequently moved from the bed to a floor mattress. The resident’s room contained a hospital bed in the lowest position with a hospital mattress placed on the floor alongside the bed, and the resident was known to occasionally lie on the floor mat. The resident’s admission history and physical documented cognitive impairment, limited capacity to understand instructions, significant hearing impairment, and dependence on others for mobility, with hospice care in place. The MDS and care plan identified the resident as a fall risk, dependent for all cares and transfers, and required assistance of two staff with a mechanical (Hoyer) lift and a medium sling for transfers, with a fall mat and low bed as interventions. Video review from the resident’s room showed that on the morning in question, the resident was partially on the bed and partially on the floor, lying on her back with her hips and legs on the floor and upper body on the bed, dressed in a gown without undergarments. One nursing assistant stood at the center of the bed, bent over, grasped the front of the resident’s gown near each armpit with both hands, and dragged the resident from the floor mattress onto the bed. The assistant paused with the resident partially on the bed, then, together with a second nursing assistant, manually manipulated the resident’s legs and hips to reposition her fully onto the bed. The resident was turned into a prone position with her head at the head of the bed, feet at the bottom, face down, initially with one arm tucked under her chest; when the assistant pulled that arm out, the resident moaned. The resident was left in a prone position on the bed, exposed from the waist down without undergarments. Interviews confirmed that staff were aware the resident’s care plan and NA guide required two-person assistance with a mechanical lift for transfers and that the facility’s Safe Resident Handling policy directed that residents unable to bear weight be transferred with lift equipment instead of manual lifting. One nursing assistant stated the resident frequently crawled off the bed to the floor mattress and acknowledged knowing a mechanical lift and two staff were required, but reported that she and another assistant had been transferring the resident back to bed in a similar manual manner over previous weeks because they felt there was not enough room in the room to use the lift around the large floor mattress. Neither assistant reported these challenges or their deviation from the care plan to nursing staff, the clinical leader, or the DON. Family reported hearing the resident say “hurt, hurt” in her language while viewing the video and described the transfer as abusive and not consistent with the resident’s cultural preferences, and the surveyors applied the reasonable person concept to determine psychosocial harm from the noncompliant transfer and handling.
Failure to Involve Resident and Representative in Person-Centered Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident the opportunity to participate in the development and implementation of a person-centered care plan. The resident had diagnoses of heart failure and respiratory failure, severe cognitive impairment, spoke Hmong, and was dependent for all cares and transfers. Her care plan identified her as a fall risk with a fall mat at the bedside and required assistance with eating, bed mobility, and transfers using two staff and a full body mechanical lift. However, the electronic medical record lacked documentation of any care conference since her admission, despite facility policies and staff statements indicating that care conferences should occur within 5–21 days of admission and then quarterly, with resident and/or representative participation. Surveyors observed the resident seated on the edge of a floor mattress with her breakfast tray placed on the mattress to her left. She was leaning on her left elbow and using her right hand to eat, with food falling onto the mattress as she tried to eat. Nursing assistants reported that the resident frequently crawled off her bed onto the floor mattress and that staff only placed her in a wheelchair when family were present to watch her. They also stated that she received bed baths instead of showers because it would take up to three staff to shower her, and one nursing assistant commented that some cultures, like Hmong, like to be on the floor, and was unsure whether eating on the floor bothered the resident. The social services director, clinical leader/LPN, DON, and administrator each confirmed that care conferences are intended to elicit resident preferences, discuss medications, cares, comfort, complaints, and ensure needs are met, and that such a conference should have been held for this resident within the required timeframe. They acknowledged that no care conference had been held and no documentation could be located. The resident’s family member stated she was never offered a care conference and, while agreeing with the use of a floor mattress for safety, expressed dissatisfaction that the resident was left on the floor mattress for hours, preferred that the resident be offered the toilet or commode, preferred showers instead of bed baths, and stated it was not their culture to eat on the floor. Facility policies on Resident Rights and Care Planning required that residents be informed of and supported in their right to participate in person-centered care planning, including incorporating personal and cultural preferences, which did not occur for this resident.
Failure to Perform Hand Hygiene and Change Gloves Between Dirty and Clean Tasks
Penalty
Summary
The deficiency involves staff failure to follow established hand hygiene and glove-use practices during incontinence care for one resident. During an observation, a nursing assistant removed a soiled brief, wiped the resident’s perineum and buttocks, discarded the soiled brief and wipes, and then continued with clean tasks without removing gloves or performing hand hygiene. While still wearing the same gloves used for peri care, the nursing assistant placed a clean brief under the resident, applied barrier cream to the perineum, fastened the brief, positioned the draw sheet, assisted with repositioning the resident, adjusted bedding, clipped the call light to the bedding, and repositioned the resident’s oxygen tubing in her nostrils before finally removing gloves and performing hand hygiene. The resident involved had an admission MDS indicating diagnoses of heart failure and respiratory failure, severe cognitive impairment, frequent bowel and bladder incontinence, and dependence on staff for all cares and transfers, and was Hmong speaking. Her care plan and NA guide documented the need for assistance with bed mobility, transfers, and incontinence care every 2–3 hours. A grievance form documented that an LPN was made aware that staff were not changing gloves between changing the resident’s brief and adjusting her oxygen tubing. A family member reported observing staff not changing gloves after peri care via a camera in the resident’s room. Facility staff, including the nursing assistant, LPN, and DON, each stated in interviews that gloves should be changed between dirty and clean tasks and that hand hygiene should be performed before donning and after removing gloves, consistent with the facility’s Handwashing Policy, which requires handwashing after changing incontinent products and before and after glove use.
Failure to Care Plan for Bath/Shower Refusals and Assistance Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and update comprehensive care plans addressing residents’ refusals of baths/showers. One resident with intact cognition, paralysis on one side related to a stroke, and full dependence on staff for bathing had a care plan noting a self-care deficit, left-sided weakness, a history of refusing ADLs, and the need for staff assistance with bathing. However, the care plan did not include any interventions for refusals of bathing or showers. Weekly skin assessments over several weeks documented that this resident refused showers, and nursing assistants reported that the resident frequently refused showers, sometimes only allowing certain staff to assist, but these preferences and alternate shower times were not reflected in the care plan or medical record. Nursing staff acknowledged that the resident missed baths, had a history of refusals, lacked a risk/benefit form, and that the care plan did not contain interventions for staff to follow when refusals occurred. Another resident with intact cognition and diagnoses including traumatic brain injury, seizure disorder, heart disease, and lung disease had a care plan indicating a self-care deficit related to weakness but incorrectly documented the resident as independent with bathing and did not reflect the need for supervision or touch assistance. Weekly skin inspections over multiple weeks showed this resident refused showers, and during observation the resident appeared disheveled with body odor and reported not bathing weekly due to feeling physically weak, stating staff did not offer help or ask about showers and being unsure of the last shower. Nursing staff later acknowledged that the resident did not bathe weekly, had refused showers for four consecutive weeks, and had no documented independent showers during that period, and that the care plan lacked interventions to promote bathing when the resident refused or did not bathe independently. The DON stated that the expectation was for staff to conduct risk/benefit education, notify the provider and power of attorney, and try different approaches when residents refused baths, and that successful interventions should be added to the care plan and updated with changes, but confirmed this had not been done for these residents despite missed baths over several weeks.
Improper Mechanical Lift Use Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who required total assistance with transfers using a full body mechanical lift, fell from the lift due to improper attachment of the sling. The resident had intact cognition and medical diagnoses including colon cancer, a previous left humerus fracture, and hemiplegia. The care plan specified the use of a mechanical lift with a particular sling size, and the transfer was being performed by two staff members from the bed to a shower chair. During the transfer, one of the sling's straps was not attached to the lift according to the manufacturer's instructions. Specifically, the lower right strap was placed at the top of the hook instead of the lower part, resulting in the strap coming off during the transfer. This caused the resident to fall approximately three feet to the floor, leading to an acute left femur fracture that required surgical intervention. The incident was witnessed on video by a family member, who confirmed the improper attachment of the sling. Interviews with staff involved in the transfer revealed that they believed they knew the correct procedure for attaching the sling, but failed to secure it properly. The manufacturer’s representative confirmed that improper attachment could result in sling detachment and injury. The facility’s policy and the manufacturer’s instructions both required that sling loops be secured at the bottom of the hooks, which was not followed in this incident.
Removal Plan
- Suspend staff involved in the incident pending investigation.
- Remove the lift and sling from use.
- Educate staff on identifying sling size, locating resident's sling size, attaching the sling to the lift, and actions to take if the care plan does not identify sling size or if the proper sling size is not available.
- Competency test all nursing staff on use of the full mechanical lift.
- Require staff who have not completed education or competency test to complete both at the start of their next scheduled shift.
Failure to Complete Self-Administration Assessment and Secure Medication Storage
Penalty
Summary
The facility failed to ensure that a proper assessment for self-administration of medications was completed and that provider orders were obtained for all medications kept at bedside for one resident. The resident, who had intact cognition and diagnoses including femur fracture, severe obesity, and asthma, was observed with multiple medication containers (Tums, Tussin DM, multi-vitamin, and anti-diarrheal medication) on her bedside table. The self-administration evaluation indicated it was acceptable for the resident to self-administer after nurse setup, but the assessment was incomplete, as key sections regarding the resident's ability to manage and store medications were not checked. Additionally, the provider order list did not include orders for several of the medications found at the bedside. Interviews with staff confirmed that the resident was allowed to self-administer medications after nurse setup, but the process was not being followed correctly. The LPN acknowledged that medications should have been kept in the nurse's cart and that provider orders were missing for some medications. The DON stated that an assessment and provider order are required for self-administration and that medications should be stored securely, not on a bedside table. The facility's policy also requires self-administered medications to be stored in a safe and secure place, which was not adhered to in this case.
Failure to Report Serious Injury from Improper Mechanical Lift Use
Penalty
Summary
The facility failed to report a serious bodily injury to the State Agency after a resident experienced a fall from a full mechanical lift, resulting in a femur fracture. The incident occurred when two staff members were transferring the resident from bed to a shower chair using the lift, and one loop of the sling handle detached from the lift hook. This caused the resident's right leg to slip out of the sling, leading to a fall onto the floor. The resident, who had intact cognition and diagnoses including colon cancer, a previous left humerus fracture, and hemiplegia, was subsequently transported to the hospital and underwent surgery for the femur fracture. Despite the severity of the injury, the administrator determined that the event was not the result of abuse, neglect, exploitation, or misappropriation, and therefore did not report it to the State Agency. However, a review of the incident video by the DON revealed that the nursing assistants did not follow the manufacturer's instructions when attaching the sling to the lift. Facility policy required reporting all serious injuries, including those considered accidental, if they resulted from improper care or procedures. The incident was not found in the Minnesota Adult Abuse Reporting Center records, indicating it was not reported as required.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to CMS for one reviewed quarter, as required. Payroll Based Journal (PBJ) data for the specified quarter indicated excessively low weekend staffing, while daily staff schedules for the same period showed adequate staffing levels on weekends. During an interview, the regional director of operations acknowledged awareness of the report indicating low weekend staffing and stated she would analyze the cause, suggesting possible factors such as bonuses, on-call nurse managers, or use of pool staff, but was uncertain about the specific reason for the discrepancy. The administrator was unavailable during the survey, and the facility's policy was requested but not provided.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident's grievances and complaints were properly investigated and resolved. The resident, who was cognitively intact and had a history of anxiety, mood disorder, and a surgical wound, reported filing multiple grievances during her stay. She expressed that her complaints were not followed up on or resolved, particularly regarding inadequate pain management, with her pain consistently rated between 7 and 9 out of 10. Documentation showed that the resident's requests for pain medication were not always addressed promptly, and there were discrepancies in the records regarding the timing and administration of pain medication. Review of grievance forms revealed that the facility's documentation did not accurately reflect the events as described by the resident. For example, a grievance form indicated that the resident received her requested pain medication at 1:00 p.m., but records showed it was not administered until 3:01 p.m. Additionally, a dressing change for her surgical wound was not completed as required. The facility's investigation into these grievances was insufficient, lacking evidence of a thorough investigation or a clear resolution provided to the resident. Interviews with facility staff, including the DON and regional nurse consultant, confirmed that grievances were reviewed but did not result in appropriate follow-up or resolution. The facility's own grievance policy required that all complaints be investigated and a written summary provided, including steps taken and any corrective actions, but this process was not followed in the resident's case. The lack of proper investigation and resolution of the resident's grievances constitutes a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Failure to Prevent and Treat Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
A resident with a history of stroke, hemiplegia, malnutrition, diabetes, and other comorbidities was identified as high risk for pressure ulcer development, with a Braden score of 12. The resident was dependent on staff for mobility, repositioning, and personal care, and was frequently incontinent. Despite these risk factors, documentation and interviews revealed that staff failed to consistently and thoroughly assess, document, and report changes in the resident's skin condition. Weekly skin assessments were incomplete, often performed without fully removing clothing, and relied heavily on nursing assistants' observations rather than direct nurse assessment. There was a lack of detailed documentation regarding the size, appearance, and progression of skin issues, and communication gaps existed between nursing staff, nurse managers, and providers. Multiple staff members, including nursing assistants and LPNs, observed wounds developing on the resident's sacral area and heel, but these findings were not promptly or adequately reported to the provider or wound care team. The resident did not consistently have a pressure-relieving cushion in her wheelchair, and interventions such as repositioning and use of barrier creams were inconsistently documented. When wounds were noted, there was confusion about who was responsible for notifying the provider and initiating treatment. The resident's care plan directed staff to monitor skin integrity daily, perform weekly skin inspections, and report changes, but these interventions were not effectively implemented or documented. The resident was eventually found unresponsive and sent to the hospital, where she was diagnosed with multiple advanced pressure ulcers, including a large necrotic sacral wound, deep tissue injury to the heel, and additional skin breakdowns. Hospital staff noted that the wounds were extensive and had developed over several weeks, indicating a prolonged period of inadequate care. Interviews with facility staff and hospital personnel confirmed that the wounds were present prior to hospital admission and that there were significant lapses in assessment, reporting, and treatment of the resident's skin issues.
Failure to Assess and Monitor G-Tube Site Leading to Skin Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident's gastrostomy (g-tube) site and provide appropriate interventions for skin irritation. The resident, who had multiple comorbidities including diabetes, stroke, hemiplegia, malnutrition, and was at high risk for pressure ulcers, required substantial assistance with mobility and was dependent on staff for all transfers and personal care. Orders were in place for staff to monitor the skin around the g-tube site and change the dressing every shift, as well as to conduct weekly skin inspections by a licensed nurse. Documentation showed that staff signed off on these tasks, but interviews and record reviews revealed gaps in the thoroughness and accuracy of these assessments. Nursing staff, including LPNs, reported that weekly skin assessments were sometimes performed without fully removing the resident's clothing, limiting the ability to visualize the entire body and the g-tube site. The LPN responsible for weekly assessments admitted to relying on nursing assistants to report skin issues and was unsure of the full requirements for the assessment. She noted minimal red bloody drainage on the g-tube dressing over several weeks but did not document this finding. The facility's wound care provider and DON confirmed that staff were expected to perform head-to-toe assessments with clothing removed and to document and report any skin concerns, including those at the g-tube site, but this was not consistently done. The resident was later hospitalized with altered mental status, hypotension, and signs of infection. Hospital records documented redness, purulent drainage, and erosion at the g-tube site, with cultures growing bacteria. Interviews with facility staff indicated that the nurse practitioner was unaware of the g-tube site irritation and would have expected to be notified. The facility's enteral tube site care competency outlined specific steps for assessment and care of g-tube sites, including cleaning, inspection, and documentation, but these procedures were not fully followed, leading to the deficiency.
Failure to Ensure Competent Weekly Skin Assessments by Nursing Staff
Penalty
Summary
Licensed nursing staff failed to demonstrate and acknowledge the required competency skills for completing weekly skin assessments for a resident identified as high risk for pressure ulcers and with worsening skin conditions. The resident had multiple comorbidities, including stroke, aphasia, hemiplegia, malnutrition, diabetes, and was dependent on staff for mobility and personal care. Despite being at high risk for skin breakdown, documentation and interviews revealed that weekly skin assessments were incomplete, with the nurse often relying on nurse aides' observations rather than conducting a thorough visual inspection of all skin areas. The nurse admitted to not always removing the resident's clothing and not assessing all areas, particularly those covered by clothing, and was unsure of the full requirements for weekly skin assessments. The resident's medical records indicated that prior to hospital admission, there were only minimal notes about skin redness and bruising, with no detailed documentation of open wounds or significant changes. However, upon hospital admission, the resident was found to have extensive skin breakdown, including a large, necrotic, unstageable pressure wound on the sacrum, deep tissue injuries on the thigh and heel, and other lesions. Hospital staff noted that these wounds were present on admission and were of significant size and severity, suggesting they had developed over a period of weeks. Interviews with hospital staff and facility nurse practitioners confirmed that the wounds could not have developed overnight and should have been identified earlier through proper skin assessments. Further review of the nurse's education and competency records showed no evidence of recent or specific training on skin assessments. Facility policy required weekly skin inspections by licensed staff, notification of providers and family for new or worsening skin issues, and detailed documentation of findings. However, these procedures were not followed, as evidenced by the lack of comprehensive skin assessments, failure to document and report changes, and inadequate communication among staff. The deficiency had the potential to affect all residents in the facility due to the systemic nature of the competency and documentation failures.
Failure to Follow Enhanced Barrier Precautions During Indwelling Catheter Care
Penalty
Summary
A deficiency occurred when a nursing assistant failed to follow proper personal protective equipment (PPE) protocols while providing care to a resident on enhanced barrier precautions (EBP) due to an indwelling urinary catheter and a history of urinary tract infections and wounds. The resident, who had multiple medical conditions including diabetes, cerebral palsy, neurogenic bladder, paraplegia, and was dependent on staff for all personal care, required staff to don both gown and gloves during high-contact care activities as indicated by facility policy and signage posted outside the room. During the observed incident, the nursing assistant entered the resident's room wearing only gloves and a mask, but did not wear a protective gown as required. While emptying the urinary catheter bag, the assistant struggled with the catheter spout, resulting in urine splashing onto the floor and paper towels. The assistant handled the catheter tubing and collection container without consistently changing gloves or using proper hand hygiene between steps, and at times used bare hands to handle potentially contaminated items. The end of the catheter tubing was not wiped with an alcohol swab prior to emptying, contrary to facility policy, and the assistant acknowledged a lack of understanding regarding the specific PPE requirements for EBP. Interviews with other staff confirmed that the expectation was to use both gown and gloves when providing care to residents with indwelling catheters under EBP. Facility policies clearly outlined the need for enhanced barrier precautions for residents with indwelling medical devices, and signage was present to direct staff. The failure to adhere to these protocols was directly observed and acknowledged by the staff involved.
Failure to Supervise Resident Smoking with Oxygen
Penalty
Summary
The facility failed to implement and enforce a process to supervise and monitor a resident who was known to smoke while using oxygen, despite clear risks associated with this behavior. The resident had a history of acute respiratory failure with hypoxia, heart failure, asthma, and tobacco use, and was cognitively intact. The resident's care plan and a signed smoking contract required that oxygen tanks be left inside the facility or at the entrance to the smoking patio, with staff assistance if needed, and indicated that non-compliance would result in a review of smoking privileges. However, there was no evidence of follow-up smoking assessments after a prior incident, and progress notes indicated the resident was observed smoking at unassigned times. Multiple observations and interviews confirmed that the resident continued to smoke on the designated patio while using oxygen, including a family member providing photographic evidence and reporting the behavior to the facility. The resident himself acknowledged being aware of the risks but did not believe his personal oxygen tank posed a danger and refused to comply with the policy. Other residents also reported witnessing similar unsafe behaviors. Staff interviews revealed there was no established plan to monitor the smoking area, and the designated patio was not directly supervised by staff, with only video surveillance available in the administrator's office and not accessible to other staff members. The facility's smoking policy stated that non-compliance could result in loss of smoking privileges but did not specifically address smoking with oxygen. The administrator confirmed that the resident had previously been observed smoking with oxygen and had been educated on the risks, but no consistent monitoring or enforcement measures were in place. The lack of direct supervision, absence of regular assessments, and failure to enforce the smoking contract led to ongoing unsafe smoking practices involving oxygen use.
Removal Plan
- Conduct a smoking assessment for R3
- Revoke R3's smoking privileges at the facility
- Revise R3's care plan to indicate his smoking privileges have been revoked
- Review the smoking policy with R3
- Notify R3's nurse practitioner
- Receive an order for nicotine lozenges for R3
- Place R3 on safety checks
- Provide education to all staff regarding designated smoking areas of the facility
- Educate staff that no oxygen is allowed on the smoking patio
- Assign the nurse on the unit closest to the smoking patio responsibility to monitor the smoking patio and document
- Require any resident who uses oxygen to exchange their oxygen for their smoking materials with the nurse
- Hold a quality assessment performance quality improvement (QAPI) meeting to review and determine a process to monitor for safe smoking practices
- Instruct staff to provide education to residents regarding safe smoking
- Instruct staff to notify the nurse if residents are non-compliant with smoking safety
- Instruct staff to document instances of non-compliance
- Instruct staff to notify the administrator or nurse on-call of non-compliance
- Post the smoking policy on the door to the smoking patio
- Post a sign indicating no oxygen allowed in the smoking patio area
Medication Diversion and Misappropriation in LTC Facility
Penalty
Summary
The facility failed to implement a system to prevent the diversion of medications, resulting in the misappropriation of controlled substances prescribed to 30 residents. A trained medication assistant (TMA) was found to have signed out narcotics from the narcotic log without consistently documenting their administration in the Medication Administration Record (MAR). This discrepancy was identified when a registered nurse (RN) noticed that narcotics were being administered via a G-tube by the TMA, which was outside the TMA's scope of practice. The facility's narcotic records showed significant discrepancies between the doses signed out and those documented as administered in the MAR. Several residents, including those with cognitive impairments and various medical conditions such as epilepsy, heart failure, and chronic pain, were affected by these discrepancies. For instance, one resident's narcotic record indicated 25 doses of oxycodone were signed out, but only 19 doses were documented as administered. Another resident's record showed 34 doses signed out, with only 18 documented as administered. These discrepancies were consistent across multiple residents, indicating a pattern of medication misappropriation. Interviews with staff revealed that the TMA had been improperly handling narcotics, including setting up medications for nurses and administering G-tube medications, which should have been performed by licensed nurses. The TMA also denied giving discharged medications to residents and claimed to have counted narcotics with licensed staff, although the documentation did not support this. The facility's policies on medication administration and controlled substance accountability were not adhered to, leading to the diversion of medications and potential harm to residents.
Deficiencies in Narcotic Security and Insulin Pen Storage
Penalty
Summary
The facility failed to implement a secure system for storing narcotics, as evidenced by the case of a resident who had discontinued medication still being signed out and administered. The resident, who was cognitively intact and had a history of a leg fracture, osteoporosis, and heart failure, had an order for oxycodone that was discontinued, yet doses were still signed out after the discontinuation date. The resident reported not using any pain medication recently and had no increased pain, raising concerns about potential medication diversion. Additionally, the facility did not ensure proper labeling and storage of medications, particularly insulin pens, across multiple medication carts. Insulin pens were stored without separation devices, lacked dosing instructions, and were not properly labeled with open dates or resident identification. This improper storage and labeling were confirmed by several nurses and care coordinators, who noted that the pens were stored in cups or boxes without plastic bags or pharmacy labels, leading to potential contamination and administration errors. The facility's policy required medications to be checked for the five rights (right resident, right drug, right dose, right route, and right time) by comparing the medication administration record with the medication label. However, the report indicates that this process was not consistently followed, as the insulin pens were not labeled correctly, and the dosing information was not available on the pens themselves. The director of nursing acknowledged the ongoing need for education on proper medication administration checks.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required nurse staffing information was posted daily for 3 out of 6 days reviewed, potentially affecting all 57 residents and their visitors. On three separate occasions, surveyors observed that the posted nurse staffing information was outdated. On 2/3/25 at 2:29 p.m., the information was dated 2/2/25; on 2/5/25 at 7:17 a.m., it was dated 2/4/25; and on 2/11/25 at 9:52 a.m., it was dated 2/10/25. According to the facility's Nursing Hours Posting policy, revised on 10/2/22, the facility was required to post nursing staffing data daily at the beginning of each shift, ensuring it was readily accessible to residents and visitors.
Failure to Honor Resident's Clothing Preferences
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence by not allowing her to dress in a manner of her choosing. The resident, who was severely cognitively impaired and required assistance with dressing due to hemiplegia following a stroke, was observed multiple times wearing a hospital gown in public areas of the facility. The resident's guardian expressed concerns about the resident being dressed in a hospital gown and had attempted to discuss clothing options with the facility's social worker, but communication was unsuccessful. Interviews with facility staff revealed that the resident's clothes had ripped and would fall off her shoulders, leading to the decision to dress her in a hospital gown. However, the resident's care plan did not specify a preference for a hospital gown, and the social worker acknowledged the importance of honoring a resident's clothing preferences for dignity. The facility's policy for clothing preferences was not followed, as there were no documented attempts to contact the guardian regarding the resident's clothing needs, and the care plan did not reflect the resident's preferences.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to properly assess a resident, identified as R39, who wished to self-administer medications. R39 was cognitively intact and had diagnoses of congestive heart failure and diabetes, receiving high-risk medications such as anticoagulants and diuretics. Despite this, R39's care plan did not include an assessment of his ability to self-administer medications. An evaluation from 2021 indicated that R39 was unsafe to administer medications independently, yet medications were found on his dresser during an observation. During interviews, it was revealed that R39 had experienced an adverse reaction to Tamiflu and had stopped taking it, with the facility being aware of this. However, there was no self-administration assessment or physician order found for R39, and medications were left in his room unattended. The facility's policy required a comprehensive assessment by an interdisciplinary team to document a resident's ability to safely self-administer medications, which was not followed in this case.
Failure to Report and Address Allegation of Sexual Abuse
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving a resident, identified as R57, to the state agency and law enforcement. R57, who was cognitively intact and dependent on staff for most activities of daily living, was alleged to have been sexually abused by a certified nursing assistant (CNA-A). The incident was reported by a family member (FM-A) who observed CNA-A leaving R57's room and noted suspicious circumstances, including a white substance on R57's mouth and her blankets being disturbed. Despite being informed of the allegation, the facility's administrator did not report the incident to the authorities, as she did not believe the allegation based on her review of hallway video footage. The administrator and other staff members, including a social worker (SW-1) and a licensed practical nurse (LPN-A), failed to follow the facility's policy on abuse reporting. The administrator was notified of the incident via text message but did not take action until the next business day. SW-1 also received a report of the incident but deemed the family member not credible and did not report it to the authorities. LPN-A, who was informed of the incident during the night shift, did not report it to the state agency or law enforcement and did not remove CNA-A from providing care to R57 or other residents. The facility's policy required all staff to report any suspected abuse to the Office of Health Facility Complaints within two hours of forming the suspicion. However, this policy was not adhered to, resulting in a failure to protect R57 from potential further abuse. R57 expressed fear and discomfort due to CNA-A's continued presence in the facility, highlighting the facility's failure to ensure her safety and well-being.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident who was cognitively intact and dependent on staff for most activities of daily living. The resident's care plan indicated she was a vulnerable adult and required care in pairs. On the night of the incident, a family member reported seeing a CNA leaving the resident's room and alleged that the CNA had sexually abused the resident. The family member took pictures of the alleged evidence and reported the incident to the social worker and administrator. The administrator, upon being notified, reviewed video footage but did not find it necessary to investigate further, as she believed the CNA was not in the room long enough to commit the alleged act. The administrator did not interview the resident, the reporting staff, or any other residents or staff. The investigation file contained minimal documentation, and the incident was not reported to the State Agency or police by the facility staff. The social worker also doubted the credibility of the family member and did not pursue further investigation. The facility's policy required immediate investigation and reporting of abuse allegations, but this was not followed. The CNA continued to work with the resident without any suspension or education following the allegation. The police were only informed of the incident by the family member nearly a month later, and the facility had not provided the police with their internal investigation. The lack of a thorough investigation and failure to report the incident to the appropriate authorities constituted a deficiency in the facility's handling of the situation.
Deficiencies in Care Planning for Dialysis and Clothing Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving dialysis, identified as R72. The care plan did not include critical information such as the use of an AV fistula on the resident's left forearm for dialysis, which had been in use since December 23, 2024. The care plan also omitted instructions to avoid taking blood pressure or drawing blood from the left arm and to monitor for a thrill and bruit at the fistula site. Despite the presence of a pressure dressing over the fistula access site, there were no physician orders or nursing tasks related to the fistula, and the nursing staff, including the nurse manager and director of nursing, were unaware of the specifics of the resident's dialysis access and care requirements. Additionally, the facility failed to address clothing preferences and passive range of motion (PROM) exercises in the care plan for another resident, identified as R59, who was severely cognitively impaired and had functional limitations due to a stroke. The care plan did not include instructions for PROM exercises, which were part of the resident's occupational therapy discharge summary. Furthermore, the care plan did not specify the resident's clothing preferences, despite the resident's desire to wear her own style of dress, which was important for her dignity. Staff interviews revealed that the resident's clothing preferences were not documented in the care plan, and there was a lack of coordination to ensure the resident's dignity and comfort in her attire.
Failure to Provide Prescribed Range of Motion Exercises
Penalty
Summary
The facility failed to ensure that a resident, identified as R59, received the necessary range of motion (ROM) exercises. R59, who was severely cognitively impaired and had functional limitations in range of motion due to hemiplegia following a stroke, was observed without receiving the prescribed passive range of motion (PROM) exercises. The occupational therapy discharge summary had included a plan for PROM to the resident's right upper extremity, but the care plan did not reflect these instructions. Additionally, the medical record lacked updates regarding the resident's refusal of the ROM program. Interviews with staff revealed a lack of clarity and communication regarding the resident's PROM exercises. Nursing assistants were unsure if R59 received the exercises, and the nursing manager could not specify when or why the exercises were discontinued. The nurse practitioner and director of therapy both indicated that the facility should have documented and communicated any refusals of the program to therapy. The failure to provide the prescribed ROM exercises could lead to decreased mobility and contractures, as noted by the director of therapy.
Failure to Monitor Dialysis Care for Resident
Penalty
Summary
The facility failed to provide proper assessment and monitoring for a resident, identified as R72, who required dialysis services. R72, who was cognitively intact, had diagnoses of end-stage renal disease and heart failure. The care plan for R72 did not accurately reflect the current dialysis access method, as it mentioned monitoring for signs of bleeding at a central dialysis catheter port site, while R72 was actually receiving dialysis through an arteriovenous (AV) fistula on the left arm. Observations and interviews revealed that R72 had a pressure dressing over the fistula access site, which should have been removed within four hours to prevent complications such as clotting, narrowing of blood vessels, and infection. However, there was no indication that staff were aware of or addressed the presence of the pressure dressing after dialysis sessions. Additionally, the facility's documentation and orders were not updated to reflect the use of the fistula for dialysis until February 5, 2025, despite the fistula being in use since December 23, 2024. Blood pressure readings were inappropriately taken on the left arm, which could compromise the fistula's function. Interviews with facility staff, including the nurse manager and director of nursing, revealed a lack of awareness and monitoring of the dialysis site, as well as a failure to adhere to the facility's dialysis policy, which required ongoing assessment and evaluation of the resident's condition, including monitoring for infection and ensuring no blood pressure or blood draws were conducted on the access arm.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during medication passes. Two errors were identified among 25 opportunities, involving two residents. The first resident, who was severely cognitively impaired and diagnosed with coronary artery disease, hypertension, and dementia, was administered metoprolol tartrate despite having a pulse below the prescribed parameter. The LPN acknowledged the error, confirming the medication should not have been given. The nursing manager expected nurses to verify pulse parameters before administering medication, and the nurse practitioner highlighted the risk of worsening bradycardia from such errors. The second error involved a resident with unspecified psychosis and dementia with behavioral disturbance. The LPN prepared and nearly administered an incorrect dose of quetiapine fumarate, exceeding the scheduled amount. The LPN confirmed the error upon comparing the medication cup to blister pack cards. The consultant pharmacist noted the increased risk of side effects from incorrect dosing, which could have been avoided with proper checks. The director of nursing emphasized the importance of adhering to provider orders and verifying medication labels against the electronic medication administration record, as outlined in the facility's medication administration policy.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to maintain safe storage of medications, as observed in multiple instances. On one occasion, a medication cart on the LTC unit was left unlocked and unattended for several minutes, with no staff in direct sight. A staff member walked past the cart without securing it, and it was eventually locked by a care coordinator. In another instance, a medication cart on the TCU was also found unlocked and unattended, with residents nearby. Additionally, during a medication pass, an RN left a resident's medications unattended in the resident's room while retrieving alcohol wipes from the medication cart. The room door was partially open, and other residents were walking past. The RN acknowledged the error, stating she was aware that medications should not be left unattended. The DON confirmed that medication carts should always be locked when not in use and that medications should never be left unattended in a resident's room.
Inadequate Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to conduct appropriate hand hygiene during tracheostomy care for a resident who was severely cognitively impaired and dependent on all cares. During the observation of tracheostomy care, the LPN and RN assisting did not perform hand hygiene after removing gloves and before donning new ones, despite acknowledging the importance of hand hygiene to prevent infections. The Director of Nursing confirmed the expectation for staff to perform hand hygiene when changing gloves between cares. Additionally, the facility failed to ensure proper catheter drainage bag care for a resident with a foley catheter. The urinary catheter drainage bag was observed lying on the floor on multiple occasions, which was acknowledged by staff as inappropriate due to cleanliness and dignity concerns. Furthermore, the LPN did not cleanse the catheter bag spout with an alcohol wipe before securing it back in the holder, despite having alcohol wipes available. The facility's policies on handwashing and indwelling catheter care were not followed, contributing to these deficiencies.
Failure to Hold Medication for Low Pulse as Ordered
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including coronary artery disease, hypertension, and dementia had a physician's order for metoprolol tartrate to be administered twice daily, with specific parameters to hold the medication if the apical pulse was less than 60 beats per minute. During a medication pass observation, an LPN measured the resident's pulse at 55 beats per minute but proceeded to administer the metoprolol tartrate, contrary to the order. The LPN confirmed during an interview that the medication should not have been given when the pulse was below the specified parameter. Review of the resident's medication administration records over a three-month period revealed multiple instances where the medication was administered despite recorded pulses below 60 beats per minute, with no indication that the medication was held as ordered. Facility staff interviews confirmed the expectation that nurses verify vital signs are within ordered parameters before administering medications. The facility's medication administration policy also required medications to be given in accordance with written orders, including verification of the five rights prior to administration.
Medication Administration Error Due to LPN's Assumption
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for one resident. The resident, who was cognitively intact and had a diagnosis of acute embolism and thrombosis of the deep vein of the left lower extremity, was supposed to receive Buprenorphine HCL sublingual tablets for pain. However, on two occasions, the resident was mistakenly given Buprenorphine HCL Buccal Film instead. The error occurred because the LPN could not find the sublingual medication and assumed the film could be administered as a substitute. The resident was aware of the medication error and attempted to inform the LPN, but the LPN did not believe the resident and proceeded with the administration of the incorrect medication. The investigation revealed that the sublingual tablets were available in the facility's narcotic box at the time of the error, and the LPN failed to perform the necessary safety checks to ensure the right medication, dose, form, and person. The error was identified when the resident reported the issue, and it was confirmed that the medication had been delivered and administered correctly on previous days. The facility's policy required staff to contact the provider in the event of a medication error, but the LPN did not do so. The interim DON noted that the root cause of the error was the LPN's inability to locate the tablets and the assumption that the film could be used instead, without provider approval.
Failure to Make Psychiatric Referral for Resident
Penalty
Summary
The facility failed to ensure a referral was made to an outside agency for psychiatric services as ordered by a physician for a resident diagnosed with bipolar disorder, protein-calorie malnutrition, and adult failure to thrive. The resident had a physician order for a referral to the Associated Clinic of Psychology (ACP) due to concerns about restrictive/avoidant eating. However, the resident was not currently being seen by ACP, and the last visit occurred several months prior. A licensed practical nurse confirmed the lack of a current referral and was unaware if a new referral had been made. The social services staff, responsible for submitting referrals, was also unaware of the order. The interim director of nursing stated that staff would typically notify social services of such orders, but no policy was available to guide this process.
Failure to Notify Family of Resident's Wound Progression
Penalty
Summary
The facility failed to notify a resident's family of changes in the resident's condition, specifically regarding the development and progression of a left toe ulcer that ultimately led to an amputation. The resident, who had severe cognitive impairment and was non-verbal, was admitted with multiple health issues, including hemiplegia, diabetes, and vascular dementia. Despite being a high-risk patient with diabetic ulcers on both great toes, the facility did not inform the resident's power of attorney (POA) about the condition of the wounds until the situation necessitated a hospital visit and subsequent amputation. The facility's records show that the resident's toe ulcers were being monitored and treated regularly, with notes indicating the wounds were stable but showed minimal improvement. However, there was no documentation of communication with the family regarding the wounds from the time they were first noted until the resident was sent to the hospital. Interviews with family members revealed that they were unaware of the resident's toe wounds and the involvement of a wound care clinic until the hospital informed them of the need for an amputation due to infection. Interviews with facility staff, including nurses and the Director of Nursing (DON), indicated a lack of clarity and consistency in the process of notifying families about changes in wound conditions. The staff expected the nurse practitioner (NP) to update families, but the NP had no contact with the family. The facility's policies required notification of changes in a resident's condition to the resident's representative, but this was not adhered to in this case, leading to a significant oversight in communication.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) for a resident who wished to have cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The resident was found unresponsive, without a pulse or respirations, and CPR was not initiated despite the resident's full code status. This resulted in the resident's death, as no resuscitative efforts were made. The incident occurred when a Licensed Practical Nurse (LPN) found the resident unresponsive and failed to initiate CPR. The LPN checked for a pulse and respirations, found none, and did not proceed with CPR, believing it was too late. The LPN did not contact the Director of Nursing (DON) or the on-call nurse for guidance and instead contacted the facility administrator, leading to a miscommunication about the actions taken. Other staff members, including a Registered Nurse (RN), confirmed that CPR was not performed, and the Automated External Defibrillator (AED) was not used. The staff were aware of the resident's full code status but did not act accordingly. Interviews with other staff members revealed that they were trained and certified in CPR and understood the protocol for initiating CPR for a full code resident, yet the protocol was not followed in this instance.
Deficiency in Methadone Management and Narcotic Documentation
Penalty
Summary
The facility failed to implement appropriate policies and procedures for the administration and management of methadone hydrochloride for a resident undergoing treatment for opioid dependence. The resident, who was cognitively intact and had a history of substance use, was receiving methadone treatment from a methadone clinic. However, the facility did not coordinate effectively with the clinic, leading to missed doses and unauthorized tapering of the medication. The facility's actions included altering the methadone doses without consulting the methadone clinic, which was against regulations, and resulted in the resident experiencing withdrawal symptoms. The facility also failed to ensure proper handling and documentation of narcotic medications, including methadone. There were significant lapses in the documentation of narcotic counts and the co-signing of narcotic waste, as required by facility policy. The facility staff did not follow proper procedures for the destruction of unused methadone, and there was a lack of communication and coordination with the methadone clinic regarding dose adjustments and the provision of urine samples for testing. Additionally, the facility's narcotic books were incomplete, lacking necessary information such as prescribing provider details, prescription numbers, and dates. The facility's failure to maintain accurate records and follow established protocols for controlled substances contributed to the deficiency. The facility did not have a policy in place for managing methadone for addiction, which further exacerbated the situation and led to the resident being cut from the methadone program.
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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