The Villas At Roseville
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseville, Minnesota.
- Location
- 1000 Lovell Avenue, Roseville, Minnesota 55113
- CMS Provider Number
- 245326
- Inspections on file
- 22
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Villas At Roseville during CMS and state inspections, most recent first.
Lack of Qualified Dietary Leadership: The facility failed to employ either a full-time RD or a qualified DM to oversee food and nutrition services, affecting all 54 residents. The CSD stated she had only recently enrolled in the CDM program and had no other food service certification or training, while the administrator said an RD worked one day a week and was on call. Requested documentation for the CSD’s qualifications and the dietary staff qualification policy were not provided.
A resident with dementia and an amputated leg was dependent on staff for ADLs, transfers, and mobility. Staff twice placed a pillow along the resident's side under the fitted sheet after a mechanical lift transfer, and one NA stated the pillow was placed there so it would not fall out and that the resident could not easily remove it. RN staff and the DON stated pillows should not be placed under fitted sheets because that could be considered a restraint.
Failure to hold required care conferences for a resident with TBI, seizure disorder, depression, opioid dependence, legal blindness, and dizziness. The resident’s EHR had no documentation of care conferences since admission, and the resident said she did not remember being invited or involved in any meetings about her care. The SS director confirmed the missing documentation, while staff stated conferences were expected within 48 hours of admission, quarterly, and as needed, with the resident and family invited.
A resident with ataxia and significant assistance needs had a provider-ordered ophthalmology referral for a skin tag under the left eye, but the appointment was not arranged. The resident said the issue was discussed with the doctor and nothing happened afterward. Staff stated the MRD handled referrals and transportation, but she had not acted on the order and said it may have been lost in paperwork; the DON and NP expected the referral to have been completed by then.
A resident with an infected tooth, severe toothache, and visible decay had provider orders for urgent dental referral and priority scheduling, but the appointment was never arranged or completed. Staff gave conflicting accounts about who handled referrals, and the MRD could not find evidence of a dental visit, a waitlist entry, or a documented refusal. The DON and NP stated the referral should have been followed up timely.
Failure to coordinate psychiatry services for a resident with BPD, PTSD, and MDD. The resident had an order for psychiatry follow-up, medication review for increased anxiety, and social work involvement for a possible transfer to a setting supporting her mental health, but the referral was not completed because social services was unaware of the order. The resident stated she felt unheard and misunderstood by staff and reported she was not offered additional therapy or mental health support beyond speaking with a grief therapist on an iPad.
The facility failed to accurately code the MDS for two residents, one with pressure ulcers and another with psychotropic medications. A resident's pressure ulcer was incorrectly staged, and another resident's use of antianxiety medication and GDR attempts were inaccurately reported. The MDS coordinator acknowledged the errors, and the DON confirmed the inaccuracies.
A facility failed to complete and retain the necessary PASARR documentation for a resident with mental health diagnoses, including bipolar disorder and schizophrenia. The admission coordinator and social services director acknowledged the absence of the required documentation, which was supposed to be completed prior to admission and uploaded into the electronic medical record. The director of nursing and a registered nurse also confirmed the lack of PAS documentation in the resident's paper chart, highlighting a deficiency in the facility's care planning and assessment process.
The facility failed to conduct timely care conferences for a resident with chronic kidney disease, who required assistance with most ADLs and mobility. The last documented care conference was several months prior, and the resident could not recall attending one. The director of social services acknowledged the oversight and mentioned efforts to improve scheduling. A policy on care conferences was requested but not provided.
A facility failed to accurately assess and document a resident's pressure ulcer, leading to a deficiency in care. The resident, with a history of anemia, heart failure, and diabetes, had a stage 2 pressure ulcer incorrectly documented despite containing granulation tissue, slough, and eschar. Staff interviews revealed confusion and incorrect staging, with the MDS coordinator acknowledging the need for modification. The facility's policy on skin assessment and wound management was not effectively implemented, resulting in the deficiency.
A resident with hemiplegia experienced pain during mechanical lift transfers, as staff failed to ensure proper positioning and did not report unsafe transfers for reassessment. The resident was observed hanging by his shoulders during a transfer, contrary to the expected safe transfer protocol. The facility lacked a documented policy on safe transfers.
A resident with cognitive impairments was prescribed Nystatin powder for candidiasis without an end date. Despite the resident's skin condition improving, the medication continued to be administered without reassessment. Interviews revealed that staff did not actively monitor the necessity of the medication, and the DON acknowledged it should have been discontinued once the condition improved.
A resident was not offered the pneumococcal vaccination series as recommended by the CDC, despite being eligible due to their age and previous vaccination history. The resident's medical records lacked documentation of shared decision-making with a physician or evidence of being offered the vaccine. The facility's infection preventionist and DON acknowledged the oversight, citing additional responsibilities as a contributing factor. This failure was contrary to the facility's policy to offer pneumococcal vaccines to all residents.
A resident with atrial fibrillation missed 12 doses of apixaban due to a transcription error, leading to a stroke and ICU hospitalization. The error occurred because the health unit coordinator entered an incorrect end date, and the verification process was not properly followed by the nursing staff.
The facility did not update the daily nurse staffing information, with the last update being over a month old. The DON acknowledged the outdated posting, and the administrator was unaware of the lapse. A policy on nurse staff posting was requested but not provided.
A resident with a history of respiratory failure and other conditions missed a dose of lorazepam due to the nurse's failure to use the emergency medication kit. Despite the facility's policy and training, the nurse did not administer the medication from the emergency kit, leading to increased anxiety and restlessness for the resident.
The facility failed to comprehensively assess two residents for the use of bedrails and did not review the risks and benefits or obtain written informed consent before installation. Both residents were cognitively intact, but the necessary evaluations and informed consent procedures were not followed, leading to the deficiency.
Lack of Qualified Dietary Leadership
Penalty
Summary
The facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since January 2020, affecting all 54 residents in the facility. During the initial kitchen tour, the Culinary Services Director (CSD) stated she worked full time at the facility and that an RD worked one day a week and was available by phone for questions. On follow-up interview, the CSD stated she had recently enrolled in the certified dietary manager (CDM) program about a month earlier and had no other certification or food service training, and she had originally enrolled during COVID but did not finish. The administrator stated the facility had an RD who worked once a week and was on call, and that the CSD had started as kitchen manager in January 2020 and was currently enrolled in school for her CDM license; the administrator also stated she believed the CSD only needed to be enrolled in the program to be qualified as the CSD. Requested documentation for the CSD’s qualifications and a facility policy regarding dietary staff qualifications were not received.
Pillow Placed Under Fitted Sheet Restricted Resident Movement
Penalty
Summary
The facility failed to ensure a resident was free from the use of a physical restraint when a pillow was placed adjacent to the resident's body underneath the fitted sheet, making it difficult for the resident to remove it independently. The resident, R44, had diagnoses of dementia and acquired absence of the right leg below the knee, and the quarterly MDS indicated the resident was dependent on staff for all ADLs, transfers, and mobility. R44's care plan identified impaired cognitive function/dementia, altered mood and behavior, and a history of putting self on the floor and crawling. The plan directed staff to keep the bed low and place a mat on the floor. During two separate observations, nursing assistants transferred R44 to bed using a mechanical lift, performed care, lowered the bed, and placed a pillow along the left side of the resident under the fitted bottom sheet. One NA stated the pillow was placed there so it would not fall out if the resident became agitated and did not think the resident could remove it. RN staff and the DON stated pillows should not be placed under fitted sheets because that could be considered a restraint, and one RN stated that if a resident could not easily remove a pillow and it prevented getting out of bed, it would be considered a restraint.
Failure to Hold Required Care Conferences
Penalty
Summary
The facility failed to provide care conferences for 1 resident reviewed for care conferences. The resident’s quarterly MDS identified the resident as cognitively intact with diagnoses of traumatic brain injury and seizure disorder. The resident’s EHR did not show any care conferences since admission on 8/20/25, and the resident’s care plan dated 11/25/25 identified the resident as a vulnerable adult at risk for decreased cognitive and physical abilities related to traumatic brain injury, depression, opioid dependence, legal blindness, and dizziness. During interview, the resident stated she did not remember being invited or involved in any meetings about her care at the facility. The social service director confirmed the EMR lacked documentation of care conferences for the resident and stated the social service director and social service designee were responsible for scheduling conferences and sending information to the IDT, resident, and family or representatives. Staff stated care conferences were expected within 48 hours of admission, quarterly, and as needed, and the DON stated they were used to align care with the resident’s needs, revisit concerns, and follow up with the plan of care. The facility policy stated the comprehensive care plan was to be developed within 7 days and that every effort would be made to have the resident and family attend care conferences.
Failure to Follow Up on Ophthalmology Referral
Penalty
Summary
The facility failed to ensure follow-up on a provider-ordered ophthalmology referral for a resident who was cognitively intact and required substantial to maximal assistance with transfers and mobility. The resident’s diagnoses included ataxia and need for assistance with personal care. A provider visit note documented that the resident asked about a small yellowish skin tag under the left eye, and an ophthalmology appointment was ordered for the skin tag under the left eye on 1/20/26. During observation and interview, the resident stated he had discussed the skin tag with the doctor and was told they would look into getting it removed, but that never happened. Staff interviews showed the medical records director was responsible for arranging referrals and transportation, and the DON expected routine and non-routine appointments to be scheduled timely. The medical records director stated she had just seen the ophthalmology referral the prior week and had not made any arrangements yet, explaining it may have been lost in paperwork while reorganizing her office. The DON and NP both stated the appointment should have been arranged and completed by then, and the facility did not provide a policy on appointment scheduling or provider orders.
Failure to Follow Up on Emergency Dental Referral
Penalty
Summary
The facility failed to ensure follow-up for an emergency dental referral for a resident with an infected tooth. The resident’s quarterly MDS indicated he was cognitively intact, needed setup or clean-up assistance with oral hygiene, and required substantial to maximal assistance with transfers and mobility. His diagnoses included ataxia and need for assistance with personal care. A provider visit note documented severe toothache, left upper molar decay with partial breakage, and erythema around the gum line, and the provider placed an order for referral to a dentist for definitive treatment of the infected left upper tooth with priority escalation for scheduling. The next day, another provider order again instructed referral to a dentist for treatment of the infected left upper tooth. During interviews, the resident stated he had a tooth infection and was supposed to see a dentist but never did. Staff gave conflicting accounts about how dental referrals were handled, with the LPN, DON, and MRD identifying the MRD as responsible for scheduling, while the MRD initially stated she thought an appointment had been set up and the resident refused care. The MRD could not locate evidence that the resident was ever seen by the outside dental provider, was on a list to be seen, or had a documented refusal. The outside dental appointment coordinator stated the resident was not enrolled for dental care and had only elected podiatry services. The MRD later stated the resident would have needed an external dental clinic of his choice and that an appointment should have been arranged when originally ordered, but she could not explain why it was missed. The DON and NP stated they expected referrals to be followed up timely and that the resident should have been seen by a dentist by then.
Failure to Coordinate Psychiatry Services
Penalty
Summary
The facility failed to ensure coordination of mental health care services for a resident who had diagnoses of borderline personality disorder, post-traumatic stress disorder, and major depressive disorder. The resident’s quarterly MDS identified her as cognitively intact, and a provider order dated 3/11/26 directed psychiatry to see her the following week, social work to contact the case manager to expedite transfer to a setting that would support her mental health, and changes to psychiatric medications due to increased anxiety; the resident also requested female caregivers. Her care plan identified her as at risk for altered behavior related to trauma and noted a need for referral for psychiatry services and collaboration with social services and psychiatry to improve social connections and minimize symptomology. Psychiatry provider notes were requested but not provided. During interview, the resident stated her PTSD, anxiety, and depression made her feel that she was not heard and understood by staff, and that although she used an iPad to speak with a grief therapist, she was not offered additional therapy or mental health support. Nursing staff stated therapeutic communication should be used with residents having stress-based outbursts, and the RN stated provider orders were to be followed and referrals were important for cohesive care, but she was unaware of the psychiatry referral. Social services stated the psychiatry appointment process was handled by that department and that the resident’s order was not completed because social services was unaware of it. The DON stated provider orders were expected to be entered into the medical record as soon as possible and outside psychiatric appointments were expected to be arranged per orders, but staff were unsure why the order was missed and whether the resident accepted or declined additional services.
Inaccurate MDS Coding for Pressure Ulcers and Psychotropic Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, one with pressure ulcers and another with psychotropic medications. For the resident with pressure ulcers, the MDS inaccurately reported the stage of the pressure ulcer. The resident had a pressure ulcer on the right Achilles, which was documented as a stage two ulcer. However, the wound contained granulation tissue, slough, and eschar, which are not characteristics of a stage two ulcer. The wound was actually unstageable due to the presence of slough and eschar, which obscured the wound bed. The MDS coordinator acknowledged the error and stated that the staging was not completed correctly. The second resident's MDS inaccurately reported the use of psychotropic medications. The resident was taking hydroxyzine for anxiety and quetiapine for depression. The MDS failed to report the use of an antianxiety medication and did not document a gradual dose reduction (GDR) attempt for the antipsychotic medication, despite a failed GDR and clinical contraindication being documented. The MDS coordinator admitted to missing the hydroxyzine and acknowledged the need to modify the MDS to correct the errors. Interviews with the Director of Nursing (DON) and the MDS coordinator revealed expectations for accurate documentation and alignment with provider documentation. The DON confirmed the inaccuracies in the wound staging and the psychotropic medication reporting. Despite requests, the facility did not provide a policy on MDS accuracy, relying instead on the RAI manual for guidance.
Failure to Complete and Retain PASARR Documentation
Penalty
Summary
The facility failed to ensure that a Level 1 Pre-Admission Screening (PAS) and, if necessary, a Level II Pre-Admission Screening and Resident Review (PASARR) were completed and retained in the medical record for a resident with mental health needs. The resident, who was admitted with diagnoses of bipolar disorder and schizophrenia, did not have the required PASARR documentation in their medical record. The admission Minimum Data Set (MDS) indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite having active diagnoses that could require active treatment. The admission coordinator (AC-E) and the social services director (SSD) both acknowledged the absence of the PASARR documentation in the resident's medical record. AC-E, who was responsible for requesting preadmission screens, initially believed the resident had a PAS but later realized that the form in the record was only a referral and not the actual PAS. SSD confirmed that the PAS screenings were supposed to be completed prior to admission and uploaded into the electronic medical record. Both AC-E and SSD recognized the importance of the PAS in determining the necessary level of care and services for the resident. The director of nursing (DON) and a registered nurse (RN-C) also verified the absence of the PAS in the resident's paper chart. The facility's policy on Pre-Admission Screening (PASSR) outlined the requirement for social services to ensure that the initial PAS results state that the resident meets the level of care for medical assistance payment before admission. However, this process was not followed, leading to the deficiency in the resident's care planning and assessment.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences for a resident, identified as R14, who was reviewed for care planning. R14's annual Minimum Data Set (MDS) indicated intact cognition and a diagnosis of chronic kidney disease, requiring staff assistance with most activities of daily living and mobility. During an interview, R14 could not recall if a care conference had occurred. The last documented care conference for R14 was on 8/27/2024, and there was no documentation of any subsequent care conferences. The director of social services acknowledged the lack of a recent care conference and mentioned efforts to develop a better system for scheduling them. A facility policy on care conferences was requested but not provided.
Inaccurate Pressure Ulcer Staging and Documentation
Penalty
Summary
The facility failed to ensure accurate wound care assessments for a resident with pressure ulcers, leading to a deficiency in pressure ulcer management. The resident, who had a history of anemia, heart failure, peripheral vascular disease, and diabetes mellitus, was at risk of developing pressure ulcers and had a stage 2 pressure ulcer that was not present upon admission. The facility's documentation and assessment of the resident's pressure ulcer were inconsistent with clinical standards, as the wound was repeatedly documented as a stage 2 pressure ulcer despite containing granulation tissue, slough, and eschar, which are not characteristics of a stage 2 ulcer. The facility's staff, including registered nurses and the MDS coordinator, demonstrated a lack of understanding and adherence to proper pressure ulcer staging guidelines. Interviews with staff revealed confusion and incorrect staging of the resident's pressure ulcer, with some staff members incorrectly documenting the presence of slough and eschar in a stage 2 ulcer. The MDS coordinator acknowledged the incorrect staging and noted that the MDS would need to be modified. Additionally, the director of nursing confirmed that the wound documentation notes were not accurate for the wound staging according to the staging definitions. The resident's care plan and physician's orders included interventions for pressure ulcer management, such as turning and repositioning, using a pressure-reducing mattress, and monitoring the skin during care. However, the facility's failure to accurately assess and document the resident's pressure ulcer staging led to a deficiency in providing appropriate pressure ulcer care. The facility's policy on skin assessment and wound management required weekly skin inspections and proper documentation, but these procedures were not effectively implemented, resulting in the deficiency.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure safe patient handling during mechanical lift-assisted transfers for a resident with hemiplegia following a stroke. The resident, who was dependent on staff for transfers, reported experiencing pain during transfers using the EZ Stand lift, stating it caused discomfort to his ribs and lungs. During an observed transfer, the resident was unable to stand fully upright, resulting in him hanging by his shoulders from the lift, which was not reported to the nursing staff for further evaluation. The physical therapist assistant noted that such posturing could indicate the need for a therapy evaluation, but no concerns had been communicated to the therapy team. The director of nursing stated that a safe transfer should allow the resident to stand fully and grasp the lift bars without hanging. However, the observed transfer did not meet these criteria, and the staff did not follow the expected protocol of reporting unsafe transfers for reassessment and care plan updates. Additionally, the facility did not provide a policy on safe transfers when requested, indicating a lack of documented procedures to guide staff in ensuring resident safety during mechanical lift transfers.
Failure to Monitor and Reassess Antifungal Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically antifungal medications without an end date. A resident with a history of non-traumatic brain dysfunction, neurosyphilis, and non-Alzheimer's dementia was prescribed Nystatin powder for candidiasis, with the order dated several months prior and lacking an end date. Despite the resident's skin condition improving and eventually clearing, the medication continued to be administered as per the original order without reassessment or adjustment. Observations and interviews revealed that the nursing staff and the physician assistant were not actively monitoring the necessity of the continued use of the antifungal medication. The physician assistant, who was not involved in the initial prescription, indicated that the medication should have been reassessed and potentially discontinued after the condition improved. The director of nursing acknowledged that the medication should have been discontinued once the skin condition improved, and the facility's policy required staff to update the provider and care plan as needed for ongoing skin issues.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the pneumococcal vaccination series as recommended by the CDC. The resident, who was of advanced age, had previously received a PPSV23 vaccine over a decade ago. However, there was no evidence in the resident's electronic medical record or paper chart that a follow-up dose of PCV15, PCV20, or PCV21 was offered or administered, nor was there documentation of shared clinical decision-making with the physician regarding the vaccination. The resident confirmed in an interview that they were not offered the pneumococcal vaccine and expressed willingness to receive it if it had been offered. The facility's infection preventionist and director of nursing acknowledged the oversight, attributing it to the additional responsibilities they were handling, including fulfilling the nurse manager's duties. The facility's policy, which aligns with CDC and ACIP recommendations, mandates offering pneumococcal vaccines to all residents to prevent pneumococcal infections. Despite this policy, the resident was not identified as at risk and was not offered the necessary vaccination, leading to the deficiency noted in the report.
Medication Error Leads to Resident's Stroke
Penalty
Summary
The facility failed to ensure that a resident received the prescribed medication, apixaban, which is crucial for preventing blood clots. The resident, who had a history of encephalopathy, atrial fibrillation, and heart failure, was admitted with orders to receive apixaban twice daily. However, due to an error in the medication administration record, the resident missed 12 doses over six days, leading to a stroke and subsequent hospitalization in the ICU. The error occurred because the health unit coordinator mistakenly entered an end date for the apixaban order, and the verification process for medication orders was not properly followed. The first nurse responsible for verifying the orders did not complete the verification process before leaving her shift, although she documented it as complete in the computer system. The second nurse also failed to notice the error and signed off on the admission checklist, indicating that the orders were accurate. The resident's family discovered the omission during a care conference, and by that time, the resident had already suffered a stroke and was unresponsive, receiving hospice care. Medical professionals confirmed that the missed doses of apixaban were directly linked to the stroke, as the medication is essential for preventing blood clots in patients with atrial fibrillation.
Removal Plan
- Review procedure for transcribing orders
- Audit all residents on apixaban
- Audit all new resident orders
- Education for all staff involved with order transcription
- Education on the medication apixaban
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required nurse staffing information was posted daily, which had the potential to affect all 58 residents and visitors. On March 4, 2025, it was observed that the daily nurse staffing form at the nursing station was outdated, displaying a date of January 23, 2025. The Director of Nursing (DON) acknowledged that the form should be updated daily and admitted it was very outdated. The purpose of the posting was to provide a rough idea of the nurse-to-patient ratio. The facility administrator, who had been responsible for staffing over the previous two months, was unaware that the posting had not been updated since January 23, 2025. A policy regarding the nurse staff posting was requested but not provided.
Failure to Administer Anti-Anxiety Medication from Emergency Kit
Penalty
Summary
The facility failed to provide pharmacy services for a resident who did not receive his anti-anxiety medication, lorazepam, when it was available in the emergency medication dispensing kit. The resident, who was cognitively intact and had a history of acute and chronic respiratory failure with hypoxia, congestive heart failure, morbid obesity, opioid dependence, chronic pain syndrome, and low back pain, missed a dose of lorazepam. The medication administration record indicated the missed dose, but there was no progress note or nurse's note explaining the missed medication. The resident reported increased anxiety and restlessness due to the missed dose. Interviews with the registered nurse, pharmacy manager, director of nursing, and the administrator confirmed that the facility had an emergency medication kit that included lorazepam and that staff were trained to use it when a resident's medication ran out. However, the nurse did not utilize the emergency medication kit as expected. The facility's policy and procedure indicated that if a current and active medication order could not be located in the medication cart, the medication should be removed from the emergency medication kit. Despite this policy, the nurse failed to administer the medication from the emergency kit, leading to the deficiency.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to comprehensively assess residents for the use of bedrails prior to their installation for two residents. Specifically, the facility did not review the risks and benefits or obtain written informed consent before installing bed rails for these residents. One resident, who was cognitively intact, had bed rails installed without a thorough assessment of medical diagnoses, size, weight, sleep habits, medications, and other relevant factors. The resident's bed mobility device evaluation did not indicate any alternatives attempted before the placement of the bed rails. Another resident, also cognitively intact, requested bed rails but did not receive a review of the risks versus benefits from the nursing staff before the installation. This resident was unaware of the risks associated with bed rails and did not sign an informed consent form prior to their installation. During interviews, the therapy director and the director of nursing both stated that the interdisciplinary team would typically meet to decide if a resident was appropriate for bed rails. However, they were unaware that bed rails had been installed for the residents in question. The interim nurse manager admitted to not reviewing the residents' medical diagnoses, height, or weight before the installation of the bed rails. The maintenance director, responsible for installing the bed rails, also did not consider the residents' height and weight and was unaware of the different types of bed rails available. The facility's policy and procedure for bed rails were requested but not provided. The interim nurse manager and the maintenance director both demonstrated a lack of knowledge regarding the different types of bed rails and their appropriate use. This lack of comprehensive assessment and informed consent before the installation of bed rails led to the deficiency identified in the report.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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