Thorne Crest Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Albert Lea, Minnesota.
- Location
- 1201 Garfield Avenue, Albert Lea, Minnesota 56007
- CMS Provider Number
- 245425
- Inspections on file
- 27
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Thorne Crest Retirement Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was injured after rolling out of bed and coming into contact with a wall heater that was positioned only 11 inches away, resulting in second-degree burns. Staff had not been consistently educated or auditing bed placement, and maintenance had not documented or continued regular checks to ensure beds were kept at a safe distance from heaters.
A resident with cerebral palsy and an elevated white blood count developed right eye pain, redness, and swelling, which progressed to suspected cellulitis and conjunctivitis. Nursing staff escalated care and new medications were ordered, but the resident's representative was not notified of the change in condition or treatment, as confirmed by staff interviews and record review.
A resident with cerebral palsy and a history of elevated WBC developed an eye infection, but staff failed to consistently monitor and document signs and symptoms of infection after antibiotics were started. Additionally, the resident was transported in a manual wheelchair without a safety assessment and left unattended at an outside appointment, despite being unable to self-mobilize. Communication lapses and lack of clear procedures contributed to the deficiencies.
A resident with a diagnosed eye infection did not receive prescribed oral and ophthalmic antibiotics on the day they were ordered, despite provider instructions for immediate administration. Medication records and staff interviews confirmed the delay, and the error was not communicated to the resident or their representative. Facility policy required timely administration and documentation of medication errors, but the process was not followed, and leadership was unaware of the incident until identified by surveyors.
Staff did not follow standard and contact precautions for a resident with active shingles, including failing to perform hand hygiene and use PPE when entering the room. The required PPE cart was not placed outside the room as expected, and staff interviews revealed a lack of understanding regarding infection control protocols, resulting in improper implementation of precautions.
A resident with severe cognitive impairment and identified as an elopement risk left the facility unsupervised through an unlocked door. The resident was found outside with hypothermia and minor injuries. Staff were unaware of the resident's elopement risk, and the facility's policy on elopement was not effectively communicated or implemented.
A resident with severe cognitive impairment was found to have inadequate hydration due to the water pitcher being placed out of reach, despite being able to drink independently. Observations and staff interviews revealed that the water pitcher was not consistently placed on a bedside table, and there was confusion among staff about the policy for refilling water pitchers. The facility's policy required water pitchers to be within easy reach and refilled each shift, but this was not consistently followed.
A facility failed to protect residents from sexual abuse by a resident with a known history of inappropriate behavior. Despite documented incidents and a care plan that included supervision and checks, these measures were inadequately implemented. Staff were not informed or trained to monitor the resident effectively, and documentation was insufficient, leading to a failure to protect residents from potential harm.
The facility failed to report incidents of inappropriate touching and sexual abuse allegations involving a resident to the State Agency within the required timeframe. Despite staff intervention, the incidents were not documented or reported promptly, as some staff perceived them as harmless. The facility's policy required immediate reporting, but a breakdown in communication and adherence to protocols led to the deficiency.
The facility failed to ensure proper hand hygiene during personal and wound care for two residents. A nursing assistant and a licensed practical nurse did not follow hand hygiene protocols, including changing gloves and washing hands at critical points during care activities, as confirmed by interviews and observations.
Failure to Maintain Safe Bed Distance from Heater Results in Resident Burns
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was placed a safe distance away from a wall heater, resulting in the resident becoming entrapped and sustaining second-degree burns. The resident involved had severe cognitive impairment, a diagnosis of neurocognitive disorder with Lewy Bodies dementia, anxiety, and a history of falls and self-transfers. The care plan indicated the resident required assistance with transfers and bed mobility, but was independent with rolling in bed. Despite these needs, the bed was positioned too close to the heater, with staff measuring the distance at only 11 inches at the time of the incident. On the morning of the incident, the resident was found between the bed and the heater, having rolled out of bed and come into contact with the heater. The resident sustained burns to the left hip and back, with multiple blistered areas and bruising on both knees. Staff interviews revealed that the bed had been near the heater for an extended period, and that the resident frequently attempted to get out of bed independently. Staff also reported that the heaters felt hot to the touch and that there was no prior education or consistent auditing to ensure beds were kept at a safe distance from the heaters. Documentation and interviews indicated that maintenance had previously performed a visual audit of bed placement but did not document the results or continue regular checks. Nursing staff were not routinely verifying bed distance from heaters, and there was no established policy or education regarding the required minimum distance prior to the incident. The lack of consistent monitoring and clear procedures contributed to the resident's ability to access the hazardous area and sustain injury.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition for one resident with a history of cerebral palsy and an elevated white blood count. The resident began experiencing right eye pain, redness, and swelling, which progressed over two days. Nursing staff documented the symptoms, administered acetaminophen, and escalated the concern to the DON, who suspected cellulitis and contacted the nurse practitioner for further evaluation. A telemedicine visit confirmed preseptal cellulitis and conjunctivitis, and new medications were ordered, including oral antibiotics and antibiotic eye drops. Despite these developments, there was no documentation that the resident's representative was notified of the change in condition or the new medical interventions. Interviews with facility staff, including the ADON, LPN, and DON, confirmed that the resident's representative was not informed of the change in condition, and all acknowledged that notification should have occurred and been documented. The resident's representative expressed frustration at not being informed and stated she only learned of the situation during a visit. The resident also indicated a preference for having his representative notified of health changes. Review of the electronic health record and staff interviews confirmed the lack of notification and documentation, and the facility was unable to provide a policy regarding notification of changes in condition.
Failure to Monitor Infection and Ensure Safe Transport for Resident with Mobility Impairments
Penalty
Summary
The facility failed to monitor for signs and symptoms of infection for a resident who was at risk due to refusal of vaccinations and had a history of cerebral palsy and elevated white blood count. The resident developed redness, swelling, and pain in the right eye, which was identified as possible cellulitis. Orders were given for oral and eye drop antibiotics, and staff were instructed to mark the area of redness and monitor for spread. However, there was no consistent daily or shift-based documentation or comprehensive assessment of the infection from the time antibiotics were started through the following week, as confirmed by multiple staff interviews and review of the electronic health record. The lack of monitoring was acknowledged by the LPN, ADON, DON, and the nurse practitioner, all of whom stated that regular assessments should have been performed and documented to detect changes in the resident's condition. Additionally, the facility failed to ensure safe transportation for the same resident to an outside appointment. The resident, who normally used a specialized electric wheelchair due to immobility from cerebral palsy and scoliosis, was transferred to a manual wheelchair for transport because the facility van could not accommodate the electric wheelchair. The resident was left unattended in the manual wheelchair at the clinic for approximately 20 to 25 minutes, during which time he was unable to move himself or seek assistance due to lack of core strength. The family member and staff interviews confirmed that the resident was not assessed for safety in a manual wheelchair prior to transport, and the director of therapy expressed concern about the lack of such an assessment given the resident's physical limitations. Communication failures also contributed to the incident, as the transport driver was not provided with proper paperwork or clear instructions regarding the resident's destination, resulting in the resident being left at the wrong location. The family member was not immediately informed of the resident's whereabouts, and facility staff were unaware that the resident had been left unattended. Facility policies for infection monitoring and safe transport were requested but not provided for review.
Failure to Timely Administer Ordered Antibiotics for Eye Infection
Penalty
Summary
A resident with intact cognition and diagnoses of cerebral palsy and elevated white blood count developed symptoms of an acute right eye infection, including redness, swelling, pain, and discharge. During a telemedicine visit, the provider ordered both oral and ophthalmic antibiotics to be started immediately due to concerns for preseptal cellulitis and conjunctivitis. The provider's orders specified that the medications should be started the same day, and nursing staff were instructed to check the emergency kit for the required eye drops and to monitor the resident for worsening symptoms. Despite these orders, the resident did not receive the prescribed oral or ophthalmic antibiotics on the day they were ordered. Medication administration records showed that both medications were not started until the following day, with missed doses documented for the initial day. Interviews with family members, the resident, and multiple staff confirmed that the medications were not administered as ordered, and the delay was not communicated to the resident or their representative. Nursing staff and leadership acknowledged that this constituted a medication error, as provider orders were not followed and the required medications were not made available or administered as directed. Facility policy required that medications be administered according to provider orders and that any medication errors be documented, assessed, and reported. However, the Director of Nursing was not aware of the error until it was identified by the surveyor, and there was inconsistency in the documentation and reporting process. The facility's medication error policy and forms did not clearly specify requirements for resident or representative notification or documentation of resident assessment following a medication error.
Failure to Follow Contact Precautions and Proper PPE Use
Penalty
Summary
Staff failed to follow standard and transmission-based precautions for a resident who was on contact precautions due to an active shingles infection affecting the right eye. The resident had a history of cerebral palsy and an elevated white blood count, and laboratory results confirmed a positive test for varicella zoster virus. Upon return from the hospital, the resident was placed on contact precautions, with a sign posted on the door indicating the need for hand hygiene and the use of gowns and gloves before entering the room. Despite these precautions, observations revealed that a hospitality aide entered the resident's room to deliver a meal tray without performing hand hygiene or donning the required personal protective equipment (PPE) as indicated by the signage. The aide was unaware of the reason for the contact precautions and could not articulate the need for PPE. Additionally, the PPE cart, which should have been placed outside the resident's room for easy access and to prevent contamination, was instead located inside the room, contrary to best practices and the facility's own infection control expectations. Interviews with staff, including a licensed practical nurse, a nursing assistant, the assistant director of nursing (who also served as the infection control nurse), and the director of nursing, confirmed inconsistent understanding and implementation of infection control protocols. Staff acknowledged the resident was on contact precautions and that hand hygiene and PPE use were required, but the PPE cart was not properly positioned, and staff did not consistently follow hand hygiene or PPE protocols. Facility policies outlined the need for standard and transmission-based precautions, but did not specify PPE cart placement, contributing to the observed deficiencies.
Resident Elopement Due to Inadequate Supervision and Unlocked Door
Penalty
Summary
The facility failed to maintain adequate supervision and safety measures for a resident identified as an elopement risk, leading to the resident leaving the facility unsupervised. The resident, who had severe cognitive impairment and was recently admitted, expressed a desire to go home and was not accepting of the facility placement. Despite being identified as at risk for elopement, no interventions were implemented to prevent the resident from leaving the facility unattended. On the night of the incident, the resident exited the building through an unlocked door to a courtyard without staff awareness. The resident was found outside in the early morning hours, suffering from hypothermia and minor injuries. The staff, including the LPN and nursing assistant on duty, were not aware of the resident's elopement risk and did not provide the necessary supervision or assistance. The facility's policy on elopement and wandering residents was not effectively communicated or implemented, contributing to the incident. Interviews with staff revealed a lack of communication and awareness regarding the resident's risks and needs. The interdisciplinary team did not effectively communicate or develop appropriate interventions to address the resident's elopement risk. The courtyard door was not equipped with a wanderguard system and was left unlocked, allowing the resident to leave the facility unsupervised.
Removal Plan
- The facility locked the courtyard doors.
- Placed all residents on checks until all residents were re-assessed for elopement risk.
- Residents at risk for elopement were placed on checks until individualized interventions were developed and implemented.
- Reviewed all resident care plans.
- Revised the elopement policy.
- Re-educated all staff on the elopement policy and on risk factors to watch for.
- Upon R1's hospital return, the facility re-assessed R1 for elopement and fall risks and implemented interventions to mitigate the risks.
Inadequate Hydration and Accessibility of Water for Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident with severe cognitive impairment, who was independent with eating and drinking but required extensive assistance for mobility, transfers, and toileting. The resident's care plan indicated that refreshments should be provided in the afternoon and that the resident could drink water without assistance if it was within reach. However, observations revealed that the resident's water pitcher was consistently placed out of reach, across the room from the bed, and not on a bedside table as required. Interviews with staff confirmed that the resident could not reach the water pitcher while in bed, and there was confusion among staff regarding the policy for refilling water pitchers. Despite the facility's policy stating that water pitchers should be placed within easy reach of residents and refilled each shift, the resident's water pitcher was often not accessible. Staff interviews indicated a lack of awareness or adherence to this policy, with some staff unsure of the procedures for refilling water pitchers. The director of nursing confirmed the existence of a policy requiring fresh water within reach, but observations showed that the resident's water pitcher was not consistently placed within reach, contributing to the resident's complaints of dry mouth and thirst.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to implement appropriate interventions to protect residents from sexual abuse by a resident with a known history of inappropriate sexual behavior. This resident, who had been admitted from another skilled facility, was observed inappropriately touching another resident in the day room. Despite the resident's history of sexual advances towards women, which was documented in physician notes and reported by family members, the facility did not have adequate measures in place to prevent such incidents. The resident's care plan, initiated after previous incidents, included measures such as constant supervision during recreation programs and 15-minute checks. However, these interventions were not effectively implemented or documented. Staff interviews revealed that the 15-minute checks were deemed inadequate, and there was a lack of communication regarding the resident's behaviors and necessary precautions. The facility's documentation was insufficient, failing to record specific incidents and the resident's whereabouts accurately. The facility's abuse policy did not adequately address the protection of residents from abuse, and staff were not informed or trained to monitor the resident effectively. The Director of Nursing was unaware of the resident's history and the severity of the incidents until after they occurred. This lack of awareness and inadequate documentation contributed to the facility's failure to protect residents from potential harm.
Removal Plan
- The facility reviewed and updated their abuse policy and procedure pertaining to resident-to-resident sexual abuse
- R1's care plan was updated with 1:1 to prevent him from having contact with vulnerable females related to his sexual inappropriate touching.
- R1 will have a video monitor on.
- R1 is not to be left by any female residents.
- The facility provided education to all facility staff on the policy and on implementation of individualized care plan and protection measures.
- The facility completed trauma informed care assessments and care plan updated on the residents affected by R1's behaviors.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report incidents of inappropriate and unwanted touching, as well as allegations of sexual abuse, to the facility administrator and the State Agency for six residents. The incidents involved a resident, R1, who was observed by a nursing assistant (NA-A) with his hand under another resident's shirt, performing inappropriate actions. Despite immediate intervention by staff, the incident was not reported to the State Agency within the required timeframe. The Assistant Director of Nursing (ADON) was informed but did not have the authority to report to the State Agency, and the Director of Nursing (DON) initially deemed the incident non-reportable. Further interviews revealed that R1 had a history of inappropriate sexual behaviors towards other residents, including R3, R4, and R6. These incidents were either not documented or not reported to supervisors, as some staff perceived them as harmless. R3 recounted uncomfortable encounters with R1, including attempts to hold her hand and inappropriate gestures. Staff interventions were noted, but the lack of documentation and timely reporting contributed to the deficiency. The facility's policy required immediate reporting of abuse allegations, defined as within two hours for serious incidents. However, the DON was unaware of R1's background and did not initiate a report or investigation promptly. The social worker eventually reported the incident to the State Agency and law enforcement after consulting with corporate, highlighting a breakdown in communication and adherence to reporting protocols within the facility.
Failure to Ensure Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during personal care and wound care for two residents. One resident, diagnosed with dementia, traumatic brain injury, and weakness, required substantial assistance with dressing and grooming. During an observation, a nursing assistant (NA) did not change gloves or perform hand hygiene after providing incontinent care and before assisting the resident with other activities, such as sitting up in bed and moving to a wheelchair. The NA only used hand sanitizer after pushing the resident to the dining room, which was confirmed during an interview with the NA. Another resident, diagnosed with malignant neoplasm of the pancreas and adult failure to thrive, had a stage two pressure injury on the coccyx. During wound care, a licensed practical nurse (LPN) and a trained medication aide (TMA) failed to perform hand hygiene at multiple critical points, including after removing soiled dressings, before applying new gloves, and after scratching the resident's back. The LPN and TMA did not follow the facility's hand hygiene policy, which was confirmed during an interview with the LPN. The facility's policy required hand hygiene immediately before and after resident contact, after contact with blood or body fluids, and after glove removal.
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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