Trinity Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington, Minnesota.
- Location
- 905 Elm Street, Farmington, Minnesota 55024
- CMS Provider Number
- 245250
- Inspections on file
- 20
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Trinity Care Center during CMS and state inspections, most recent first.
The facility failed to notify the provider of a significant orthostatic BP drop for one resident and failed to notify the provider after two blood glucose readings over 400 mg/dL for another resident. One resident had intact cognition, antipsychotic use, and an order for monthly orthostatic BP checks, but the EMR showed a systolic drop from lying to standing without provider notification. Another resident with type 1 DM and severe cognitive impairment had orders to update the provider for BG >400 mg/dL, yet EMR review showed readings of 498 mg/dL and 449 mg/dL with no documented provider notification.
The facility failed to complete and transmit a required DRNA MDS for a resident who was discharged home with family and home health services. The census and progress note showed the resident’s status changed to STOP BILLING and the discharge occurred, but the MDS record showed no transmitted discharge assessment. The ADON/MDS coordinator stated the discharge MDS had been missed and that he sometimes delayed submission to ensure the resident was not readmitted, then may have forgotten to complete it.
A resident with moderate cognitive impairment and a progressive neurologic condition had conflicting mobility documentation, including care plan and Kardex entries showing both non-ambulatory status and an active ambulation program. Staff interviews and a progress note showed the resident had stopped ambulating with nursing staff and the restorative program was no longer active, yet the restorative care plan still listed ambulation tasks and had not been updated to reflect the change in status.
A resident with multiple sclerosis and osteoporosis, requiring substantial assistance for transfers, was injured when a nursing assistant used the wrong size sling and failed to secure safety straps during a stand lift transfer. This improper use of equipment led to the resident falling, sustaining a head laceration and mild concussion.
The facility failed to secure medications in two observed medication carts, which were left unattended and unlocked near resident areas. A nurse and a medication aid acknowledged responsibility for the carts and confirmed they should be locked to prevent unauthorized access. The DON and facility policy both emphasize the importance of locking medication carts when not in use.
During a COVID-19 outbreak, a facility failed to ensure proper PPE practices, particularly on the Chateau Unit. Despite CDC guidance and facility policy requiring masks, a trained medication aide was observed repeatedly wearing a mask improperly while performing duties. Interviews with staff confirmed the expectation to wear masks at all times, but the aide admitted to non-compliance due to discomfort. The director of nursing verified the expectation for proper mask use, highlighting a breach in PPE protocol.
The facility did not offer or administer the PCV20 vaccine to five eligible residents, despite their medical conditions and previous vaccinations. Interviews revealed that residents and their representatives were not offered the additional vaccination, although they were willing to receive it. The nurse manager cited difficulties in obtaining a standing house order from the medical director, leading to delays in vaccination, contrary to the facility's policy to follow CDC guidance.
A resident with severe cognitive impairment and dependent on staff for all ADLs, including oral care, did not receive adequate oral hygiene. Despite the care plan requiring oral care twice daily, the resident received it only seven times over several weeks. The family member reported the lack of oral care, and staff confirmed it was not part of the typical morning routine, contrary to facility policy.
A resident with severe cognitive impairment and on Eliquis, a blood thinner, had unmonitored bruising and scabbing on the left shin. Despite care plan instructions to monitor for side effects, the facility's records lacked documentation of these skin alterations. Staff noticed the condition but did not report or document it, and the nurse manager was unaware of the issue. The facility's policy on non-pressure skin concerns was not provided.
A resident with severe cognitive impairment and dependent on staff for all ADLs did not receive routine ROM exercises as per their care plan. Observations and interviews confirmed that nursing staff failed to perform and document ROM exercises, despite the resident having stiff and contracted legs. The facility's policy required ROM exercises to maintain joint mobility.
A facility failed to ensure the proper cleaning of a CPAP machine for a resident, leading to potential risks of respiratory infection. The resident's CPAP machine was observed with a buildup of dust and a white substance, indicating a lack of daily cleaning as required by the manufacturer's guidelines. Nursing staff confirmed that only weekly cleanings were scheduled, and the nurse manager acknowledged the oversight, stating that daily cleaning should have been performed.
A resident with cognitive impairment and fall risk fell from a bed that was not in the lowest position, resulting in fractures. The care plan required a low bed and floor mat, but these were not consistently followed. Staff provided conflicting accounts of the resident's ability to use the bed remote and the presence of the floor mat.
Failure to Notify Provider of Orthostatic BP Drop and Critical Hyperglycemia
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident with orthostatic hypotension. R5’s quarterly MDS showed intact cognition, antipsychotic use, and substantial to maximum assistance with ADLs. R5 had an order for monthly orthostatic blood pressure monitoring because of antipsychotic use, and the 4/18/26 vital signs record showed a blood pressure of 122/72 lying, 118/71 sitting, and 101/62 standing, reflecting a systolic drop greater than 20 mmHg from lying to standing. The EMR did not show that the physician was notified of this orthostatic blood pressure drop. During interviews, RN-D and RN-C stated staff should notify the provider for a 20-point orthostatic drop, and RN-C stated the 4/18/26 drop had not been reported. The facility also failed to notify the physician after two hyperglycemic blood glucose readings greater than 400 mg/dL for another resident. R68’s quarterly MDS showed severely impaired cognition and substantial to maximum assistance with ADLs, and diagnoses included type 1 diabetes mellitus with other diabetic neurological complications and other frontotemporal neurocognitive disorder. R68 had an order for accuchecks three times daily with meals and to update the provider if blood sugar was less than 90 mg/dL or greater than 400 mg/dL. The EMR showed blood glucose readings of 498.0 mg/dL on 3/26/26 and 449.0 mg/dL on 4/20/26, but there was no evidence the provider was notified for either reading. RN-B and RN-A stated staff should notify the provider for elevated blood sugar readings over 400 mg/dL, and RN-A could not locate documentation of provider notification for the two events.
Missed DRNA MDS for a Resident Discharged Home
Penalty
Summary
The facility failed to ensure a discharge return not anticipated (DRNA) MDS was completed and transmitted to CMS for one resident, R23, who was discharged home with family and was to receive home health services. R23’s census listing showed the resident’s status changed to STOP BILLING on 1/6/26, and a progress note the same day documented the discharge home. Review of the MDS listing dated 12/16/25 showed no record that the required DRNA MDS had been transmitted for the discharge. During interview, the ADON/MDS coordinator stated the discharge MDS had been missed and explained that he sometimes waited a few days to submit a discharge MDS to make sure the resident was not readmitted, and then may have forgotten to complete the assessment. The facility’s MDS 3.0 Assessment policy dated 8/20/24 stated that a discharge assessment should be completed within 14 days of discharge.
Care Plan Not Updated for Resident’s Change in Ambulation Status
Penalty
Summary
The facility failed to revise R42’s care plan to reflect changes in ambulation status. R42’s quarterly MDS indicated moderate cognitive impairment, partial to substantial assistance with ADLs, and that walking was not attempted during the assessment period. R42 had a diagnosis of a progressive neurologic condition and was not on a ROM or walking program at that time. R42’s care plan history showed conflicting and outdated mobility information. One care plan for risk for decline in ambulation stated R42 would ambulate 10-20 feet three times per week with a gait belt, front wheeled walker, and assist of 2 with a wheelchair following. A later mobility care plan stated R42 was non-ambulatory and required ROM exercises twice daily, while the self-care deficit care plan indicated transfer with 2 assist and sit-to-stand mobility. The Kardex also listed R42 as non-ambulatory with ROM twice daily and assist of 2 for transfers with a sit-to-stand lift, but it still included an ambulation task to encourage and assist walking 10-20 feet with a front wheeled walker, gait belt, and assist of 2 three times per week. Documentation and interviews showed R42 had stopped participating in ambulation with nursing staff and the restorative program was no longer active, yet the ambulation task remained in the charting system. A progress note stated R42 preferred not to ambulate with staff and would remain non-ambulatory going forward per her preference. Staff interviews confirmed R42 had been refusing ambulation since late December 2025 or January 2026, that the restorative nurse realized the ambulation task was still active, and that the task should have been removed when the program was discontinued. The restorative nurse and RN confirmed the restorative care plan still reflected an ambulation program even though R42 was not currently participating.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nursing assistant failed to provide a safe transfer for a resident who required the use of a stand lift. The resident, who had diagnoses including multiple sclerosis and osteoporosis, was cognitively intact and required substantial assistance with transfers. The care plan specified the use of a medium-sized sling with the stand lift and assistance from one staff member. However, the nursing assistant used a large sling instead of the prescribed medium size, did not secure the waist or calf straps, and failed to ensure all loops were properly attached to the lift. During the transfer, after assisting the resident with toileting and perineal care, the nursing assistant attempted to move the resident out of the bathroom using the stand lift. At this point, one of the sling loops detached from the lift, causing the resident to fall and strike her head on the floor. The resident sustained a laceration to the back of her head, resulting in active bleeding, and was subsequently diagnosed with a mild concussion and required stitches. Interviews confirmed that the nursing assistant did not follow the care plan or facility policy regarding the use of mechanical lifts, specifically by using the incorrect sling size and not securing the required safety straps. The incident was attributed to improper use of the lift and harness, as verified by staff and a representative from the lift manufacturer. The resident's transfer status was later changed following reassessment, but the deficiency was directly related to the failure to follow established procedures for safe transfers.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure the secure storage of medications in two of the six medication carts observed. On two separate occasions, surveyors observed unattended and unlocked medication carts outside nursing stations in units named The Cottages and The Chateau. These carts were located near areas with several residents present, posing a risk of unauthorized access to medications. During the first observation, a registered nurse (RN-A) acknowledged responsibility for the unlocked cart and confirmed that medication carts should be locked when unattended to prevent access by unauthorized staff, residents, and visitors. In the second instance, a trained medication aid (TMA-A) verified responsibility for another unlocked and unattended medication cart. TMA-A confirmed that the cart should be locked to prevent medication errors and unauthorized access. The director of nursing (DON) stated that medication carts are expected to be locked when unattended to prevent access by unlicensed personnel or residents. The facility's policy on medication administration, dated 8/7/23, requires that medication carts be stored in designated areas and locked when not in use, with the nurse or TMA retaining the key while on duty.
Improper PPE Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) practices during a COVID-19 outbreak, specifically on the Chateau Unit. The Centers for Disease Control and Prevention (CDC) guidance requires source control measures, such as wearing masks, during an outbreak. Despite signage at the facility entrance indicating a COVID outbreak and the requirement for masking, observations revealed non-compliance with these measures. A trained medication aide (TMA-A) was repeatedly observed with a surgical mask improperly worn, either below the nose or chin, while performing duties such as obtaining and administering medications and moving through resident areas. This occurred despite the facility's policy and the infection control preventionist's statement that all staff were required to wear surgical masks at all times, with additional PPE required when entering COVID-positive rooms. Interviews with various staff members, including nursing assistants, housekeepers, and nurses, confirmed the understanding that masks should be worn at all times in resident areas to prevent the spread of infection. However, TMA-A admitted to not wearing the mask properly due to discomfort, acknowledging the vulnerability of the residents. The director of nursing verified the expectation for all staff to wear masks appropriately, highlighting a breach in PPE protocol as identified in the facility's policy.
Failure to Offer Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations, as outlined by the CDC, were offered and/or provided to five residents reviewed for immunizations. These residents, who had various medical conditions such as impaired cognition, kidney disease, diabetes, dementia, heart failure, heart dysrhythmia, and hypertension, had previously received the PPSV23 and PCV13 vaccines. However, the facility did not offer or administer the PCV20 vaccine to these residents prior to the survey entrance, despite their eligibility for it. Interviews with resident representatives and the residents themselves revealed that they were not offered the additional pneumococcal vaccination, and they expressed willingness to receive it if it had been offered. The infection preventionist indicated that the nurse manager was responsible for tracking and offering pneumococcal vaccinations. The nurse manager acknowledged that the residents were eligible for the PCV20 dose but cited difficulties in obtaining a standing house order from the medical director, which led to delays in offering and administering the vaccination. The facility's Resident Immunization policy stated that pneumococcal vaccines would be offered according to current CDC guidance, which was not adhered to in this case.
Failure to Provide Adequate Oral Care to Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral care to a resident with severe cognitive impairment who was dependent on staff for all activities of daily living, including oral hygiene. The resident, who was unable to take any food or fluids by mouth and required a gastrostomy tube for nutrition, was observed to have received oral care only seven times over a period of several weeks. Despite the care plan specifying the need for oral care twice daily, the nursing assistants and registered nurse involved in the resident's care did not perform oral care during their morning routine, as confirmed by their statements and observations. The resident's family member, who spent significant time with the resident, reported that oral care was not being performed as required, despite education provided by speech therapy to the nursing staff. The facility's policy on oral hygiene, which was revised in May 2023, indicated that all residents should receive oral care as defined by their care plan to promote cleanliness and prevent oral infection. However, the staff's failure to adhere to this policy and the care plan resulted in the deficiency noted in the report.
Failure to Monitor Skin Alterations in Resident on Blood Thinner
Penalty
Summary
The facility failed to monitor bruising and scabbing on a resident's left shin who was on a blood thinner. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was on Eliquis, a blood-thinning medication. Despite the care plan instructing staff to monitor for potential side effects of Eliquis, including excessive bruising, the resident's electronic medical record lacked documentation of any wounds being monitored. Observations and interviews revealed that the resident had multiple bruises and scabs on the left shin, which were not documented or addressed in the facility's records. Interviews with staff indicated that the bruising and scabbing had been noticed by both a nursing assistant and a licensed practical nurse, who attributed the condition to the resident's tendency to run his shins into objects and pick at his skin. However, these observations were not reported or documented as required by the facility's procedures. The nurse manager confirmed that she was unaware of the skin alterations and emphasized the importance of monitoring such conditions. The facility's policy on non-pressure skin concerns was requested but not provided, indicating a potential gap in policy adherence or availability.
Failure to Provide Routine ROM Exercises
Penalty
Summary
The facility failed to provide routine range of motion (ROM) exercises for a resident with severe cognitive impairment who was dependent on staff for all activities of daily living (ADLs). The resident's care plan, dated July 22, 2022, specified that ROM should be performed daily during dressing. However, observations and documentation from July 1, 2024, to July 23, 2024, showed no evidence of nursing assistants providing ROM to the resident. Interviews with the resident's family member, who spent extensive time with the resident, confirmed that no ROM exercises were observed being performed by the nursing staff. Further observations on July 24, 2024, revealed that during routine morning care and dressing, nursing assistants and a registered nurse did not perform ROM exercises on the resident, despite the resident having stiff and contracted legs. The registered nurse and restorative nurse confirmed that staff were instructed to provide ROM during dressing and should document it under Observations by Resident. The facility's policy on ROM, revised on November 8, 2013, indicated that the restorative ROM program was intended to maintain and improve joint mobility, with exercises to be repeated 10 times per joint when care planned.
Failure to Properly Clean CPAP Machine
Penalty
Summary
The facility failed to ensure proper cleaning of a non-invasive ventilation machine for a resident using a CPAP machine, which could lead to complications such as respiratory infections. The ResMed AirFit F20 Full Face Mask User Guide and the ResMed AirSense 10 User Guide provided specific cleaning instructions, including daily cleaning of the mask and weekly cleaning of the machine and its components. However, the facility's records and observations indicated that the CPAP machine was not cleaned daily as required. The resident, who had intact cognition and required assistance with personal care, reported that the CPAP machine appeared unclean, and observations confirmed the presence of a white substance and dust on the machine and mask. Interviews with nursing staff revealed that the CPAP machine was scheduled for weekly cleanings, but daily cleanings were not performed. A registered nurse acknowledged the mask appeared dirty and confirmed that daily cleaning was not part of the routine. The nurse manager admitted that the CPAP machine should be wiped down daily and expressed that the buildup of grime was unacceptable. The facility's policy on cleaning and disinfecting resident care equipment emphasized that respiratory therapy equipment should remain free from microorganisms, highlighting the deficiency in maintaining the CPAP machine's cleanliness.
Failure to Implement Fall Precautions Leads to Resident Injury
Penalty
Summary
The facility failed to implement care-planned fall precautions for a resident who was moderately cognitively impaired and dependent on staff for activities of daily living and transfers. The resident's care plan included interventions such as a low bed with a bedside mat due to their risk for falls. However, on the night of the incident, the resident was found on the floor with injuries, including a fractured humerus and tibia, after falling from a bed that was not in the lowest position, and without a floor mat in place. Interviews and document reviews revealed that the nursing assistant responsible for the resident's care had raised the bed to a working height to check the resident's incontinent brief and forgot to lower it back down. Additionally, there was confusion among staff about whether the resident could use the bed remote to adjust the bed height, with some staff believing the resident could and others stating they could not. The absence of the floor mat was also noted, with staff providing conflicting accounts of its presence in the room. The resident had been experiencing increased hallucinations and agitation, which contributed to their fall risk. Despite being care-planned for a low bed and floor mat, these interventions were not consistently followed, leading to the resident's fall and subsequent injuries. The facility's policy on fall prevention and management emphasized the importance of environmental rounds to minimize accidents, but these measures were not effectively implemented in this case.
Removal Plan
- Nursing leadership reeducated all staff.
- Education included expectations for rounding and lowering beds.
- NA-A was educated by the DON and provided a written warning.
- Bed height and floor mat audits were conducted.
- An interdisciplinary team meeting was conducted to review R1's fall.
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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