Valley View Manor Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lamberton, Minnesota.
- Location
- 200 East Ninth Avenue, Lamberton, Minnesota 56152
- CMS Provider Number
- 245378
- Inspections on file
- 35
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 13 (2 serious)
Citation history
Health deficiencies cited at Valley View Manor Hcc during CMS and state inspections, most recent first.
A facility failed to implement and communicate individualized elopement-prevention interventions for three cognitively impaired residents identified as elopement risks. One resident with dementia and suspected Lewy Body Disease repeatedly removed a Wanderguard and continued to wander and make exit-seeking comments, yet no elopement-focused care plan, comprehensive reassessment, or increased supervision was put in place, and hourly safety checks were inconsistently documented. This resident later left the building unsupervised during the night after staff redirected her toward her room but did not verify her return. Two other residents with dementia, one with a history of elopement and one who verbalized a desire to go home and stayed near exits, were assessed as elopement risks, but their care plans and Kardexes lacked clear elopement interventions, triggers, or consistent use of wander alarms, and staff interviews confirmed limited awareness of their elopement status and absence of specific preventive measures.
A resident with dementia, depression, moderate cognitive impairment, delusions/hallucinations, a history of falls, and daily use of a wander alarm was assessed as being at risk for elopement and had a wanderguard applied, but no elopement-focused care plan with specific interventions was initiated at that time. The resident later removed and refused the wanderguard, and staff were not aware of any increased supervision or alternative interventions in the care plan. The resident, known to wander the halls and express a desire to leave, was discovered missing shortly after being given food in the early morning, and was found outside the facility and refused to return. The DON acknowledged that a wandering/elopement care plan should have been started when the elopement risk was first identified, but it was not developed until after the elopement incident, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
A resident with diabetes who required blood glucose monitoring and insulin administration was cared for by nursing staff who had not received training or demonstrated competency in using a continuous glucose monitoring device. Staff were unfamiliar with the device's instructions, and there was no facility policy or process in place to guide its use.
Dietary staff lacked proper training and competency in monitoring dish machine temperatures, resulting in repeated failures to achieve required sanitation levels. Staff were unclear about which gauges to use, did not consistently document or report low temperatures, and competency records were incomplete or missing. The facility's policies for temperature monitoring and reporting were not consistently followed.
The facility failed to ensure dietary staff consistently monitored and documented dish machine temperatures, resulting in repeated failures to reach required sanitizing levels and lack of staff competency documentation. Additionally, a resident using a continuous glucose monitoring device was not assessed for knowledge or competency, and nursing staff had not received training or completed competencies on the device, despite facility expectations for diabetic management and equipment use.
A resident using a continuous blood glucose monitoring device was not assessed for competency or provided guidance on its use, including when to perform manual blood glucose checks. Facility staff had not received training or competency checks on the device, and there was no policy or process in place to ensure proper use and understanding of the device's functions.
A resident with moderate cognitive impairment and multiple medical conditions was prescribed several psychotropic medications without documentation of target behaviors or symptoms, and there was no monitoring for medication side effects. Staff reported the resident experienced hallucinations, but the care plan lacked individualized non-pharmacological interventions and did not address how to respond to these symptoms. The facility's reliance on a standardized care plan library contributed to the absence of personalized interventions.
A resident with documented PTSD, anxiety, and depression did not have PTSD identified on the admission MDS assessment, despite this diagnosis being present in preadmission screening and medical records. The omission was confirmed by the ADON, who noted that the admission MDS had been completed by contracted staff, and that accurate MDS coding is required to ensure appropriate care planning.
A resident with atrial fibrillation and a hip fracture, who was prescribed Eliquis, did not have a care plan that included individualized interventions or monitoring for side effects related to anticoagulant therapy. Nursing staff confirmed the absence of documentation and monitoring measures in the care plan, despite facility policy requiring such details.
A resident with multiple chronic conditions experienced a fall resulting in a fractured ankle, which led to a change in transfer needs from one-person assist to requiring a Hoyer lift with two staff. Despite this significant change, the care plan was not updated to reflect the new transfer requirements, as confirmed by staff interviews and observation.
A resident dependent on staff for all care and receiving hospice services did not have an integrated care plan specifying which services were to be provided by hospice and which by facility staff. The care plan and staff Kardex lacked mention of hospice involvement, and staff interviews revealed inconsistent communication and documentation practices between the facility and hospice provider.
A housekeeping aide did not receive the required second step of the two-step TB skin test at the appropriate interval after hire. Both TSTs were administered on the same day, contrary to guidelines that require the second test 1–3 weeks after the first. The aide was not informed of the need for a second test, and facility documentation did not show proper completion of the TB screening process.
A resident with a history of neuromuscular bladder dysfunction and an indwelling catheter was prescribed ciprofloxacin for a UTI and prostatitis. The facility did not complete or document the required 48-72 hour antibiotic time-out to assess the appropriateness of continued therapy, as outlined in CDC guidelines and facility policy.
A resident with dementia, anxiety, and diabetes, who had previously received multiple pneumococcal vaccines, consented to an additional dose but did not receive it as planned. The vaccine administration was held without notifying the resident's POA or reassessing the resident's suitability for vaccination, contrary to facility policy and CDC recommendations.
A resident with cognitive decline and a history of elopement was inadequately supervised, leading to an elopement incident. The facility failed to update the resident's care plan with specific interventions for supervision, and staff were unclear about supervision responsibilities. Despite the resident's increased risk, the care plan did not reflect necessary precautions, contributing to the resident's unsupervised departure from the facility.
A resident reported an abuse allegation to an LPN, who informed the DON. The DON initially dismissed the claim as a hallucination and delayed reporting it to the administrator and SA. The incident was reported beyond the required two-hour timeframe, violating the facility's policy on immediate reporting of abuse.
The facility failed to implement enhanced barrier precautions (EBP) and ensure proper use of PPE for two residents with wounds and indwelling catheters. Staff inconsistently applied EBP, and the director of nursing was unaware of new requirements. Additionally, the facility did not effectively monitor, track, or trend infections, with incomplete surveillance documentation and no regular review of infection data. The facility's QAPI meeting minutes lacked infection tracking, and the administrator confirmed a lack of infection monitoring.
The facility's acting infection preventionist (IP), also the director of nursing (DON), had not completed specialized training in infection prevention and control, potentially affecting all 21 residents. The DON was assigned as the IP designee after the assistant director of nursing (ADON) resigned abruptly. The facility administrator confirmed the absence of a certified IP and was unable to provide records for two residents' COVID vaccine offerings. A policy related to the IP was requested but not provided.
A medication cart in a common area was left unattended with the electronic health record system open, exposing sensitive resident information. This involved 10 residents with complex medical conditions. Staff interviews revealed expectations to lock screens, but breaches had occurred. The director of nursing and administrator emphasized the importance of safeguarding information.
The facility failed to ensure that four residents were appropriately vaccinated against pneumonia upon admission, as per CDC guidelines. Despite previous vaccinations, there was no documentation that the updated PCV-15 or PCV-20 vaccines were offered or declined. Interviews revealed reliance on a local clinic for routine vaccines, but PCV vaccines were not offered due to in-house standing orders, and consent or declination was not obtained. The facility's policy to assess and document vaccination status was not followed, leading to the deficiency.
The facility failed to offer the COVID-19 vaccine to two residents upon admission, as required by policy. Both residents were cognitively intact and had no record of being offered the vaccine or declining it. The DON could not confirm if the vaccine was administered and lacked declination forms. The facility's policy required education and documentation of vaccine status, overseen by the Infection Preventionist.
The facility failed to ensure appropriate infection control techniques during a meal service, with Cook-A repeatedly using the same gloves to handle various items, including food, utensils, and tray cards, without changing gloves or performing hand hygiene, potentially affecting all 23 residents.
The facility failed to follow CDC infection control guidelines during an Influenza A outbreak, resulting in 9 out of 23 residents being affected. Staff did not use PPE properly, perform adequate hand hygiene, or report illnesses promptly. Observations showed staff entering and exiting isolation rooms without changing masks or using PPE, and symptomatic staff continued to work without testing.
The facility failed to allocate adequate time and resources for the infection preventionist (IP) to manage the infection control program, resulting in an Influenza A outbreak affecting 9 out of 23 residents. The IP, who also served as the ADON, was unable to implement necessary infection control practices due to insufficient time and unclear guidance on required hours.
The facility failed to ensure all dietary staff had adequate training on equipment use, food safety, and sanitation, leading to untrained staff, including a TMA and nursing assistants, working in the kitchen. The dietary manager also neglected proper infection control practices during an Influenza-A outbreak.
The facility failed to ensure residents had access to their personal funds upon request. A resident reported limited access to her money, and staff confirmed that funds could only be accessed during business hours. The administrator believed there was a cash box for after-hours access, but staff were unaware of it and had difficulty locating it. The ADON confirmed that residents only had access to their funds when the administrator or business office manager were present.
The facility failed to provide timely notifications for a resident who experienced multiple falls, resulting in injuries. Despite the facility's policy requiring immediate notification of the DON, medical provider, and family, there was no documentation of such notifications for two of the three falls. The family expressed concerns about the lack of communication during a care conference.
The facility failed to provide adequate OT and PT services for two residents, leading to inconsistent therapy sessions and lack of progress. Despite treatment plans indicating frequent therapy, residents received limited sessions, and there was no evaluation of the therapy's effectiveness. Interviews revealed concerns about the facility's inadequate therapy services and the absence of a full-time PTA.
Failure to Implement and Communicate Elopement Interventions for Identified At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate interventions and supervision to prevent elopement for three residents who had been identified as elopement risks. One resident with dementia and suspected Lewy Body Disease was determined to be at risk for elopement on 3/26/26, and a Wanderguard device was applied as an intervention. Progress notes show that between 3/28/26 and 3/31/26 this resident repeatedly removed or cut off the Wanderguard, refused reapplication, and would not allow staff to check for the device. Despite this, the facility did not complete a comprehensive assessment to determine individualized interventions or an appropriate level of supervision after the device was removed and refused. The resident’s care plan from 3/26/26 through 4/13/26 did not include an elopement-focused care plan, and staff, including the SSD, were not consistently aware of the resident’s elopement risk when interpreting exit-seeking comments. The same resident exhibited ongoing confusion, hallucinations, wandering, and exit-seeking behaviors in the days leading up to the elopement. Progress notes document wandering in hallways, following staff, nervousness, hallucinations of groundhogs, and threatening statements, as well as comments about wanting to leave for a couple of weeks and feeling that staff would not let her go. The resident was moved to a room closer to the nursing station on 4/10/26, but this move was not based on her elopement risk. Hourly safety checks, which had been initiated on 3/23/26, were not consistently documented from 4/3/26 through 4/13/26, with multiple days and shifts showing no recorded checks. On 4/13/26, during the night shift, the resident was observed wandering, given food, and verbally redirected toward her room, but staff did not verify that she actually returned to the room before attending to other tasks. Shortly thereafter, staff discovered she was missing, and she was later found several blocks away after having left the building unsupervised. The facility also failed to implement and communicate individualized elopement interventions for two additional residents identified as elopement risks. One resident with dementia had an elopement evaluation on 3/27/26 and again on 4/14/26 indicating risk due to verbally expressing a desire to go home and staying near exit doors. However, the care plan labeled this resident as low risk and did not include individualized interventions or triggers to mitigate elopement, and the Kardex did not identify the resident as an elopement risk. Staff interviews confirmed that this resident could self-propel in a wheelchair, operate the handicap door button, and made exit-seeking comments when his wife left, yet no specific elopement interventions such as alarms or enhanced monitoring were in place. Another resident with dementia and Parkinson’s disease was identified on admission as an elopement risk due to a history of elopement from a previous facility and poor safety awareness. An elopement evaluation on 3/31/26 documented this risk and indicated use of a wander/elopement alarm, but there was no evidence of Wanderguard placement until 4/15/26, and the care plan only directed staff to engage the resident in purposeful activity without additional elopement-prevention measures. Staff acknowledged that no other interventions had been implemented to prevent this resident from leaving unsupervised prior to the later application of a Wanderguard. The facility’s own policies on Safety and Supervision of Residents and Wander Management required individualized, resident-centered assessments, care planning, communication of interventions to staff, and consistent implementation and monitoring of those interventions. Despite these policies, the records and interviews show that for all three residents, the facility did not ensure that elopement risk assessments were translated into comprehensive, individualized care plans with clear interventions and supervision levels. Staff were often unaware of residents’ elopement risk status, did not consistently perform or document required safety checks, and did not adjust interventions when residents refused or removed Wanderguard devices. These actions and inactions culminated in an elopement incident for one resident and left the other two residents at continued risk without fully implemented elopement-prevention measures.
Failure to Develop Timely Elopement Care Plan for At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered elopement care plan with measurable objectives and interventions for a resident identified as being at risk for elopement. The resident had diagnoses of unspecified dementia without behavioral disturbance and depression, with a quarterly MDS indicating moderate cognitive impairment, delusions/hallucinations, independence with transfers and ambulation, a history of two or more falls since admission, and daily use of a wander/elopement alarm. An elopement evaluation completed on 3/26/26 identified the resident as at risk for elopement due to wandering behaviors likely to affect the safety or wellbeing of others, and a personal safety device (wanderguard) was applied. Despite this assessment and intervention, no elopement-focused care plan with specific interventions was initiated between 3/26/26 and 4/13/26. During this period, the resident reportedly wandered in the hallways during the day and made comments about wanting to leave the facility. A nursing assistant stated the resident had a wanderguard placed a few weeks before the elopement, removed the bracelet on 3/29/26, and refused to have another applied, and the assistant was not aware of any increased supervision or other interventions in the care plan after the device was removed. On 4/13/26, after being brought a sandwich at 4:55 a.m., the resident was found to be missing from the room at 5:03 a.m.; staff searched the facility and grounds, notified management, and located the resident at 5:28 a.m., at which time the resident refused to return. The DON acknowledged that a wandering/elopement care plan should have been initiated when the elopement assessment was completed on 3/26/26, but the resident’s elopement care plan was not developed and initiated until 4/15/26, contrary to the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives and timetables for each resident.
Failure to Ensure Staff Competency in Use of Continuous Glucose Monitoring Device
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the use of a continuous glucose monitoring device (FreeStyle Libre 3) for a resident with diabetes. The resident required assistance with activities of daily living and had multiple diagnoses, including diabetes, heart failure, respiratory failure, and mental health conditions. The resident's care plan required blood glucose monitoring three times daily and insulin administration based on those readings. Documentation showed the resident's blood glucose levels fluctuated widely, but there was no evidence that staff had received training or demonstrated competency in using the device. Interviews with nursing staff revealed that some had prior experience with similar devices at other facilities but had not received training or completed competency assessments at this facility. Staff were unaware of the location of manufacturer instructions, and the assistant director of nursing confirmed there was no policy or process for the use of the device, nor had any training or competencies been completed. The resident reported relying on staff to interpret her blood sugar readings and was not familiar with when a manual check was needed or how device alarms functioned. The administrator acknowledged that staff should be trained and competent in the use of medical equipment for resident care.
Failure to Ensure Dietary Staff Competency in Dish Machine Temperature Monitoring
Penalty
Summary
The facility failed to ensure that dietary staff were properly trained and competent in monitoring dish machine temperatures to achieve appropriate sanitation. Observations and interviews revealed that staff were unclear about which gauges to use for monitoring wash and rinse cycles, and some staff believed there was no specific temperature requirement. The maintenance director and dietary manager confirmed confusion regarding the correct use of the gauges, and it was found that the right gauge was not functioning as expected, while the left gauge was used for both wash and rinse cycles. The Ecolab data plate and operation manual specified that the wash temperature should be at least 150 degrees Fahrenheit and the rinse temperature at least 180 degrees Fahrenheit, but staff were not consistently following these guidelines. Review of dish machine temperature logs for March, April, and May showed multiple instances where the rinse temperature fell below the required 180 degrees Fahrenheit, and there were several days with missing documentation of temperature monitoring. Staff were instructed to contact the dietary manager if temperatures were not met, but interviews revealed that low rinse temperatures had not been addressed with staff. The dietary manager acknowledged that staff had been trained using an online system and in-person instruction, but admitted that staff did not always follow directions and that she had not previously intervened regarding the low temperatures. Further review of staff training and competency records indicated that dietary aides and cooks lacked documentation of competencies related to monitoring dish machine temperatures, and in some cases, there was no evidence that dietary policies had been read or reviewed. The facility's policy required staff to verify proper temperatures and machine function before use, monitor gauges throughout the cycle, and report any issues to the dietary manager, but these procedures were not consistently followed or documented.
Deficiencies in Dietary Sanitation Monitoring and Blood Glucose Device Competency
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of dish machine temperatures in the dietary department, resulting in repeated instances where the rinse cycle did not reach the required sanitizing temperature of 180 degrees Fahrenheit. Observations and interviews revealed that staff were unclear about which gauges to use for monitoring, and there was confusion regarding the correct temperature requirements. Review of temperature logs for March, April, and May showed multiple days where the rinse temperature fell below the required level, and there were numerous instances of missing documentation. Staff did not consistently follow the policy to notify the dietary manager when temperatures were inadequate, and the dietary manager confirmed that she had not addressed these issues with staff. Additionally, competency documentation for dietary aides and cooks was lacking, with no evidence that staff had been trained or deemed competent in monitoring dish machine temperatures or reviewing relevant policies. In the area of blood glucose monitoring, a resident using a continuous glucose monitoring device (Freestyle Libre 3) was not assessed for knowledge or competency in using the device, including when to perform manual blood glucose checks or how to respond to device alarms. The resident reported that nursing staff relied on her to report her blood sugar readings and provided interventions such as snacks or juice for low readings, but she was not familiar with the device's alarm functions or manual testing procedures. Review of the resident's self-administration assessment showed no evidence of guidance or assessment regarding the use of the device. Manufacturer instructions require users to review all product instructions and complete tutorials, but this was not documented for the resident. Nursing staff, including RNs and the ADON, reported they had not received training or completed competencies on the use of the Freestyle Libre 3 device. Staff were unaware of the location of manufacturer instructions and had not been provided with a policy or process for using the device. The facility's assessment indicated that staff were to be trained and competent in diabetic management and the use of medical equipment, but there was no evidence that this had occurred for the continuous glucose monitoring device. The administrator confirmed the expectation that staff should be trained and competent in the use of any medical equipment used for resident care.
Failure to Assess Resident Competency and Staff Training for Blood Glucose Monitoring Device
Penalty
Summary
The facility failed to determine whether a resident was safe to self-monitor diabetic medication treatment results using a continuous blood glucose monitoring system (FreeStyle Libre 3). Observation and interview revealed that the resident used a sensor and handheld meter to check blood glucose levels and reported the results to nursing staff. The resident was not aware of when a manual blood glucose check would be necessary and was unfamiliar with the device's alarm functions. There was no evidence that the resident had been given guidance or assessed for knowledge on using the monitor or recognizing when to perform a manual check for accuracy. Further review showed that the resident's self-administration of medications assessment did not address the resident's competency with the device or provide any guidance. The assistant director of nursing confirmed that the facility lacked a policy or process for the use of the FreeStyle Libre 3 device and had not provided training or competency checks for nursing staff regarding its operation. Manufacturer instructions for the device require users to review all product instructions and complete tutorials, including understanding symbols that indicate when a manual blood glucose check is needed, but this was not ensured by the facility.
Failure to Identify and Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to a resident had clearly identified target behaviors or symptoms, and did not monitor for those behaviors or for adverse effects of the medications. The orders for multiple psychotropic medications, including an antipsychotic and two antidepressants, lacked documentation specifying the symptoms or behaviors they were intended to treat. Additionally, there was no evidence of monitoring for medication side effects, and the care plan did not include individualized non-pharmacological interventions or address the resident's hallucinations and delusional thoughts. Interviews with staff confirmed that while the resident experienced visual and auditory hallucinations, staff responses were limited to reassurance and reporting to nursing, without specific interventions documented in the care plan. The resident involved had a history of moderate cognitive impairment, functional limitations, and multiple medical diagnoses, including a neurological condition, stroke, heart failure, diabetes, and seizure disorder. Despite these complexities, the care plan and medication administration records did not identify target behaviors or symptoms for the psychotropic medications, nor did they outline how staff should respond to the resident's hallucinations. The facility's use of a standardized care plan library further contributed to the lack of individualized interventions, as confirmed by the assistant director of nursing. The facility's policy required comprehensive assessment and documentation of specific conditions for psychotropic medication use, which was not followed in this case.
Failure to Accurately Identify Resident Diagnosis in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified in the Minimum Data Set (MDS) assessment. Specifically, a resident with documented diagnoses of post-traumatic stress disorder (PTSD), anxiety, and depression, as indicated in the Preadmission Screening Results and medical diagnosis list, did not have PTSD identified on the admission MDS assessment. Subsequent quarterly and significant change MDS assessments did include the PTSD diagnosis. The assistant director of nursing confirmed that the admission MDS, completed by contracted staff, lacked the PTSD diagnosis, which would have triggered care planning for PTSD to ensure appropriate support. The Resident Assessment Instrument (RAI) manual requires that MDS submissions be accurate and reflect the resident's actual condition during the look-back period.
Failure to Develop Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing anticoagulant therapy and related safety precautions for a resident with atrial fibrillation and a hip fracture. The resident, who was moderately cognitively impaired, was prescribed Eliquis 2.5 mg twice daily for atrial fibrillation. Despite the ongoing use of this anticoagulant, the resident's care plan did not include individualized documentation of pharmacological and non-pharmacological interventions, nor did it address potential side effects or adverse effects associated with the medication. Interviews with nursing staff confirmed that the care plan lacked evidence of monitoring for anticoagulation therapy, such as observing for symptoms like dark stools, bruising, abnormal bleeding, or severe paleness. The assistant director of nursing also acknowledged that the care plan should have included interventions specific to anticoagulant use and its side effects. Review of facility policy indicated that care plans were required to include measurable objectives, timeframes, and ongoing assessments, but these elements were missing in the resident's care plan regarding anticoagulant therapy.
Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
The facility failed to revise the care plan for a resident following a significant change in condition. The resident, who had diagnoses including Alzheimer's disease, congestive heart failure, osteoarthritis, and diabetes mellitus, was previously assessed as having intact cognition and required extensive assistance from one staff member for transfers, toileting, and bed mobility. After experiencing increased weakness and falls, the resident was evaluated in the emergency department, where a fractured left ankle was diagnosed and splinted. Upon return to the facility, the resident became non-weight bearing and required the use of a Hoyer mechanical lift with assistance from two staff members for all transfers. Despite this change in the resident's condition and care needs, the care plan was not updated to reflect the new requirement for total assist by two staff using a mechanical lift. Observations and staff interviews confirmed that the resident's transfer method had changed due to the fracture, but the care plan continued to indicate the need for only one staff assist and a walker for ambulation. The assistant director of nursing acknowledged that the care plan had not been revised to address the resident's current needs following the injury.
Failure to Coordinate and Document Hospice Services in Care Plan
Penalty
Summary
The facility failed to develop and implement an integrated care plan that clearly coordinated and delineated the responsibilities of hospice and facility staff for a resident receiving hospice care. The resident, who was dependent on staff for all activities of daily living and had multiple diagnoses including dementia, alcohol dependence, and other chronic conditions, was receiving hospice services. However, the facility's care plan did not mention hospice involvement or specify which services were to be provided by hospice versus the facility. The direct care staff Kardex also lacked any reference to hospice services or coordination with hospice staff for tasks such as bathing. Interviews with facility staff revealed that the electronic medical record system's new care plan library limited the ability to personalize care plans, resulting in the omission of hospice information. The assistant director of nursing acknowledged that hospice was not mentioned in the care plan and that communication with hospice could be inconsistent. The hospice provider reported faxing care plans to the facility and leaving information in a binder, but was unsure how the facility handled this information. Facility policy and the hospice agreement required coordinated care planning, but this was not reflected in the resident's documentation.
Failure to Administer Second TB Test per Protocol for New Employee
Penalty
Summary
The facility failed to ensure that a housekeeping aide received appropriate tuberculosis (TB) testing in accordance with state and federal guidelines. Upon hire, the employee completed a baseline TB symptom screen and received both the first and second tuberculin skin tests (TST) on the same day, with both tests read two days later and found to be negative. However, both the Minnesota Department of Health and CDC guidelines require that if the first TST is negative, the second TST should be administered 1 to 3 weeks after the first, not on the same day. Documentation in the employee's health file indicated that the tests were not spaced appropriately, and there was no evidence that a second TST was completed at the correct interval. Interviews with the housekeeping aide revealed she was not informed that a second TST was required, and the Assistant Director of Nursing (ADON) acknowledged that the TB screening form was filled out incorrectly and that the second TST was not properly documented or administered according to policy. The facility's policy required all employees to be screened and tested for active TB prior to employment, but this process was not followed for the housekeeping aide, resulting in a failure to comply with TB control regulations.
Failure to Complete Timely Antibiotic Review
Penalty
Summary
The facility failed to complete a required review of antibiotic therapy within 48-72 hours for one of three sampled residents. According to CDC guidelines, an antibiotic time-out should be performed within this timeframe to ensure the appropriateness of continued antibiotic use by evaluating the resident's current symptoms and laboratory results. Documentation review showed that the infection control log tracked residents with potential infections and included relevant clinical information. However, for one resident who was prescribed ciprofloxacin for a urinary tract infection and prostatitis, there was no evidence of an initial comprehensive assessment or a completed antibiotic time-out in the medical record. The resident in question had a diagnosis of neuromuscular dysfunction of the bladder and an indwelling catheter, placing them at increased risk for infection. The care plan directed staff to monitor for urinary complaints and manage catheter patency. Despite these risk factors and the initiation of antibiotic therapy, the required review to assess the ongoing need for antibiotics was not documented. The assistant director of nursing confirmed that the antibiotic time-out, which should have been completed and documented in the electronic health record, was missing for this resident.
Failure to Administer and Document Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that one resident was properly offered and/or provided updated pneumococcal vaccinations in accordance with CDC recommendations. The resident, who had diagnoses including dementia, anxiety, and diabetes, had a documented history of receiving PCV-7, PPSV23, and PCV-13 vaccines. Despite consenting to receive an additional pneumococcal vaccine, the administration of the vaccine was held without communication to the resident's power of attorney or reassessment of the resident's appropriateness for vaccination. The facility's policy required assessment and administration of the PCV vaccine within 30 days of admission, with documentation of refusals or contraindications, but this process was not followed as required for this resident.
Inadequate Supervision and Elopement Risk Management
Penalty
Summary
The facility failed to comprehensively assess and provide an adequate plan for supervision and appropriate interventions to protect a resident identified as at risk for elopement. The resident, who had intact cognition upon admission, experienced cognitive decline over time, as evidenced by a decrease in their Brief Interview for Mental Status (BIMS) score and observations of forgetfulness and confusion. Despite being identified as a low risk for elopement initially, the resident had a history of elopement or attempted elopement, which was not adequately addressed in their care plan. The resident's care plan and Kardex lacked specific staff interventions to ensure adequate supervision, particularly when the resident was outdoors. The care plan was not updated to reflect the resident's increased risk of elopement and the need for supervision. Interviews with staff revealed that there was confusion and inconsistency regarding the resident's supervision requirements, with some staff believing that the resident's spouse, who was also a resident, could supervise them, despite her own vulnerabilities and inability to effectively prevent elopement. The deficiency was further highlighted by an incident where the resident eloped from the facility, was found by law enforcement, and returned unharmed. The facility's failure to communicate and implement specific interventions for the resident's supervision, as well as the lack of a comprehensive assessment of the resident's cognitive decline and elopement risk, contributed to the incident. The facility's policies on care planning and resident safety were not effectively followed, leading to inadequate supervision and an environment not free from accident hazards.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident, identified as R1, to the administrator and State Agency (SA). On the night of 6/17/24, R1, who had intact cognition and required staff supervision for certain activities, reported to an LPN that a large woman had grabbed her neck the previous night, causing pain and fear. The LPN notified the Director of Nursing (DON) within an hour of the allegation, but the DON initially dismissed it as a hallucination and did not report it immediately to the administrator or SA. The DON informed the administrator the following morning, and the interdisciplinary team decided to report the incident to the SA. However, the report was not submitted until the evening of 6/18/24, which was beyond the required two-hour timeframe for reporting allegations of abuse. The facility's policy mandates immediate reporting of suspected abuse, defined as within two hours for incidents involving abuse or serious bodily injury. The delay in reporting was a violation of this policy.
Failure to Implement Enhanced Barrier Precautions and Monitor Infections
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and ensure personal protective equipment (PPE) was used according to EBP indications for two residents with a wound and indwelling catheter. Observations revealed that staff did not consistently use gowns and gloves for high-contact care activities, such as wound care and catheter handling, despite the presence of signs indicating the need for such precautions. Interviews with staff, including nursing assistants and the director of nursing (DON), indicated a lack of understanding and inconsistent application of EBP, with some staff believing that gowns were only necessary when directly handling urine or the catheter. The facility also failed to monitor, track, and trend signs and symptoms of infections effectively. The DON admitted to being unaware of the new requirements for implementing EBP for residents with infections or colonized CDC-targeted multi-drug-resistant organisms (MDROs), wounds, and/or indwelling medical devices. The facility's infection control surveillance documentation was incomplete, with multiple entries under the category of infection marked as unknown, and there was no evidence of regular review or analysis of infection data for trends. Additionally, the facility's Quality Assurance and Assessment (QAA)/Quality Assessment and Performance Improvement (QAPI) meeting minutes lacked a review of infections or a summary of tracking or trending of infections. The DON reported that the previous DON and assistant DON had left the facility, and she was unable to find any surveillance information, indicating a gap in infection control oversight. The administrator confirmed that no one had been monitoring or tracking infections for trends, further highlighting the facility's failure to maintain an effective infection prevention and control program.
Inadequate Infection Preventionist Training
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP), who is also the director of nursing (DON), had completed specialized training in infection prevention and control. This deficiency had the potential to affect all 21 residents residing in the facility. During an interview, the DON admitted that she had not completed her IP training and certification, and no other staff in the facility had IP training. She was assigned as the IP designee after the assistant director of nursing (ADON) resigned abruptly. Additionally, the facility administrator confirmed that there was no certified IP at the facility due to the ADON's departure and was unable to provide records for two residents to confirm that COVID vaccines were offered. A review of the facility assessment from July 2023 indicated that the facility previously had a certified IP and conducted monthly infection control meetings. However, a policy related to the IP was requested but not provided by the end of the survey.
Privacy Breach of Resident Medical Information
Penalty
Summary
The facility failed to ensure the privacy of residents' medical information, as observed with a medication cart located in a common area accessible to residents and visitors. The cart was left unattended with the electronic health record system open, displaying sensitive information such as residents' names, pictures, and room numbers. This incident involved 10 residents, including those with complex medical conditions like diabetes, depression, schizophrenia, neurological conditions, and dementia. The medication aide responsible for the cart admitted to forgetting to close the electronic medical record screen, leaving it exposed to unauthorized access. Interviews with staff, including nursing assistants and the director of nursing, revealed that there was an expectation for staff to lock screens to prevent exposure of patient records. However, it was noted that on rare occasions, patient information had been left accessible on the medication cart. The director of nursing and the administrator both emphasized the importance of safeguarding residents' information, aligning with the facility's confidentiality policy. Despite these expectations, the breach in securing resident data was not previously known to the director of nursing.
Failure to Ensure Pneumococcal Vaccination Compliance
Penalty
Summary
The facility failed to ensure that four out of five sampled residents were appropriately vaccinated against pneumonia upon admission, as per the current CDC guidelines. The residents in question were admitted in May 2024, and their vaccination records indicated that they had received previous pneumococcal vaccines, but there was no documentation to support that they had been offered or declined the updated PCV-15 or PCV-20 vaccines upon admission. Specifically, one resident had received PPSV-23 and PCV-13 in the past, another had received Prevnar 13 followed by PPSV-23, and a third had received PCV-13 followed by PPSV-23. The fourth resident's record lacked documentation of any pneumococcal vaccines, and there was no evidence that the PCV-20 or PCV-15 vaccines were offered or administered according to the current guidelines. Interviews with the Director of Nursing (DON) and the administrator revealed that the facility relied on a local clinic to visit residents for routine vaccines, but the PCV vaccines were not offered during these visits due to in-house standing orders. The staff were required to obtain consent or declination of the vaccine for residents, but this was not completed for the new residents identified. The facility's policy from January 2022 stated that they would assess new residents' vaccination status and document refusals, but this was not adhered to, leading to the deficiency.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to two residents, identified as R172 and R173, upon their admission. Both residents were cognitively intact, with R172 having a diagnosis of anemia and R173 having diagnoses of heart disease and high blood pressure. The vaccine history logs for both residents were undated and showed no record of being offered the COVID-19 vaccine or any declination of it. This indicates a lack of documentation and follow-through on the facility's part in offering the vaccine to these residents. During an interview, the Director of Nursing (DON) was unable to confirm whether the facility had administered COVID-19 vaccines to residents, including R172 and R173. The DON speculated that the residents might not have been interested in receiving the vaccine but could not provide any declination forms to support this claim. The facility's policy from December 2021 required that residents be educated about the vaccine and have the option to accept or refuse it, with the Infection Preventionist or a designee responsible for overseeing education, documentation, and vaccine status. The facility's assessment from July 2023 indicated adherence to guidelines from the Minnesota Department of Health and the CDC, which included offering COVID-19 vaccines to residents and employees.
Infection Control Deficiency During Meal Service
Penalty
Summary
The facility failed to ensure appropriate infection control techniques during a meal service, potentially affecting all 23 residents. Observations revealed that Cook-A repeatedly used the same gloves to handle various items, including food, utensils, tray cards, and resident wheelchairs, without changing gloves or performing hand hygiene. Cook-A was seen touching food directly with gloved hands, handling utensils, and serving meals without proper sanitation practices, leading to potential cross-contamination. During the meal service, Cook-A was observed using his gloved hands to support pieces of fish, arrange food on plates, and handle various items such as glasses and tray cards. He also failed to check the temperature of mechanically altered foods adequately and used the same gloves to handle different food items and equipment. Cook-A admitted to not being oriented to the kitchen and relied on his previous experience with a local food service company for his job duties. Interviews with the Dietary Manager (DM) and the Registered Dietitian (RD) revealed that there were expectations for dietary staff to follow infection control practices, including glove changes and hand hygiene. However, Cook-A's training and competency were not reviewed or assessed by the DM. The facility's policy on preventing foodborne illness required all employees handling food to be trained in safe food handling practices and demonstrate competency before working with food, which was not adhered to in this case.
Failure to Implement Infection Control Practices During Influenza A Outbreak
Penalty
Summary
The facility failed to implement infection control practices in accordance with CDC recommendations to prevent and mitigate the spread of Influenza A. This failure included improper utilization of personal protective equipment (PPE), inadequate hand hygiene, allowing ill staff to work, not implementing active symptom screening for residents and staff, and not providing ongoing education to staff during the outbreak. These lapses resulted in an Influenza A outbreak affecting 9 out of 23 residents and potentially exposing the remaining residents, visitors, and staff to the virus. The infection preventionist (IP) admitted to several deficiencies in the facility's infection control program. The IP was unaware of CDC guidelines for active symptom screening and did not maintain an up-to-date illness tracking system for staff. The IP also reported that staff frequently failed to communicate their illnesses, and department managers did not relay information about ill calls. Additionally, the IP noted that staff were not consistently practicing appropriate hand hygiene or using PPE correctly, despite ongoing education and reminders. Observations during the survey revealed multiple instances of staff not adhering to infection control protocols. Staff members were seen entering and exiting rooms of residents on isolation without changing masks or using PPE. One dietary manager continued to work while symptomatic and refused to get tested for Influenza A. Furthermore, several residents on contact and droplet precautions had their room doors open, and staff were observed not performing hand hygiene after interacting with these residents. These actions contributed to the spread of the virus within the facility.
Inadequate Time and Resources for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the infection preventionist (IP) was allocated adequate time and resources to effectively manage the infection prevention and control program. The IP, who also served as the assistant director of nursing (ADON), was not aware of the required hours to be dedicated to infection control activities and had only logged approximately 40 hours since November 2023. The IP's responsibilities included meeting residents' needs, managing wounds, staff education, and orientation, which left insufficient time for infection control tasks. Consequently, the IP did not implement active symptom screening for residents and staff during an Influenza A outbreak, nor did she complete infection control audits or document staff education due to time constraints. The facility's infection prevention program policies and facility assessment did not specify the required time for the IP to perform infection surveillance based on the resident population or during communicable disease outbreaks. During the survey, it was found that the facility failed to implement infection control practices in accordance with CDC recommendations, which included the use of appropriate personal protective equipment (PPE), hand hygiene, preventing ill staff from working, and providing ongoing staff education during the outbreak. This failure resulted in an Influenza A outbreak affecting 9 out of 23 residents, with five residents remaining in isolation. The IP acknowledged that not enough time had been dedicated to infection control, and she was unsure how to balance her other job responsibilities with the necessary infection control activities. The facility's policies and job descriptions did not provide clear guidance on the required time for the IP to effectively manage the infection control program.
Lack of Training and Infection Control in Dietary Department
Penalty
Summary
The facility failed to ensure all staff working in the dietary department had adequate training on the use of equipment, safe temperatures for food safety, and sanitation processes. This deficiency was identified during an entrance conference where the director of nursing (DON) and administrator admitted to staffing issues in the dietary department, leading to multiple staff, including themselves, assisting with meal preparation and cleanup without proper training. The dietary schedule review revealed that a trained medication aide (TMA-A) was frequently scheduled as the evening cook without any specialized orientation or documented training in dietary management or food safety. Observations confirmed that TMA-A and other nursing assistants, who had no training for kitchen duties, were working in the dietary department due to staff shortages. Interviews with various staff, including the assistant dietary manager (ADM) and the dietary manager (DM), corroborated the lack of training and orientation for non-dietary staff assisting in the kitchen. The DM also failed to ensure proper infection control practices, as she was observed coughing and sneezing while working, and had declined to be tested for Influenza-A despite an outbreak in the facility. The registered dietitian (RD) confirmed awareness of the staffing issues and the outbreak, emphasizing the need for proper infection control and training for all staff involved in meal preparation and serving. The facility's policies on influenza prevention and foodborne illness prevention were reviewed, highlighting the requirement for training and competency in safe food handling practices, which were not adhered to in this case.
Failure to Ensure Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure residents had access to their personal funds upon request. A resident reported that she could only access her money when the administration or business office was open, and not on weekends or holidays. Interviews with staff confirmed that residents had to go to the administrator or business office manager during business hours to access their funds. The administrator believed there was a cash box with $30 in the medication room for after-hours access, but staff were unaware of its existence and had difficulty locating it. Eventually, the cash box was found with $45, but the staff did not know how to access it. The assistant director of nursing (ADON) confirmed that residents only had access to their funds when the administrator or business office manager were present. The ADON was also unaware of any money in the medication room for resident use or how to access it. The facility's policy stated that resident requests for access to their funds should be honored as soon as possible, but no later than the same day for amounts less than $100 ($50 for Medicaid residents) and within three banking days for larger amounts.
Failure to Provide Timely Notifications for Resident Falls
Penalty
Summary
The facility failed to provide timely notifications for a resident who experienced multiple falls. The resident, who had diagnoses including dementia, malnutrition, and a history of falls, experienced three documented falls in March. On 3/11/24, the resident was found on the floor with a large lump and laceration on the back of her head, and minor injuries on her hand, forearm, and ankle. The family was notified of this incident. However, on 3/20/24, the resident fell again while walking in the hall with a gait belt, resulting in a cut on her knee. There was no documentation of notification to the Director of Nursing (DON) for this incident. On 3/21/24, the resident was found on the floor with a large hematoma on her forehead and a skin tear on her elbow, but there was no documentation of notification to the responsible party or family members. During a care conference on 3/27/24, the family expressed concerns about the lack of notification, especially regarding the fall on 3/21/24. The DON confirmed that the facility's policy required timely notification of the DON, medical provider, and family following an incident. The DON acknowledged that the family should have been notified immediately after the assessment of the fall on 3/21/24 to determine if the resident needed to be sent to the Emergency Department. The facility's Falls-Clinical Protocol also required documentation of the fall, assessment data, interventions, and notifications, which was not followed in these instances.
Inadequate Rehabilitative Services for Residents
Penalty
Summary
The facility failed to provide adequate and specialized rehabilitative services of occupational therapy (OT) and physical therapy (PT) according to the individualized needs of two residents, R2 and R10. R2, who had diagnoses including bilateral osteoarthritis, sepsis, and a pressure wound, was admitted with orders for OT and PT. Despite the treatment plan indicating a frequency of three to five times per week for OT and daily sessions for PT, R2 received inconsistent therapy sessions, with OT provided only seven times and PT only twice over an 18-day period. The lack of consistent therapy sessions did not meet the ordered treatment plan, and there was no evaluation of the goal status or effectiveness of the limited therapy provided. R10, who had a stroke and weakness on one side of his body, was also admitted with orders for OT and PT. The treatment plan for PT indicated a frequency of one to five times per week, but R10 only completed three PT sessions over a 23-day period. The PT notes did not include the duration of the visits or an evaluation of the goal status and effectiveness of the therapy provided. The inconsistency in therapy sessions and the lack of a full-time physical therapist assistant (PTA) contributed to the deficiency in providing adequate rehabilitative services. Interviews with the Director of Nursing (DON) and the physical therapist (PT)-A revealed that the facility did not have adequate therapy services in place, leading to concerns about residents' potential decline in mobility and strength. The facility had switched therapy companies and was actively working on hiring additional therapy staff. However, the lack of consistent therapy services and the absence of a full-time PTA negatively impacted the residents' progress and the quality of care provided.
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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