Whitewater Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in St Charles, Minnesota.
- Location
- 525 Bluff Avenue, St Charles, Minnesota 55972
- CMS Provider Number
- 245270
- Inspections on file
- 27
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Whitewater Health Services during CMS and state inspections, most recent first.
Two residents admitted with benign prostatic hyperplasia and indwelling urinary catheters did not have their need for enhanced barrier precautions (EBPs) identified or addressed in their baseline care plans. Although their care plans documented indwelling Foley catheters, they lacked EBP-related interventions, and the medical records contained no evidence that staff were informed of these EBP needs. Observations showed each resident with a visible Foley catheter bag and no EBP signage or supplies at the room doors, and the DON later acknowledged that both residents should have been on EBPs since admission and that she had forgotten to include this in their care plans, despite a facility policy requiring baseline care plans within 48 hours of admission.
Surveyors found that required daily nurse staffing information was not posted anywhere in the building, including the administrator’s office door, primary areas, hallways, or entrance. The administrator acknowledged responsibility for posting the information and admitted it was not printed or posted. Facility policy required that nurse staffing information be posted daily, seven days a week, in a readable format and be readily available to residents and visitors, but this was not done, potentially affecting all 33 residents and visitors seeking this information.
A resident with benign prostatic hyperplasia and an indwelling Foley catheter was not managed under required Enhanced Barrier Precautions (EBP) despite facility policy stating EBPs must be initiated for residents with urinary catheters and that PPE is required for high-contact care such as transfers and toileting. The resident’s medical record lacked documentation showing staff awareness of the EBP requirement, there was no EBP signage or supplies at the room door, and a PT assisted the resident out of the bathroom and into a wheelchair using a gait belt without donning PPE. The PT reported she depended on door signage to identify residents on EBPs, while the DON stated staff were expected to gown and glove when assisting residents on EBPs, demonstrating a failure to follow the facility’s EBP policy.
Nursing staff, under the direction of the DON and supervisory RNs, routinely took medications prescribed for one resident and administered them to others when their medication supply was depleted. This practice involved several types of medications and was documented on medication cards, often without proper explanation or consent. Neither residents nor their families were informed or asked for permission, and staff interviews confirmed that this was a common and directed practice, constituting misappropriation of resident property.
The facility did not report incidents of medication misappropriation to the state agency within the required timeframe. Multiple staff, including RNs, LPNs, and DONs, were aware of and directed the practice of borrowing medications from one resident to administer to another, often without proper documentation or resident consent. Despite knowledge of these events, the required reporting was not completed, and residents and families were unaware of the medication transfers.
Staff were routinely directed by supervisory personnel to borrow medications from one resident to administer to another, with medication cards showing undocumented or improperly documented dose removals. Multiple nurses confirmed this practice, and administrative staff failed to conduct a thorough investigation into the misappropriation of medications as required by facility policy.
Nursing staff, under direction from facility leadership, routinely borrowed medications from one resident to administer to another when supplies ran out, despite facility policy prohibiting this practice. Multiple residents with complex medical needs received medications not specifically ordered for them, and staff interviews confirmed this was a long-standing and common practice. Documentation and medication records showed doses were removed from medication cards and given to other residents, with unclear processes for replacement and inconsistent documentation.
A resident who was cognitively intact and had an order for Nystatin powder was observed receiving the medication at bedside to self-administer, but no self-administration of medication (SAM) assessment was completed as required. Nursing staff confirmed that a SAM assessment and provider order are necessary before allowing self-administration, and facility policy mandates this process, but it was not followed in this instance.
A resident with multiple medical conditions, including pressure ulcers and urinary retention requiring a catheter, was admitted without a baseline care plan being completed within 48 hours. The resident experienced ongoing, unmanaged pain and reported that staff had not discussed pain goals. Facility leadership confirmed that a resident-specific pain care plan was not in place, and a care plan policy could not be provided.
A resident with multiple complex medical conditions experienced frequent, severe pain that was not adequately managed due to the facility's failure to assess pain needs upon admission, complete pain assessments for all prescribed medications, and offer or document non-pharmacological pain interventions as required by policy. Staff were aware of the resident's ongoing pain but did not consistently follow expectations for timely and comprehensive pain management.
Staff did not consistently follow infection control protocols, including failing to keep a urinary catheter drainage bag off the floor for a resident with a history of infections, not disinfecting a mechanical transfer lift between uses for different residents, and improper use of PPE by housekeeping staff who wore the same gown while cleaning multiple contact precaution rooms. These actions were contrary to facility policy and staff knowledge, as confirmed by interviews.
The facility did not keep state survey results in a location that was easily accessible to residents and visitors. A resident council president was unaware of the availability of these results, and staff were initially unable to locate the survey binder, which was eventually found out of sight among other binders. No policy regarding the posting of survey results was provided when requested.
A resident with a history of brain hemorrhage became unresponsive, and the facility failed to perform a comprehensive assessment or notify the physician promptly. Despite being unresponsive and having a fever, the resident's condition was not adequately communicated to the physician, leading to a delay in hospitalization. The resident was later diagnosed with a new brain hemorrhage and passed away.
Staff at the facility failed to follow hand hygiene protocols during personal care and meal service for three residents. A resident with moderate cognitive impairment was assisted by two NAs who did not perform hand hygiene after removing gloves. Another resident with severe cognitive impairment was similarly assisted without proper hand hygiene. Additionally, a resident with moderate cognitive impairment was assisted by an NA and RN, who also failed to perform hand hygiene. The facility's hand hygiene policy was not followed, as confirmed by the nursing leadership.
The facility failed to submit accurate staffing data for Quarter 2 of Federal Fiscal Year 2024 to CMS, leading to a report of excessively low weekend staffing. The issue was due to the omission of agency pool staff hours in the reports by past interim administrators.
Failure to Include Enhanced Barrier Precautions in Baseline Care Plans for Residents With Indwelling Catheters
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission that identified and addressed the need for enhanced barrier precautions (EBPs) for residents with indwelling urinary catheters. One resident was admitted with benign prostatic hyperplasia (BPH) with lower urinary tract symptoms and had an order for an indwelling urinary catheter documented on admission. The resident’s care plan, initiated approximately two weeks later, noted the presence of an indwelling Foley catheter but did not include the resident’s need for EBPs or any related interventions. The medical record did not contain evidence that staff were informed of or knowledgeable about this resident’s EBP needs. A second resident was also admitted with BPH with lower urinary tract symptoms and an order for an indwelling urinary catheter. This resident’s care plan, developed two days after admission, documented an indwelling Foley catheter but likewise omitted the need for EBPs and associated interventions. The medical record lacked documentation to show staff awareness of this resident’s EBP needs. Observations showed both residents with visible Foley catheter bags and no EBP signage or supplies at their room doors. The DON later acknowledged that both residents should have been on EBPs since admission due to their indwelling catheters and that she was responsible for ensuring the care plans reflected this need, stating she was unsure why the signage was not in place and that she had forgotten to include EBPs on their care plans. The facility’s baseline care plan policy required development and implementation of a baseline care plan within 48 hours of admission to provide effective, person-centered care meeting professional standards.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required daily nurse staffing information was posted and readily visible to residents and visitors. During an observation on 4/15/26 at 9:59 a.m., the nurse staffing information was not posted on the administrator’s office door, where it was expected to be located. A subsequent observation at 10:16 a.m. of the primary areas, hallways, and entrance of the facility also did not reveal any posted nurse staffing information. At 11:23 a.m., the administrator stated she was responsible for posting the nurse staffing information, acknowledged it should have been on her office door, and admitted it was not posted because she had not printed or posted it. The facility’s policy, revised 10/13/22, required that staffing information be readily available in a readable format to residents and visitors at any given time and be posted on a daily basis, seven days a week. This failure had the potential to affect all 33 residents residing in the facility and any visitors who may wish to see the information. No specific residents, medical histories, or clinical conditions were described in the report beyond the reference to the total census of 33 residents who could be affected by the lack of posted staffing information.
Failure to Implement Enhanced Barrier Precautions for Resident With Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented Enhanced Barrier Precautions (EBP) in accordance with CDC guidelines for a resident with an indwelling urinary catheter. The resident’s admission record documented benign prostatic hyperplasia with lower urinary tract symptoms, and orders and care plan confirmed the presence of an indwelling Foley catheter. The medical record did not contain evidence that staff were knowledgeable about the resident’s need for EBPs. Facility policy, revised 8/8/24, stated that EBPs would be initiated for residents with urinary catheters and that PPE use was required for high-contact care activities such as transfers, assisting with toileting, and personal hygiene. On observation, the resident was seen sleeping in a recliner with the Foley catheter leg bag visible and attached to the leg, and there was no EBP signage or EBP supplies at the room door. Later, a physical therapist was observed assisting the resident out of the bathroom and into a wheelchair using a gait belt, remaining in close contact without wearing the required PPE for a resident on EBPs. In interview, the physical therapist stated she relied on door signage to know if a resident was on EBPs and did not use PPE because there was no such signage for this resident. The DON stated that staff were expected to gown and glove when transferring and assisting a resident on EBPs to the bathroom, confirming that the observed practice did not meet facility expectations or policy requirements.
Misappropriation of Resident Medications by Nursing Staff
Penalty
Summary
Multiple nursing staff at the facility engaged in the practice of taking medications prescribed for one resident and administering them to other residents when their own medication supply ran out. This was observed across several residents, with medication cards showing doses removed and annotated for use by other residents, often without proper documentation or consent. The medications involved included levothyroxine, potassium chloride, glipizide, clozapine, oxycodone, and pregabalin. In several cases, there was no indication or explanation for the removal of doses, and the medication cards were marked with initials or notes referencing other residents. Interviews with nursing staff revealed that this practice was directed by the Director of Nursing (DON) and other supervisory nurses, who instructed staff to borrow medications from one resident to give to another. Staff reported that this was a common occurrence, sometimes happening every other day, and that they had received education from the DON on how to borrow medications, though the date of this education was unclear. Staff described a process of contacting the DON or other RNs for direction when a resident's medication was unavailable, and being told to use another resident's supply. Residents and family members interviewed were not aware that medications had been borrowed from them or their family members, and had not been asked for consent. The facility's policy on abuse, neglect, and exploitation defines misappropriation of resident property as the wrongful use of a resident's belongings without consent. The actions observed and described in interviews constitute misappropriation of property, as medications were taken from residents without their knowledge or permission and used for other residents.
Failure to Timely Report Misappropriation of Resident Medications
Penalty
Summary
The facility failed to ensure that alleged violations involving the misappropriation of resident medications were reported to the state agency within 24 hours of the incidents, as required. The misappropriation involved at least five residents, where medications were removed from one resident's supply and administered to another without proper documentation or consent. Multiple medication cards showed doses removed and given to other residents, with some cards lacking clear documentation of the reason for removal, the date, or the initials of the staff involved. The practice of borrowing medications was confirmed through observation, record review, and staff interviews. Several staff members, including RNs, LPNs, and DONs, acknowledged that the practice of borrowing medications from one resident to give to another was common and often directed by nursing leadership. Staff interviews revealed that this practice occurred frequently, sometimes every other day, and that nurses were instructed to document the removal on the medication card, though this was inconsistently done. Residents and family members interviewed were unaware that medications had been borrowed from or for them, and there was uncertainty about whether any doses had been missed as a result. Despite knowledge of the misappropriation by various staff, including human resources and nursing leadership, the incidents were not reported to the state agency as required by facility policy and federal regulations. Staff cited reasons such as lack of access, uncertainty about reporting procedures, or not being involved in the investigation as reasons for not reporting. The facility's own policy defined misappropriation as the wrongful use of a resident's property without consent and required reporting within 24 hours, but this was not followed in these cases.
Failure to Investigate Misappropriation of Resident Medications
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident medications for five of eight residents. Multiple medication cards showed doses removed without proper documentation or explanation, and in several cases, medications were taken from one resident and given to another without following appropriate procedures. Staff interviews revealed that nurses were routinely directed by the Director of Nursing (DON) and other supervisory staff to borrow medications from one resident to administer to another when medications were unavailable, a practice that was reportedly common and sometimes accompanied by informal documentation on medication cards. Specific examples included medication cards for levothyroxine, potassium chloride, glipizide, clozapine, and oxycodone, where doses were removed and either not documented or documented as being given to other residents. In some cases, the initials on the medication cards could not be identified, and the dates and reasons for removal were unclear. Residents involved had a range of medical conditions, including hemiplegia, hypothyroidism, chronic kidney disease, schizoaffective disorder, and acute pain, and the medications in question were prescribed for these conditions. The practice of borrowing medications was confirmed by several nurses, who stated they received direct instructions from the DON or other supervisory staff to do so. Despite the discovery of these practices, the facility did not conduct a thorough investigation as required by its own policies. Interviews with human resources and administrative staff revealed confusion about who was responsible for the investigation, with some staff unaware of any completed investigation, education, corrective action, or audits. The facility's policy required a thorough investigation of misappropriation allegations, including identifying all involved parties, interviewing witnesses, and documenting findings, but these steps were not completed or documented as having been completed.
Failure to Ensure Proper Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that residents' medications were ordered in advance and administered as prescribed. Multiple instances were observed where residents were given medications that were prescribed for other residents when their own supply ran out. This practice was confirmed through medication card reviews, interviews with nursing staff, and documentation, showing that doses were removed from one resident's medication card and administered to another resident. The facility's own policies explicitly prohibit administering medications supplied for one resident to another, yet this practice was ongoing and had become routine among nursing staff. Several residents were affected by this deficiency, including those with complex medical histories such as hemiplegia, hypothyroidism, diabetes, schizoaffective disorder, chronic kidney disease, and post-surgical aftercare. Medication administration records and pharmacy receipts revealed that medications such as levothyroxine, potassium chloride, glipizide, clozapine, oxycodone, and pregabalin were borrowed from one resident and given to another. In some cases, the medication cards were annotated to indicate which resident received the borrowed dose, but there was often no clear documentation or rationale for the removal of doses, and the process for replacing borrowed medications was unclear to staff. Interviews with nursing staff, including RNs and LPNs, confirmed that they had received direction from nursing leadership, including the DON, to borrow medications from other residents when a medication was not available for the intended resident. This direction was given multiple times and had become a long-standing practice in the facility. Staff reported that they would attempt to reorder medications when supplies were low, but if the medication was not available, they would check the emergency medication kit or call the pharmacy. If the medication was still unavailable, they were instructed to borrow from another resident's supply. This practice was not communicated to residents or their families, and some staff expressed awareness that this was not a proper nursing practice.
Failure to Complete Required Self-Administration Assessment Before Allowing Resident to Self-Administer Medication
Penalty
Summary
A resident who was assessed as cognitively intact had a provider order for Nystatin antifungal powder to be applied to both breasts and groin folds every 12 hours as needed. During observation, an RN dispensed the antifungal powder into a medication cup and handed it to the DON, who then placed the cup on the resident's bedside table and left the room. The DON stated that the resident would apply the powder herself when ready. However, there was no documentation of a self-administration of medication (SAM) assessment for this resident. Interviews with nursing staff confirmed that a SAM assessment is required to determine if a resident is safe to self-administer medications and that a provider order is necessary for medications to be left at the bedside. Both the RN and ADON acknowledged that no current residents had a SAM assessment on file, and that such assessments are reviewed every three months for safety. Facility policy also requires specific authorization and assessment before allowing residents to self-administer medications, but this process was not followed in the case of the resident observed.
Failure to Initiate Baseline Care Plan and Address Pain Management Upon Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for a newly admitted resident with multiple complex medical conditions, including heart failure, respiratory disease, several pressure ulcers, spinal and lumbar pain, adult failure to thrive, and urinary retention requiring a catheter. At the time of the survey, the resident's admission Minimum Data Set (MDS) assessment had not been completed, and no baseline care plan had been initiated. The resident reported experiencing significant pain, particularly at the site of the urinary catheter, and stated that the pain management provided was ineffective. She also indicated that staff had not discussed her pain goals with her. Interviews with the ADON and DON confirmed that the resident had been experiencing frequent and high levels of pain since admission, and that a resident-specific care plan addressing pain had not been completed. The facility was unable to provide a care plan policy when requested. These findings demonstrate that the facility did not assess or address the resident's immediate needs, particularly regarding pain management, within the required 48-hour timeframe following admission.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a newly admitted resident with multiple complex medical conditions, including heart failure, respiratory disease, several pressure ulcers, spinal and lumbar pain, adult failure to thrive, and urinary retention requiring a catheter. Upon admission, the resident's baseline care plan was not completed, and pain management needs, treatments, and goals were not assessed. Although the resident had physician orders for scheduled pain medications (Lyrica and acetaminophen), pain assessments were inconsistently completed, and non-pharmacological interventions were not documented or offered as required by facility policy. Throughout the resident's stay, documentation and direct observation revealed frequent and severe pain, with the resident repeatedly calling out and expressing that her pain was not being adequately managed. Staff interviews confirmed that non-pharmacological interventions, such as ice, heat, or distraction, were expected to be offered and documented, but these were not provided or recorded for the resident. The treatment administration record lacked evidence of attempted non-pharmacological pain interventions on multiple days, despite ongoing high pain scores and vocal complaints from the resident. Interviews with nursing staff and the assistant director of nursing indicated an awareness of the resident's persistent pain and the expectation to address pain within 15-20 minutes of notification, using both pharmacological and non-pharmacological methods. However, the resident's record showed that these expectations were not met, as non-pharmacological interventions were neither offered nor documented, and pain assessments were incomplete for one of the prescribed medications. Facility policy required staff to recognize, evaluate, and manage pain, but these steps were not consistently followed for this resident.
Failure to Follow Infection Control Practices for Catheter Care, Equipment Disinfection, and PPE Use
Penalty
Summary
Staff failed to follow proper infection control practices in several instances involving residents with complex medical needs. One resident with a urinary catheter and a history of spina bifida, paraplegia, and recurrent urinary tract infections was observed multiple times with their catheter drainage bag placed directly on the floor without a barrier, contrary to facility policy and staff instructions. The resident expressed a preference for the bag to be as low as possible, sometimes resulting in the bag being placed on the floor. Staff interviews confirmed awareness that placing the catheter bag on the floor was an infection control issue, but the practice continued due to the resident's preferences and concerns about drainage effectiveness. In another instance, staff failed to clean and disinfect a mechanical transfer lift between uses for different residents. Nursing assistants used the same lift for two residents without wiping it down or sanitizing it before or after each use. Staff interviews confirmed knowledge of the requirement to clean equipment between residents to prevent infection transmission, but this protocol was not followed during the observed instances. Additionally, proper use of personal protective equipment (PPE) was not maintained by housekeeping staff when cleaning rooms under contact precautions. A housekeeper was observed wearing the same gown while cleaning multiple rooms, only changing gloves between rooms, despite facility policy and supervisor expectations that both gown and gloves should be changed after each room. Interviews with the housekeeper and supervisors confirmed that the correct procedure was not followed, increasing the risk of cross-contamination between rooms.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that state survey results were kept in a location that was readily accessible to all residents and visitors. During a resident council meeting, the resident council president, who was cognitively intact, stated she was unaware that the state survey results were available for review and expressed interest in seeing them. When interviewed, the social worker was unsure of the survey binder's location and was unable to find it in the main atrium. Later, the assistant director of nursing and a corporate vice president located the survey binder stacked among other facility binders, out of sight and not easily accessible to residents or visitors. Additionally, when requested, the facility did not provide a policy regarding the posting of survey results.
Failure to Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify, assess, and respond appropriately to a sudden change in condition for a resident, leading to an immediate jeopardy situation. The resident, who had a history of nontraumatic intracerebral hemorrhage and severe cognitive impairment, became unresponsive and remained so for at least seven hours before being hospitalized. Despite the resident's unresponsiveness and elevated temperature, the facility staff did not perform a comprehensive assessment or notify the physician in a timely manner. The resident's condition was first noted to be abnormal between midnight and 1:30 a.m. when a nursing assistant observed the resident to be lethargic, warm, flushed, and weak. This information was reported to an LPN, who took the resident's vital signs but did not find them concerning and did not perform a neurological assessment. The resident's condition was reported again during the shift change at 6:00 a.m., but no significant action was taken until later in the morning when the resident's temperature was recorded at 101.6°F, and the resident remained unresponsive. Throughout the morning, the resident's condition did not improve, and the staff failed to communicate the severity of the situation to the physician, who was only informed of a fever and sleepiness. It was not until the resident's breathing became irregular and the resident was unresponsive to a sternal rub that an ambulance was called. The resident was later diagnosed with a new large brain hemorrhage and passed away. The facility's policy on change in condition was not followed, leading to a delay in appropriate medical intervention.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during personal care and meal service, as observed in three residents. Resident 1, who had moderate cognitive impairment and was dependent on staff for assistance, was observed being assisted by two nursing assistants (NAs) with incontinent care. The NAs did not perform hand hygiene after removing gloves and before applying a new brief and transferring the resident to a wheelchair. Additionally, one of the NAs continued to handle items and assist other residents without performing hand hygiene. Resident 2, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was assisted by the same NAs from a wheelchair to bed. The NAs did not perform hand hygiene after removing gloves following the removal of soiled briefs and application of barrier cream. This lack of hand hygiene was acknowledged by the NAs during an interview, where they admitted to not following the facility's hand hygiene policy. Resident 4, with moderate cognitive impairment and dependent on staff for dressing and grooming, was assisted by an NA and a registered nurse (RN) in changing an incontinent brief. The NA did not perform hand hygiene after removing soiled gloves and before donning a new pair. The facility's policy on hand hygiene, which requires handwashing or the use of an antiseptic hand rub in various situations, was not adhered to by the staff, as confirmed by the regional nurse consultant, director of nursing, and assistant director of nursing during an interview.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate and complete staffing data for Quarter 2 of Federal Fiscal Year 2024 to the Centers for Medicare and Medicaid Services (CMS). The CMS Payroll Based Journal (PBJ) Staffing Report indicated excessively low weekend staffing, which was not consistent with the facility's daily staff postings and staffing schedules. The review showed that the number of staff and total hours worked on weekends were not drastically different from weekdays, and the census did not fluctuate significantly during this period. However, the facility did not include agency pool staff hours in their reports, leading to the appearance of low weekend staffing. During an interview, the Corporate President of Customer Success confirmed that staffing needs were determined based on resident acuity and census, and that the level of staffing on weekends was the same as on weekdays. The issue arose because past interim administrators failed to include agency pool staff hours in the required staffing reports. This omission caused the facility's staffing data to appear inaccurate. A facility policy was requested but was not received.
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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