Citations in Minnesota
Statistics, citations and compliance trends for long-term care facilities in Minnesota.
Statistics for Minnesota (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in Minnesota
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Minnesota
- Reeducated staff using the facility’s mechanical lift competency checklist via shift huddles and 1:1 sessions conducted by the DON, nurse manager, and staff development nurse (J - F0689 - MN)
- Completed audits/observations of mechanical lift transfers using the lift competency checklist to verify correct practice (J - F0689 - MN)
- Identified all residents using sit-to-stand/mechanical lifts and verified correct sling/harness sizing through therapy documentation, direct measurement, manufacturer guidelines, and care plan accuracy (J - F0689 - MN)
- Reviewed and updated the mechanical lift transfer policy to require sling/harness size documented in the care plan and Kardex, require 2-assist transfers when indicated, require staff verification of sling size prior to transfer, and require cinching of waist/middle straps before elevation (J - F0689 - MN)
- Updated care plans, Kardex, and care sheets to specifically identify lift type, assist level, and sling/harness size and ensure consistency across documents (J - F0689 - MN)
- Educated licensed nurses and other certified individuals on mechanical lift use including manufacturer recommendations, proper sling application, proper strap placement and cinching, when sit-to-stand lifts were contraindicated, and following the care plan (J - F0689 - MN)
Improper Mechanical Lift Transfer Leading to Resident Fall and Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe mechanical lift transfer by not confirming that all four sling straps were properly attached before moving a resident. The resident involved was an elderly female with hemiplegia and hemiparesis following cerebral infarction affecting the left side, osteoarthritis, and fibromyalgia, who required a mechanical lift with assistance of two staff for transfers and used a medium-sized sling. On the day of the incident, two NAs used the mechanical lift and the appropriately sized sling to transfer the resident from her wheelchair to her bed. One NA attached the right upper and lower loops of the sling while positioned on the resident’s right side, and the other NA attached the lower loops and was responsible for operating the lift. After the sling was attached, the NAs raised the resident into the air and moved the lift backward, pausing between the wheelchair and the bed to obtain the resident’s weight using the lift’s weighing feature. During this process, the top left strap of the sling came loose from the lift, causing the resident to fall from the lift onto her left shoulder. The resident sustained acute displaced fractures of the 2nd and 3rd left ribs and required transfer to the hospital for further evaluation and care. The incident was documented in a progress note and an incident report, and an IDT meeting was held regarding the fall. Interviews conducted during the survey revealed that facility policy and staff expectations required that all four sling loops be checked for secure attachment before moving a resident, including lifting the resident slightly off the surface to verify tension and stability of the loops. The DON and nurse manager stated that staff are expected to perform a safety check by slightly lifting the resident and visually confirming that all sling loops are tight and completely attached before proceeding with the transfer. The DON’s investigation concluded that the upper left loop of the sling was either not attached or not properly attached by one of the NAs, and that both NAs failed to complete the required pause and safety check prior to moving the resident away from the original surface. This failure to follow established procedures for mechanical lift use led directly to the resident’s fall and injuries.
Removal Plan
- Removed the mechanical lift and sling involved in the incident from the floor
- Interviewed the staff involved and completed reenactments/demonstrations to determine what happened
- Suspended NA-A and NA-B pending investigation findings
- Immediately reeducated all staff on shift using the existing mechanical lift competency checklist used for onboarding
- Continued retraining for all shifts, including part-time staff and staff returning from leave as applicable
- Provided education via shift huddles and 1:1 reeducation sessions conducted by the DON, nurse manager, and staff development nurse
- Completed audits/observations of mechanical lift transfers for like-residents using the lift competency checklist to verify correct practice
Failure to Provide Adequate Supervision and Individualized Elopement Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized, care-planned interventions for residents at risk of elopement. One resident with severe cognitive impairment and a diagnosis of malnutrition was initially assessed on admission as non-wandering and completely dependent for mobility and personal care. However, an elopement assessment completed days later identified this resident as an elopement risk who was able to self-propel a wheelchair, was cognitively impaired, actively exit-seeking, and expressing a desire to go home. The resident’s care plan, initiated after this assessment, included use of a wander device, monitoring the device for proper functioning, and prompt response to door alarms, but it lacked specific supervision measures and individualized interventions tailored to the resident’s escalating exit-seeking behavior. In the days leading up to the elopement, multiple progress notes documented that this resident was wandering up and down the hallway, confused, disoriented, and repeatedly attempting to leave the facility despite staff redirection. On the day of the elopement, documentation indicated the resident was very agitated, wandering into other residents’ rooms, calling the police, stating staff were holding her hostage, and attempting to leave multiple times. Video surveillance from the floor exit area showed the resident making several attempts over the course of the evening to open the stairwell and exit doors, triggering alarms that were reset by staff who redirected her away from the doors. Despite these repeated attempts and clear evidence of escalating exit-seeking, no additional formal interventions beyond the wander device were implemented, and staff did not revise the care plan to include increased supervision or other individualized strategies. Later that evening, the video showed the resident successfully exiting through the floor door without staff present. A police report documented that the resident, who was not dressed for the weather and wearing all black, was later found about five blocks from the facility after knocking on a private residence’s door and asking for help. She was transported to the hospital for evaluation and was discharged in stable condition without injuries. Interviews with staff revealed that agency NAs working that shift were not informed which residents were at risk for elopement and that their care sheets did not identify elopement risks or related interventions. Additional residents assessed as elopement risks also had care plans that included wander devices and general directions to monitor for exit-seeking and answer door alarms, but these plans similarly lacked specific supervision measures and individualized interventions, and NA care sheets did not consistently reflect elopement risk status. The facility’s elopement policy directed staff to establish a process to check bracelet alarm/device batteries according to manufacturer directions, and the user guide for the wander management transmitters required at least weekly testing to verify proper operation. Interviews with nursing and management staff showed inconsistent understanding of responsibilities for testing and ensuring functionality of wander devices, as well as for updating care plans and communicating elopement risk to direct care staff. Some nurses believed only nurse managers or the DON could change care plans, while the DON stated all nurses could make care plan changes. Nurse managers reported that residents at risk for elopement should be noted on NA care sheets, but agency NAs reported they were not alerted to any residents at risk to wander or elope. These documented gaps in assessment translation to care plans, supervision, communication, and device management contributed to the resident’s elopement and the identified deficiency. Three additional residents identified as elopement risks had diagnoses including dementia, moderate to severe cognitive impairment, and conditions such as breast cancer and acute encephalopathy. Their elopement assessments indicated confusion, disorientation, and requests to go home. Their care plans directed use of wander devices, monitoring and documentation of exit-seeking behavior, prompt response to door alarms, and inviting them to activities, but similarly lacked explicit supervision requirements and individualized interventions to prevent elopement. NA care sheets for these residents either did not indicate elopement risk or did not include interventions to prevent elopement. These findings showed that the facility failed to consistently integrate elopement risk assessments into clear, individualized supervision strategies and to communicate those strategies to all staff responsible for resident care.
Removal Plan
- Audited the care plans of residents identified as elopement risks
- Provided education to staff regarding the elopement policy
- Provided education to staff regarding elopement assessments
- Provided education to staff regarding one-to-one supervision
- Provided education to staff regarding safety checks
- Provided education to staff regarding wander device management
- Developed and implemented individualized care plans with interventions including supervision for residents at risk for elopement
Failure to Manage NPO, Food-Seeking Resident on G-Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, care plan, implement interventions, and provide supervision for a resident who was NPO and dependent on G-tube feedings, despite known food-seeking behaviors and severe cognitive impairment. The resident’s admission MDS documented severe cognitive impairment, dependence on staff for ADLs, incontinence, and G-tube nutrition, with NPO status due to dysphagia and a history of silent aspiration. On 2/19, the care plan and a risk-versus-benefit form identified that the resident self-sought food and fluids while NPO, required reminders and redirection, and was at risk for aspiration, pneumonia, loss of airway, hospitalization, and possible death if consuming oral intake. The RD documented that the resident was self-seeking food and fluids, had impaired cognition, and could not repeat back understanding of the NPO education, and an order was added to the TAR to observe for self-seeking food and provide re-education as needed. Subsequent clinical notes showed ongoing concerns that the resident was eating and drinking despite strict NPO orders. On 2/25, the NP documented that staff reported continued food- and fluid-seeking, and the resident nodded yes when asked if she was eating or drinking; a chest X-ray was ordered, which was normal. On 3/4, the NP again documented silent aspiration, cough, coarse lung sounds, and that the resident continued to report oral intake despite strict NPO, and another chest X-ray was ordered and read as normal. An email exchange on 2/24 showed the IDT was aware of the resident’s low SLUMS score indicating dementia, wandering, and the need for a memory care bed, but no new interventions were established beyond continued monitoring when no memory care bed was available. Staff interviews and documentation revealed multiple unaddressed episodes of food-seeking and wandering into areas where food was present. A staff member reported seeing the resident eating a gummy jolly rancher given by another resident and observing her wandering into other residents’ rooms and attempting to eat food from leftover trays, as well as being in the dining room during and after meals; the record lacked evidence of any action taken in response to these events. Another staff member also reported seeing the resident wandering all over the unit and in the dining room during and after meals. The SLP stated the resident had severe cognitive deficits, wandered around the unit, did not understand what NPO meant, and was at high risk for aspiration if she ate regular food or fluids, based on a prior hospital video swallow study recommending NPO. The NP later stated she was never informed about the resident eating gummy candy and would have expected immediate notification for further assessment and monitoring. Ultimately, the resident was found unresponsive with heavy breathing and a very high temperature, was sent to the ED, and was diagnosed with acute hypoxic and hypercarbic respiratory failure with aspiration pneumonia; large food material was suctioned from the oropharynx, and the resident required intubation and CPR for a brief cardiac arrest. The surveyors concluded that the facility failed to assess, develop, and implement appropriate interventions and supervision for this known NPO, food-seeking resident, resulting in an immediate jeopardy situation.
Removal Plan
- Completed a full house audit of residents with modified diets
- Audited care plans for residents with modified diets
- Provided training to staff on modified diets and changes made to care plans
Failure to Recognize and Respond to Resident’s Change in Condition Leading to Sepsis and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to identify and act on a resident’s change in condition despite clear signs of acute illness and a care plan for potential infection. The resident had intact cognition per the annual MDS and no baseline hallucinations, delusions, or behaviors. Her care plan identified a self-care deficit and potential for infection related to urinary incontinence, with directions to update the provider as needed. Beginning several days before hospitalization, progress notes documented new hallucinations and emotional distress, including the resident yelling and crying about her babies being murdered and being taken from her, and an IDT discussion noting hallucinations and behavioral changes. These symptoms were atypical for this resident and represented a change from her baseline. Over the following days, the resident developed and sustained fevers and other signs of systemic illness. Vital signs showed temperatures of 101.7°F with a pulse of 140 bpm, later rising to 103.2°F and remaining elevated around 101–100°F over multiple readings, along with low-grade fevers on subsequent days. Progress notes documented vomiting, visible shaking, feeling cold, episodes of incontinent diarrhea, reports of pain “everywhere,” crying, tearfulness, fatigue, and refusal of medications and meals. Despite these findings, nursing staff treated the resident only with scheduled acetaminophen and did not conduct a documented comprehensive nursing assessment or notify the provider when the fevers and other symptoms emerged and persisted. The IDT discussed the resident’s fevers, fatigue, medication refusals, and verbal behaviors but did not review the progress notes or vital signs in detail, and no provider notification occurred at that time. Staff interviews further confirmed that the change in condition was not appropriately recognized or escalated. One RN stated she had not identified anything out of the ordinary beyond weakness and a presumed low-grade influenza, and that staff believed the resident might be recovering when a single temperature reading was normal. Another RN acknowledged that the resident’s change in condition occurred over a weekend when the IDT was not present and that the team did not review the progress notes or vital signs during the subsequent IDT meeting. A different RN reported that she did not assess the resident after the IDT discussion because the resident was asleep and her temperature had decreased slightly, and she felt that the resident’s bipolar diagnosis and prior behaviors had masked the change and interfered with judgment. The facility’s own policy required licensed nurses to evaluate significant changes in condition, obtain vital signs, and notify the provider of abnormal vital signs, behavioral or neurological changes, and worsening pain, but this process was not followed for this resident, resulting in delayed recognition and treatment of sepsis and subsequent hospitalization. Ultimately, the resident was sent to the ED only after she appeared pale with a grey hue, had dark circles under her eyes, was shivering, reported generalized pain, and continued to feel unwell. In the ED, she was found to be ill-appearing and toxic-appearing, with a high fever, tachycardia, hypotension, low GFR, and a diagnosis of sepsis with acute renal failure, septic shock, acute kidney injury, ureteral obstruction, and UTI. The attending MD later stated that the facility had not contacted her when the resident developed a fever and that earlier evaluation could have avoided the septic shock. The NP who saw the resident in the ED described her as barely responsive, with low blood pressure requiring IV fluids and vasopressors, and indicated that while the ureteral stone itself was not avoidable, the sepsis and unnecessary pain could have been prevented if the resident had been sent to the ED sooner. These facts support the finding that the facility failed to provide appropriate treatment and care according to orders, the resident’s preferences and goals, and its own change-in-condition policy.
Removal Plan
- Review policies and procedures related to change in condition and physician notification.
- Review all residents for a potential change in condition.
- Educate nursing staff on policies and procedures related to change of condition and resident monitoring, qualifying factors for a change of condition, assessment of resident symptoms without bias, and timely physician notification and treatment of resident symptoms.
Failure to Protect Cognitively Impaired Resident From Physical and Verbal Abuse and Delayed Response to Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical and verbal abuse by a nurse aide and to respond appropriately once the allegation was reported. On the evening in question, two nurse aides were providing toileting and peri-care to the resident, who had non-Alzheimer’s dementia, depression, a psychotic disorder, and moderately impaired cognition with long- and short-term memory loss. The resident functioned at an estimated developmental level of an 8-year-old, had unclear speech, responded only to simple direct communication, and was dependent on staff for all ADLs including toileting and hygiene. During care, the resident became combative, yelling and swinging her arms, and one aide (NA‑B) responded by raising her voice, using foul and aggressive language, and striking the resident on the bare buttocks while stating that if the resident wanted to act like a child, she would be treated like one. A trained medication assistant (TMA‑A) standing outside the closed door heard NA‑B yelling at the resident to hurry up and grab the “fucking bar” and to walk to bed, and later learned from the other aide (NA‑A) that NA‑B had swatted the resident’s buttocks. NA‑A, who was in the room, described NA‑B’s tone as loud, aggressive, and intimidating, and reported that the resident was grunting and appeared nervous. NA‑A stated that after the resident yelled and grunted during brief placement, NA‑B told the resident that if she wanted to act like a child she would be treated like one, then smacked her on the right buttock with an open hand, skin-to-skin, producing a loud smack. NA‑A reported feeling very uncomfortable and believed the conduct was verbal and physical abuse. After leaving the room, NA‑A immediately told TMA‑A what had happened and, within about five minutes, located the charge nurse (LPN‑A) and reported the incident. NA‑A completed an Employee Concern form describing the incident and placed it in the DON’s box. TMA‑A also informed LPN‑A during the evening medication count that she had heard raised voices, swearing, and the resident crying, and that NA‑B had smacked the resident’s buttocks. Despite these reports, LPN‑A did not read the written complaint, did not conduct an immediate assessment of the resident, did not contact the on‑call nurse, and allowed NA‑B to continue working the remainder of the 12‑hour shift, caring for the resident and other residents without additional supervision. In the hours and days following the incident, the resident demonstrated changes in behavior and mood that were documented by staff. The next morning, staff noted the resident was tearful, withdrawn, and refusing food and drink, including favorite beverages, and she cried while in her wheelchair in a common area. Nursing notes and behavior monitoring entries over the subsequent days documented increased yelling, hitting, scratching, cursing, and physical aggression during care, as well as episodes of sadness, tearfulness, withdrawal, and isolation. Staff familiar with the resident, including RN‑A and NA‑E, reported that this withdrawn, tearful, and non‑eating behavior was not typical for her and that she usually did not cry without a reason. Although a full body assessment was later documented as showing no bruising and no verbalized pain, the facility’s own records and interviews describe that the resident became more tearful, had decreased appetite, and increased crying following the incident, and that she appeared different than normal—quiet, exhausted, withdrawn, and refusing to participate in usual activities and intake. These events, combined with the failure of the charge nurse to act on the initial reports and remove the alleged perpetrator from resident care, led to the cited deficiency for failure to protect the resident from abuse.
Removal Plan
- Reported abuse to the State Agency (SA).
- Investigated allegations of physical and verbal abuse and implemented resident protection.
- Re-educated staff on abuse and neglect, reporting, abuse prevention, resident rights, dementia, and vulnerable adults.
- Verified education through interviews and training records.
Improper Mechanical Lift Use and Inadequate Fall Root Cause Analysis
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of sit-to-stand and total body mechanical lifts, including correct sling/harness sizing, proper strap application, and adherence to care plans and manufacturer instructions. One resident (R4), with diagnoses including heart failure, chronic kidney disease, pancreatic cancer, diabetes, osteoarthritis, and a history of falls, was assessed as high fall risk and required assistance of two staff with a sit-to-stand lift using a large harness for all transfers. Despite this, on a prior date R4 experienced a witnessed fall from a sit-to-stand lift when a nursing assistant transferred the resident alone, contrary to the care plan, and the resident slipped out of the harness and fell to the floor, later reporting left shoulder pain. The facility’s documentation of that incident did not identify the sling size used, did not show a comprehensive assessment to determine the correct sling size for subsequent transfers, and the care plan was not revised to address the resident’s tendency to fall asleep in the lift. On a later observation, two nursing assistants (NA-C and NA-D) prepared to transfer R4 from bed to shower chair using a sit-to-stand lift with an extra-large (XL) harness draped over the lift, which they both believed was the correct size. Neither had a resident care guide in the room identifying the correct harness size. After the surveyor intervened and prompted verification, NA-D checked the resident care guide and discovered R4 was supposed to use a large harness, not an XL, and had to obtain the correct size from another unit because it was not available on R4’s wing. During the same transfer, after the large harness was applied and R4 was raised to standing, the torso strap was not cinched until the surveyor intervened and instructed the staff to tighten it. NA-C acknowledged she knew the torso strap needed to be cinched as the resident stood and that failure to do so could allow a resident to fall out of the lift, but stated she had overlooked this step. Staff also reported they had not received any re-education on proper mechanical lift use or following care plans since initial orientation. A second resident (R9), with diagnoses including heart failure, chronic respiratory failure, and chronic kidney disease, required total mechanical lift transfers and had been assessed via a sling/harness sizing assessment as needing a large sling. However, the resident’s care plan and Kardex directed staff to use an XL sling, conflicting with the sizing assessment. During observation, R9 was seated in a wheelchair on top of a sling whose size markings were washed off; a trained medication aide identified the sling as XL based on its color coding and confirmed via the Kardex that the resident was supposed to be in a large sling. The aide stated the resident could have fallen out of the oversized sling. The DON later confirmed that staff had been using the paper nurse aide care guide to verify sling size and that R9 had not been transferred with the correct sling size. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate, person-centered interventions for another resident (R3) with malignant brain neoplasm, heart failure, osteoporosis, moderate cognitive impairment, and a history of falls. R3’s fall care plan included general interventions such as following the fall protocol, routine safety checks, anticipating needs, and reviewing past falls to determine causes, but subsequent fall incident documentation and root cause analysis worksheets were incomplete or lacked clear causal analysis and corresponding interventions. After an unwitnessed bathroom fall assisted by a family member, the root cause section was left blank, and the only care plan revision was to encourage family not to transfer the resident and to ask staff for assistance. Later falls, including one where the resident was found on the bathroom floor without a walker and another where the resident independently walked to the bathroom and lost balance, identified factors such as brain cancer, weakness, and self-transfers, but did not show comprehensive analysis or immediate interventions to mitigate further falls. One intervention, placing a dycem mat in the wheelchair seat, lacked a documented rationale linked to the identified causal factors. The DON acknowledged that comprehensive causal analyses had not been completed for each of R3’s falls and that toileting, identified as a root cause, was not addressed in the care plan until several days after repeated falls. The immediate jeopardy began when NA-C and NA-D had to be stopped from using the wrong harness size for R4 and failed to cinch the torso strap during a sit-to-stand transfer, despite R4’s prior fall from a sit-to-stand lift and existing care plan requirements. The medical director stated that any resident being transferred using a mechanical lift without the care plan and/or policy being followed had the likelihood to cause serious harm, serious injury, or death in the event of a fall from the lift.
Removal Plan
- The facility identified all residents who use a sit-to-stand lift, assessed each resident for the correct harness size needed, and educated each member of the nursing staff who will or may use the sit-to-stand lift.
- The facility assessed R4 and all residents using mechanical lifts for proper transfer method, correct sling/harness size, and care plan accuracy.
- The facility verified sling/harness size for each resident through therapy documentation, direct measurement, manufacturer guidelines, and care plan accuracy.
- The facility reviewed and updated the mechanical lift transfer policy to require sling/harness size documented in the care plan and Kardex, require 2-assist transfers when indicated, require staff verification of sling size prior to transfer, and require cinching of waist/middle straps before elevation.
- The facility updated care plans to specifically identify type of lift, assist level, and sling/harness size.
- The facility updated the Kardex to match the care plan.
- The facility updated care sheets to match the care plan.
- The facility provided education to all licensed nurses and other certified individuals on manufacturer recommendations, proper sling application, proper strap placement and cinching, when sit-to-stand lifts are contraindicated, and always following the care plan.
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