Bayshore Residence And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Duluth, Minnesota.
- Location
- 1601 St Louis Avenue, Duluth, Minnesota 55802
- CMS Provider Number
- 245227
- Inspections on file
- 33
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Bayshore Residence And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents had their leave of absence (LOA) privileges revoked by physician order due to concerns about substance use and safety, without evidence that less restrictive alternatives were considered. Staff interviews confirmed that suspicions of drug and alcohol use, refusal of urinalysis, and unsafe behaviors led to the restrictions, and facility policy was interpreted as allowing LOA privileges to be revoked as a matter of safety.
A resident with a history of substance abuse and revoked LOA privileges left the facility with family against medical advice. Despite being informed that her LOA privileges were revoked, the resident departed, and staff processed the discharge as AMA. Attempts to obtain signatures on the AMA form from the resident and her family were unsuccessful, so staff signed with a witness. Staff interviews confirmed the discharge was due to the resident leaving without authorization, in accordance with physician orders and facility policy.
Surveyors observed that an LPN was unable to identify the owner of an insulin aspart pen found in a medication cart, which lacked proper labeling and had not been removed after its beyond-use date. The DON confirmed that insulin should be labeled with the resident's name and opened-on date, and removed after the BUD, in accordance with facility policy.
A resident with dementia and Parkinson's disease, who was not approved for self-administration of medication, was found with a bottle of nystatin powder at their bedside on two occasions. SAM assessments indicated the resident could not identify medication expiration dates and was not cleared to self-administer. Staff interviews confirmed that facility policy required a SAM assessment and provider order for bedside medication storage, but the medication remained accessible to the resident in violation of policy.
Two residents had their rooms and personal belongings searched by staff without consistently obtaining voluntary consent, despite facility policy requiring resident understanding and approval. One resident, who was cognitively intact and her own responsible party, experienced repeated searches after visits or absences, sometimes only consenting after persistent staff requests. Staff interviews revealed confusion about the need for consent, and documentation showed searches occurred even when the resident was not present.
A resident with a recent surgical amputation reported that his room was too dark, had wall damage, and visible stains, which were confirmed during observations. Staff interviews revealed a lack of routine maintenance and cleaning schedules, and responsibilities for repairs and cleaning were unclear. The facility's policy did not address wall repairs, and the administrator was aware of the room's condition but did not inspect it.
Two residents' MDS assessments were inaccurately coded, including one case where a non-insulin injectable medication was recorded as insulin, and another where a resident's dysphagia diagnosis, swallowing disorder symptoms, and need for supervision with eating were omitted from the assessment, despite supporting documentation in the medical record and care plan.
The facility did not consistently monitor or document fluid restrictions for two residents with kidney and heart conditions, resulting in missed or incomplete intake records. Additionally, a resident with multiple chronic illnesses refused diuretic medication and experienced significant weight gain, but provider notification and documentation were lacking as required by policy. Staff interviews confirmed gaps in documentation and communication regarding these care issues.
A resident with quadriplegia and a history of pressure ulcer risk developed an unstageable pressure ulcer after weekly skin checks were not consistently performed and the care plan was not updated to reflect the new wound or individualized interventions. Staff were inconsistently educated on the maintenance of the resident's Roho cushion, which was found deflated, and documentation of wound assessments and care plan updates was incomplete.
A resident with significant cognitive and physical impairments was provided bed rails without a comprehensive assessment addressing all FDA-recommended entrapment zones, and there was no documentation of alternatives attempted prior to use. Staff interviews revealed that only limited measurements were taken, and maintenance installed the rails without performing required safety assessments, contrary to facility policy.
A resident with multiple chronic conditions was prescribed several medications without documented indications for use in the medical record. Nursing staff and the DON confirmed that medication orders should include the reason for administration, but this was not done, resulting in a failure to ensure the resident's drug regimen was free from unnecessary drugs.
Staff did not follow proper hand hygiene and glove change protocols during peri care for a dependent resident, failed to disinfect a shared glucometer according to manufacturer instructions after blood sugar testing, and did not use gloves or perform hand hygiene during eye drop administration for a resident. These actions were inconsistent with facility policies and infection control standards.
A resident with severe cognitive and physical impairments was found to have bedrails in use without evidence of regular, comprehensive inspections of the bed, mattress, and bedrails for safety and entrapment risks. Maintenance staff only performed monthly checks for looseness, and there was no documentation of routine inspections or ongoing risk assessments, contrary to facility policy.
The facility did not make the most recent state survey results easily accessible or post required signage about inspection reports. Survey results were kept in a binder secured at the front desk, limiting privacy for review, and only included results up to the previous year until more recent documents were added after surveyors arrived. No related policies were provided when requested.
A nursing assistant in a LTC facility took and shared humiliating photos and videos of residents on social media, violating their privacy and dignity. The assistant was aware of the facility's policies against such actions but continued to engage in abusive behavior, including physical aggression and inappropriate gestures. The residents involved had various medical conditions, making them vulnerable to abuse.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy between the EHR and the POLST. The resident's care conference identified them as full code, but the POLST indicated DNR. The facility changed the EHR to DNR without verifying with the family, against the resident's wishes to be resuscitated. This led to an immediate jeopardy situation due to inconsistent documentation and lack of communication.
The facility failed to provide 56 residents with access to their personal funds after hours and on weekends. Residents could only access their money during specific weekday hours, and staff were generally unaware of any arrangements for access outside these times. The facility did not maintain petty cash, contrary to its policy, leading to the deficiency.
The facility failed to monitor the nurse aide registry, allowing an inactive nurse aide to continue working with residents. A nurse aide, hired in December, was found to have an inactive status as of May, yet continued to work shifts during a survey. The facility administrator was unaware of the inactive status, despite procedures for registry checks and notifications.
The facility failed to ensure proper PPE use and hand hygiene, leading to infection control deficiencies. Staff did not wear gowns for a resident under Enhanced Barrier Precautions, citing lack of PPE in the dementia unit. Additionally, a nurse failed to sanitize hands between treatments and used another resident's medication, posing cross-contamination risks. The DON confirmed the need for proper PPE and hand hygiene practices.
A facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to a resident who stayed after their Medicare Part A coverage ended. The resident's medical record lacked evidence of the SNFABN, which should have explained the cost and rationale for continued care. Interviews confirmed the oversight, and the facility did not provide a beneficiary policy, though they had a CMS form with SNFABN instructions.
A facility failed to accurately code the MDS for a resident, marking their vision as adequate despite multiple diagnoses indicating impairment. The resident had conditions such as diabetic retinopathy and cataracts, and their care plan noted vision impairment. The ADON confirmed the coding error, stressing the importance of MDS accuracy for care and reimbursement.
A resident with severe cognitive impairment received Nystatin powder from another resident's supply due to a registered nurse's inability to locate the correct medication. This action violated the facility's policy, which requires medications to be administered as per prescriber orders and prohibits sharing between residents. The incident was confirmed by the RN and the DON.
The facility failed to follow medical orders and document necessary information for residents with specific health conditions. A resident with heart failure did not have weight changes reported as ordered, and another resident missed doses of prescribed pain medication. Additionally, the facility did not document behaviors related to PRN medication administration for a resident with schizophrenia. The DON confirmed the expectation for proper medication administration and documentation.
A resident's room contained four oxygen tanks, with two unsecured, posing a potential hazard. The resident, on oxygen therapy, was using an oxygen concentrator, and the tanks were intended for discharge. Staff confirmed the tanks should not be free-standing, and the DON acknowledged the fire hazard risk.
A resident with dementia and GERD experienced significant weight loss over several months, dropping from 163.9 to 147.1 pounds. Despite the facility's policy requiring notification of the physician and dietician for nutritional problems, the provider was not informed of the weight loss. The registered dietician recommended nutritional supplements, but the facility failed to update the provider, as confirmed by RN-B and the DON.
A resident with bipolar disorder and metabolic encephalopathy, known for exit-seeking behavior, eloped from the facility despite wearing a wanderguard. Staff, including a nursing assistant and a maintenance worker, mistook the resident for a visitor when the wanderguard alarm activated and did not conduct a thorough search. Approximately 1.25 hours passed before a code 99 was called, and the resident was found two miles away. The report highlights lapses in staff response to the wanderguard alarm and delayed recognition of the resident's absence, raising concerns about supervision protocols for residents at risk for elopement.
Failure to Honor Residents' Rights to Leave Facility
Penalty
Summary
The facility failed to honor the rights of two residents to leave the facility, as required, by restricting their leave of absence (LOA) privileges through physician orders. One resident, who had diagnoses including type 2 diabetes, infection, pain, weakness, and substance abuse, was assessed as low risk for elopement but had her LOA privileges revoked due to suspected drug and alcohol use. The care plan and physician order specifically indicated that the resident was not allowed to leave the facility, and staff interviews confirmed that the restriction was based on suspicions of substance use and refusal to comply with urinalysis requests. There was no evidence that less restrictive alternatives were considered prior to revoking the resident's right to leave. Another resident, with diagnoses including depression, head laceration, anemia, tobacco use, and alcohol dependence, also had his LOA privileges revoked due to a history of impaired decision-making and risk for self-harm related to chemical dependency. The care plan and physician orders documented the suspension of LOA privileges due to safety concerns. Despite this, written agreements were made between the resident and the administrator to allow limited, supervised outings, which were to be reported to the physician. Staff interviews indicated that the resident had previously engaged in unsafe behaviors and had not returned to the facility on time, leading to the revocation of LOA privileges. Facility policy recognizes residents' rights to leave the facility for therapeutic reasons and outlines procedures for granting and documenting LOA privileges. However, the policy also allows for the revocation of these privileges by the physician. Staff interviews revealed a belief that leaving the facility is a privilege rather than a right, and that the facility's safety policy could override resident rights. There was no documentation or evidence that less restrictive measures were explored before restricting the residents' ability to leave, resulting in a failure to fully honor their rights to self-determination and a dignified existence.
Failure to Ensure Resident Discharge Rights During Unauthorized Leave
Penalty
Summary
The facility failed to ensure appropriate discharge rights for a resident who was discharged following a leave of absence (LOA) despite having her LOA privileges revoked by physician order. The resident, who had diagnoses including diabetes mellitus type II, infection of the left hip, pain, weakness, and gait abnormalities, was identified as low risk for elopement but had a history of substance abuse and dependence. Her care plan and physician orders specifically indicated that LOA privileges were revoked due to substance use, and she was not allowed to leave the facility. On the day of the incident, the resident left the facility with her family against medical advice (AMA), despite being aware that her LOA privileges had been revoked. Facility staff documented that the resident and her family were informed of the revoked privileges and that leaving under these circumstances was considered an AMA discharge. The resident later contacted the facility and was told she had violated the physician's order and was officially considered to have left AMA. When staff attempted to have the resident and her daughter sign the AMA form, both refused, and staff signed the form with a witness instead. Interviews with facility staff, including the RN, social services designee, administrator, DON, and social worker, confirmed that the resident's LOA privileges were revoked due to substance use and that the decision to proceed with an AMA discharge was based on her leaving the facility without authorization. The administrator and staff indicated that the resident had previously left the facility without permission and had been re-educated, but the final decision to discharge her AMA was made after she left despite the revoked LOA order. Facility policy requires a 30-day advance notice for discharge except in specific circumstances, but in this case, the discharge was processed as AMA due to the resident's actions.
Failure to Properly Label and Remove Expired Insulin
Penalty
Summary
Surveyors found that the facility failed to ensure biologic medications, specifically insulin aspart, were properly labeled with a pharmacy label indicating the resident's name and prescription information. During an observation of a medication cart in the Harbor Light community, an LPN confirmed the presence of an insulin aspart mix pen in the top drawer without knowledge of its owner. The LPN also acknowledged that the cart was checked regularly for expired or beyond-use medications, but the insulin pen was not labeled with the required information and had not been removed after its beyond-use date (BUD). Further interviews revealed that the DON expected insulin to be labeled with the resident's name, the date it was opened, and to be removed from use after reaching its BUD. The facility's policy on labeling medication containers required all medications to be properly labeled with specific information, including the resident's name, prescriber's name, pharmacy details, drug information, prescription number, dispensing date, cautionary statements, expiration date, and directions for use. The policy also required checking the expiration or BUD prior to medication administration. These requirements were not met for the insulin aspart pen found in the medication cart.
Medication Storage at Bedside Without Self-Administration Approval
Penalty
Summary
A deficiency occurred when a resident with diagnoses of dementia and Parkinson's disease, who had intact cognition but was not approved for self-administration of medication, was found to have a bottle of nystatin powder at their bedside on two separate occasions. The resident's Self Administration of Medication (SAM) assessments indicated that the resident could not identify the expiration date of medications and either did not want to or was unable to self-administer medications. The care plan lacked documentation related to the SAM assessment. Interviews with nursing staff, including an LPN, RN, and the DON, confirmed that facility policy required a completed SAM assessment and a provider order before a resident could self-administer or keep medications at bedside. Despite this, the medication remained accessible to the resident, contrary to policy and assessment findings. The facility's policy stated that if a resident was not safe to self-administer, nursing staff would administer the medications, but did not address storage of medications at bedside for residents not cleared for self-administration.
Failure to Obtain Resident Consent for Room Searches
Penalty
Summary
The facility failed to honor the rights of two residents to be treated with respect and dignity regarding their personal space and possessions. Specifically, one resident, who was her own responsible party and had intact cognition, was subjected to repeated room and personal property searches without her voluntary consent. Documentation showed that searches were conducted after visits from family or when the resident returned from a leave of absence, as per physician orders. The resident's care plan identified room searches as a trigger for behavioral issues, and progress notes detailed multiple instances where searches were performed, sometimes after the resident initially refused consent and only acquiesced after persistent staff requests. In some cases, searches were conducted while the resident was not present, including during a period when she was hospitalized. Interviews with staff, including an LPN, social services designee, RN, and the administrator, revealed inconsistent understanding and application of the facility's policy, which required reasonable suspicion, administrator approval, and documented verbal consent from the resident or representative before conducting searches. Staff acknowledged that consent was not always obtained voluntarily and that searches were sometimes justified by facility policy or physician orders rather than resident agreement. The facility's written policy emphasized the necessity of resident understanding and consent, which was not consistently followed in practice.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified when a resident with a primary diagnosis of orthopedic care following a right lower leg amputation reported that his room was too dark, had stains and holes in the walls, and that one of the blinds was not functioning. Observations confirmed several screw holes between the windows, multiple brownish-black streaks on the wall behind the bed and chair, and dried brown substances on the light fixture over the sink. The resident stated these issues bothered him and that he had complained to staff. Interviews with maintenance and housekeeping staff revealed there was no routine schedule for checking rooms for maintenance issues, and deep cleaning was performed only when a room was vacated or annually. Maintenance staff were unaware of the holes in the wall and deferred responsibility for stains to housekeeping, while housekeeping staff acknowledged the stains but indicated that cleaning the light fixture would require maintenance. The facility's policy on a homelike environment did not address wall repairs, and the administrator confirmed knowledge of the room's condition but did not inspect it at the time.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents. For one resident with intact cognition and a diagnosis of morbid obesity, the MDS incorrectly identified the administration of insulin when the resident was actually receiving Trulicity, a non-insulin injectable medication. The registered nurse responsible for the MDS confirmed that Trulicity was the only injectable medication administered during the assessment period and acknowledged that it was mistakenly coded as insulin. The facility was unable to provide a policy for MDS completion when requested. For another resident with diagnoses including cancer, atrial fibrillation, and generalized muscle weakness, the MDS assessment failed to document an active diagnosis of dysphagia, did not identify symptoms of a swallowing disorder, and did not indicate the need for supervision with eating, despite clear documentation in the medical record and care plan. The resident had a history of oropharyngeal dysphagia, a choking episode, and specific dietary and supervision orders. The nurse responsible for the MDS acknowledged that these items should have been coded and that accurate coding is important for updating the care plan and staff instructions.
Failure to Monitor Fluid Restrictions and Notify Provider of Medication Refusals and Weight Changes
Penalty
Summary
The facility failed to properly monitor and document fluid restrictions for two residents with significant medical conditions requiring such interventions. One resident with anemia and end stage renal disease on hemodialysis had a care plan and provider order for a 1200 ml fluid restriction, but records showed an intake of 1580 ml on one day and multiple shifts where fluid intake was either not documented or marked as 'NA' or 'X' instead of recording the actual amount. Another resident with anemia, heart failure, and renal insufficiency had a care plan and orders for a 1920 ml daily fluid restriction, but over several months, numerous shifts lacked any documentation of intake or used 'NA' instead of actual numbers. Interviews with nursing staff confirmed the lack of consistent documentation and the importance of tracking fluid intake for residents with such restrictions. Additionally, the facility did not notify the provider when a resident with multiple chronic conditions, including atrial fibrillation, morbid obesity, chronic kidney disease, hypertension, and COPD, refused prescribed diuretic medication and experienced significant weight gain. The resident's orders required notification of the heart center for weight changes of five pounds or more in a week and documentation of refusals. However, the electronic medical record did not reflect provider notification for either the medication refusals or the weight gain, despite the resident refusing the diuretic for several days and gaining over 14 pounds in a short period. Interviews revealed that some notifications may have been made outside the EMR, but there was no consistent documentation as required by policy. The facility's own policy on refusal of treatment required detailed documentation of refusals, including the resident's response, reason for refusal, and provider notification, but this was not consistently followed. The director of nursing and nurse manager both stated expectations for documentation and provider notification in such cases, but the records did not support that these actions were taken according to policy.
Failure to Perform Weekly Skin Checks and Update Care Plan for Pressure Ulcer
Penalty
Summary
A resident with multiple sclerosis, quadriplegia, and muscle weakness developed an unstageable pressure ulcer to the left buttock while in the facility. The resident was identified as being at risk for pressure ulcers, requiring maximum assistance with bed mobility, and using a Roho cushion in the wheelchair and a pressure-reducing mattress. Despite provider orders for weekly skin checks and care plan interventions for pressure ulcer prevention, documentation revealed that weekly skin checks were not consistently performed, and the presence of an actual pressure ulcer was not promptly reflected in the care plan. Progress notes indicated that staff observed redness and later an open wound on the resident's left buttock, with the Roho cushion found to be flat and reportedly having been that way for some time. The cushion was reinflated only after the wound was discovered. Staff interviews revealed inconsistent knowledge and education regarding the proper maintenance and inflation of the Roho cushion, with some nursing assistants unaware of specific requirements and others relying on informal checks or verbal instructions. The care plan lacked individualized interventions such as specific repositioning frequency and did not include the presence of the actual pressure ulcer or integrated wound therapies in a timely manner. Further, the facility's documentation and assessments were incomplete, with missing sections in wound evaluation forms and a lack of detailed care plan updates following the development of the pressure ulcer. Staff interviews confirmed that repositioning and skin checks were not always performed or documented as required, and education materials regarding the Roho cushion were not provided. The facility's policy required individualized repositioning schedules and weekly skin inspections, but these were not consistently implemented for the resident.
Failure to Comprehensively Assess Bed Rail Use and Entrapment Risk
Penalty
Summary
The facility failed to conduct a comprehensive assessment prior to the use of bed rails for a resident with moderate to severe cognitive impairment, Huntington's disease, and depression, who was dependent for all mobility needs. The resident's care plan indicated the use of bed rails to promote independence, but the Bedrail Risk Assessment (BRA) did not address all required safety zones as outlined by FDA guidance, specifically lacking information for zones 1, 2, the footboard portion of zone 6, and zone 7. Additionally, the BRA did not document what alternatives to bed rails were attempted before their use. Observations confirmed that half bedrails were installed on both sides of the resident's bed. Interviews with facility staff revealed that maintenance installed bedrails after confirming provider orders but did not perform measurements or assessments related to entrapment risks. The physical therapy assistant, responsible for bedrail assessments, acknowledged that only limited measurements were taken and that the most recent assessment did not fully address all entrapment zones. Facility policy required compatibility checks and adherence to FDA safety dimensions, but these were not fully documented or implemented in this case.
Failure to Document Indications for Use on Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders for a resident included clear indications for use, as required to prevent unnecessary drug administration. Review of one resident's medication orders revealed that multiple prescribed drugs, including aspirin, atorvastatin, finasteride, levothyroxine, pantoprazole, psyllium, solifenacin, tamsulosin, thiamine, and vibegron, did not have documented indications for use in the medical record. This omission was confirmed during interviews with a trained medication aide, a registered nurse, and a licensed practical nurse, all of whom acknowledged that medication orders should specify the reason or diagnosis for each drug prescribed. The resident in question had a complex medical history, including moderately impaired cognition, dementia, muscle weakness, Wernicke's encephalopathy, hypertension, hypothyroidism, urinary incontinence, type 2 diabetes, and alcohol use in remission. Despite these diagnoses, the medication administration records lacked specific indications linking each medication to the resident's conditions. The director of nursing and nursing staff verified during interviews that the facility's expectation is for all medication orders to include an appropriate indication, which was not met in this case.
Infection Control Deficiencies in Hand Hygiene, Glucometer Disinfection, and Medication Administration
Penalty
Summary
Staff failed to perform appropriate hand hygiene and glove changes during peri care for a resident with severe cognitive impairment and total incontinence. Two nurse assistants washed their hands and donned gloves before beginning care, but did not change gloves or wash hands after removing a soiled brief and cleaning the resident's peri area. They proceeded to place a clean brief and dress the resident without changing gloves or performing hand hygiene, only removing gloves and washing hands at the end of the process. The nurse assistants stated they only changed gloves or washed hands if there was visible stool, contrary to facility policy and infection preventionist guidance, which required glove changes and hand hygiene when moving from dirty to clean tasks. A shared glucometer was not cleaned and disinfected according to the manufacturer's instructions after use for blood sugar testing. An LPN used the glucometer for a resident with diabetes, then cleaned it with an alcohol wipe before returning it to the medication cart. The LPN stated this was her usual process, but the manufacturer's instructions required a two-step process: cleaning with detergent and then disinfecting with a validated bleach wipe, ensuring the device remained wet for the required contact time. The assistant director of nursing confirmed that shared glucometers should be disinfected with the appropriate wipes, and was unaware that a shared device was in use. During eye drop administration for a resident with moderately impaired cognition and multiple diagnoses, a trained medication aide did not wear gloves or perform hand hygiene. The aide used bare hands to hold the resident's eyelids open and administer the drops, repeating the process when the first attempt was unsuccessful. The aide acknowledged that gloves should be worn to prevent germ transmission but did not do so in this instance. Facility policy required staff to follow infection control procedures, including hand hygiene and glove use, during medication administration.
Failure to Conduct Regular Bed and Bedrail Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails as part of a routine maintenance program for a resident with significant cognitive and physical impairments. The resident had diagnoses including dementia, Huntington's disease, and depression, and was dependent on staff for all mobility needs. The care plan indicated the use of bedrails to promote independence, and observations confirmed the presence of half bedrails on both sides of the bed. However, interviews revealed that maintenance staff only checked bedrails for looseness and tightened them monthly, without performing measurements or assessments related to entrapment risks. There was no established schedule for comprehensive inspections of beds, mattresses, or bedrails beyond this limited check. Further, while a physical therapy assistant performed initial bedrail assessments when rails were first installed, there were no ongoing evaluations to monitor changes in the resident's risk of entrapment. The facility's policy required routine inspections to identify risks, including entrapment, and mandated that inspection results be reported to the administrator and QAPI committee. Despite this, maintenance records documenting regular bed inspections and maintenance were requested but not provided, indicating a lack of documentation and follow-through on required safety checks.
Survey Results Not Readily Accessible or Properly Posted
Penalty
Summary
The facility failed to ensure that the most recent state agency survey results were readily accessible to residents, visitors, and families, and did not post appropriate signage or notice of the inspection reports within the campus. During observation and interviews, it was found that no posted signs were available for survey results, and the survey results were kept in a green binder secured with a cable on a shelf near the front desk, requiring review at the front desk rather than in private. The binder was organized by year, but only contained survey results up to June 2023 at the time of observation. The administrator confirmed responsibility for maintaining the binder and acknowledged that more recent survey results and complaints from 2024 and 2025 were only added after the survey team arrived. No policies related to survey results were provided when requested.
Nursing Assistant's Abusive Actions and Social Media Violations
Penalty
Summary
The facility failed to protect residents from mental, emotional, and physical abuse, as evidenced by the actions of a nursing assistant (NA-A) who took humiliating photographs and videos of four residents and posted them on social media. NA-A was observed setting up a camera to record interactions with a resident, during which she aggressively threw the resident into bed, hit them with a shoe, and made obscene gestures. These actions were captured on video and shared on Snapchat, violating the residents' privacy and dignity. The report details that NA-A took and shared inappropriate images of residents, including one resident in their underwear, another with exposed private areas, and a third holding a phone displaying an inappropriate image. These actions were not only a breach of privacy but also constituted mental and emotional abuse. The residents involved had various medical conditions, including cognitive impairments, which made them particularly vulnerable to such abuse. Interviews with staff and residents revealed that NA-A was aware of the facility's policies prohibiting the use of cell phones during care and the posting of residents' images on social media. Despite this, NA-A continued to engage in these abusive practices, which were not reported by other staff members who witnessed some of the behavior. The facility's failure to enforce its policies and protect residents from abuse resulted in an immediate jeopardy situation, highlighting significant lapses in oversight and staff compliance with established protocols.
Removal Plan
- Policy review
- Appropriate education and training of all employees
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately and consistently documented in the electronic health record (EHR), the Provider Order for Life Sustaining Treatment (POLST), and physician orders. This discrepancy involved a resident whose code status was not accurately documented, leading to an immediate jeopardy situation. The resident's care conference initially identified them as a full code, but the POLST in the EHR indicated a Do Not Resuscitate (DNR) status. When the facility became aware of the discrepancy, they changed the EHR banner to DNR to match the POLST, which was against the resident's wishes to be resuscitated. The issue was identified when a licensed practical nurse (LPN) and the assistant director of nursing (ADON) reviewed the POLST book and the EHR, finding that they did not match. The ADON stated that code status should be reviewed at each care conference, but the actual POLST was not reviewed unless there was a concern. The resident's family member recalled that the resident's code status was originally DNR but was changed to full code per the resident's wishes. However, the facility had not communicated with the family member before changing the order to DNR. The care conference notes consistently identified the resident's code status as full code, and the social service progress note confirmed that the resident's current wishes were to be resuscitated. Despite this, the facility had changed the order to DNR without verifying with the family member. The discrepancy in documentation and lack of communication led to the immediate jeopardy situation, as the resident's wishes were not accurately reflected in the facility's records.
Removal Plan
- Corrected the code status for R86 to full code per R86's wishes.
- Updated R86's POLST in the EHR to full code per R86's wishes.
- Completed a facility-wide audit to ensure there were no other code status discrepancies.
- Reviewed policies and procedures.
- Provided education for staff involved with care conferences.
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that 56 residents with personal funds accounts had access to their funds after hours and on weekends. Interviews with residents, including those who were cognitively intact, revealed that they could only access their money during specific hours on weekdays, typically between 1:30 p.m. and 3:30 p.m. This limitation was inconvenient for residents, as they had to plan ahead to have the money they needed, and there was no access to funds on weekends. Observations confirmed that a sign at the front desk indicated restricted banking hours, and staff interviews corroborated the limited access to funds. Staff members, including registered nurses, trained medication aides, and licensed practical nurses, were generally unaware of any arrangements for residents to access their funds outside the specified hours. The business office manager stated that residents could request money during open banking hours or by talking with staff, who would then relay the request to the business office manager or administrator. However, there was no petty cash available in the facility, and the facility's policy indicated that resident requests for access to their funds should be honored as soon as possible. The facility's failure to maintain petty cash and provide access to funds outside of the limited banking hours led to the deficiency.
Failure to Monitor Nurse Aide Registry for Inactive Status
Penalty
Summary
The facility failed to monitor the nurse aide registry for inactive nursing assistants during their employment, resulting in an inactive nurse aide continuing to work directly with residents. Specifically, a review of the personnel file for a nurse aide identified a hire date of December 7, 2023. However, a search on the Minnesota Nurse Aid Registry revealed that the nurse aide's status became inactive as of May 16, 2024. Despite this, the facility schedule showed that the nurse aide was actively working day shifts during the survey conducted on May 20th, 21st, 22nd, and 23rd of 2024. During an interview, the facility administrator stated that both the staffing agency and the facility check the nurse aide registry upon hire, and the agency was responsible for notifying the facility of upcoming expirations. The administrator was unaware that the nurse aide no longer had an active registration.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene, leading to deficiencies in infection prevention and control. For one resident with severe cognitive impairment and a vascular wound, staff did not wear gowns as required under Enhanced Barrier Precautions during high-contact care activities. Despite a sign indicating the need for gloves and gowns, nursing assistants only donned gloves while changing the resident's soiled brief and providing hygiene care. The nursing assistants acknowledged the requirement to wear gowns but cited the absence of PPE in the dementia unit as a reason for non-compliance. The Director of Nursing confirmed the expectation for staff to wear appropriate PPE during personal care. In another instance, a registered nurse failed to perform hand hygiene during medication administration for a resident with severe cognitive impairment and multiple diagnoses. The nurse did not sanitize hands or change gloves between different treatments, leading to potential cross-contamination. Additionally, the nurse used another resident's medication, which was not acceptable and posed an infection prevention concern. The Director of Nursing emphasized the importance of hand sanitization after glove removal and before applying new gloves to prevent cross-contamination.
Failure to Provide SNFABN to Resident After Medicare Coverage Ended
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to a resident who remained in the facility after their Medicare Part A covered services ended. The resident's CMS-10123 form indicated that their last covered day was 3/7/24, but their medical record lacked evidence of an SNFABN being provided to explain the estimated cost per day or the rationale for the extended care services. Interviews with the business manager and administrator confirmed that the resident did not receive the SNFABN, despite having remaining Medicare Part A days. The facility did not provide a beneficiary policy but did have a CMS form with instructions for SNFABN completion, which states that an SNFABN must be issued prior to providing services that Medicare may not cover.
Inaccurate MDS Coding for Resident's Vision
Penalty
Summary
The facility failed to accurately code section B of the Minimum Data Set (MDS) for a resident, identified as R67, who was reviewed for MDS accuracy. R67's significant change MDS indicated that the resident's vision was marked as adequate, despite having multiple diagnoses that suggested otherwise. These diagnoses included type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral posterior synechiae, bilateral iridocyclitis, and cataract with neovascularization of the right eye. The resident's care plan also identified a vision impairment, with interventions to assist the resident in locating items. Additionally, R67 had an order for timolol maleate ophthalmic solution to treat high pressure inside the eye, further indicating a vision issue. The assistant director of nursing (ADON) confirmed that the MDS was incorrectly coded, stating that R67's vision was impaired and not adequate as marked. The director of nursing (DON) also emphasized the importance of MDS accuracy, as it influences care and reimbursement. The discrepancy in the MDS coding was identified during a review of R67's significant change MDS, highlighting a failure in the facility's assessment process to accurately reflect the resident's condition.
Medication Administration Error Due to Policy Violation
Penalty
Summary
The facility failed to adhere to standard practices for safe medication administration for a resident with severe cognitive impairment and multiple diagnoses, including major depression, anxiety, osteoarthritis, and diabetes. During a medication pass observation, a registered nurse (RN) was seen using Nystatin powder from another resident's supply to treat the resident's groin area, as the RN could not locate the resident's own medication. This action was contrary to the facility's policy, which mandates that medications ordered for a specific resident must not be administered to another. The incident was confirmed through interviews with the RN involved and the Director of Nursing (DON). The RN admitted to using another resident's Nystatin powder and acknowledged that it was inappropriate, even though the dosage was the same. The DON reiterated that each resident should have their own designated medication and that it was unacceptable to use medication from one resident for another. The facility's policy on administering medications clearly states that medications must be administered in accordance with prescriber orders and should not be shared between residents.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to follow medical orders and document necessary information for residents with specific health conditions. For one resident with heart failure, the facility did not adhere to the order to report weight changes to the cardiology heart failure program. The resident's care plan did not address heart failure, and there were missing daily weight records and communications with the heart failure program, despite significant weight fluctuations. The assistant director of nursing acknowledged the importance of monitoring weights for medication adjustments, especially after the resident's recent heart surgery. Another resident, who was cognitively intact and diagnosed with malignant neoplasm of the liver, hypertension, and diabetes mellitus, did not receive prescribed pain medication doses as ordered. The electronic medication record showed missed doses of hydrocodone-acetaminophen, and the resident reported inconsistent medication administration depending on the staff. The director of nursing confirmed the expectation for all medications to be administered and documented as ordered. Additionally, the facility failed to document behaviors related to as-needed medication administration for a resident with severe cognitive impairment and schizophrenia. The medication administration record did not consistently reflect behavior charting, and there was a lack of documentation for the use of PRN medications. The director of nursing expected charting to accompany PRN behavior medication administration, and the facility's protocol emphasized documenting new or changed behaviors and utilizing non-pharmacologic approaches before antipsychotic medications.
Oxygen Tanks Unsecured in Resident Room
Penalty
Summary
The facility failed to secure oxygen tanks in a resident's room, leading to a potential accident hazard. The resident, identified as R75, was cognitively intact and on oxygen therapy due to conditions such as morbid obesity and chronic respiratory failure. During an observation, four oxygen tanks were found in R75's room, with two tanks unsecured and free-standing. The resident mentioned that the tanks were delivered by the oxygen company and were intended for use upon discharge. Staff members, including an LPN and a nursing assistant, confirmed that the tanks were full and should not be free-standing. The LPN noted that the resident was using an oxygen concentrator, and the tanks should not have been stored in the room. The assistant director of nursing and a licensed social worker later removed the tanks, and the director of nursing acknowledged that storing oxygen tanks in resident rooms is a potential fire hazard. The facility's policy on oxygen administration and medical gas cylinder storage emphasized the importance of securing portable oxygen cylinders to prevent mechanical damage and potential hazards.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
The facility failed to notify the provider of a significant weight loss in a resident, identified as R56, who was under review for nutrition and weight loss. R56 had a history of dementia without behavior and gastroesophageal reflux disease (GERD) and required partial assistance with eating. The resident's care plan aimed to maintain a weight of 163 pounds within five percent, with no signs of malnutrition and consuming at least 50 percent of meals. However, the resident experienced a significant weight loss over several months, dropping from 163.9 pounds in January to 147.1 pounds in May. Despite this, there was no notification to the provider about the weight loss, as confirmed by RN-B during an interview. The registered dietician noted significant unplanned weight loss at various intervals, with a recommendation for nutritional supplements three times daily due to the weight loss. The facility's policy required nursing services to notify the physician and dietician when a nutritional problem was identified, but this was not followed. The director of nursing stated that her expectation was for the provider to be notified in such cases. The failure to update the provider about the resident's significant weight loss constitutes a deficiency in the facility's care practices.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident (R1) who was at risk for elopement, resulting in an immediate jeopardy situation. R1, diagnosed with bipolar disorder and metabolic encephalopathy, had a history of exit seeking and attempting to leave the building, putting him at high risk for elopement. Despite having a wanderguard on his wrist, R1 was able to elope from the facility unnoticed. Staff members, including a nursing assistant and a maintenance worker, mistook R1 for a visitor when the wanderguard alarm went off, failing to conduct a thorough search for the missing resident. It took approximately 1.25 hours before a code 99 (missing resident) was called, and R1 was found two miles away from the facility. The report highlighted lapses in staff response to the wanderguard alarm and the delayed realization of R1's absence. The nursing assistant and maintenance worker failed to properly investigate the alarm, assuming R1 was a visitor outside the building. Nurses and management were only alerted to R1's disappearance after a significant delay, raising concerns about the facility's supervision protocols for residents at risk for elopement.
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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