Benedictine Living Community | Mother Of Mercy
Inspection history, citations, penalties and survey trends for this long-term care facility in Albany, Minnesota.
- Location
- 230 Church Avenue, Box 676, Albany, Minnesota 56307
- CMS Provider Number
- 245339
- Inspections on file
- 30
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Benedictine Living Community | Mother Of Mercy during CMS and state inspections, most recent first.
Two residents with heart failure were inadequately monitored, leading to one being re-hospitalized. The facility failed to follow physician orders for weight monitoring and PRN Lasix administration, resulting in significant weight gain and edema. Despite recommendations to clarify medication orders, the facility discontinued the PRN Lasix without proper authorization, contributing to the deficiency in care.
The facility failed to post accurate daily staffing information, affecting all 57 residents and their visitors. From 11/17/24 to 12/20/24, postings lacked details on the number of licensed staff and hours worked. The DON admitted to incorrect postings due to miscommunication, and the information was not updated on weekends. No policy was provided.
The facility failed to conduct a comprehensive facility-wide assessment, missing critical components such as facility information, quality assurance input, and contingency staffing plans. The administrator acknowledged the importance of the assessment for guiding staffing and resident care needs, but the document provided was incomplete, potentially affecting all 57 residents.
The facility's QAPI program was ineffective, failing to identify and address quality deficiencies, including communication of medication changes, bed-hold notices, and heart failure interventions. A resident was re-hospitalized due to exacerbation of heart failure. The facility lacked comprehensive assessments and proper hand hygiene practices. Meeting documentation was insufficient, and there was a delay in addressing known issues.
A facility failed to ensure a resident's advanced directives were accurately reflected in their medical records. The resident's POLST indicated a DNR status, but the EMR banner showed FULL CODE. This discrepancy was discovered by a nurse manager and confirmed by the DON, highlighting a failure to ensure the resident's wishes were documented correctly for emergency situations.
A facility failed to provide a written bed-hold notice during two hospital transfers for a resident with multiple health conditions, including dementia and CHF. Verbal consent was obtained from the family, but no written notice was given, contrary to the facility's policy requiring written information at the time of transfer or within 24 hours for emergencies.
The facility failed to complete and transmit a discharge MDS for two residents, one with osteoarthritis and another with hyponatremia, due to communication lapses. The MDS nurse, working offsite, did not receive necessary updates on resident discharges, and the DON noted a lack of involvement in MDS processes. The policy for MDS submissions was not provided, highlighting procedural gaps.
The facility failed to ensure proper hand hygiene during medication administration and handling of soiled clothing. An RN and an LPN did not perform hand hygiene between tasks and residents, while a nursing assistant carried soiled clothing without bagging it or wearing gloves. These actions were contrary to infection control standards and acknowledged by the staff involved.
A facility failed to provide a pneumococcal vaccine in a timely manner to a resident. The resident's MDS indicated they were not up to date with vaccinations, and a consent form was signed and uploaded to the EMR. The DON was unsure of the immunization process, and the IP, who reviewed immunization status using MIIC and an app, confirmed the vaccine was not administered by the expected date.
A facility failed to notify a resident's representative about the discontinuation of a PRN Lasix prescription for CHF-related edema. Despite the resident's significant medical conditions, including dementia and CHF, the family was not informed of the medication change, which was confirmed by the DON. This oversight violated the facility's policy on promptly notifying changes in medical care.
The facility failed to notify and consult the provider for two residents with heart failure monitoring needs. One resident did not receive prescribed Lasix for weight gain, and another had multiple missed weigh-ins without provider notification. The DON confirmed the nursing staff's responsibility to document and communicate concerns, which was not adhered to, leading to the deficiency.
The facility failed to update care plans for two residents with heart failure. One resident's care plan lacked updates for monitoring lung congestion and weight gain, while another's care plan did not reflect the required frequency of weight monitoring. Interviews with the DON confirmed the care plans were not updated as expected, which is essential for preventing acute exacerbations of heart failure.
A resident experienced a critical low potassium level due to missed medication doses, as the facility failed to notify the physician about the unavailability of potassium supplements. Despite knowing the medication was not available, staff did not contact the physician for guidance, leading to a critical drop in potassium levels and the need for emergency medical services.
A resident missed 10 doses of potassium due to the facility's failure to ensure timely administration, resulting in a critically low potassium level and an emergency room visit. The resident, recently discharged from the hospital, experienced a drop in potassium levels after starting a diuretic. Despite multiple faxes to the pharmacy, the medication was not delivered, and staff failed to notify the provider or follow up adequately.
The facility failed to implement effective infection control measures during a renovation project, leading to the spread of dust and potential mold exposure. The project was not overseen by a licensed contractor, and CDC guidelines were not followed. Immunocompromised residents were not relocated or monitored, and communication among staff was inadequate.
A resident with severe environmental allergies experienced significant health issues due to inadequate precautions during facility renovations. The care plan lacked necessary information on her allergies, and staff were not properly informed, leading to repeated exposure to allergens. Despite being offered measures like an N95 mask and supplemental oxygen, the resident declined a room change, believing odors were pervasive. The facility's failure to update the care plan and ensure staff awareness resulted in ongoing distress for the resident.
Failure to Monitor and Implement Heart Failure Interventions
Penalty
Summary
The facility failed to adequately monitor and implement interventions for heart failure in two residents, resulting in actual harm to one resident who was re-hospitalized due to exacerbation of heart failure. The resident, who had a history of dementia, chronic diastolic congestive heart failure (CHF), diabetes, and other conditions, was prescribed furosemide (Lasix) 20mg daily as needed for lung congestion and lower extremity edema. However, the facility did not contact the cardiologist for specific parameters for administering the PRN diuretic, nor did they monitor the resident for signs of lung congestion and edema as required. The resident's records showed multiple instances where weight gain and edema were not properly assessed or reported to the provider, and the PRN Lasix was not administered according to the prescribed parameters. Despite recommendations from the pharmacist to clarify the PRN Lasix order, the facility discontinued the medication without proper authorization or clarification from the provider. This lack of monitoring and communication led to the resident experiencing significant weight gain and edema, ultimately resulting in hospitalization for acute exacerbation of CHF. Another resident with a history of acute on chronic congestive heart failure and other cardiac conditions also experienced inadequate monitoring. The facility failed to consistently obtain and document weights as ordered, missing numerous opportunities to monitor the resident's condition. Despite the resident's reports of weight gain and tighter legs, the facility did not notify the provider of missed weights or changes in the resident's condition. This lack of adherence to physician orders and failure to communicate critical information contributed to the deficiency in care for both residents.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the required staffing information was posted daily, which had the potential to affect all 57 residents and their visitors. Upon entrance on 12/16/24 and 12/17/24, the staff postings were observed to include licensed staff and total hours worked. However, from 11/17/24 through 12/20/24, the postings lacked accurate information regarding the number of licensed staff working each day, the hours worked, and the total hours of all licensed staff. On 12/20/24, the Director of Nursing (DON) acknowledged that the information on the staff postings was incorrect due to miscommunication and that the information had been lost. The DON and the HR manager confirmed that the daily staffing sheets were incorrect or missing and were not updated in person on weekends. Additionally, the facility was unable to provide a policy regarding the posting of staffing information.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment necessary for providing adequate care and services to its residents. During the entrance conference, the survey team requested the facility assessment, which was not provided within the stipulated time. Subsequent requests were made, and eventually, the administrator sent an incomplete Facility Assessment Tool. The document, dated September 5, 2024, lacked critical components such as the facility's information, input from the quality assurance team, and a list of personnel involved in the assessment. Additionally, it did not include a contingency staffing plan, staff competencies, and health information technology resources. The administrator confirmed their responsibility for creating the facility assessment and acknowledged the importance of its completion in guiding staffing, equipment, and resident care needs. However, the assessment was incomplete, and no facility assessment policy was provided upon request. This deficiency had the potential to affect all 57 residents in the facility, as it indicated a lack of preparedness in both day-to-day operations and emergency situations.
Ineffective QAPI Program Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Assessment/Quality Assurance and Performance Improvement (QAA/QAPI) program, which resulted in several deficiencies. The facility did not conduct ongoing quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct repeated quality deficiencies. These deficiencies included failing to communicate medication changes to residents or their representatives, not providing written notice of a bed-hold during hospital transfers, and failing to monitor and implement interventions for heart failure, which led to the re-hospitalization of a resident. Additionally, the facility did not conduct a comprehensive facility-wide assessment and failed to ensure appropriate hand hygiene during medication pass and while handling soiled clothing. The facility's QAPI meeting minutes for the past 12 months were not adequately documented, with only one meeting agenda provided, which did not address previous survey results or current performance improvement projects. Interviews with the Director of Nursing (DON) and the administrator revealed awareness of ongoing quality of care issues, such as staff obtaining and documenting resident weights, but there was a delay in providing staff education or training. The administrator mentioned that the facility held monthly QAA meetings and quarterly QAPI meetings, but no monthly meeting minutes were provided, and the QAPI agenda lacked evidence of the reported performance improvement projects.
Failure to Accurately Reflect Advanced Directives in Medical Records
Penalty
Summary
The facility failed to ensure that a resident's advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart. This deficiency was identified for a resident who was moderately cognitively impaired and had multiple diagnoses, including hypertension, arthritis, osteoporosis, and asthma. The resident's Provider Orders for Life-Sustaining Treatment (POLST) indicated a Do Not Attempt Resuscitation (DNR) status, signed by the healthcare agent and a physician's assistant. However, the electronic medical record (EMR) banner incorrectly displayed the resident's resuscitation status as FULL CODE. The discrepancy was discovered when the registered nurse manager (RN-D) reviewed the resident's code status and found that the EMR banner did not match the POLST. The director of nursing (DON) confirmed that the EMR banner and POLST form did not match prior to the survey start. The facility's policy required that resuscitation orders be reviewed upon admission and verified with the POLST. The inconsistency in the resident's resuscitation status was noted to have been corrected after the survey entrance, indicating a failure to ensure the resident's wishes were accurately documented and could be implemented correctly in an emergent situation.
Failure to Provide Written Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of a bed-hold at the time of transfer for a resident who was hospitalized on two separate occasions. The resident, who had a significant change in their Minimum Data Set (MDS) indicating diagnoses of dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation, peripheral neuropathy, and diabetes, was transferred to the hospital for increased redness and swelling in the left foot and later for increased pain and a change in transfers. In both instances, verbal consent for a bed-hold was obtained from the resident's family member, but there was no evidence that a written bed-hold notice was provided to the resident or their representative at the time of transfer. The facility's Bed-Holds and Returns Policy, revised in October 2022, required that residents or their representatives be provided with written information regarding bed-hold policies at the time of transfer or within 24 hours for emergency transfers. Despite this policy, the facility did not provide the necessary written documentation during the resident's transfers on both occasions. The Director of Nursing (DON) confirmed that the written bed-hold information was not provided as required, emphasizing the importance of such documentation to ensure residents and their representatives understand their rights and the implications of a bed-hold.
Failure to Complete and Transmit Discharge MDS for Two Residents
Penalty
Summary
The facility failed to complete and transmit a discharge return not anticipated Minimum Data Set (MDS) for two residents, leading to a deficiency in the transmission of resident assessments. Resident 25, who was cognitively intact and had a primary diagnosis of osteoarthritis with a joint replacement, was discharged without a completed discharge MDS. Similarly, Resident 48, who was also cognitively intact and had a primary diagnosis of hyponatremia, left the facility without a completed discharge MDS. The medical records for both residents lacked evidence of the required discharge MDS completion. The MDS registered nurse, who worked offsite, confirmed that she relied on the facility to update her on admissions, discharges, or significant changes in residents' conditions. She acknowledged that the discharge MDS was not completed for both residents, possibly due to a lack of updates from the facility. The Director of Nursing, who had limited involvement with MDS completion and submission, mentioned that there was a leadership email group intended to provide updates on resident status changes, which the MDS nurse should have been part of. However, the policy for MDS submissions was requested but not provided, indicating a potential gap in communication and procedural adherence within the facility.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration and handling of soiled clothing, which could potentially affect all 57 residents, staff, and visitors. During a medication pass, an RN did not wash hands or use alcohol-based hand sanitizer after administering medication to a resident and before preparing medication for another resident. Similarly, an LPN did not perform hand hygiene after removing gloves following a blood sugar check and insulin administration, and before handling medication for another resident. Both staff members acknowledged the oversight during interviews, with the RN stating she intended to use hand sanitizer and the LPN admitting she forgot to do so. Additionally, a nursing assistant was observed carrying soiled clothing without placing it in a bag and without wearing gloves, as required by infection control standards. The nursing assistant confirmed the clothing should have been bagged before being removed from the resident's room. The infection preventionist stated that staff were expected to bag soiled items and wear gloves to prevent the spread of infection. The facility's policy on handling soiled clothing was requested but not provided.
Failure to Timely Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal vaccine in a timely manner to one resident reviewed for immunizations. The resident's admission Minimum Data Set (MDS) indicated that they were not up to date with pneumococcal vaccinations. A consent form for the vaccination was signed by the resident and uploaded to the electronic medical record within the same week as admission. However, the Director of Nursing was unsure of the process for reviewing and administering immunizations, deferring to the infection preventionist. The infection preventionist stated that she reviewed immunization status upon admission using the Minnesota Immunization Information Connection and used an app recommended by the facility pharmacy to determine vaccine eligibility. Despite these steps, the immunization was not received and administered by the expected date.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to ensure that changes in medication were communicated to a resident's representative, leading to a deficiency in the notification of change in medications. The resident, who had a significant change in their Minimum Data Set (MDS), was diagnosed with dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation, peripheral neuropathy, and diabetes. A cardiology clinic note indicated that the resident was prescribed furosemide (Lasix) 20mg daily as needed for lung congestion and lower extremity edema related to CHF. However, the medication was discontinued without notifying the resident's representative. The resident's family member, who accompanied them to the cardiologist, was not informed of the discontinuation of the PRN Lasix. This lack of communication was confirmed by the Director of Nursing (DON), who acknowledged that the progress notes failed to indicate that the family had been notified of the medication change. The facility's policy required prompt notification of any changes in medical care or nursing treatments, which was not adhered to in this case, resulting in a deficiency.
Failure to Monitor and Notify Provider for Heart Failure Management
Penalty
Summary
The facility failed to notify and consult the provider for two residents with heart failure monitoring needs. Resident R33 had a significant change in condition, with diagnoses including dementia, chronic diastolic congestive heart failure, atrial fibrillation, peripheral neuropathy, and diabetes. Despite having a physician's order for Lasix 20mg to be administered as needed for specific weight gains, the medication was not given on two occasions when the resident experienced weight gains that met the criteria. The registered nurse confirmed the failure to administer the medication as ordered. Resident R43, who was cognitively intact and had a history of acute on chronic congestive heart failure, hypertensive heart disease, and other related conditions, had an order for weights to be taken three times a week. However, the facility missed several opportunities to record weights over multiple months, and there was no evidence of provider notification regarding these missed weights. The resident reported feeling like she was gaining water weight, and her weight had increased over time, but the scheduled weigh-ins were not consistently performed. The Director of Nursing confirmed the orders for both residents and acknowledged the nursing staff's responsibility to obtain, document, and communicate any concerns regarding scheduled weights. The facility's policy required prompt notification of the resident's attending physician for changes in the resident's condition, but this was not adhered to in these cases, leading to the deficiency.
Failure to Update Care Plans for Residents with Heart Failure
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents, R33 and R43, who were reviewed for heart failure. R33 was admitted with diagnoses including chronic diastolic congestive heart failure (CHF), atrial fibrillation, chronic obstructive pulmonary disease (COPD), and diabetes. Despite a cardiology clinic note indicating the need for a PRN diuretic for lung congestion and lower extremity edema, R33's care plan was not updated to include interventions for monitoring these conditions. Additionally, hospital discharge orders for weight monitoring were not transcribed or implemented, and the care plan lacked updates for monitoring weight gain or signs of CHF exacerbation. R43, admitted with acute on chronic congestive heart failure and other cardiac conditions, had a care plan that included monitoring for signs of CHF exacerbation. However, despite an order for weights to be taken three times weekly, the care plan was not updated to reflect this, and weights were only recorded once weekly. This discrepancy was noted in physician notes, which highlighted ongoing concerns about the resident's weight gain due to fluid retention. Interviews with the Director of Nursing (DON) confirmed the expectations for nursing staff to implement interventions and update care plans based on assessments, provider notes, and hospital discharge orders. The DON acknowledged that the care plans for both residents were not updated as required, which is crucial for maintaining resident health and providing clear directives to prevent acute exacerbations of heart failure. A policy was requested during the interview but was not provided.
Failure to Notify Physician of Missed Medication Leads to Critical Low Potassium
Penalty
Summary
The facility failed to notify a resident's physician about a missed administration of medication, which led to a critical low potassium level in the resident. The resident, who had been admitted from the hospital with increased edema and pain, was prescribed Bumex for edema and potassium supplements due to low potassium levels. However, the potassium medication was not available from the pharmacy, resulting in the resident missing ten doses over several days. Despite the critical nature of the resident's low potassium levels, the facility staff did not inform the resident's physician about the missed doses until several days later. Interviews with staff revealed that they were aware of the medication's unavailability and the resident's low potassium levels but failed to contact the physician for further guidance. The facility's policy required prompt notification of the provider in the event of significant medication-related errors, which was not adhered to in this case. The resident's potassium level continued to drop, reaching a critically low level, which necessitated emergency medical services. The facility's failure to communicate the medication error and the resident's declining condition to the physician in a timely manner was a significant oversight, as per the facility's policies on medication errors and changes in resident condition.
Failure to Administer Potassium Timely Leads to Critical Deficiency
Penalty
Summary
The facility failed to ensure that potassium was available and administered timely as prescribed by the physician for a resident, resulting in the resident missing 10 doses of potassium. This led to a critically low potassium level of 2.4 mmol/L, requiring intravenous potassium administration. The resident, who was asymptomatic and stable, had been admitted from the hospital with a history of E. coli pneumonia and septic shock, and was experiencing pain and edema in the lower extremities. The resident's potassium level was initially recorded at 3.8 mmol/L upon admission, but dropped to 2.8 mmol/L, prompting an order for potassium chloride to be administered twice daily. However, the medication was not available from the pharmacy, and despite multiple faxes sent by the facility to the pharmacy, the potassium was not delivered until several days later. During this period, the resident's potassium level further decreased to 2.4 mmol/L, necessitating an emergency room visit for treatment. Interviews with facility staff revealed that there was a breakdown in communication and follow-up procedures, as staff did not adequately follow up with the pharmacy or notify the provider about the unavailability of the medication. The pharmacy also failed to process the order correctly, leading to a delay in medication delivery. The facility's policies on medication administration and error reporting were not adhered to, contributing to the deficiency.
Inadequate Infection Control During Renovation
Penalty
Summary
The facility failed to implement effective infection control measures during a demolition and renovation project, which had the potential to impact all 51 residents. The project was not overseen by a licensed contractor, and the facility did not adhere to CDC guidelines for infection control in long-term care construction. As a result, construction odors and dust traveled into resident areas, and a potential black mold discovery was not properly remediated. The facility did not establish a multidisciplinary team to coordinate the project, nor did it perform an Infection Control Risk Assessment (ICRA) before the project began. The construction area lacked proper barriers to prevent dust and mold spores from spreading, and there was no negative air pressure or air filtration system in place. The facility also failed to relocate immunocompromised residents or monitor their respiratory health during the project. Communication among staff was inadequate, with the Director of Nursing (DON) and Infection Control Preventionist (ICP) not being involved in decision-making or risk mitigation. Volunteers, rather than qualified contractors, managed the project, and there was no evidence of proper mold remediation. The facility's policies on construction and infection control were not followed, and there was a lack of documentation and monitoring of resident health during the construction.
Failure to Address Severe Allergies During Construction
Penalty
Summary
The facility failed to provide necessary care and services to a resident with severe environmental allergies, particularly during a period of construction. The resident, who was cognitively intact and had a history of chronic systolic congestive heart failure and allergic rhinitis, experienced significant discomfort and health issues due to exposure to construction-related odors and dust. Despite being offered a room change and other measures like an N95 mask and supplemental oxygen, the resident declined the room change, believing the odors permeated the entire facility through the ventilation system. The facility's care plan for the resident lacked critical information regarding her severe allergies and the necessary interventions to mitigate risks. The care plan did not include details about the resident's perfume and medication allergies, nor did it provide guidance on how to manage her reactions to allergens. Staff were not adequately informed or trained on the resident's specific needs, leading to repeated exposure to allergens and subsequent health issues for the resident. The resident expressed frustration and fear for her safety, feeling that staff did not take her allergies seriously or understand the severity of her condition. Observations during the survey revealed inadequate barriers to contain construction debris and odors, contributing to the resident's distress. Interviews with staff indicated a lack of consistent communication and documentation regarding the resident's allergies and the necessary precautions. The facility's failure to update the care plan and ensure all staff were aware of the resident's needs resulted in ongoing exposure to allergens, causing the resident to experience respiratory issues and consider relocating due to the facility's inability to provide a safe environment.
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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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.
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