Benedictine Living Community Owatonna
Inspection history, citations, penalties and survey trends for this long-term care facility in Owatonna, Minnesota.
- Location
- 2255 30th Street Nw, Owatonna, Minnesota 55060
- CMS Provider Number
- 245426
- Inspections on file
- 25
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Benedictine Living Community Owatonna during CMS and state inspections, most recent first.
A resident with a history of intestinal perforation and a colostomy developed nausea, abdominal discomfort, and later epigastric/chest‑area pain, refused supper, and exhibited elevated BP, dry heaving, pallor, diaphoresis, and anxiety. A physician examined the resident, ordered PRN ondansetron (Zofran) for nausea, and later ordered transfer to the ED, expecting prompt implementation. The RN did not administer the Zofran for several hours after the order and delayed calling for ambulance transport despite repeated requests from the resident and reports from NAs that the resident looked unwell and wanted to go to the hospital. Progress notes and interviews show ongoing severe epigastric pain, abnormal VS, low O2 sats requiring increased oxygen, and continued nausea before non‑emergency transport was finally arranged, and leadership later stated that earlier focused assessment, MD notification, and immediate ambulance activation were expected.
A resident receiving hospice care, with multiple serious diagnoses and dependent for transfers, did not have a current hospice care plan, visit schedule, or documentation of hospice visits available in the facility. LPNs and the DON reported that hospice nurses did not communicate with facility staff about care provided or changes in the plan of care, and the hospice RN manager was unaware that required documentation and schedules were not being received. The facility's policies and hospice agreement required collaborative care and communication, but these were not followed, resulting in a failure to coordinate and document hospice services.
Multiple residents consistently received cold, unappetizing, and incorrectly prepared meals, with staff failing to follow standardized recipes and proper food temperature procedures. Ongoing complaints about food quality, temperature, and presentation were documented, and staff interviews revealed confusion about temperature monitoring and documentation, resulting in persistent dissatisfaction among residents.
A resident with hemiplegia and cognitive impairment was left in bed unclothed and exposed after an inexperienced agency NA failed to complete morning care and left the room. Another NA found the resident exposed, covered him, and finished his care. The incident was not promptly reported to nursing leadership, resulting in a failure to maintain the resident's dignity.
The facility did not provide a method for residents to submit grievances anonymously, and residents were unaware of any such process. Additionally, a resident's report of a missing personal item was not documented or investigated according to facility policy, as staff failed to communicate and follow up on the concern.
A resident with a documented diagnosis of PTSD and related care plan interventions was not coded for PTSD on the MDS assessment, despite evidence of the diagnosis in the medical record and care plan. Staff indicated the diagnosis was omitted because it was not in the most current provider note, even though it was present in recent documentation and active interventions were in place.
A resident with type 2 diabetes was administered insulin by an LPN who failed to disinfect the rubber septum of the insulin pen with an alcohol wipe before attaching the needle and giving the injection. The LPN confirmed the expected procedure was not followed, and the DON verified that facility policy requires disinfection of the septum prior to each dose.
A resident who was unable to perform activities of daily living independently did not receive the necessary care and assistance from facility staff.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in care that was not individualized or consistent with regulatory requirements.
A resident with diabetes was administered insulin from a pen that was not labeled with their name or the date it was opened, contrary to facility policy. An LPN confirmed the omission during medication administration, and a second insulin pen for the same resident was also missing the date opened. Nursing staff and the DON acknowledged that both the resident's name and the date opened were required on insulin pen labels.
Staff failed to maintain infection control standards when a resident's Foley catheter drainage bag was repeatedly observed lying on the floor, contrary to care plan instructions, and another resident's soiled washcloths were placed on an overbed table used for meals during peri-care. Staff interviews confirmed these lapses, and the DON acknowledged the practices were unacceptable.
The facility did not ensure that posted nurse staffing information accurately reflected the actual number of CNAs and total hours worked, as required by policy. The posted schedule was not updated to account for staff call-outs or last-minute changes, resulting in discrepancies between posted and actual staffing data. This issue was confirmed by both the DON and the staffing coordinator.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
A resident with chronic kidney disease was mistakenly given 100 units of insulin instead of the prescribed Heparin by an LPN, leading to hypoglycemia and hospitalization. The LPN misread the medication label, resulting in the error.
A facility failed to ensure proper hand hygiene and cleaning protocols during medication administration and wound care. An LPN did not perform hand hygiene before entering rooms or after removing gloves, and a universal glucometer was not disinfected after use. Additionally, Enhanced Barrier Precautions were not implemented during wound dressing changes for residents with chronic wounds, despite facility policies requiring such measures. Staff interviews confirmed these lapses in protocol adherence.
The facility failed to update care plans for two residents with non-pressure related skin injuries. One resident experienced a fall resulting in significant injuries, but their care plan was not revised to address impaired skin integrity. Another resident suffered burns from hot food, yet their care plan lacked necessary interventions. Staff interviews revealed communication gaps and unmet expectations for care plan updates.
A resident with severe cognitive impairment suffered a leg laceration after a fall. The facility failed to adequately monitor and document the wound care, leading to a deficiency. The wound was not properly assessed or communicated among staff, resulting in inadequate treatment and pain for the resident.
A resident with multiple diagnoses, including hemiplegia and epilepsy, required substantial assistance for transfers. Despite the care plan requiring two staff members for transfers, only one nursing assistant assisted the resident during a transfer, resulting in a fall. The resident's foot got caught on the door frame, leading to a fall and subsequent hospitalization for pain management. Interviews confirmed the care plan was not followed, contributing to the incident.
A resident fell from a mechanical lift in an LTC facility, resulting in a fractured sternum and hip hematoma. The incident occurred during a transfer from a commode to a bed when a sling strap detached. Staff failed to check the tension and security of the sling straps, leading to the fall. The equipment was found to be in working order, suggesting operator error.
A resident with intact cognition and dependent on staff for transfers fell from a mechanical lift, resulting in skin tears. The incident was not reported to the Director of Nursing within the required 2-hour timeframe, and the state agency was notified the following day, contrary to the facility's policy for immediate reporting of such incidents.
A resident with severe cognitive impairment and a history of wandering exhibited disrobing behavior in public areas, which was not addressed in their care plan. Despite assessments noting these behaviors, the care plan was not updated with interventions until after an incident occurred. Staff interviews indicated a lack of direction on managing the behavior, highlighting a deficiency in the facility's care planning process.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as staff did not use PPE during care. Interviews revealed a lack of awareness and education about EBP among staff, and the infection preventionist, still in training, acknowledged the absence of EBP implementation. The facility's policy required EBP for such residents, but it was not followed.
Culinary aides at the facility failed to follow proper hand hygiene practices, potentially impacting 30 residents. Observations showed aides handling food without changing gloves or washing hands after touching various items. Interviews revealed a lack of documented training on hand hygiene, and the facility's infection prevention policy highlighted the risk of microorganisms entering through unclean hands.
A resident with a history of hemiplegia and hemiparesis was served a meal inconsistent with her dietary orders, leading to a failure in providing a dignified dining experience. Despite having a diet order for soft and bite-size meals, she was given ground steak bites and asparagus, which she found demeaning. The culinary director acknowledged the error, and the director of nursing noted that dietary staff should have checked with the resident or offered an alternative before altering the food texture.
The facility failed to accurately identify PTSD on the MDS assessment for two residents. Despite having PTSD listed as an active diagnosis on their face sheets, it was not marked on their quarterly MDS assessments. Interviews revealed that the clinical reimbursement manager relied on the most current provider note for MDS marking, while the DON and regional director indicated that active diagnoses should be marked. A policy on MDS was requested but not provided.
Two residents did not receive copies of their baseline care plans upon admission, despite attending care conferences. One resident, with multiple health issues, expressed a desire to be informed about her care plan, while another resident, with conditions like rhabdomyolysis, also did not receive her care plan. Facility staff confirmed that care plans are discussed but not routinely distributed unless requested, contrary to the facility's policy.
A resident with neuropathy and osteoporosis was not consistently walked as per her care plan, which required twice-daily ambulation with assistance. Despite being on the walk list, she reported not being walked for weeks, and documentation confirmed infrequent implementation of the walking program. Staff interviews revealed inconsistencies in following the care plan, and the clinical manager had not verified the program's execution.
The facility failed to assess and manage the vaping practices of two residents, leading to a deficiency in maintaining a smoke-free environment. Despite being informed of the policy, the residents continued to vape indoors, and the staff did not conduct safety assessments or update care plans. The facility's policies on smoking and medical cannabis were not effectively enforced, resulting in ongoing vaping activities within the facility.
A resident with obstructive sleep apnea did not receive proper CPAP care due to the facility's failure to provide distilled water, as required by the manufacturer's guidelines. Staff used tap water for several days, which was confirmed through interviews and observations. The purchasing coordinator was unaware of the shortage until informed, and the director of nursing expected staff to use distilled water and contact the on-call nurse if supplies were depleted. The facility did not provide a policy for CPAP use when requested.
The facility failed to assess and implement trauma-informed care for two residents with PTSD. One resident lacked a care plan addressing PTSD, while another's initial assessment did not capture triggers. Staff were unaware of these needs, and care plans were not updated to reflect trauma-informed approaches, despite facility policy requiring such care.
Delay in PRN Anti‑Nausea Medication and ED Transfer After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to timely implement a physician’s order for an anti‑nausea medication and to timely act on an order to transfer a resident to the emergency department (ED) following a change in condition. The resident had diagnoses including a non‑traumatic perforation of the intestine and colostomy status, used a walker and wheelchair, required one‑person assistance with several ADLs, and had an ostomy. On the afternoon in question, a nursing assistant reported that after emptying the resident’s colostomy bag and taking him to dinner, the resident soon stated he did not feel well, had stomach pain, was not hungry, and wanted to lie down. Vital signs taken at 6:43 p.m. showed elevated blood pressure (171/95), oxygen saturation of 94%, pulse 90, temperature 96.7°F, respirations 18, and pain 3/10. A clinician note documented that the resident had developed nausea that afternoon, chose not to eat supper, had mild diffuse abdominal tenderness with bowel sounds present, and nausea over the past couple of hours without abdominal pain at that time. The note indicated Zofran was available and that nursing was to update the physician later that evening. A signed physician order dated that day directed administration of ondansetron (Zofran) 4 mg by mouth every 6 hours as needed for nausea. The physician later clarified that this order was written between 6:00 p.m. and 7:00 p.m. and that she expected the Zofran to be administered at that time because the resident had acute issues requiring immediate attention. However, the medication administration record shows Zofran 4 mg was not given until 9:40 p.m., with a comment time of 9:15 p.m., and was documented as not effective. During interview, the RN on duty acknowledged that she did not administer the Zofran after the order was written and could not clearly articulate why, stating she associated the resident’s symptoms with indigestion and was occupied with other paperwork and documentation. Multiple nursing assistants reported that between approximately 9:00 p.m. and 10:00 p.m. the resident repeatedly requested to go to the ED, appeared gray, sweaty, anxious, and complained of epigastric or chest‑area pain, with abnormal vital signs reported to the RN. Progress notes document that the resident refused supper, complained of stomachache, dry heaved, and later complained of epigastric pain while spitting clear phlegm. Zofran was given at about 9:15 p.m. with no relief. The note was later edited to add that the physician had been at the facility, ordered Zofran every 6 hours as needed, and was called again when the resident did not improve. A subsequent edit at 10:22 p.m. recorded that the physician ordered the resident sent to the ED for increased belly pain. The physician stated her expectation that an ambulance should be called right away after she gave the order to send the resident to the ED. Instead, the record shows ongoing documentation of severe epigastric pain rated 10/10, continued dry heaving, elevated blood pressure, low oxygen saturations requiring an increase in supplemental oxygen, and the resident remaining pale and diaphoretic. The resident continued to state he wanted to go to the ED. Non‑emergency dispatch was called for transport, and the resident ultimately left with paramedics after midnight. The DON later stated that, based on the vital signs and symptoms documented at 6:43 p.m. and again around 9:10 p.m., she would have expected focused assessment, timely physician notification, and that the ambulance should have been called when the order to send the resident to the ED was obtained. The facility also lacked a policy on administering newly ordered medications for a change of condition.
Failure to Ensure Communication and Documentation for Hospice Services
Penalty
Summary
The facility failed to ensure effective communication and coordination between its staff and the hospice provider for a resident receiving hospice services. The resident, who had diagnoses including heart failure, atrial fibrillation, and anxiety disorder, was dependent for all transfers and was cognitively intact. The hospice focus care plan indicated that the facility should coordinate with hospice providers and reference the hospice care plan for the resident’s preferences and needs. However, interviews with LPNs revealed that the hospice binder did not contain a current hospice care plan, visit schedule, or documentation of hospice visits, and that hospice nurses did not communicate with facility staff about care provided or changes in the plan of care. Further interviews with the RN contact for hospice agencies and the DON confirmed that there was inconsistent communication from the hospice agency, and that the hospice plan of care and visit schedules were not present in the hospice binder or the electronic health record. The hospice registered nurse clinical manager stated that the hospice care plan had been sent to the facility but had not verified its receipt, and was unaware that the facility was not receiving visit schedules or documentation. The facility’s own policies and hospice agreement required collaborative care, documentation of hospice assessments and care in the facility chart, and verbal communication with staff after each visit, but these procedures were not being followed. The lack of documentation and communication meant that facility staff were not consistently informed about the care being provided to the resident by hospice, nor about any changes to the plan of care. This failure to maintain a communication process and ensure the availability of essential hospice documentation resulted in the facility not meeting its obligations to coordinate and deliver appropriate end-of-life care as outlined in its policies and agreements.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Multiple residents, both cognitively intact and impaired, consistently reported receiving cold, unappetizing, and sometimes incorrect food items. Observations and interviews revealed that food such as sweet potato fries and grilled ham and cheese sandwiches were served cold or at inconsistent temperatures, with some items being undercooked, overcooked, or not prepared according to the menu or standardized recipes. Residents expressed ongoing dissatisfaction with the quality, temperature, and presentation of meals, noting that their concerns had been raised repeatedly over several months without improvement. Staff interviews and document reviews indicated a lack of clear procedures and consistent practices for monitoring and documenting food temperatures. Dietary aides and culinary staff were observed taking food temperatures at varying stages, such as after removal from the oven or warmer, but not consistently at the point of cooking as required. The Food Temperature Log lacked documentation of cooking temperatures, and staff were uncertain about the formal process for temperature checks. The Culinary Services Director acknowledged that staff could benefit from further education on proper food temperature procedures and confirmed that issues with food timing, appearance, and temperature had persisted despite the formation of a food committee and ongoing audits. Resident council meeting minutes and concern reports documented repeated complaints about cold food, incorrect menu items, and poor food quality, including instances of burnt, tough, or frozen food. The facility's own policies required that food be prepared to retain nutritive value, enhance flavor and appearance, and be served at appropriate temperatures, but these standards were not met. The facility's dietician was unaware of the ongoing food concerns and confirmed that recipes and temperature documentation were not being properly followed. Despite staff acknowledgment of the issues and some attempts at education, there was no evidence of measurable improvement in the quality or temperature of food served to residents.
Resident Left Unclothed and Exposed Due to Incomplete Care by Inexperienced NA
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and moderately impaired cognition was left in bed unclothed, with his genitals exposed, after an agency nursing assistant (NA) failed to complete his morning care. The resident, who required assistance with dressing and personal hygiene due to his medical condition, reported that the NA was unfamiliar, lacked a name tag, and appeared unsure of the care routine. The NA began cleaning the resident but then left the room, instructing the resident to find someone else to finish the care. The resident called out to another NA, who found him exposed and immediately covered him before completing his care. The second NA reported the incident to an LPN, but the LPN did not escalate the issue to nursing leadership. The director of nursing (DON) only became aware of the incident two days later through staff communication. The NA responsible for leaving the resident exposed was a new employee who had recently completed orientation and training on resident dignity and personal care. The facility's policy required prompt notification and protection of resident rights, but the incident was not reported in a timely manner, and the resident's dignity was not maintained during care.
Failure to Provide Anonymous Grievance Submission and Follow Grievance Process for Missing Property
Penalty
Summary
The facility failed to provide residents and their representatives with a method to submit grievances anonymously, as required by facility policy. Multiple residents reported during a council meeting that they were unaware of any anonymous grievance process, and no grievance box or designated area for anonymous submissions was available in resident-accessible locations. Additionally, there was no signage or posted information indicating an option for submitting concerns confidentially or anonymously. The administrator confirmed the absence of a grievance box and acknowledged that the location of concern forms was difficult for residents to access independently. In a separate incident, the facility did not follow its grievance process regarding a missing personal item for a resident with chronic pain, restless leg syndrome, muscle weakness, and type 2 diabetes mellitus. The resident reported a missing windchime after being moved to a new room, and although an activity assistant stated she reported the missing item to her supervisor, there was no evidence that the concern was documented or investigated. The wellness director recalled being told about broken items but did not follow up, and the social services staff was unaware of the missing or damaged items. The administrator acknowledged that the required process for reporting and investigating missing items was not followed.
Failure to Accurately Code PTSD Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified on the Minimum Data Set (MDS) assessment. Specifically, a resident with documented diagnoses of major depressive disorder and post traumatic stress disorder (PTSD) was not coded for PTSD on the quarterly MDS assessment, despite this diagnosis being present on the resident's face sheet and care plan. The care plan included interventions related to trauma responses, such as ensuring clear paths to doors and honoring the resident's preferences regarding door positions, which were observed being implemented during facility activities. Interviews with facility staff revealed that the clinical reimbursement manager did not mark PTSD on the MDS because it was not documented in the most current provider note, even though the diagnosis was active in the last 60-day provider note and the care plan had active interventions for PTSD. The administrator indicated there had been previous efforts to ensure only documented active cases were marked on the MDS, but acknowledged the need to review this process. Facility policy requires that assessments accurately reflect the resident's status and that staff certify the accuracy of their portions of the assessment.
Failure to Disinfect Insulin Pen Septum Prior to Administration
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to disinfect the rubber septum of a resident's insulin pen with an alcohol wipe prior to attaching the needle and administering insulin. The incident was observed during a medication administration for a resident with type 2 diabetes, who was receiving Novolog Flex Pen U-100 Insulin per sliding scale. The LPN removed the pen cap and immediately attached the needle without disinfecting the septum, then proceeded to prime the pen and inject the insulin into the resident's abdomen. The LPN later confirmed that the same pen was used daily and acknowledged that the rubber top was expected to be wiped with alcohol before each use. The facility's policy on safe injection practices, dated September 2023, requires that the rubber stopper of medication vials and the neck of glass ampules be disinfected with sterile 70% alcohol before inserting a needle. The director of nursing (DON) confirmed that the rubber septum of an insulin pen should be disinfected with an alcohol wipe prior to each dose. The failure to follow this protocol was confirmed through observation, staff interview, and review of facility policy and resident records.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
A deficiency was identified in the facility's provision of care and assistance with activities of daily living (ADLs) for residents who are unable to perform these tasks independently. The report notes that care and assistance were not provided as required for at least one resident who was unable to complete ADLs without help. This failure to provide necessary support directly affected the resident's ability to perform essential daily activities.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Properly Label Insulin Pens for a Resident
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes was administered insulin using a NovoLog FlexPen that was not properly labeled with the resident's name or the date it was opened. During medication administration, an LPN retrieved the insulin pen from the emergency kit, attached a needle, primed, and administered the insulin without ensuring the pen was labeled according to facility policy. The pen only had a manufacturer label and an E-Kit sticker, with a blank space for the resident's name and no date of opening. The LPN confirmed that the labeling was incomplete and acknowledged the expectation for both the resident's name and the date opened to be documented on the pen label. Further inspection of the medication cabinet revealed a second insulin pen (Toujeo Solostar) that was labeled with the resident's name but also lacked the date it was opened. Interviews with nursing staff, including an RN case manager and the DON, confirmed that facility policy required insulin pens to be labeled with both the resident's name and the date opened. The facility's Safe Injection Practice policy specifically stated that insulin pens should be dedicated to one resident, not used if unassigned or unlabeled, and that labels should be affixed directly to the pen.
Failure to Maintain Infection Control During Catheter and Peri-Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in two separate instances involving catheter and peri-care. For one resident with a Foley catheter and diagnoses including acute kidney failure and obstructive uropathy, observations on multiple occasions revealed the urinary drainage bag was lying on the floor next to the resident's recliner chair. Staff interviews confirmed that the catheter bag was frequently found on the floor, despite care plan interventions requiring the bag to be kept off the floor and below the level of the bladder. The facility was unable to provide documentation of a catheter care policy when requested. In a separate incident, a resident with dementia and urinary incontinence was observed receiving peri-care during which a nursing assistant placed soiled washcloths on the resident's overbed table, which also held personal items and was used for meals. The nursing assistant initially denied the action but later admitted to placing the soiled washcloths on a strip of plastic on the table, acknowledging that this did not adequately protect the surface from contamination. The DON confirmed that this practice was unacceptable, especially since the table was used for eating.
Inaccurate Posting of Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information accurately reflected the actual number of nursing assistants (NAs) and the total number of hours worked for the posted schedules. On the observed date, the posted information indicated that ten CNAs were scheduled from 6:00 a.m. to 2:00 p.m. with 65 staffing hours, and one CNA from 6:00 a.m. to 12:30 p.m. with 6 hours, totaling 81 hours. However, a review of the actual staffing schedule revealed that only one CNA worked from 7:55 a.m. to 2:00 p.m. (7 hours and 5 minutes), and eight CNAs worked from 6:00 a.m. to 2:00 p.m. (72 hours total), resulting in a total of 79 hours and 5 minutes, not the 81 hours posted. This discrepancy was confirmed by the Director of Nursing, who acknowledged that the posted information did not accurately reflect the actual number of NAs or their hours worked on that day. Further interview with the staffing coordinator revealed that the posted staffing hours were not updated to reflect staff call-outs or last-minute changes, leading to discrepancies between the actual and posted staffing hours. The facility's policy required that the number of licensed and unlicensed nursing staff, as well as their actual hours worked, be posted daily and amended as schedule changes occurred. The failure to update the posted information as required by policy had the potential to affect all residents and visitors who relied on the accuracy of the posted nurse staffing information.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Significant Medication Error Due to Insulin Administration
Penalty
Summary
The facility failed to ensure the correct administration of medication, resulting in a significant medication error for one resident. The error occurred when an LPN administered 100 units of short-acting insulin instead of the prescribed 5,000 mL of Heparin. This mistake led to the resident experiencing iatrogenic hypoglycemia, requiring hospitalization, continuous monitoring, and intravenous fluid recovery to return to baseline. The resident involved had a medical history that included hypertensive chronic kidney disease with stage 5 chronic kidney disease, requiring dialysis, and was not diabetic or insulin-dependent. The error was discovered when the LPN, unable to locate the prescribed Heparin in the medication cart, mistakenly administered insulin from a vial found in the medication room. The LPN misread the label on the vial, believing it contained the correct medication for the resident. Following the administration of insulin, the resident was transferred to the emergency department after the error was realized. The resident's blood glucose levels were monitored, and treatment was provided to stabilize the condition. The incident was reported to the facility's administration, and the error was acknowledged as significant, with potential for serious harm or death, as noted by the nurse practitioner and pharmacist involved in the case.
Removal Plan
- LPN-A suspended pending investigation and then completed re-education and competency education.
- Interviewed residents for any medication error concerns.
- Provided education and competency testing on the rights of medication administration to licensed nursing staff.
- Replaced the vial of Fiasp insulin with insulin pen.
- Removed the vial of heparin from the medication cart and placed in resident's locked medication cupboard.
- Updated procedure for administration of all subcutaneous injections, when signing off in the electronic medication administration record, to include the lot number and expiration date of the medication.
- Implemented an auditing system for administration of subcutaneous injections.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and cleaning protocols during medication administration and wound care, as observed in several instances. An LPN did not perform hand hygiene before entering rooms or after removing gloves while administering medication and performing blood sugar checks for residents with diabetes and other conditions. The LPN also failed to disinfect a universal glucometer after use, which was then placed back into the medication cart for potential use with other residents. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) during wound dressing changes for residents with chronic wounds. Observations revealed that an LPN and other staff members did not use EBP or provide signage and supplies outside the rooms of residents with wounds, such as a burn on the left thigh and a laceration on the right lower leg. This oversight occurred despite the presence of a chronic wound and the facility's policy requiring EBP for such conditions. Interviews with staff, including the DON and the infection preventionist, confirmed the lapses in protocol adherence. They acknowledged that the glucometer should have been cleaned after use and that hand hygiene should be performed before and after resident contact and glove use. The facility's policies on hand hygiene, resident care equipment, and EBP were not followed, contributing to the deficiencies observed during the survey.
Failure to Revise Care Plans for Residents with Skin Injuries
Penalty
Summary
The facility failed to revise the care plans for two residents who had non-pressure related skin injuries. The first resident, identified with multiple diagnoses including contusion to the head and laceration to the right lower leg, experienced a fall on 10/10/24, resulting in significant injuries. Despite these injuries, the resident's care plan, dated 9/16/23, was not updated to reflect the impaired skin integrity or to include goals and individualized interventions following the fall. Interviews with staff revealed a lack of communication regarding the resident's wound, which was not included in the care plan, and the Infection Preventionist/Wound Nurse was not informed of the wound, preventing it from being added to her list for monitoring. The second resident, who had a history of surgical aftercare and burn risk due to decreased sensory perception, suffered burns from hot food items. The care plan, dated 10/1/24, did not include the burns or the necessary interventions to prevent further incidents. Despite a physician's evaluation and prescribed treatment for the burn, the care plan was not revised to include these details. Interviews with the Director of Nursing and a nurse practitioner indicated an expectation for such incidents to be documented in the care plan, but this was not done, leading to a deficiency in care planning for the resident's condition.
Failure to Monitor and Document Wound Care
Penalty
Summary
The facility failed to comprehensively assess, monitor, and notify the physician of new wounds for two residents who had non-pressure related skin injuries. One resident, identified as R1, had a history of severe cognitive impairment and was involved in an incident where her wheelchair rolled off a curb, resulting in multiple injuries including a complex laceration on her right lower leg. Despite a physician's order to monitor the laceration site daily for signs of infection, the facility did not conduct a comprehensive assessment or document continuous monitoring of the wound's condition. Observations and interviews revealed that the wound care was inadequate. A Licensed Practical Nurse (LPN) noted that the dressing on R1's leg was not dated and adhered to the wound, causing pain during removal. The wound was described as open with some erythema, and the dressing applied was too small to cover the entire wound. The Nurse Practitioner (NP) was unaware of the wound and had not been following its care, indicating a lack of communication and documentation among the staff. Further investigation showed that the facility's Director of Nursing (DON) and Infection Prevention and Wound Nurse (IPWN) were not adequately informed about the wound's status. The DON expected the Clinical Manager to follow up on wounds not monitored by the wound nurse, but there was no clear process for notifying the IPWN of new or worsening wounds. The facility's policy required weekly measurements and documentation of wounds, but this was not adhered to, leading to a deficiency in the care provided to the resident.
Failure to Follow Transfer Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan for a resident who required assistance during transfers, resulting in a fall. The resident, who had diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, muscle weakness, and epilepsy, required substantial assistance for transfers. Initially, the care plan required assistance from one staff member with a non-mechanical sit-to-stand aid, which was later updated to require two staff members. However, this intervention was discontinued shortly before the incident. On the day of the incident, the resident was left in the bathroom by two staff members but was later assisted by only one nursing assistant during a transfer from the toilet. The resident's foot got caught on the door frame, leading to a fall. The nursing assistant attempted to manage the situation alone, despite the care plan's requirement for two staff members to assist with transfers. The resident reported that the sit-to-stand machine was moved too quickly, contributing to the fall. Interviews with staff revealed that the nursing assistant did not follow the care plan, which required two people for transfers. The director of nursing confirmed that the transfer process should have involved two staff members, as per the care plan. The incident resulted in the resident being hospitalized for pain management, although no fractures were found. The facility's failure to follow the care plan for transfers directly led to the resident's fall and subsequent hospitalization.
Failure to Safely Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to safely use a mechanical lift according to the manufacturer's recommendations, resulting in a resident falling from the lift and sustaining serious injuries. The incident occurred when two nursing assistants were transferring the resident from a commode to a bed using a full-body mechanical lift. During the transfer, the upper right sling strap detached from the lift, causing the resident to fall approximately three feet to the floor. The resident, who was on anticoagulants, suffered a fractured sternum and a large left hip hematoma, requiring hospital admission and a blood transfusion. The resident's care plan specified the use of a medium-sized sling and two staff members for transfers with the mechanical lift. However, the nursing assistants involved in the incident did not adequately check the tension and security of the sling straps after lifting the resident. Although they confirmed using the same color sling straps, they failed to ensure the straps were properly secured before moving the resident. This oversight led to the sling strap detaching and the subsequent fall. Interviews with staff revealed a lack of adherence to proper procedures for using the mechanical lift. The nursing assistants involved were unable to articulate how the sling strap became detached and admitted to not checking the tension of the straps. The facility's director of nursing confirmed that the equipment was inspected and found to be in working order, indicating that the fall was likely due to operator error. The incident highlighted the need for staff to follow the manufacturer's instructions and ensure the safety of residents during transfers.
Failure to Timely Report Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to report an allegation of neglect within the required timeframe after a resident fell from a mechanical lift. The incident occurred when the resident, who had intact cognition and was dependent on staff for transfers, fell during a transfer from a chair to a bed, resulting in skin tears to her right index and middle fingers and left bicep area. The resident's progress note documented the fall at 9:40 p.m. on 7/21/24, but the Director of Nursing (DON) was not informed until 8:03 a.m. on 7/22/24, which was beyond the 2-hour reporting requirement. The facility's policy mandates immediate notification of the Charge of Building and subsequent reporting to the Executive Director or designee for any suspected abuse, neglect, or misappropriation of resident property. In cases involving serious bodily injury, the report must be made no later than 2 hours after forming the suspicion. However, the facility did not adhere to this policy, as the incident was reported to the state agency only on 7/22/24 at 1:34 p.m., indicating a delay in the required notification process.
Failure to Revise Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to revise the care plan for a resident with behavioral issues, specifically disrobing in public, which was not addressed in the care plan. The resident, who had severe cognitive impairment and a history of wandering, was observed to disrobe in public areas, including other residents' rooms and common areas. Despite these behaviors being noted in assessments, the care plan was not updated to include interventions for managing the disrobing behavior until several days after an incident was reported. The resident's medical history included anxiety disorder, dementia, restless leg syndrome, pain, arthritis, abnormalities of gait and mobility, a history of falling, and weakness. The resident was independent with transfers and wheelchair use but exhibited behaviors such as wandering and disrobing, which intruded on the privacy and activities of others. Staff interviews revealed that the resident frequently disrobed in public, and there was a lack of direction or interventions provided to staff on how to manage this behavior. The facility's policy required comprehensive assessments and care plans to be developed, reviewed, and revised based on direct observation and communication with the resident and staff. However, the care plan for the resident was not revised in a timely manner to address the disrobing behavior, and staff were not provided with appropriate interventions to manage the behavior, leading to a deficiency in the care provided to the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as observed in five residents. These residents included those with pressure injuries, catheters, and chronic wounds, yet staff did not use personal protective equipment (PPE) such as gowns and gloves during care. For instance, a nursing assistant provided care to a resident with a pressure injury without using gowns or gloves, and another resident with a suprapubic catheter did not have staff using PPE during care. Interviews with staff, including nursing assistants and licensed practical nurses, revealed a lack of awareness and education regarding the necessity of EBP for residents with wounds or indwelling devices. Staff members indicated that they only used PPE when there was an active infection and were not informed about the requirement to use EBP for residents with catheters or wounds. The infection preventionist, who was still in training, acknowledged the lack of EBP implementation and mentioned that the person training her did not agree with the guidelines. The facility's policy on EBP, dated March 2024, clearly stated that EBP should be used for residents with chronic wounds or indwelling devices, regardless of MDRO colonization status. However, observations and interviews indicated that this policy was not being followed. The regional clinical director confirmed that residents with wounds or indwelling devices should be on EBP and had instructed the infection preventionist to identify residents requiring EBP, but this had not yet been implemented.
Inadequate Hand Hygiene by Culinary Aides
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by culinary aides during food handling, which had the potential to impact all 30 residents on the Kindle and Oak units. Observations revealed that a culinary aide on the Kindle unit did not change gloves, wash hands, or don new gloves after handling various items and before directly handling food. Similarly, on the Oak unit, another culinary aide was observed handling food with the same gloves used for other tasks. Both aides admitted to not following proper hand hygiene protocols, and one aide did not recall receiving specific training on the matter. Interviews with the culinary services director and the infection preventionist confirmed that the aides should have removed contaminated gloves, washed their hands, and donned new gloves before handling food. However, there was no documentation of hand hygiene training during orientation for the aides, and the culinary services competency checklist was blank. The facility's infection prevention and control program policy indicated that microorganisms could enter residents through food handling with unclean hands, but the corporate policy or recommendations for hand hygiene were not provided.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident who required a general soft and bite-size texture diet. The resident, who had a history of hemiplegia and hemiparesis following a stroke, was served a meal that was not consistent with her dietary orders. Despite having a diet order for soft and bite-size meals, the resident was given ground steak bites and asparagus, which she found demeaning and likened to being treated like a baby. The culinary aide and LPN confirmed that the meal did not meet the resident's dietary requirements, as it was ground instead of being soft and cut into bite-size pieces. The culinary director acknowledged the error, explaining that the meat served had gristle, which could be difficult to chew, and they erred on the side of caution by serving a ground consistency. The resident expressed distress over the meal presentation, stating it made her feel like a child and hindered her ability to feed herself. Speech therapy confirmed that the resident had no swallowing issues but required smaller bites due to esophageal mobility issues. The director of nursing indicated that dietary staff should have checked with the resident or offered an alternative before altering the food texture. The facility's meal service policy emphasizes catering to dietary requirements and preferences, which was not adhered to in this instance.
Inaccurate MDS Assessment for PTSD Diagnosis
Penalty
Summary
The facility failed to ensure that the resident status was accurately identified on the Minimum Data Set (MDS) assessment for two residents reviewed for mood and behaviors, specifically post-traumatic stress disorder (PTSD). Resident 62's face sheet indicated an admission date and diagnoses including PTSD, but the quarterly MDS did not list PTSD as an active diagnosis. Similarly, Resident 23's face sheet included an active diagnosis of PTSD, but the quarterly MDS assessment did not reflect this. During interviews, the clinical reimbursement manager confirmed that both residents had an active problem noted in the last 60-day visit from the provider, but it was not marked on the MDS because it was not on the most current provider note. The director of nursing and the regional director of clinical services indicated that if PTSD is listed as an active diagnosis, it should be marked on the MDS. A policy on MDS was requested but not received.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to newly admitted residents and/or their representatives, as evidenced by the cases of two residents. One resident, who was admitted and readmitted with multiple diagnoses including cerebral infarction and heart failure, reported never receiving a copy of her baseline or current care plan. Despite being cognitively intact and able to communicate, she expressed a desire to be informed about her care plan. Documentation from a care conference involving the resident, social services, and family members did not indicate that a copy of the care plan was shared with those present. Another resident, admitted with conditions such as rhabdomyolysis and peripheral autonomic neuropathy, also did not receive a copy of her care plan upon admission or thereafter. Although she attended a care conference with nursing and therapy staff, there was no documentation that a copy of the baseline care plan was provided. Interviews with facility staff, including a registered nurse and the regional director of clinical services, revealed that while care plans are discussed during conferences, copies are not routinely distributed unless specifically requested by the resident. The facility's policy states that residents have the right to see and sign their care plans, but this was not adhered to in these cases.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as R35, who was assessed to require assistance with ambulation to maintain or improve her range of motion and mobility. R35, who has diagnoses including idiopathic peripheral autonomic neuropathy, osteoporosis, and a history of repeated falls, was supposed to be walked twice daily with the assistance of one staff member using a front-wheeled walker. Despite being on the walk list and having a care plan that specified these interventions, R35 reported not being walked for weeks and expressed a desire to walk to improve her chances of going home. Observations and interviews revealed inconsistencies in the staff's adherence to the care plan, with some staff members claiming to walk R35 while others, including the clinical manager, had not witnessed such activities. Documentation review showed that R35 was walked only twice in April and not at all in May, with some instances marked as deferred due to her condition. In June, she was walked on two occasions, but there were still days when the walking program was not implemented. The facility's Restorative Nursing Program policy requires regular assessments and oversight to ensure restorative interventions are carried out as planned, but the lack of consistent documentation and execution of the walking program indicates a failure to meet these standards. The director of nursing acknowledged the expectation for staff to follow the care plan, highlighting a gap between policy and practice.
Failure to Assess and Manage Resident Vaping Practices
Penalty
Summary
The facility failed to comprehensively assess two residents, R7 and R23, for safe vaping practices, leading to a deficiency in ensuring a smoke-free environment. R7, diagnosed with multiple sclerosis and using medical cannabis, was observed vaping inside the facility despite being educated multiple times about the smoke-free policy. The facility's staff, including RN-B, the DON, and the administrator, were aware of R7's vaping but did not conduct a vaping assessment or update the care plan to address this behavior. R7 refused to cooperate with assessments and continued to vape inside, indicating a lack of effective supervision and enforcement of the facility's policies. R23, with diagnoses including quadriplegia and psychosis, was also involved in vaping activities within the facility. Despite being informed of the smoke-free policy, R23 continued to vape indoors and refused to sign a non-smoking agreement. The facility's staff, including RN-B and SS-B, were aware of R23's non-compliance but did not document any attempts to assess the safety of R23's vaping practices. The care plan addressed smoking but did not include vaping, and there was no evidence of a vaping safety assessment in R23's medical record. The facility's policies on smoking and medical cannabis were not effectively implemented, as evidenced by the lack of assessments and care plan updates for residents who vape. The staff's repeated attempts to educate the residents on the smoke-free policy were met with resistance, and there was a failure to document and address the ongoing vaping activities adequately. This deficiency highlights the facility's inability to maintain a safe environment free from smoke and vape hazards, as required by their policies.
Failure to Follow CPAP Guidelines Due to Distilled Water Shortage
Penalty
Summary
The facility failed to ensure staff followed the manufacturer's guidelines for the use of a CPAP machine for a resident diagnosed with heart failure, spinal stenosis with neurogenic claudication, and obstructive sleep apnea. The resident's care plan did not include a respiratory plan or the use of a CPAP machine, and the physician's orders did not specify CPAP use, only that distilled water should be used. Observations and interviews revealed that the facility had been out of distilled water for several days, leading staff to use tap water in the CPAP machine, contrary to the manufacturer's instructions. The resident reported that staff had been using tap water for four to five days due to the unavailability of distilled water. Staff interviews confirmed the use of tap water and the lack of distilled water in the storeroom. The purchasing coordinator was unaware of the shortage until informed and subsequently procured distilled water from a local store. The director of nursing stated that staff should use distilled water and contact the on-call nurse if supplies were depleted. The facility did not provide a policy for CPAP machine application and use when requested.
Failure to Implement Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to comprehensively assess and reassess past trauma and implement care plan interventions utilizing a trauma-informed approach for two residents diagnosed with PTSD. One resident, identified as R23, had an active diagnosis of PTSD but lacked a care plan that addressed this condition. The care plan did not include individualized trauma-informed approaches or interventions, nor did it identify triggers to avoid potential re-traumatization. A PTSD/trauma assessment was not present in the medical record, and staff interviews revealed a lack of awareness and assessment attempts regarding R23's PTSD. Another resident, R62, also had a diagnosis of PTSD related to experiences in Vietnam. Although a PTSD/trauma assessment was completed, it initially did not capture the resident's triggers. The resident later expressed willingness to discuss his PTSD and identified specific triggers, such as military celebrations and loud noises. However, the facility's staff, including the clinical manager, were not initially aware of these triggers, and the care plan did not reflect this information until after further assessment. The facility's policy on trauma-informed care required that residents who are trauma survivors receive culturally competent, trauma-informed care, including the identification and mitigation of triggers. Despite this policy, the facility did not adequately assess or document the PTSD conditions of the residents, nor did it develop comprehensive care plans that addressed their trauma-related needs. Interviews with staff confirmed the lack of assessments and care plans related to PTSD for both residents.
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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