Bywood East Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 3427 Central Avenue Northeast, Minneapolis, Minnesota 55418
- CMS Provider Number
- 24E185
- Inspections on file
- 49
- Latest survey
- May 7, 2026
- Citations (last 12 mo.)
- 26 (3 serious)
Citation history
Health deficiencies cited at Bywood East Health Care during CMS and state inspections, most recent first.
Infection control failed during laundry services when staff reported using the same personal T-shirt for handling dirty laundry and then hanging clean laundry, while using disposable gowns only for laundry from a resident with an infection. The DON also acknowledged that the Infection Prevention Program policy was overdue for annual review, and the policy showed no indication of an annual review.
A facility failed to honor residents’ right to manage their financial affairs when two cognitively intact residents could only access trust funds during limited posted banking hours. Interviews showed residents were redirected to set weekday and weekend times, weekend staff directed requests to the nurse or posted hours, and an RN confirmed residents could not access money after business office hours on weekdays. The DON verified funds were only available at specific times, despite stating residents should be able to access their money when they wanted it.
Unsafe and unsanitary resident rooms were observed with clutter, uncovered food, and rodent activity. A resident with schizophrenia and depression had food crumbs and meat under the bed, while another resident reported mouse droppings and hoarded food in a crowded room. Other rooms had overflowing bins, bags of belongings, and uncovered food, and staff reported that some residents refused housekeeping access and that pest control service in resident rooms was inconsistent.
Pest control bait stations were not consistently monitored or serviced, and several resident rooms had clutter, food, or signs of rodent activity. A resident with schizophrenia and depression had food debris under the bed and a room that was not checked for months, while another resident reported mouse droppings and mice in the room. The maintenance director said there was no master list of bait stations, and the pest control company filled them only when management requested it.
A resident with diagnoses including disorganized schizophrenia, dementia with behavioral disturbance, developmental disorder of scholastic skills, and metabolic encephalopathy had a PASARR level two referral that was not acted upon. The resident’s care plan did not identify level two recommendations, and the DON confirmed the level two screening was not in the EMR. An OBRA Level 1 screening had identified serious mental illness and referred the resident for level two screening.
Survey results were not readily visible for residents and visitors to access without asking. The admin stated the survey book was kept behind the front desk in a holder, but a chest-high partition blocked it from view even though a posted sign said the annual state survey results were available and readily accessible 24 hours daily. During a resident council interview, a resident said the survey results were there, but they had to ask for them.
Daily staffing postings on all three units showed staff names and disciplines, but the hours scheduled and current census were not visible. The DON confirmed the census was not included, and the administrator verified that the hours on the back of the posting reflected the prior day's schedule because the new posting had been placed on top of it.
Shared rooms did not provide the required 80 SF per resident in 23 rooms. A census report showed multiple rooms with three residents or capacity for three residents, and a tour confirmed the room arrangements. The DON stated bed management meetings did not address moving residents to meet the space requirement, and the administrator said current residents were not informed when a bed opened unless they requested a room change. One room measured 230 SF, providing 76.67 SF per resident when occupied by three residents, and a resident stated more space would be helpful for belongings and movement.
A resident with schizophrenia, dementia, traumatic brain injury, and mild cognitive impairment, care planned for risk of abuse and rarely understood, was sitting in a wheelchair near an elevator when a contracted lab technician approached, gestured for the resident to move, and then slapped the resident’s face in view of others, causing facial redness. The lab technician stated he slapped the resident in response to a derogatory comment. The DON acknowledged that a slap is abuse and that facility staff did not supervise lab technicians. Both the DON and administrator reported that contracted lab staff did not receive or have verified VA abuse-prevention training, and the facility’s VA Abuse Prevention policy did not address abuse-prevention education for contracted staff.
A contracted lab technician slapped a resident in the face while the resident was seated in a wheelchair near an elevator, in view of other residents and staff. The technician later stated he would slap anyone who spoke derogatorily about his mother. Interviews with the lab supervisor, DON, and administrator showed that contracted lab staff did not receive VA abuse prevention training from the facility, and the facility did not verify any prior abuse-prevention education before allowing them to work with residents. The written VA Abuse Prevention policy, although stating zero tolerance for abuse by anyone including outside agency staff, lacked protocols for verifying abuse-prevention education for contracted personnel.
A resident with cognitive impairment and behavioral health diagnoses repeatedly harassed and physically grabbed another resident, causing emotional distress and hospitalization. Despite ongoing incidents and staff awareness, the facility failed to assess the situation comprehensively or implement effective interventions beyond ineffective redirection. Care plans lacked specific strategies to address the behaviors, and the events were not reported or investigated as potential abuse according to facility policy.
A resident with cognitive impairment and psychiatric conditions experienced repeated hair pulling and grabbing by another resident, leading to fear and agitation. Despite staff and management awareness of the ongoing incidents and the resident's distress, the altercation and its effects were not reported to the State agency within the required timeframe, nor was a formal investigation initiated as per facility policy.
A resident with mild cognitive impairment and a prescribed pureed diet for dysphagia was assisted by an RN to obtain a sticky bun from a vending machine. The resident choked on the non-pureed item, became unresponsive, and later died after being hospitalized. The RN did not consider the resident's dietary restrictions when assisting with the purchase, leading to the fatal incident.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, failing to meet required safety standards.
A cognitively impaired resident was involved in a sexual act with another resident, and staff failed to immediately report the suspected abuse to the state agency due to confusion over the resident's identity. The delay occurred because the DON initially interviewed the wrong resident, resulting in late notification to authorities as required by facility policy.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
Staff did not consistently cover clean linens during transport or storage, and clean linens were left exposed in open bins and a cluttered room with the door open. Staff, including an LPN and nursing assistants, accessed these bins to retrieve linens due to supply shortages and lack of restocking, contrary to infection control expectations. The infection preventionist confirmed that clean linens should remain covered and the room door closed, but these practices were not followed.
Staff failed to ensure that pre-cooked chicken and dumplings were reheated to the required 165°F before serving, with inaccurate temperature logging and lack of adherence to manufacturer instructions. As a result, 12 residents consumed food that may not have been reheated to a safe temperature.
Staff failed to promptly report allegations and observations of verbal and mental abuse involving three residents, resulting in delayed notification to facility leadership and the State agency. Despite a policy requiring immediate reporting, incidents witnessed by staff and reported by a physician were not communicated as required, leading to deficiencies in abuse reporting procedures.
Two residents' MDS assessments were inaccurately coded, failing to reflect the administration of hypoglycemic and antianxiety medications as documented in the MAR. The responsible RN confirmed the errors after reviewing the records, noting that the medications should have been coded according to their pharmacological classification and actual administration.
The facility did not maintain comprehensive or updated care plans for three residents, including one with a urinary catheter lacking infection control interventions, one with repeated alcohol use not addressed in the care plan, and another with multiple chronic conditions whose care plan omitted key information on ADLs, discharge planning, and medication management. Staff interviews confirmed reliance on care plans for resident care, but critical information was missing.
A resident with cognitive impairment repeatedly refused bathing and personal hygiene care, resulting in poor grooming and hygiene. Staff observed that certain individualized approaches were more successful in gaining the resident's cooperation, but these strategies were not documented in the care plan or consistently used by all staff. The facility did not assess or implement alternative interventions to address the resident's ongoing refusals, and documentation of care provided, especially nail care, was inconsistent.
A resident with cognitive impairment and a history of heart failure repeatedly complained of heart pain and gastrointestinal distress. Staff administered as-needed Maalox but did not consistently document symptoms, assess whether the pain was cardiac or gastrointestinal, or notify the physician about the ongoing complaints and repeated medication use. The care plan lacked interventions for gastroesophageal reflux disease, and the medical record did not show appropriate evaluation or follow-up.
A resident with memory impairment and known hearing difficulties was not comprehensively assessed or referred for audiology services despite observed and reported issues. The care plan included interventions for hearing loss, but there was no documentation of completed hearing assessments or follow-up on a scheduled audiology appointment, and staff were unclear about routine hearing evaluations and equipment availability.
A resident with a history of indoor smoking was not reassessed for safe smoking despite multiple documented incidents of violating the facility's smoking policy. Staff and the DON acknowledged that a reassessment should have occurred, but the resident continued to have access to smoking materials and was only provided with education and reminders.
A resident with moderate cognitive impairment and multiple medical conditions, including heart failure and schizophrenia, did not receive an in-person physician visit within the required 60- to 70-day timeframe. Despite ongoing symptoms and complex medication needs, staff confirmed that the resident's last documented physician visit was over 70 days prior, and there was no system in place to ensure timely visits as required by facility policy.
A resident with cognitive impairment and a history of asthma was given a steroid inhaler by a medication aide who failed to assist with a required mouth rinse after administration, despite clear instructions on the medication label. The omission was only corrected after surveyor intervention. Interviews confirmed that staff were not recently educated or audited on this procedure, and no facility policy was provided.
A resident with heart failure and cognitive impairment was prescribed digoxin, but the facility did not act on the consulting pharmacist's recommendation to obtain a digoxin level or document a rationale for not doing so. Despite the physician indicating acceptance of the recommendation, there was no evidence in the medical record that the lab was completed, and subsequent reviews did not address the omission.
A resident with heart failure and cognitive impairment was administered digoxin daily without evidence of appropriate laboratory monitoring for digoxin levels over the past year. The care plan lacked specific guidance on digoxin monitoring, and repeated requests from the consulting pharmacist for lab checks were not fulfilled. The absence of documented digoxin level testing and a relevant facility policy contributed to the deficiency.
A resident who was eligible for a pneumococcal vaccine did not receive the recommended PCV15, PCV20, or PCV21 dose after previously receiving PPSV23, despite having consented to vaccination. The facility's process only provided influenza vaccines on-site and did not ensure timely administration of other recommended vaccines, resulting in a failure to follow CDC guidelines.
The facility did not act on or investigate multiple allegations of verbal and mental abuse involving a resident who reported being called derogatory names by a roommate, as well as two residents who reported staff verbal abuse. Despite staff and direct care workers being aware of these incidents, there was no evidence of investigation, documentation, or interventions to ensure resident safety, contrary to facility policy and staff expectations.
Survey results were stored in a locked office, making them inaccessible to residents. Two residents interviewed were unaware of the availability of these results, and the administrator confirmed the binder containing the results was kept locked due to concerns about potential damage or loss.
The facility did not complete or transmit required discharge MDS assessments to CMS for three residents who had been discharged, as confirmed by documentation and staff interview. The responsible RN cited electronic system issues and missed notifications as reasons for the oversight, and no facility policy on MDS completion was provided.
The facility did not provide the required 80 square feet per resident in 23 shared rooms, with each room offering only 77.57 square feet per resident when fully occupied. Observations and interviews revealed that rooms were set up for three residents, with some expressing concerns about space and storage. The administrator confirmed no changes to room sizes and acknowledged the potential for three residents per room, while facility policy requires informing residents of rooms that do not meet the minimum space requirement.
A resident with a history of traumatic brain injury was involved in an altercation that resulted in a fall and potential head injury. Staff responded and moved the resident from the floor to his wheelchair without performing a comprehensive assessment or using a gait belt, as confirmed by video footage and staff interviews. This action was inconsistent with facility policy and staff expectations, leading to a deficiency for not properly assessing and safely transferring the resident after an unwitnessed fall.
A resident with a history of traumatic brain injury and other conditions was sent to appointments without an escort, despite being assessed as unsafe in the community. The resident became lost and was missing for several hours before being found by a family member. Communication breakdowns among staff contributed to the oversight.
The facility failed to address a rodent infestation affecting all residents. Observations revealed that a resident was feeding mice, leading to food and feces accumulation. Staff struggled to manage the situation, and pest control measures were ineffective. The QAPI program documented the issue but lacked a plan to resolve it.
The facility failed to implement effective pest control measures, leading to a mouse infestation affecting all residents. Observations revealed mice in a resident's room, where food was left to feed them, and excess mouse feces. Staff confirmed the ongoing issue, and the maintenance director admitted to inadequate pest control efforts. The facility's pest management policy was not effectively implemented, contributing to the persistent problem.
A resident with cognitive impairment and a history of brain dysfunction was sent to an appointment without an escort and went missing for seven hours. The facility failed to notify the resident's guardian and provider in a timely manner, contrary to its policy. The resident was eventually found by a family member in a confused state downtown.
A resident with cognitive impairment and recent traumatic brain injury lost $50.00 after withdrawing it from their account. The facility failed to provide a promised lock box for the resident's personal property and did not investigate the missing money. The facility administrator acknowledged the oversight, and no policy on personal property was available.
A resident with a traumatic brain injury and cognitive impairment went missing after being allowed to attend appointments without an escort, despite being at risk for elopement. The facility staff failed to realize the resident was missing until hours later, and communication breakdowns among staff contributed to the oversight. The resident was eventually found by a family member in a downtown area, raising concerns about potential access to illicit substances.
The facility failed to prevent falls and conduct necessary neurological assessments for three residents, leading to a traumatic brain injury for one resident. Despite multiple falls, the facility did not update care plans or implement new interventions. Additionally, there was a lack of documentation and communication regarding follow-up care for another resident who fell in the community.
The facility failed to notify medical providers of changes in condition related to falls for three residents. One resident with multiple diagnoses experienced falls and a brain bleed without timely provider notification. Another resident was found on the floor, and a third fell in the community, both without provider updates. The facility's policy to notify physicians of significant changes was not followed.
The facility did not have a policy or procedure for physician delegation of tasks to physician assistants, nurse practitioners, or clinical nurse specialists. This deficiency was identified during a policy review, and the administrator confirmed the absence of such a policy, potentially affecting all 69 residents.
The facility did not have a policy for physician delegation of tasks to the dietitian, as revealed during a policy review. The administrator confirmed the absence of such documentation, potentially affecting all 69 residents.
The facility did not have a policy regarding the administrator's responsibility to report to and be accountable to the Governing Body. This deficiency was identified during a review of facility policies, and the administrator confirmed the absence of such a policy, potentially affecting all 69 residents.
The facility did not have a policy or procedure defining the responsibilities of the Medical Director, nor a position description for the role. This deficiency was confirmed by the administrator during an interview.
The facility did not notify the State Agency when the new Director of Nursing (DON) was hired, as required. This was discovered during a survey when the administrator confirmed the oversight, potentially affecting all 69 residents.
The facility failed to ensure timely physician visits for residents, with one newly admitted resident not receiving required 30-day visits and two long-term residents missing routine 60-day visits. The DON confirmed these deficiencies, and the facility lacked a policy on physician delegation of tasks.
Infection Control Lapses in Laundry Services and Policy Review
Penalty
Summary
The facility failed to ensure appropriate infection control during laundry services and failed to review its Infection Prevention Program policy annually. During a laundry room tour and interview, other staff stated they put a personal T-shirt on over their clothes when handling dirty laundry and used the same T-shirt when hanging clean laundry. They also stated they used disposable gowns when handling laundry from a resident with an infection, but had no concerns about wearing the same clothing for clean and dirty laundry if the resident did not have an infection. The director of maintenance stated the facility used an external company for on-site laundry and housekeeping services and believed laundry staff wore gloves and a gown when handling dirty laundry, but was not concerned if no gown was worn as long as staff clothing did not touch the dirty clothing. The Bywood East Infection Control and Prevention Program policy dated 4/26/24 had no indication of an annual review, and the DON stated the infection prevention program policy was overdue for review.
Resident Trust Funds Not Available Outside Scheduled Hours
Penalty
Summary
The facility failed to honor residents’ right to manage their financial affairs by not having appropriate funds available for two cognitively intact residents who wanted to withdraw money outside of the facility’s scheduled withdrawal hours. One resident stated they could obtain five dollars on weekends by going to the nurse’s station and could withdraw money Monday through Friday only from 1:00 p.m. to 2:00 p.m., and that if the time was missed, the money could not be obtained. Another resident stated the facility kept money for him and that he could access it only during set weekday hours, from 8:00 a.m. to 9:00 a.m. and from 1:00 p.m. to 2:00 p.m., and that he could not take money out on weekends. Staff interviews confirmed the restricted access to resident funds. The BOC stated the business office had posted banking hours Monday through Friday from 8:00 a.m. to 9:00 a.m. and from 1:00 p.m. to 2:00 p.m., with weekend and holiday access through the 1st floor nursing station during posted times, and that residents requesting money outside those hours would be redirected unless leaving the building and needing money right away. Weekend staff stated they would direct residents to the nurse or to the posted times, and an RN verified that after the business office closed Monday through Thursday, residents would not be able to access their money. The DON verified funds were available only during specific times and stated residents should be able to access their money when they wanted it. The policy stated resident trust cash was available during set banking hours, on weekends and holidays through the Charge Nurse at specified times, and outside banking hours in an emergency through the Charge Nurse.
Unsafe and unsanitary resident rooms with clutter, uncovered food, and rodent activity
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment for 7 of 7 residents reviewed for environment. Multiple resident rooms were observed with clutter, food, and signs of rodent activity, while several rooms were not being routinely checked or serviced for pest control. The report also identified a missing light cover over one resident’s bed and a garage used for resident belongings that was filled with stored items and had no pest control in place. One resident with schizophrenia, depression, and moderate cognitive impairment had a care plan that addressed her belief that mice were her friends and directed staff to discourage food in her room. During observation, a large amount of black crumbs and two patties of what appeared to be meat were found under the bed. The infection preventionist stated staff were supposed to look for food in the room on every shift and housekeeping was supposed to clean the room twice a day. The maintenance director confirmed that bait stations in resident rooms were not serviced during one month reviewed, and the room service records showed the room was not checked during several months and had light rodent activity when it was checked. Another resident with delusional disorder and intact cognition reported finding mouse droppings on the bed and said the roommate hoarded food and garbage. The room contained stacked bins, bedside stands, an overbed table with a coffee maker and wrapped fruit tray, and a shopping bag of personal items. The maintenance director stated he had seen mouse droppings in the room and that pest control traps were present, but the room service records showed no rodent bait stations in that room. Additional residents with diagnoses including paranoid schizophrenia, PTSD, depression, bipolar depression, and homelessness had rooms observed with overflowing bins, bags of belongings, uncovered food on a plate, and crowded storage throughout the room. Several care plans did not address clutter or overcrowding, and staff stated some residents would not allow housekeeping to clean their rooms.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to ensure bait stations were monitored and serviced to prevent or reduce pest problems for residents reviewed for environment. The report identified that the pest control company came monthly and would fill bait stations in resident rooms only when management told them to do so, and the maintenance director stated there was not a master list of which rooms had bait stations. The maintenance director also verified that during 4/2026 none of the bait stations in any rooms were serviced. For one resident with schizophrenia, depression, and moderate cognitive intactness, the infection preventionist stated the resident was trying to feed the mice. During an observation, a large amount of black crumbs that looked like chocolate cake and two patties of what looked like white meat were found under the bed. The room service summary showed the room was not checked in 4/2026, 3/2026, 1/2026, 12/2025, or 11/2025, and was checked in 2/2026 with light rodent activity noted. The maintenance director stated housekeeping was supposed to clean the room after breakfast and lunch. Other residents reviewed had cluttered rooms and food or belongings that could contribute to pest concerns. One resident with delusional disorder reported mouse droppings on the bed, mice in the room, and that the roommate hoarded food; the maintenance director stated he had seen mouse droppings in that room, but the service summary showed no rodent bait stations in the room. Another resident with paranoid schizophrenia had several plastic bags on the floor with uncovered pie on a plate, and the service summary showed no bait stations in the room. Additional residents with psychiatric diagnoses had overflowing bins, crowded rooms, or food brought to rooms, and the owner stated uncovered pie in a resident room was not okay because of pest control concerns. The DON stated cluttered rooms could attract bugs and lead to pest problems.
PASARR Level Two Referral Not Acted Upon
Penalty
Summary
The facility failed to ensure a PASARR level two screening referral was acted upon for 1 of 1 resident reviewed for the PASARR screening process. The resident’s quarterly MDS identified diagnoses of disorganized schizophrenia, dementia with behavioral disturbance, developmental disorder of scholastic skills, and metabolic encephalopathy. The resident’s care plan did not identify PASARR level two recommendations. During interview, the DON confirmed a level two screening was not in the resident’s electronic medical record and stated it was important to identify what services were needed. An OBRA Level 1 screening identified serious mental illness and a referral to level two screening with the Hennepin County preadmission screening team, but a policy regarding the PAS process was requested and not received.
Survey Results Not Readily Visible
Penalty
Summary
The facility failed to ensure that survey results were available for residents and others to view without first needing to ask for them. During observation and interview, the administrator stated that the survey book was kept at the front desk behind the desk in a holder, with a notification indicating where it was located. However, the book was not visible from the front of the desk because a chest-high partition blocked it, even though a posted sign stated that annual state survey results were located at the front desk reception and were available and readily accessible for residents to view 24 hours daily. During an interview with the resident council, an anonymous resident stated that the survey results were there, but they had to ask for them.
Daily Staffing Posting Missing Census and Visible Hours
Penalty
Summary
The facility failed to ensure that the daily nurse staffing posting included the current census and visible hours worked. During observations on 5/4/26, 5/5/26, and 5/6/26, staffing sheets were posted on all three floors, and the facility name, staff names, and disciplines were visible, but the hours scheduled and current census were not visible. During an interview on 5/7/26 at 12:04 p.m., the DON stated the scheduler posted the daily staffing on all three units and confirmed the current census was not included in the posting. During an interview on 5/5/26 at 6:04 p.m., the administrator showed the staffing schedule posted on the first floor in an acrylic stand behind a plexiglass window; the front page visible through the plexiglass showed staff names and titles sorted by shift, but hours worked were not visible. The administrator then spun the posting around and confirmed the total hours listed on the back reflected 5/4/26 rather than 5/5/26 because the 5/5/26 posting had been placed on top of the prior day's posting. The administrator also stated the census was not printed on the daily staffing sheets, but it could be.
Shared Rooms Did Not Provide Required Floor Space
Penalty
Summary
The facility failed to ensure shared resident rooms had at least 80 square feet per resident in 23 rooms identified as 101, 102, 107, 108, 109, 208, 212, 213, 214, 215, 216, 217, 301, 302, 307, 308, 309, 312, 313, 314, 315, 316, and 317. A Room Assignment and Census Report dated 4/13/26 showed a census of 64 and identified rooms with current residents and open beds that would be occupied by three residents when full. The report indicated three rooms already housed three residents, two rooms were empty and could take two residents, and five rooms had one resident and could take a second resident. A tour on 5/5/25 verified the listed rooms either had three residents or could accommodate three residents if needed. During interview, the DON stated there had been no discussion in weekly bed management meetings about moving residents to meet the 80 square foot per resident requirement. The DON reviewed the census report and confirmed there were two completely empty rooms and five rooms with only one resident. The maintenance supervisor measured one room at 230 square feet, which provided 76.67 square feet per resident when divided among three residents, and stated all rooms had the same square footage. Observation of room [ROOM NUMBER] showed R25 had belongings on the floor from the back wall to the foot board of the bed and from the side of the bed to the curtain separating him from the roommate in the middle. R25 stated he was not sure why the facility had three residents to a room and said more space would be nice for belongings and movement. The administrator stated the facility discussed behaviors, incident reports, and possible admissions in weekly bed management meetings, but did not discuss moving residents when a bed opened to provide at least 80 square feet of living space. The administrator also stated new admissions were told the room size was less than 80 square feet, but current residents in three-person rooms were not told when a bed opened unless they noticed an open room and requested a bed change.
Failure to Protect Resident From Physical Abuse by Contracted Lab Technician
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a contracted laboratory technician. The resident had diagnoses including disorganized schizophrenia, dementia, a history of traumatic brain injury, and mild cognitive impairment, and was documented as rarely understood with moderately impaired cognition. The resident’s care plan identified a focus on potential for abuse, neglect, and/or exploitation related to vulnerable adult status, with interventions directing staff to follow the Vulnerable Adult (VA) policy to keep the resident free from exploitation, abuse, and/or neglect. A general condition note documented that the resident was hit at 2:00 p.m. by an external vendor, resulting in slight redness to the left cheek. Video footage from the date of the incident showed the resident sitting in a wheelchair by the elevator doors with several other residents and staff in the area. A tall male, identified by the DON as a contracted laboratory technician, approached the elevator, motioned for the resident to move back, and then stepped forward and slapped the resident’s face with an open right hand. The technician later stated he slapped the resident because the resident said something derogatory about his mother and that he would slap anyone who did so. The DON stated that a slap on the face is considered abuse and acknowledged that facility staff did not supervise laboratory technicians and that residents were supposed to be protected from abuse by contracted staff through VA abuse prevention training. The DON and administrator both stated that the facility did not provide or verify VA abuse prevention training for contracted laboratory staff, and the VA Abuse Prevention policy did not address VA abuse prevention education for contracted staff.
Failure to Implement Abuse Prevention and Verification for Contracted Lab Staff
Penalty
Summary
The deficiency involves the facility’s failure to implement and operationalize written policies and procedures to prohibit and prevent abuse, neglect, and theft by contracted staff. Video footage showed a contracted laboratory technician approach a resident seated in a wheelchair near the elevator, motion for the resident to move back, and then slap the resident’s face with an open hand in the presence of other residents and staff. The technician later stated to the ADON that the resident had said something derogatory about his mother and that he would slap anyone who did so. The ADON questioned what the technician might do in a resident room with a resident who could not speak up for themselves. Interviews with the lab supervisor, DON, and administrator revealed that contracted laboratory technicians did not receive VA abuse prevention training, and the facility did not verify VA abuse prevention education for these contracted staff before they worked with residents. The DON and administrator both stated that residents were protected from abuse by contracted staff through VA abuse prevention training, yet acknowledged that the facility neither provided this training to lab technicians nor verified that they had received it elsewhere. Review of the VA Abuse Prevention policy, revised 10/1, showed it did not address protocols for assuring verification of abuse prevention education for contracted staff, even though the policy stated the facility does not tolerate abuse or misappropriation of resident property by anyone, including staff of other agencies serving the individual.
Failure to Protect Resident from Ongoing Abuse and Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to comprehensively assess, develop, or implement effective interventions to reduce the risk of ongoing physical and mental abuse between two residents. One resident with moderate cognitive impairment, schizoaffective disorder, and a history of behavioral disturbances repeatedly harassed and physically grabbed another resident, who also had moderate cognitive impairment, dementia, anxiety disorder, and a history of delusional thinking. Despite over 20 documented behavioral incidents involving the aggressor, the facility's records lacked detailed descriptions of the behaviors, the specific interventions attempted, and their effectiveness. The primary intervention used was redirection, which was consistently noted as ineffective, and there was no evidence that alternative strategies were considered or implemented. Direct care staff and medication aides reported that the aggressor persistently sought out and targeted the other resident, engaging in behaviors such as hair pulling, grabbing, and entering her room, which caused significant emotional distress. Staff interviews revealed that these incidents had been ongoing for several months, and that management was aware of the situation. However, the care plans for both residents did not include specific interventions or strategies to address the repeated interactions or to protect the victim from further harm. Documentation also showed that the aggressor's care plan lacked a behavioral focus or interventions related to her actions toward other residents. The victim experienced increasing anxiety and distress as a result of these interactions, leading to multiple calls to 911, involvement of law enforcement, and eventual hospitalization for psychiatric care. Despite these outcomes and repeated documentation of the aggressor's behaviors, the facility did not conduct a comprehensive assessment or implement effective interventions to ensure the victim's safety. The facility's abuse prevention policy required identification and investigation of patterns or trends that may constitute abuse, but there was no evidence that the ongoing incidents were reported or investigated as potential abuse, nor that the required immediate interventions were put in place.
Failure to Timely Report Resident-to-Resident Abuse Resulting in Psychosocial Harm
Penalty
Summary
The facility failed to immediately report a resident-to-resident physical altercation to the State agency as required. One resident, who had moderate cognitive impairment and a history of anxiety, delusional thinking, and psychiatric disorders, was repeatedly subjected to hair pulling and grabbing by another resident. Progress notes and staff interviews confirmed that these behaviors had been ongoing for several months, with staff attempts at redirection proving largely ineffective. The affected resident expressed fear and agitation as a result of these incidents, which ultimately contributed to her psychiatric hospitalization. Despite multiple documented incidents and staff awareness of the ongoing interactions, the facility did not report the altercation or the resident's reaction to the State agency within the mandated two-hour timeframe. Staff and management interviews revealed that the events were not recognized as reportable abuse, even though the facility's own policy defined abuse to include nonverbal contact causing fear or mental anguish. The care plan for the affected resident did not include specific interventions related to the other resident's behaviors, and staff had not been provided with new strategies to address the situation. The facility's Vulnerable Adult Abuse Prevention Policy required immediate reporting and investigation of all allegations of potential abuse, including those causing mental anguish. However, the ongoing pattern of physical and psychological distress experienced by the resident was not reported as required, and the facility did not initiate a formal investigation using its Behavioral Assessment Form. Staff interviews confirmed that management was aware of the situation, but no action was taken to escalate or report the incidents to the appropriate authorities.
Failure to Provide Prescribed Diet Results in Fatal Choking Incident
Penalty
Summary
A resident with a history of schizophrenia, diabetes, major depression, obsessive-compulsive personality disorder, and lung disease was assessed as having mild cognitive impairment and required moderate assistance with eating. The resident was on a prescribed Level 1 Dysphagia pureed diet, which required smooth, pudding-like food textures to prevent choking. There were no prior issues with choking while the resident was maintained on this diet. On the day of the incident, a registered nurse assisted the resident in purchasing a sticky bun from a vending machine, despite the resident's dietary restrictions. The nurse did not consider the resident's ordered diet at the time of the purchase. After receiving the sticky bun, the resident began eating it in the dining room, subsequently started to choke, became unresponsive, and fell from his chair. Staff initiated CPR and emergency services were called. Food was found lodged in the resident's throat and was removed during resuscitation efforts. The resident was transported to the hospital, where he was found to have suffered a witnessed aspiration event, cardiac arrest, cervical and rib fractures, anoxic brain injury, and seizure activity. He was later placed on comfort care and pronounced brain dead. The failure to adhere to the prescribed pureed diet and the provision of an inappropriate food item directly led to the choking incident and subsequent fatal outcome.
Removal Plan
- Vending machines were locked in the conference room.
- No staff would assist a resident to get food out of the vending machine.
- If a resident requested an item against his prescribed diet orders, staff would notify the charge nurse, offer a safe snack, and always verify the diet before offering food or drink.
- All snacks for residents must be approved by the dietician and come from dietary services.
- Facility policy updated to require staff to check resident's code status prior to performing CPR, initiate CPR if full code, call 911, and remove visible obstruction during every pulse check.
- Staff are re-educated on choking procedures annually.
- Nursing and dietary staff receive additional training regarding the different types of mechanical soft diets, where to find a resident's diet type, and feeding assistance/aspiration prevention techniques.
- DON completed random diet order checks for ten residents twice a week.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific nature of the hazards, the supervision provided, or the condition of any residents involved are included in the report.
Delayed Reporting of Suspected Sexual Abuse Due to Resident Misidentification
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving two residents, one of whom was cognitively impaired, to the state agency as required. The incident occurred when a cognitively intact resident was found engaging in a sexual act with a cognitively impaired resident, with an allegation that a cigarette was offered in exchange for sex. The cognitively impaired resident had a care plan indicating vulnerability to abuse, neglect, or exploitation. Upon discovery, there was confusion among staff regarding the identity of the involved resident, leading to an initial interview with the wrong individual who was alert and oriented. The Director of Nursing (DON) did not realize the correct resident involved was cognitively impaired until later the following day, at which point the appropriate internal and external notifications were made, including contacting the police, case manager, and responsible party. The DON acknowledged that the report to the state agency was delayed due to the confusion over resident identity and confirmed that the incident should have been reported immediately as per facility policy. The facility's policy requires immediate internal reporting of suspected mistreatment of vulnerable adults.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Properly Handle and Store Clean Linens for Infection Control
Penalty
Summary
The facility failed to ensure that laundry was handled and transported in a manner that would prevent the spread of infection. Observations and interviews revealed that staff did not wear gowns when handling dirty laundry, only gloves and masks. Clean linens and personal laundry were transported to resident floors in large, uncovered bins and metal carts, and were not covered during transport. In one unoccupied room with an open door to the hallway, multiple open-top bins containing clean linens were found, with linens exposed and some scattered within the bins. Additional clean linens were stacked on top of an armoire alongside various medical equipment, and the room was cluttered with both clean and soiled items. Staff were observed entering this room to retrieve linens due to supply shortages and lack of assigned personnel to restock the linen closet, resulting in staff rummaging through the bins for needed items. Interviews with staff, including nursing assistants and LPNs, confirmed that the room intended for clean linen storage was often used inappropriately, with clean linens left uncovered and the door left open. The infection preventionist acknowledged that the expectation was for all clean linen to remain covered and for the room door to be closed, but confirmed that reeducation was needed. The facility's infection control policy required active efforts to control and prevent communicable diseases, but these practices were not consistently followed, potentially affecting all 70 residents in the facility.
Failure to Reheat Food to Safe Temperature Prior to Service
Penalty
Summary
The facility failed to ensure that food was reheated to the appropriate temperature as required by both manufacturer instructions and professional standards. During meal preparation, a cook removed multiple bags of chicken pot pie filling from a steam cooker, mixed them, and did not take the temperature at that time. Later, the cook was observed taking the temperature of the chicken and dumplings at the steam table, which measured 90°F, significantly below the required 165°F. The director of nutritional services (DNS) then reheated the food in the oven, but it only reached 145.3°F before being served to residents. The temperature log indicated a reading of 170°F, but both the cook and DNS could not confirm when or how this measurement was taken, and the DNS suspected the log entry was inaccurate. Further review revealed that the DNS was unaware of the manufacturer's instructions requiring the food to be reheated to 165°F and acknowledged uncertainty about whether this protocol was being followed. The cook admitted she was never sure the food had reached the required temperature and had only assumed it was 170°F. Additionally, when asked, the facility was unable to provide a policy regarding reheating food. As a result, 12 residents consumed food that may not have been reheated to a safe temperature, contrary to established standards and protocols.
Failure to Timely Report Allegations of Verbal and Mental Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal and/or mental abuse were reported to the administrator and State agency (SA) in a timely manner for three residents who reported or were observed to have experienced potential abuse. One resident, who had intact cognition but demonstrated delusional thinking, reported feeling abused by her roommate, who allegedly called her derogatory names and swore at her. The resident stated she had not reported the abuse previously, and a nursing assistant confirmed overhearing the roommate calling the resident names about a month prior but did not report it, assuming nurses present had witnessed it as well. There was no evidence that this allegation was reported to the SA until the surveyor brought it to the attention of the administrator and DON, who were previously unaware of the situation. Two additional residents, both with intact cognition and various medical and psychiatric diagnoses, were involved in separate incidents where a facility physician reported allegations of staff verbal abuse to the DON. The physician's progress notes indicated that one resident was called a derogatory name by an unknown staff member and was left uncomfortable and agitated, while the other resident experienced rudeness from staff. Although the DON was informed of these allegations, he did not report them to the SA, and the administrator was not made aware until later, during the survey process. The facility's Vulnerable Adult Abuse Prevention Policy defined verbal and mental abuse and required mandated reporters to immediately report any knowledge or belief of abuse to the administrator, DON, or their designee. Despite this policy, staff failed to report witnessed or alleged abuse in a timely manner, resulting in delayed notification to both facility leadership and the State agency, as required by regulation and facility policy.
Inaccurate MDS Coding for Administered Medications
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded regarding the administration of specific medications for two residents. For one resident, the MDS indicated that no hypoglycemic medications were administered during the assessment period, despite the Medication Administration Record (MAR) showing that semaglutide, a hypoglycemic medication used for diabetes mellitus, was given within the review period. For another resident, the MDS recorded that no antianxiety medications were administered, while the MAR documented that buspirone, an anxiolytic medication, was given multiple times during the same period. These discrepancies were confirmed through interviews with the registered nurse responsible for completing the MDS, who acknowledged the errors after reviewing the medical records. The nurse verified that the medications in question should have been coded on the MDS based on their pharmacological classification and actual administration as documented in the MAR. The facility did not provide a policy on MDS completion and accuracy when requested.
Failure to Maintain Comprehensive and Updated Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive and up-to-date care plans were developed and implemented for three residents, resulting in deficiencies related to continuity of care. For one resident with a long-term indwelling urinary catheter, the care plan did not include Enhanced Barrier Protection (EBP) measures as recommended by CDC guidelines for residents at high risk of multidrug-resistant organism (MDRO) transmission. Observations confirmed the absence of PPE signage or equipment outside the resident's room, and staff interviews revealed reliance on care plans for guidance, yet the necessary infection control interventions were not documented or implemented. Another resident with diagnoses of alcoholic cirrhosis and alcohol dependence had multiple documented episodes of alcohol use within the facility, including possession and consumption of alcohol in their room. Despite repeated incidents and staff awareness, the care plan did not address the resident's substance use, associated risks, or interventions for monitoring and assessment. Staff interviews confirmed that care plans are used to inform monitoring practices, but the lack of documentation meant new or unfamiliar staff would not have clear guidance on managing the resident's ongoing alcohol use. A third resident with multiple chronic conditions, including diabetes, depression, and hypertension, as well as an active discharge plan, had a care plan that lacked essential information. The care plan did not address the resident's abilities with activities of daily living (ADLs), use of assistive devices, discharge planning, medication management, or the management of their medical and psychiatric diagnoses. Interviews with staff and the director of nursing confirmed that these omissions were inconsistent with facility policy and expectations for comprehensive care planning.
Failure to Assess and Develop Interventions for Resident Refusing Personal Hygiene Care
Penalty
Summary
The facility failed to comprehensively assess and develop individualized interventions to promote acceptance of bathing and personal hygiene care for a resident with impaired memory and cognitive function. The resident was observed to be disheveled, with greasy hair, soiled and long fingernails, and a visible brown substance on his hands. Documentation showed a pattern of the resident refusing showers and personal hygiene care, with staff offering alternative methods such as basin and wipes, which were also refused. Despite these repeated refusals, there was no evidence in the medical record that the facility had assessed or evaluated alternative approaches to facilitate the resident’s acceptance of care. Interviews with staff revealed that some nursing assistants had more success with the resident by using specific approaches, such as offering care when the resident returned from smoking or having the shower water running and hot. However, these successful strategies were not documented in the care plan, and other staff did not consistently re-approach the resident to provide care. Staff also noted that nail care was not consistently offered or documented, and there was uncertainty about whether it was being performed or recorded appropriately. The resident’s care plan identified a need for assistance with personal hygiene and bathing due to mental illness and impaired cognition, and set a goal for the resident to be clean and well-groomed. However, the care plan lacked specific interventions or strategies to address the resident’s repeated refusals or to promote acceptance of care. The facility’s personal hygiene policy required assistance based on individual needs and preferences but did not address how to manage or evaluate repeated refusals of care.
Failure to Assess and Act on Repeated Chest Pain Complaints
Penalty
Summary
The facility failed to adequately assess and respond to repeated complaints of pleuritic and gastrointestinal distress, specifically heart pain, for a resident with moderate cognitive impairment and significant medical history including heart failure and use of anticoagulants. The resident had a standing as-needed order for Maalox to treat indigestion or heartburn, which was administered multiple times by staff. However, documentation in the medical record did not consistently include the symptoms prompting administration, nor did it provide evidence of assessment to distinguish between cardiac and gastrointestinal causes of the pain. Vital signs and symptom characteristics were not always recorded, and there was a lack of follow-up to determine the effectiveness of the intervention or to reassess the resident after medication was given. Staff interviews revealed that the resident had a history of voicing complaints such as "my heart hurts" and "my stomach hurts" over a long period, with staff typically providing Maalox in response. Some staff reported occasionally taking vital signs, but not consistently with each complaint. There was also uncertainty among staff regarding whether the resident's physician was aware of the ongoing symptoms, despite the repeated use of as-needed medication. The care plan included interventions for cardiac and respiratory conditions but did not address the resident's gastroesophageal reflux disease or provide specific interventions for this diagnosis. The medical record lacked evidence that the resident's symptoms were evaluated in real-time or retrospectively to determine their cause, nor was there documentation that the physician or medical team had been notified about the persistent symptoms and repeated use of as-needed medication. The director of nursing confirmed that the expected process for assessment, documentation, and physician notification was not followed, and acknowledged that the medical record did not reflect appropriate evaluation or communication regarding the resident's ongoing complaints.
Failure to Assess and Address Resident's Hearing Concerns
Penalty
Summary
A deficiency occurred when the facility failed to act upon and assess a resident's voiced complaints and observed difficulties with hearing. The resident, who had impaired memory and was identified as hard of hearing, was observed struggling to hear during interactions and did not use hearing aids. The care plan acknowledged the resident's hearing issues and included interventions such as minimizing background noise and offering an audiology appointment. Despite these interventions, there was no evidence in the medical record that a comprehensive hearing assessment was completed or that the resident was evaluated for potential reversible causes of hearing loss, such as earwax buildup. Staff interviews revealed that hearing assessments were only performed if a complaint was made and not on a routine basis, and there was uncertainty about the availability of necessary equipment for ear examinations. Additionally, although a family member requested an audiology appointment and documentation indicated that one was scheduled, there was no evidence that the appointment was completed, refused, or rescheduled. The facility's documentation lacked follow-up regarding the outcome of the scheduled audiology appointment, and no policy on hearing evaluations was provided when requested. These inactions resulted in the resident's hearing concerns not being adequately addressed, despite both family and staff noting ongoing hearing difficulties.
Failure to Reassess Resident After Multiple Indoor Smoking Incidents
Penalty
Summary
The facility failed to ensure that a resident who had multiple incidents of smoking indoors was reassessed for safe smoking, as required by policy. The resident, who was cognitively intact and independent with activities of daily living, had a care plan and assessment indicating she was a safe smoker and only smoked in designated areas. However, progress notes documented at least three separate incidents over a period of 6-7 months where the resident was found smoking in her room, in violation of the facility's smoking policy. On each occasion, the resident was educated on the risks and signed the smoking policy, but no reassessment for safe smoking was conducted. Observations showed the resident kept a significant number of cigarettes and a lighter at her bedside. Staff interviews confirmed awareness of the resident's indoor smoking incidents and indicated that, while staff would sometimes hold onto smoking materials and provide education, the resident was still able to access her own cigarettes. The social services designee and DON both acknowledged that a reassessment should have occurred after the incidents, but it was not completed. The facility's policy required immediate action and reporting when indoor smoking was observed, but this was not fully implemented in the resident's case.
Failure to Ensure Timely Physician Visits for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure that a resident received timely in-person physician visits as required, specifically every 60 to 70 days, to promote continuity of care and reduce the risk of disease complications. The resident in question had moderate cognitive impairment and multiple medical conditions, including non-traumatic brain dysfunction, heart failure, and schizophrenia, and was prescribed several medications such as antipsychotics and anticoagulants. Despite these complex needs, the medical record showed that the last in-person physician visit was documented over 70 days prior, with the most recent psychiatric progress note dated more than three months earlier. The facility's own policy required physician visits at least every 60 days after the initial 90-day period post-admission. Observations and interviews revealed that the resident had ongoing symptoms, such as chest pain, and was receiving medications for these complaints. Staff, including the DON and consulting pharmacist, confirmed that the resident's primary care was managed by a VA provider and that there was a lapse in scheduling and tracking required physician visits. The DON acknowledged that the resident had not been seen by a physician in the required timeframe and that the facility did not have a system in place to ensure compliance with the 60-day visit requirement, resulting in the resident not being seen as needed.
Failure to Ensure Proper Mouth Rinse After Steroid Inhaler Administration
Penalty
Summary
Staff failed to implement manufacturer-directed steps to prevent post-administration complications for a resident receiving a steroid-infused inhaler. During a medication administration observation, a trained medication aide provided a resident with a mometasone furoate (Asmanex) inhaler, which was clearly labeled with instructions to rinse the mouth thoroughly after each use. The aide administered the inhaler but did not offer or assist the resident with a mouth rinse before proceeding to give oral medications. The omission was only identified when the surveyor intervened and questioned the aide, who then acknowledged forgetting the step and subsequently assisted the resident with rinsing. The resident involved had moderate cognitive impairment and a history of pneumonia and asthma, as documented in their quarterly MDS. Interviews with the DON and consulting pharmacist confirmed that a mouth rinse should be completed after using an inhaled corticosteroid to prevent oral thrush, and that such instructions should be visible on the MAR for staff reference. The facility did not provide a policy on metered-dose or steroid-infused inhaler use, and there was no evidence of recent staff education or audits regarding proper inhaler administration procedures.
Failure to Act on Pharmacist's Recommendation for Digoxin Level Monitoring
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations for laboratory monitoring of a resident receiving digoxin were acted upon and addressed in a timely manner. A resident with moderate cognitive impairment, heart failure, and schizophrenia was prescribed digoxin for chronic diastolic heart failure, with daily administration documented and pulse checks recorded. The resident's care plan included general interventions for cardiac complications but did not specify how or when digoxin levels should be monitored. The consulting pharmacist identified the absence of a digoxin level in the medical record and recommended obtaining a digoxin level and basic metabolic panel. Although the physician indicated acceptance of the recommendations, there was no documentation that the digoxin level was obtained or that a rationale was provided for not doing so. Subsequent medication regimen reviews by the consulting pharmacist did not identify further irregularities, but the medical record continued to lack evidence of digoxin level monitoring. Interviews with the DON and consulting pharmacist confirmed that the recommendation for laboratory monitoring was not addressed, and there was no follow-up or documentation explaining the omission. The facility was unable to provide a policy on consulting pharmacist recommendations, and the process for ensuring such recommendations were implemented was not clearly documented or followed.
Failure to Monitor Digoxin Levels in Resident Receiving Cardiac Glycoside
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not appropriately monitoring the resident's use of digoxin, a cardiac glycoside medication. The resident, who had moderate cognitive impairment and multiple medical conditions including heart failure and schizophrenia, had been prescribed digoxin for chronic diastolic congestive heart failure. Despite ongoing daily administration of the medication, there was no evidence in the medical record that a digoxin level had been checked or obtained within the last 12 months. The care plan did not specify how often digoxin levels should be monitored, and the facility was unable to provide documentation of any recent laboratory testing for digoxin levels. Observations and interviews revealed that the resident had experienced chest pain, which staff attributed to heartburn, and that the consulting pharmacist had repeatedly requested digoxin level checks without success. The director of nursing confirmed the absence of digoxin level results in the medical record and acknowledged the need for such monitoring. The facility also failed to provide a policy on medication management and monitoring when requested. These actions and omissions resulted in a lack of appropriate monitoring for potential digoxin toxicity, as required by standard care practices.
Failure to Administer Recommended Pneumococcal Vaccine
Penalty
Summary
The facility failed to implement current standards for pneumococcal vaccination for one resident over the age of [AGE]. According to the resident's electronic medical record, the only pneumococcal vaccine received was PPSV23, administered in 2011. The CDC recommends that individuals over a certain age receive at least one dose of PCV15, PCV20, or PCV21 at least one year after the last PPSV23 dose. The resident's immunization record did not show any additional pneumococcal vaccines, and the vaccine consent or declination form did not indicate whether the resident consented to or refused the vaccine. During an interview, the infection preventionist confirmed that all residents should be offered influenza, pneumococcal, and COVID vaccines upon admission, but the facility only provided the influenza vaccine on-site and sent residents out for the other two. The infection preventionist also confirmed that the resident had consented to the pneumococcal vaccine and was due for it, but was not yet on the list to receive it. The facility's immunization policy states that it will follow CDC and state recommendations, but this was not followed in the case of this resident.
Failure to Investigate and Respond to Allegations of Verbal and Mental Abuse
Penalty
Summary
The facility failed to respond appropriately to allegations of verbal and/or mental abuse for three of four residents reviewed. One resident, who had intact cognition but demonstrated delusional thinking, reported feeling abused by her roommate, who allegedly called her derogatory names and swore at her. The resident stated she did not always feel safe in her room and had not reported the incidents previously. A nursing assistant confirmed overhearing the roommate calling the resident names in the dining room about a month prior, but did not report the incident, assuming nurses present had witnessed it as well. There was no evidence in the care plan or medical records that the facility had investigated these allegations or implemented interventions to ensure the resident's safety, despite the behavior being witnessed by direct care staff. Additionally, two other residents reported allegations of staff verbal abuse, which were submitted to the State Agency by the facility physician. Both residents had intact cognition and various medical and psychiatric diagnoses. Progress notes indicated that the director of nursing (DON) was informed of the allegations, but there was no documentation of an investigation or any follow-up in the electronic medical record. Interviews with the residents revealed that they felt staff were rude or had made derogatory statements, but they were unable to identify the specific staff member or the timing of the incidents. The DON acknowledged being informed of the allegations but admitted to failing to initiate or document an investigation. Interviews with facility staff, including medication aides and LPNs, confirmed the expectation that all allegations or observations of abuse should be reported immediately to management for investigation. However, the administrator and DON both stated they were unaware of the allegations until informed by others, and no investigation or documentation was completed as required by facility policy. The facility's abuse prevention policy outlined the need for immediate assessment and investigation upon receiving a report, but this was not followed in these cases.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that state survey results were kept in a location that was readily accessible to all residents. During interviews, one resident with intact cognition and another with severely impaired cognition both confirmed they were unaware that survey results were available for them to read, with the cognitively intact resident expressing interest in viewing them. Observation revealed that the survey results were stored in a binder inside a locked office at the first-floor nursing station, and the administrator stated that the binder had been kept there since his tenure began due to concerns about residents potentially taking or damaging the binder. A policy regarding the posting of survey results was requested but not provided.
Failure to Complete and Transmit Discharge MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that discharge Minimum Data Set (MDS) assessments were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for three residents. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, discharge assessments must be transmitted within 14 calendar days of the MDS completion date. For each of the three residents, documentation showed that they had been discharged from the facility, with corresponding progress notes indicating their discharge status, such as leaving against medical advice, not returning from a leave of absence, or being discharged to another care center. Despite these discharges, the medical records for all three residents lacked evidence that a discharge MDS had been started, completed, or transmitted to CMS, even though several months had passed since their discharge dates. During an interview, the registered nurse responsible for MDS completion confirmed that the discharge MDS assessments for these residents had not been completed, citing issues with the electronic system and missed notifications of resident discharges. The facility was unable to provide a policy on MDS completion when requested.
Shared Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that shared resident rooms provided the required minimum of 80 square feet per resident, as mandated for multiple occupancy rooms. Specifically, 23 rooms were identified as having only 232.72 square feet total, resulting in 77.57 square feet per resident when three residents occupied the space. Documentation and direct observation confirmed that these rooms either currently housed three residents or were set up to accommodate three, affecting all 69 residents who currently or potentially could occupy these rooms. The Aspen Central Office database also indicated that the facility had shared rooms below the required square footage, and no construction or room size changes had occurred since the previous survey. During interviews, one resident expressed confusion and dissatisfaction about sharing a room with two others, stating the space felt suitable for only one person. Another resident reported having enough space for her bed but noted insufficient closet and storage space, with all three closet cubbies observed to be overflowing. The administrator acknowledged that all rooms were the same size and that three residents could be assigned per room, and stated there had been no complaints from current residents about the room arrangements. Facility policy indicated that residents are informed if a room does not meet the 80 square foot minimum requirement.
Failure to Assess and Safely Transfer Resident After Unwitnessed Fall
Penalty
Summary
The facility failed to comprehensively assess and appropriately transfer a resident following an unwitnessed fall with potential head injury. The resident, who had a history of traumatic brain injury and used a manual wheelchair, was involved in an altercation with another resident, resulting in his wheelchair being flipped backward and the resident striking the back of his head on the elevator floor. Progress notes indicated that the resident complained of head pain and was later sent to the hospital for evaluation, but initial on-site assessment documented no apparent injury. Video footage of the incident revealed that three staff members responded quickly, but two staff members manually assisted the resident off the ground and into his wheelchair without performing a comprehensive assessment or using a gait belt, contrary to facility policy and staff statements. Interviews with the DON, TMA, and LPN confirmed that the expected protocol was to conduct a full assessment—including range of motion, head and body checks, vital signs, and neurological checks—before moving the resident. However, the video evidence showed that these assessments were not completed prior to transferring the resident. Facility policy required a nurse to assess the seriousness of any accident or incident, especially those involving unwitnessed falls or potential head injuries, and to document vital signs and neurological checks. The policy did not specifically address the method of transferring a resident after a fall, but staff and leadership interviews consistently stated that a comprehensive assessment should occur before any movement. The failure to follow these procedures led to the deficiency cited in the report.
Resident Elopement Due to Lack of Supervision
Penalty
Summary
The facility failed to ensure comprehensive assessments and interventions were implemented for a resident who was assessed to be unsafe in the community and at risk of elopement. This deficiency resulted in an immediate jeopardy situation when the resident left the facility without supervision for appointments, became lost, and was gone for over five hours before staff were aware. The resident was eventually found by a family member outside a hospital in a highly trafficked area. The resident had a recent diagnosis of traumatic brain injury, diabetes, schizoaffective disorder, seizure disorder, and substance abuse issues. Despite being identified as at risk for elopement and requiring an escort, the resident was sent to appointments without supervision. The facility's social worker had verbally informed the medical records staff that the resident needed an escort, but there was a communication breakdown, and the resident attended appointments unsupervised. Interviews with facility staff revealed that the resident's absence was not noticed until hours after the scheduled appointments. The director of nursing was informed late in the evening, and a missing person report was filed. The facility's policy required assessments and care plans to be updated for residents at risk of wandering, but these procedures were not effectively followed, leading to the resident's unsupervised departure.
Removal Plan
- Ensuring R1 was care planned to require an escort while in the community.
- All residents were re-assessed for need for an escort while in the community and care plans were updated accordingly.
- All nursing staff were educated regarding appointment/escort procedures.
- All residents with any significant change in condition had elopement risk assessments completed.
- Any resident deemed for elopement risk had interventions in place and care planned for elopement.
- A list of residents requiring escorts was newly posted at each nurse's station.
- The facility social worker was educated to update the list of residents requiring escorts when changes requiring supervision by an escort were required.
Rodent Infestation and Inadequate Pest Control Measures
Penalty
Summary
The facility failed to adequately address and monitor a known rodent infestation, which affected all 68 residents. Interviews and observations revealed that residents, including R3 and R4, frequently encountered mice in their rooms. R3 was observed feeding the mice, which led to an accumulation of food and mouse feces in her room. Staff were aware of R3's behavior but struggled to manage it effectively, as R3 resisted their attempts to clean her room. The maintenance director was aware of the issue but did not have a comprehensive plan to address it. The facility's pest control measures were insufficient, relying primarily on sticky traps that were ineffective. The maintenance director admitted to placing traps in rooms where mice were found but lacked a systematic approach to track and change them. The pest control company was supposed to provide monthly services, but there was a lack of communication and coordination between the facility and the company. The pest control company had not visited the facility since August, and the maintenance director was unaware of the specifics of their services. The facility's Quality Assessment and Performance Improvement (QAPI) program failed to address the rodent issue effectively. Despite documenting the presence of mice in their quarterly reports, there was no plan to reduce or eliminate the problem. The administrator acknowledged the deficiency and recognized the need for a more proactive approach, but at the time of the report, no effective measures had been implemented.
Failure to Implement Effective Pest Control Measures
Penalty
Summary
The facility failed to implement effective and timely pest control measures to address a mouse infestation, affecting all 68 residents. Observations and interviews revealed that mice were frequently seen on the second floor, particularly in a resident's room where food was intentionally left to feed them. The room was found to have an excess of mouse feces and food debris, indicating a severe infestation. Staff members, including a trained medical assistant and a licensed practical nurse, confirmed the presence of mice and the resident's habit of feeding them, which had been ongoing for a significant period. Interviews with other residents and staff highlighted the widespread nature of the problem. Another resident reported seeing mice coming from baseboard heaters and expressed frustration with the ineffective sticky traps used by the facility. The maintenance director admitted to placing traps and using steel wool to block holes but lacked a systematic approach to tracking and addressing the infestation. The director also acknowledged the limited involvement of the pest control company, which had not visited the facility since August 2024. The facility's pest management policy outlined responsibilities for the maintenance director, including coordinating with pest control contractors and recording pest sightings. However, the policy was not effectively implemented, as evidenced by the ongoing mouse problem and the lack of regular pest control services. The director of nursing was unaware of the severity of the issue, particularly the presence of mice in a resident's bed, which could have implications for resident health and safety.
Failure to Notify Guardian and Provider of Missing Resident
Penalty
Summary
The facility failed to provide timely notification to a provider and guardian for a resident who went missing after being sent to an appointment without an escort. The resident, who had a history of non-traumatic brain dysfunction, cognitive impairment, and was not safe in the community, was missing for seven hours. The resident's care plan indicated that he should not leave the facility without an escort due to his cognitive impairment and risk for falls. Despite this, the resident was sent to an appointment alone and was found by a family member in a confused state, wandering downtown. The facility's staff did not realize the resident was missing until two and a half hours after his scheduled medication time, as they were unaware of his return time from the appointment. The family member was not notified of the resident's disappearance until several hours later, and the nurse practitioner was informed weeks after the incident. The facility's policy required immediate notification of significant changes in a resident's condition to the physician and designated contacts, which was not followed in this case.
Failure to Protect Resident's Property and Provide Lock Box
Penalty
Summary
The facility failed to protect a resident's property from loss or theft and did not provide a lock box for personal property and/or monies, resulting in the loss of $50.00. The resident, who had a recent traumatic brain injury and memory issues, withdrew $50.00 from his account after returning from the hospital. The resident's family member expressed concern about the facility allowing the withdrawal given the resident's cognitive impairment and noted that the promised lock box was never provided. Despite being informed of the missing money, the facility did not investigate the loss or implement measures to prevent future occurrences. The resident's medical history included non-traumatic brain dysfunction, diabetes mellitus, asthma, anxiety, and schizophrenia, with a care plan indicating cognitive impairment and a history of substance abuse. Interviews with facility staff confirmed the withdrawal and the lack of clarity on how the money was spent. The facility administrator acknowledged awareness of the unaccounted money and agreed that a lock box should have been provided. No policy related to personal property was available at the end of the survey.
Failure to Timely Report Missing Resident with Cognitive Impairment
Penalty
Summary
The facility failed to timely report an allegation of a missing resident, identified as R1, who had a traumatic brain injury and was cognitively impaired. R1 was at risk for elopement and was not safe in the community without an escort. Despite this, R1 was allowed to attend appointments without an escort, leading to his disappearance. The facility's Wandering and Elopement Risk Assessment and Care Plan both indicated that R1 required an escort for safety, but this was not communicated effectively among staff. On the day of the incident, R1 left for appointments at a hospital but did not return as expected. The facility staff did not realize R1 was missing until 7:30 p.m., despite R1 being scheduled to receive medications at 5:00 p.m. The staff assumed R1 was still at his appointments and did not verify his return time. It was only after a family member found R1 in a downtown area that the facility was notified of his whereabouts. The family member expressed concerns about R1's mental state and potential access to illicit substances due to his history of substance abuse. Interviews with facility staff revealed communication breakdowns regarding R1's need for an escort. The social worker claimed to have informed the medical records staff, who did not receive a clear answer. The director of nursing was notified of R1's absence after 8:00 p.m. and instructed staff to search the facility and contact the police. The facility's Vulnerable Adult Abuse Prevention Policy requires reporting within two hours of any suspected abuse or neglect, which was not adhered to in this case.
Failure to Prevent Falls and Conduct Neurological Assessments
Penalty
Summary
The facility failed to comprehensively assess and implement interventions to prevent falls for three residents, leading to an immediate jeopardy situation for one resident. This resident, diagnosed with orthostatic hypotension and impaired cognition, experienced multiple unwitnessed falls resulting in a traumatic brain injury and subarachnoid hemorrhage. Despite the falls, the facility did not conduct necessary neurological checks or update the resident's care plan to include new interventions to prevent further falls. Another resident, with diagnoses including osteoporosis and dementia, was found lying on the floor after feeling weak. Although neurological assessments were reportedly completed, there was no documentation to support this. The resident's care plan included interventions such as wearing non-skid shoes and using a call light, but these measures were not sufficient to prevent the fall. A third resident, with a history of epilepsy and head injury, fell in the community and required follow-up care, which was not documented or communicated to the primary care provider. The facility lacked a protocol for neurological assessments and did not update the fall risk assessments or care plans for any of the residents after their falls, contributing to the deficiency.
Removal Plan
- Update Fall Risk Assessment Policy and Procedure
- Update protocol for neurological assessments
- Update neurological assessment form
- Train nursing staff about new neurological assessments and post-fall procedures
- Review falls for all residents who fell
- Update care plans for residents who fell
- Perform post-fall assessments for residents who fell
- Complete Falls Risk Assessment for each resident identified
Failure to Notify Medical Providers of Resident Falls and Injuries
Penalty
Summary
The facility failed to provide timely notification to a medical provider for changes in condition related to falls or treatment after falls for three residents. One resident, with a history of schizophrenia, anxiety, depression, diabetes, and orthostatic hypotension, experienced multiple falls. After a fall near the elevator, the resident reported hitting their head, and although neuro checks were ordered, the resident refused hospital transfer initially. Later, the resident fell again, was found with low vital signs, and was eventually sent to the hospital with a brain bleed. Despite these incidents, the medical provider was not updated promptly about the resident's condition or the subsequent hospital admission. Another resident, diagnosed with schizoaffective disorder, osteoporosis, and dementia, was found lying on the floor, claiming weakness. Although neurological assessments were completed, the nurse practitioner was not notified of the fall. A third resident, with epilepsy and a history of head injury, fell in a community store and was taken to the hospital. The hospital recommended follow-up lab work, but the primary provider was not informed. The facility's policy required notifying the physician of any significant change in condition, including head trauma, which was not adhered to in these cases.
Lack of Physician Delegation Policy
Penalty
Summary
The facility failed to develop a policy and procedure for the delegation of tasks by physicians to physician assistants, nurse practitioners, or clinical nurse specialists. This deficiency was identified during a review of facility policies on 9/6/24, which revealed the absence of a procedure for physician delegation of tasks. The administrator confirmed the lack of such a policy or procedure when interviewed on the same day at 5:22 p.m. This oversight had the potential to affect all 69 residents residing at the facility.
Lack of Policy for Physician Delegation to Dietitian
Penalty
Summary
The facility failed to develop a policy and procedure for the delegation of tasks by physicians to the dietitian. This deficiency was identified during a review of facility policies, which revealed the absence of a procedure for physician delegation of tasks to the dietitian. The administrator confirmed the lack of such a policy or procedure when interviewed, indicating that no documentation could be found to address this delegation process. This oversight had the potential to impact all 69 residents residing at the facility.
Lack of Governing Body Policy
Penalty
Summary
The facility failed to establish and implement a policy regarding the responsibility of the administrator to report to and be held accountable by the Governing Body. This deficiency was identified during a review of facility policies and procedures, which revealed the absence of a policy related to the Governing Body. On September 6, 2024, the administrator confirmed that the facility did not have such a policy in place. This oversight had the potential to affect all 69 residents residing in the facility.
Lack of Medical Director Responsibilities Policy
Penalty
Summary
The facility failed to develop a policy and procedure defining the responsibilities of the Medical Director. During a review of facility policies on 9/6/24, it was found that there was no policy or procedure in place for the responsibilities of the Medical Director. Additionally, the facility lacked a position description for the Medical Director. This deficiency was confirmed by the administrator during an interview on the same day at 5:22 p.m., who acknowledged the absence of a policy addressing the Medical Director's responsibilities.
Failure to Notify State Agency of New DON
Penalty
Summary
The facility failed to notify the State Agency (SA) as required when the current Director of Nursing (DON) was hired. This deficiency was identified during an extended survey conducted on September 6, 2024, when evidence was requested to demonstrate that the SA had been informed of the new DON's hiring. The facility administrator confirmed that the SA was not notified of this change in administrative personnel, which had the potential to affect all 69 residents in the facility.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that newly admitted residents received a physician visit every 30 days for the first ninety days, as well as routine physician visits every 60 days for long-term residents. Specifically, one resident, identified as R5, did not receive the required physician visits every thirty days after admission. The clinical records showed that an NP conducted the initial visit, and the physician only examined the resident once after admission. The Director of Nursing confirmed that R5 did not receive the necessary physician visits as required for a newly admitted resident. Additionally, the facility did not ensure routine physician visits for long-term residents, as evidenced by the cases of residents R1 and R6. R1's medical records indicated a lack of routine 60-day visits and alternating visits by a physician, with the last physician visit recorded several months prior. Similarly, R6's records showed a lack of routine 60-day visits, with the physician examining the resident only twice over several months. The Director of Nursing confirmed these deficiencies, and the facility administrator acknowledged the absence of a policy addressing physician delegation of tasks.
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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