Crest View Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia Heights, Minnesota.
- Location
- 4444 Reservoir Boulevard Northeast, Columbia Heights, Minnesota 55421
- CMS Provider Number
- 245018
- Inspections on file
- 29
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Crest View Lutheran Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of loud vocalizations was assaulted in a TV room by another ambulatory resident with dementia and moderate cognitive impairment, resulting in facial injuries including a nasal fracture and hematoma. Staff had repeatedly observed that the aggressive resident became visibly agitated, spoke in Spanish, and directed anger toward others when exposed to loud environments and the victim’s frequent calling out, and they informally redirected or separated him at times. However, these behaviors and triggers were not documented, a prior psych recommendation to track behavioral dysregulation and develop a behavior support plan was not implemented, and the care plan lacked specific behavioral interventions or supervision strategies. Nursing and NA staff reported awareness of agitation and a prior altercation but were unsure where to document behaviors and were unaware of any behavior support plan, resulting in inadequate protection of a resident’s right to be free from physical abuse.
A resident with significant mobility deficits and on hospice care was left on a bare air mattress without a draw sheet during a bed bath. Staff failed to follow the care plan requiring two-person assistance and proper use of a draw sheet, and did not ensure bed brakes were engaged. During repositioning, excessive force was used, causing the resident to slide off the bed and sustain a femur fracture requiring surgery.
A nurse failed to perform proper hand hygiene and did not disinfect a glucometer after use during blood glucose monitoring and insulin administration for a resident. Additionally, soiled laundry was not consistently bagged before transport, and clean linens were stored improperly, including on the floor and near contaminated areas. These actions did not follow facility infection control policies.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
Nutritional supplements were found stored directly on the floor in two medication rooms, with staff unaware of proper storage requirements despite available shelf and cupboard space. Additionally, the ice machine door in the kitchen was damaged, exposing insulation and making it impossible to clean or disinfect properly, with no maintenance records or policy provided for its upkeep.
Surveyors observed that the kitchen floor in the dishwashing area had missing tile chunks, missing grout, and a green substance on the subfloor. The dietary director acknowledged these issues and identified them as a cleaning concern, but no maintenance work orders or relevant cleaning and maintenance policies were found.
Surveyors found that several rooms had broken window blinds, compromising resident privacy, and multiple shower rooms were observed with mold, cracked or missing tiles, and unclean surfaces. Staff interviews revealed inconsistent cleaning practices and lack of clarity about responsibilities. Additionally, a resident with significant medical needs reported numerous missing personal items over several months, with staff failing to adequately track or resolve the losses as required by facility policy.
Handrails in several hallway locations, including between rooms and near the dining area, were found to be loose and not securely attached. Staff interviews revealed that maintenance relied on staff to report issues using forms, but no work orders for handrail repairs were found in the reviewed period. No facility policy or procedure on handrails was available when requested.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that ensure restraints are only used for medical treatment.
A resident with moderate cognitive impairment and multiple complex medical conditions was hospitalized twice, but the facility did not include these transfers in its required monthly notifications to the Ombudsman. The social service assistant confirmed the omissions, and no relevant policy was provided during the survey.
A resident with a diagnosis of PTSD and a history of complex trauma did not have PTSD triggers or interventions included in their care plan, despite clinical recommendations and facility policy. Multiple staff members, including nursing and social services, were unaware of the resident's PTSD history or specific needs, and trauma assessments were not completed or incorporated into the care plan.
A resident with multiple complex medical conditions and moderate cognitive impairment was receiving oxygen therapy, but the care plan did not specify the reason for oxygen use, the flow rate, or the route of administration. Facility staff confirmed that the care plan lacked necessary resident-specific details, contrary to facility policy requiring individualized and comprehensive care plans.
A resident lost the ability to perform ADLs without a documented medical reason, as the facility did not ensure maintenance of the resident's highest practicable level of functioning or provide evidence that the decline was clinically unavoidable.
Three residents with varying cognitive and physical impairments did not have their individualized activity needs and preferences consistently met, as evidenced by missing or inadequate activity supplies, limited participation in preferred activities, insufficient documentation of one-to-one interactions, and a lack of updates to care plans despite ongoing assessments and staff awareness of their preferences.
A resident dependent on staff for mobility was repeatedly observed in a wheelchair without footrests, leaving her heels unsupported and contrary to her care plan, which lacked specific wheelchair positioning instructions. Another resident with a care plan intervention for eyeglass padding to protect skin integrity was observed multiple times without the required padding, resulting in skin discoloration and indentations. Staff interviews confirmed the lack of intervention implementation and monitoring, and facility policies did not provide adequate guidance for these care needs.
A resident with severe cognitive impairment and significant hearing loss was not consistently provided with hearing assistive devices as required by their care plan. Staff observations and interviews revealed the resident frequently did not have access to or use a pocket talker or hearing aids, resulting in ongoing difficulty communicating with staff and peers. Staff were unclear about the location of the resident's hearing aids and did not consistently ensure the use of available assistive devices.
A resident with multiple diagnoses, including COPD and nicotine dependence, was not provided with a thorough and current smoking assessment as required by facility policy. The resident's care plan indicated the need for a smoking apron while smoking, but the most recent assessment did not address this, and staff were inconsistent in ensuring its use. Staff interviews revealed confusion about assessment frequency and apron use, and the facility's policy for regular smoking assessments and safety equipment was not followed.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A resident with a history of PTSD and past trauma did not receive a comprehensive trauma assessment or individualized trauma-informed interventions. Staff were unaware of the resident's diagnosis and triggers, and the care plan lacked necessary information, despite facility policy requiring such assessments and care planning.
The facility did not ensure that results of complaint investigations, including surveyor reports and facility responses, were available for review by residents, families, or staff. Only recertification survey results were posted, and the administrator was unaware of the requirement to include all investigation results.
The facility's policy for reporting abuse, neglect, and misappropriation of property contained conflicting timelines and was not fully consistent with federal requirements. The administrator confirmed that staff were expected to report sexual abuse within two hours and other types of abuse within 24 hours, which did not align with the federal mandate that all abuse or serious bodily injury allegations be reported within two hours. This inconsistency had the potential to affect all residents.
A resident in a LTC facility, with diagnoses including anxiety and depression, was not provided with adequate clothing and shoes, impacting her ability to socialize and use her prosthetic limb. Despite multiple assessments and staff awareness, the facility failed to address her needs, resulting in her isolation and feelings of loneliness and depression.
Two residents at risk for pressure ulcers did not receive the necessary interventions as outlined in their care plans. One resident's wheelchair lacked a required cushion, and another resident did not have lamb's wool or dressings applied to her toes as directed. Staff confirmed the care plans were not followed, and the DON acknowledged the oversight, which placed the residents at risk.
A resident with moderate cognitive impairment was not provided with individualized activities that matched her preferences, such as crocheting and card games. Despite her expressed interests, the facility's care plans and life enrichment assessments did not reflect her specific needs, leading to minimal engagement in activities. Interviews revealed that staff did not offer meaningful one-to-one activities, and the resident expressed dissatisfaction with the lack of personalized options.
A resident with a cervical fracture was not provided the required assistance from two licensed staff members when applying a cervical collar, as per physician orders. Instead, a family member was involved, contrary to facility policy. The resident expressed discomfort due to improper application. Interviews with staff confirmed the failure to adhere to the protocol, despite training and policy requirements.
A facility failed to follow a care plan for a resident with a history of trauma, requiring two female staff for care and transfers. Despite the care plan's directives, a nursing assistant was observed providing care alone. The resident had moderate cognitive impairment and was dependent on staff for transfers, with a care plan in place due to past trauma and recent allegations of sexual assault.
The facility failed to ensure food was labeled, dated, and stored properly, and did not maintain proper sanitization levels for dishware. Additionally, vents over clean dishes were not adequately cleaned, posing a risk of contamination.
The facility failed to implement transmission-based precautions for a resident with emesis and loose stools during an outbreak, did not place a resident with MRSA on TBP, and neglected enhanced barrier precautions for two residents with indwelling catheters and wounds. Additionally, proper handling of linens was not ensured, compromising infection control efforts.
The facility failed to provide a resident with a written discharge notice and the basis for discharge, and did not notify the Ombudsman Office for Long-Term Care (OOLTC) of the transfer or discharge. The resident, who was on parole due to a felony history, was discharged without proper documentation or notification. The social worker was unaware of the requirement to notify the OOLTC, and the facility's policies were not followed.
A resident with COPD, CHF, and CKD was observed adjusting their own oxygen settings without a physician's order, despite a SAM assessment indicating they required assistance with medications. Staff confirmed that residents should not adjust their own oxygen settings and need a SAM assessment and physician's order for self-administration of medications.
A facility failed to ensure a call light was accessible for a resident who was moderately cognitively impaired and dependent on staff for turning in bed. The call light cord was found on the floor, out of reach, and despite the resident calling for help multiple times, no staff responded. The DON briefly looked into the room but did not notice the call light or respond to the resident's calls.
A resident was discharged from the facility without a documented medical reason after the facility was informed of the resident's felony history. The discharge was initiated by the administrator, and the physician provided discharge orders without documenting the reason. The resident's family had to arrange alternative accommodation, and the facility's policy for discharges was not properly followed.
A facility failed to complete a comprehensive MDS assessment for a resident with anxiety, depression, and schizoaffective disorder. The responsible social worker was not on campus during the assessment period, and no other staff were authorized to complete the MDS, resulting in unassessed cognitive and mood sections. Staff interviews confirmed the importance of these assessments for appropriate care and mental health referrals.
The facility failed to ensure that physical devices were assessed and reassessed for continued appropriateness for a resident who had perimeter mattresses placed on their bed as a fall intervention. Despite being identified as a high fall risk, the facility did not assess or reassess the perimeter mattress. Observations and interviews revealed that the resident had not attempted to get out of bed independently and required total assistance with bed mobility. The perimeter mattress was eventually removed, and the bed was positioned in the lowest position to the floor.
The facility failed to ensure a resident's preferred activities, such as listening to country music and playing with dolls, were consistently provided. Despite these preferences being documented in the care plan, staff did not adhere to it, leaving the resident often without music or dolls. Observations and interviews revealed a lack of awareness and implementation of the care plan, leading to the deficiency.
Failure to Assess, Document, and Care Plan Behavioral Triggers Leading to Resident‑to‑Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident (R1) had diagnoses including primary hypertension, traumatic subdural hemorrhage with loss of consciousness, and non‑Alzheimer’s dementia, with a comprehensive MDS indicating severe cognitive impairment and no documented behaviors. R1’s care plan identified her as a categorically vulnerable adult who required substantial/maximal assistance with transfers and toileting, and directed staff to monitor for emotional distress or mood/behavior changes and to provide a safe, consistent environment with supervision as needed. On the evening of 3/15/26, while R1 was seated in the TV room, another resident (R2) struck her in the face, causing her to fall from her chair. Staff were present and witnessed the event, which was described as unprovoked based on staff accounts. R1 sustained swelling to the eyebrow, a lip laceration, and was transferred to the ED, where imaging showed a large left forehead hematoma with associated swelling, a lip laceration, and a closed nasal bone fracture. Interviews with family confirmed that R1 had been sitting in the TV area with other residents when R2, seated behind her, suddenly punched her, resulting in a broken nose and forehead hematoma. Multiple nursing assistants reported that R1 frequently spoke loudly to the television or called out to staff, and that R2 became agitated or angry in response to these loud vocalizations. Staff described that when R2 was agitated, he would show facial expression changes and speak in Spanish, and that they would sometimes separate him from other residents or redirect him to his room during these episodes. However, these observations and known triggers were not documented in the medical record. R2 had diagnoses including disorientation, dementia, and behavioral symptoms, with an MDS indicating moderate cognitive impairment and no behaviors identified, and was independent with transfers and ambulation. R2’s ADL care plan directed staff to monitor for emotional distress or mood and behavior changes, including agitation/aggression, but did not identify specific agitative or aggressive behaviors or triggers. A psychiatric assessment recommended that the care team track and monitor R2’s behavioral dysregulation to identify triggers and beneficial interventions, and advised the IDT to review findings and develop a behavior support plan if agitation persisted, with emphasis on maintaining appropriate supervision, reinforcing boundaries, and objectively monitoring behaviors. Record review from 3/11/26 through 3/15/26 showed no evidence that these recommendations were implemented: there was no tracking or monitoring of behavioral dysregulation, no identification of triggers, no documentation of interventions attempted, and no behavior support plan developed. Staff interviews revealed that nurses and aides were aware of R2’s agitation, prior altercations, and specific triggers related to loud environments and R1’s vocalizations, but they were unsure where to document behaviors, were unaware of any behavioral support plan, and did not report that the IDT had reviewed or addressed these behaviors. This lack of assessment, documentation, and care planning for R2’s known behavioral issues and triggers led to the failure to protect R1’s right to be free from physical abuse.
Failure to Prevent Accident During Bed Bath Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide care consistent with a resident's needs and care plan during a bed bath, resulting in an accident. The resident involved had multiple diagnoses, including low back pain, chronic congestive heart failure, a prior left femur fracture, generalized weakness, and was on hospice care. The care plan required two staff to assist with bed mobility and directed the use of a draw sheet to prevent shearing and sliding. During the incident, the resident was left on a bare air mattress without a draw sheet after the soiled linen was removed, and one staff member left the room to retrieve a clean draw sheet, leaving the other staff member alone with the resident. While repositioning the resident for care, staff did not use a draw sheet and applied excessive force, causing the resident to slide off the bed and fall to the floor. The bed brakes were not engaged on both sides, and the resident was undressed at the time of the fall. The staff involved did not review the care plan prior to providing care, and one of the staff members was unfamiliar with the resident and the hallway. There were inconsistencies in staff accounts regarding their presence and actions during the incident, and it was unclear whether proper procedures were followed. As a result of the fall, the resident sustained a comminuted and displaced fracture of the left femur, which required surgical intervention. The incident was witnessed by other staff who responded after hearing a noise and finding the resident on the floor. The facility's policy required protection from harm and adherence to care plans, but these were not followed during the incident, directly leading to the resident's injury.
Infection Control Deficiencies in Hand Hygiene, Glucometer Cleaning, and Laundry Handling
Penalty
Summary
Surveyors observed that a registered nurse failed to consistently perform hand hygiene during blood glucose monitoring and insulin administration for a resident on the memory care unit. The nurse applied gloves before retrieving the glucometer, performed the blood glucose test, and then returned the glucometer to the medication cart without cleaning or disinfecting it. The nurse also failed to perform hand hygiene after removing gloves and before donning new gloves for insulin administration, as well as after completing the insulin injection. The nurse acknowledged that hand hygiene should have been performed at multiple points and that the glucometer should have been disinfected after each use, but stated that cleaning was sometimes delayed due to competing responsibilities. Additionally, the facility did not ensure proper handling and containment of soiled personal laundry and linens. In the main laundry washroom, soiled clothing was transported unbagged across areas where clean clothing was stored, and clean clothing and bedding were placed in garbage bags or boxes directly on the floor. In the upstairs laundry unit, soiled laundry was placed on the floor before sorting, and clean clothing was placed on countertops near sinks, which were identified as highly contaminated areas. Mechanical lift slings were also stored in baskets and boxes on the floor. The housekeeper responsible for laundry acknowledged that soiled items were not always bagged prior to transport and that clean items should not be stored on the floor. Facility policies required that glucometers be disinfected after every use and that hand hygiene be performed before and after resident care, after glove removal, and after contact with potentially contaminated items. Policies also specified that soiled laundry should be bagged at the point of use and that clean linens should be handled and stored to prevent contamination. However, these procedures were not consistently followed, as confirmed by staff interviews and direct observation.
Failure to Properly Label and Securely Store Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper procedures for the labeling and secure storage of medications and biologicals within the facility.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Improper Storage of Nutritional Supplements and Damaged Ice Machine Door
Penalty
Summary
Surveyors observed that nutritional supplements were being stored directly on the floor in two medication rooms, including the memory care unit and the transitional care unit (TCU). Multiple open and unopened cases of supplements such as Breeze, Boost, and Ensure Plus were found on the floor. Staff, including registered nurses and the clinical coordinator, stated that the supplements were placed on the floor upon delivery and were unaware that this was not an acceptable storage practice. It was also noted that there was available space in cupboards and on shelves that could have been used for proper storage. No facility policy regarding the storage of nutritional supplements was provided upon request. Additionally, the facility failed to maintain the ice machine in good repair. During a kitchen tour, the ice machine was found to have two areas on the door where the black plastic surface was missing, exposing yellow insulation that was worn and had a brown, yellow substance along the broken edge. The dietary director acknowledged that the damaged areas could not be properly cleaned or disinfected, raising concerns about infection control. No maintenance or housekeeping work orders related to the ice machine door were found in the facility's records, and no policy for ice machine maintenance was provided.
Unsanitary Kitchen Floor with Missing Tiles and Grout
Penalty
Summary
The facility failed to maintain the kitchen in a clean, sanitary, and good state of repair, as evidenced by multiple observations of missing tile chunks, missing grout, and the presence of a green substance on the subfloor in the dishwashing area. The dietary director acknowledged the missing tiles, grout, and green substance, and demonstrated that water could fill the damaged areas, noting this as a cleaning concern with potential for bacterial growth. Despite regular mopping, the damaged floor condition persisted on subsequent observation. A review of maintenance and housekeeping work order forms over a ten-month period revealed no documentation of any requests to repair the kitchen floor. Additionally, when asked, the facility was unable to provide a policy or procedure regarding kitchen cleaning and maintenance.
Deficiencies in Resident Privacy, Cleanliness, and Personal Property Management
Penalty
Summary
Multiple rooms on the Evergreen unit were observed to have large windows with white plastic blinds that were missing several slats, allowing visibility into the rooms from outside even when the blinds were closed. Maintenance and housekeeping work order records reviewed over a ten-month period did not show any requests for repair or replacement of these blinds. Staff interviews confirmed that many blinds throughout the building were broken, creating privacy concerns for residents, especially during personal care activities. Facility policy required broken blinds to be repaired or replaced and for audits to be conducted, but these actions were not documented for the affected rooms. Shower rooms throughout the facility were found to be in poor condition, with observations of mold-like black substances, cracked and missing tiles, slimy and discolored surfaces, and unclean fixtures. In several shower rooms, tiles were missing or cracked, exposing bare walls to water, and various colored substances were present on floors, walls, and fixtures. Staff interviews revealed inconsistent knowledge and practices regarding cleaning responsibilities and frequencies, with some staff unsure about the presence of mold or the adequacy of cleaning. The facility's cleaning policy did not specifically address shower rooms, and the Environmental Service Director acknowledged the need for tile replacement and ongoing issues with mold. A resident with multiple chronic health conditions, including alcoholic cirrhosis, hypertension, renal failure, hepatic encephalopathy, and fibromyalgia, reported numerous personal items missing over a period of approximately nine months. The missing items included clothing, jewelry, and personal care products. Interviews with staff indicated that missing item reports were completed and distributed, but there was a lack of follow-up, tracking, or resolution regarding the recovery of the resident's belongings. The facility's policy required thorough investigation, documentation, and follow-up for missing items, but staff were unaware of the need to track or resolve these reports, and the resident had not received updates about her missing possessions.
Handrails Not Firmly Secured in Facility Hallways
Penalty
Summary
Surveyors observed that handrails in multiple areas of the facility, including between resident rooms and outside the dining room by the men's restroom, were loose and not securely attached to the wall. Specifically, one handrail was not attached to the second bracket, and others were generally loose. During interviews, the Environmental Service Director (ESD) explained that staff were expected to report maintenance concerns using designated forms, which were then placed in specific boxes for follow-up. The ESD also stated that maintenance staff were attentive to needed repairs, but emphasized that identifying issues was a joint effort among all staff. A review of maintenance and housekeeping work order forms over a period of several months revealed no documented work orders related to handrail repairs. Additionally, the facility was unable to provide a policy or procedure regarding handrails when requested.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of transfers and discharges for one resident who was hospitalized on two separate occasions. The resident, who had moderate cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including atrial fibrillation, heart failure, hypertension, cerebrovascular accident, depression, ADHD, and aortic aneurysm and dissection. Medical records showed that the resident was discharged to the hospital with return anticipated on two occasions, and hospital discharge summaries indicated hospitalizations for acute metabolic encephalopathy and acute on chronic hypoxemic hypercapnic respiratory failure. Review of the facility's monthly notices to the Ombudsman for the relevant months did not include this resident's transfers or discharges. During an interview, the social service assistant confirmed that the resident's hospitalizations were not reported to the Ombudsman as required. No policy regarding the notification process was provided by the facility during the survey.
Failure to Develop and Implement PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing post-traumatic stress disorder (PTSD) triggers and interventions for a resident with a documented diagnosis of PTSD. The resident, who had intact cognition and required assistance with all activities of daily living, had a history of complex trauma and abuse, as well as other significant medical conditions including alcoholic cirrhosis, renal failure, hepatic encephalopathy, and fibromyalgia. Clinical notes from a psychology provider indicated the resident experienced re-experiencing of trauma, mistrust of authority, and anxiety about dependency on others, and recommended specific memory care approaches and coping tools. Despite this, the resident's care plan did not include PTSD triggers or interventions. Interviews with facility staff, including nursing assistants, registered nurses, the clinical coordinator, social worker, and assistant director of nursing, revealed that none were aware of the resident's PTSD history or specific triggers. Staff confirmed that trauma assessments and related care planning were not completed or included for this resident, despite facility policy requiring trauma-informed care assessments and individualized care plans for residents with a history of trauma or PTSD. The absence of this information in the care plan meant staff were not equipped with the necessary knowledge or strategies to appropriately respond to the resident's needs related to PTSD.
Failure to Individualize Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to update and individualize the care plan for a resident who was receiving respiratory care, specifically oxygen therapy. The resident, who had moderate cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including atrial fibrillation, heart failure, hypertension, cerebrovascular accident, depression, ADHD, and aortic aneurysm and dissection. The Minimum Data Set (MDS) indicated that the resident was receiving oxygen therapy. However, upon review, the care plan only noted the use of oxygen without specifying the reason for its use, the prescribed oxygen flow rate, or the route of administration. Interviews with facility staff, including an LPN clinical coordinator and the assistant director of nursing, confirmed that the care plan lacked resident-specific information regarding oxygen therapy. Both staff members acknowledged that the care plan should include detailed instructions so that staff are aware of when, how, and at what liter flow oxygen should be administered. The facility's care planning policy requires that care plans be comprehensive, individualized, and include measurable goals and specific interventions, but these requirements were not met in this case.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Meet Residents' Individualized Activity Needs and Preferences
Penalty
Summary
The facility failed to consistently meet the identified needs and preferences for activities for three of four residents reviewed. For one resident, assessments indicated a strong preference for listening to music and engaging in independent activities such as coloring. However, the resident's CD player was missing for three weeks, preventing access to preferred music, and there was no evidence that staff updated the care plan or provided alternative means to meet these preferences. Activity calendars showed minimal participation, and documentation of one-to-one interactions was lacking in narrative notes, with no subsequent changes to interventions. Another resident, who required assistance with all activities of daily living and had multiple diagnoses including dementia and depression, expressed preferences for music, being around animals, and going outside. Despite these preferences, the resident participated in a limited number of scheduled activities and received few one-to-one visits, with narrative notes lacking documentation of these interactions. Staff interviews revealed that the resident often refused activities and preferred to roam the hallway, but there was no evidence of updated care plan interventions to address these behaviors or preferences. A third resident with severe cognitive impairment and significant hearing loss also had specific activity preferences, including group activities and being around animals. This resident attended very few scheduled activities and received minimal one-to-one attention, with poor documentation of these visits. Staff acknowledged the resident's hearing difficulties and inconsistent participation, but there were no updates to the care plan to better address the resident's needs. The facility's policy required individualized activity programming and documentation of one-to-one visits, but the frequency and focus of these visits were not specified, and the policy was not consistently followed.
Failure to Provide Positioning Assistance and Implement Vision-Related Interventions
Penalty
Summary
The facility failed to provide appropriate positioning assistance for a resident with impaired cognition, dementia, and physical limitations who was dependent on staff for activities of daily living and used a wheelchair. Observations over several days revealed that the resident was repeatedly seated in a wheelchair without footrests, resulting in her heels being elevated off the ground and only the tips of her slippers touching the floor. Staff interviews confirmed that footrests were not in use, and staff were unaware of their absence. The care plan directed staff to assist with repositioning and transfers but lacked specific instructions for wheelchair positioning, and the facility policy did not provide guidance on wheelchair positioning assistance. Additionally, the facility failed to implement a care plan intervention for another resident who required eyeglasses and had a history of skin integrity issues on the bridge of the nose. The care plan specified that a band-aid should be applied to the metal nose piece of the glasses for extra padding. Multiple observations showed the resident wearing glasses without the required padding, resulting in an indent and purple discoloration of the skin under the metal nose piece. Staff interviews confirmed awareness of the skin issue but revealed that the intervention was not being followed, and there was no documentation or monitoring of the resident's skin condition as required by the care plan. The facility's policies on activities of daily living required services to maintain mobility and nutrition and called for documentation and evaluation of interventions, but did not provide specific direction for wheelchair positioning or eyeglass-related skin protection. The lack of adherence to care plan interventions and absence of clear policy guidance contributed to the deficiencies observed in the care and treatment of both residents.
Failure to Ensure Consistent Access to Hearing Assistive Devices
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and significant hearing loss consistently had access to and used hearing assistive devices as required to meet their communication needs. The resident, who had diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, diabetes mellitus, anxiety disorder, and depression, was care planned to wear bilateral hearing aids daily. Multiple observations over several days showed the resident was not wearing any hearing assistive devices and had difficulty hearing staff and other residents. Staff were observed speaking loudly and directly into the resident's ear, and on one occasion, a pocket talker was retrieved and placed on the resident, but the resident continued to have difficulty hearing. Interviews with nursing assistants and nurses confirmed the resident was extremely hard of hearing and should use a pocket talker at all times when awake, but it was only provided upon request or not at all. Staff were unsure about the whereabouts of the resident's hearing aids, and there was inconsistency in ensuring the resident had access to or used the pocket talker. The facility was unable to provide a policy regarding the provision of hearing assistive devices when requested.
Failure to Complete and Document Smoking Assessment and Safety Measures
Penalty
Summary
The facility failed to ensure a thorough and up-to-date smoking assessment was completed for a resident who wished to smoke. The resident, who had intact cognition but required assistance with all activities of daily living, had multiple diagnoses including COPD, non-Alzheimer's dementia, anxiety disorder, depression, schizophrenia, and nicotine dependence. The resident's care plan indicated she was an independent smoker and required the use of a smoking apron when smoking, in accordance with facility policy. However, the most recent smoking assessment did not document the use or assessment of the smoking apron, and there was no evidence that the assessment had been updated as required. Observations showed staff inconsistently reminded the resident to use the apron, and interviews with staff revealed confusion and inconsistency regarding the resident's use of the smoking apron and the frequency of required smoking assessments. Further review of facility policy indicated that residents identified as smokers should be assessed upon admission, quarterly, annually, and as needed for significant changes or incidents. The policy also required that residents needing a smoking apron, as determined by the assessment, must always wear one while smoking. Despite this, the last documented smoking assessment was not current, and it did not address the use of the smoking apron. Multiple staff interviews confirmed that the required assessments were not completed as per policy, and the use of the smoking apron was not consistently enforced or documented.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care in accordance with their needs. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Assess and Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement trauma-informed care for a resident with a known history of post-traumatic stress disorder (PTSD) and past traumatic experiences. The resident, who had intact cognition and required assistance with all activities of daily living, reported a long history of verbal, physical, and sexual abuse, and continued to experience distressing symptoms such as seeing demon-like shadows and feeling triggered by staff interactions. Despite the resident's disclosure of PTSD and ongoing trauma-related symptoms, there was no evidence in the electronic health record (EHR) of a trauma assessment being completed, nor were individualized trauma-informed interventions or identification of triggers included in the care plan. Interviews with facility staff, including nursing assistants, registered nurses, the clinical coordinator, and the social worker, revealed that none were aware of the resident's PTSD diagnosis or specific triggers. The social worker and assistant director of nursing confirmed that a trauma assessment had not been completed and the PTSD diagnosis was not documented in the EHR or care plan. The facility's own policy required trauma-informed care assessments upon admission and as needed, with care plans reflecting identified triggers and interventions, but this was not followed for the resident in question.
Failure to Make Complaint Investigation Results Available for Review
Penalty
Summary
The facility failed to make the results of complaint investigations available for review by residents, families, visitors, and staff. During an observation, survey results were found in a binder labeled Annual Survey Results, which included only the past three recertification survey results and did not contain the 2567 forms or reports related to complaint investigations. Review of the Aspen Central Office system confirmed that several complaint investigations had been completed, some with citations, but these were not included in the posted or available survey results. The administrator stated she was unaware that posting the corresponding letters from all investigations was required, and no facility policy for posting survey results was available.
Deficient Abuse Reporting Policy with Conflicting Timelines
Penalty
Summary
The facility failed to develop and implement a policy for reporting allegations of abuse that was consistent with federal requirements and free of conflicting information. The Resident Protection Plan policy, last revised in February 2023, stated that reports of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of property, are to be promptly and thoroughly investigated and reported immediately. However, the policy contained conflicting timelines, indicating that if the events involved abuse or resulted in serious bodily injury, the report must be made immediately and no later than two hours after the allegation, but for other events, the report could be made within 24 hours. Additionally, the policy stated that certain findings, such as unexplainable injuries or substantiated abuse, must be reported to the Office of Health Facility Complaints immediately, not to exceed 24 hours, which is inconsistent with the federal requirement for reporting within two hours if abuse or serious bodily injury is involved. During interviews, the administrator confirmed that the current policy was in use and stated that staff were expected to report allegations of abuse immediately to her, with reports of sexual abuse to be made within two hours and all other reports within 24 hours. The administrator also stated that verbal abuse would need to be reported within 24 hours of being made aware of the incident. These statements and the policy itself were not fully aligned with the federal regulation, which requires all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, to be reported immediately, but not later than two hours if the events involve abuse or result in serious bodily injury. This inconsistency had the potential to affect all residents in the facility.
Failure to Provide Adequate Clothing and Shoes
Penalty
Summary
The facility failed to provide medically related social services, specifically clothing and shoes, to a resident, resulting in harm. The resident, who had diagnoses including anxiety disorder, depression, and an acquired absence of the left leg below the knee, expressed a need for proper clothing and shoes to participate in social activities and leave her room. Despite multiple assessments and progress notes indicating the resident's feelings of loneliness, depression, and isolation, the facility did not adequately address her need for clothing and shoes. The resident's records showed that she had limited finances and lacked proper clothing and shoes, which affected her ability to use her prosthetic limb and participate in social activities. Interviews with staff revealed that the resident was often seen wearing an oversized shirt over a hospital gown and a single gripper sock, and she expressed a desire to eat in the dining room and attend activities if she had appropriate attire. Staff acknowledged the resident's lack of clothing but failed to provide a long-term solution, relying instead on temporary fixes such as donated clothes from the laundry. The facility's social services and life enrichment staff were aware of the resident's needs but did not take sufficient action to address them. The Director of Social Services and other staff members recognized the impact of inadequate clothing on the resident's dignity, mental health, and socialization but did not follow through with a comprehensive plan to meet her needs. The resident's primary care provider and psychology provider also noted the potential negative psychosocial impact of her isolation and lack of proper clothing, yet the facility did not implement effective measures to resolve the issue.
Failure to Implement Pressure Ulcer Prevention Care Plans
Penalty
Summary
The facility failed to implement the comprehensive care plan for two residents, R1 and R2, who were at risk for pressure ulcers. R1, who had moderate cognitive impairment and was frequently incontinent, required a pressure-reducing cushion in her wheelchair as per her care plan. However, observations and interviews revealed that R1's wheelchair did not have any cushion, and staff confirmed that the care plan was not being followed. The Director of Nursing (DON) acknowledged that R1 was at risk for skin integrity issues and expected the interventions to be in place. R2, who had mild cognitive impairment and a history of skin diseases, was also at risk for pressure ulcers. Her care plan included placing lamb's wool around her toes and ensuring a dressing was present if she wore specific shoes. However, during observations, it was found that these interventions were not being implemented. Staff interviews confirmed that the care plan directives were not being followed, and the DON noted that the absence of these interventions placed R2 at risk of developing new skin issues. The facility's policies on skin and pressure ulcer prevention and care planning emphasized the importance of implementing prevention protocols and ensuring care plans are followed. Despite these policies, the facility did not adhere to the care plans for R1 and R2, leading to a deficiency in providing the necessary care to prevent pressure ulcers.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities for a resident, identified as R1, who was reviewed for activities. R1's admission Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a preference for certain activities such as going outside, participating in religious services, and listening to music. Despite these preferences, the facility's life enrichment assessments and care plans did not reflect R1's specific interests or provide individualized activities. R1's care plan noted she was independent in making activity choices, but interventions were limited to providing activity invites and a monthly calendar, without addressing her specific interests. R1's activity attendance records from June to October 2024 showed limited engagement in activities, with several refusals and minimal one-to-one visits. Interviews with life enrichment aides revealed that R1 often declined group activities, and there was no clear strategy to offer her individualized activities during one-to-one visits. The aides admitted to not offering activities related to R1's interests, such as crafts or card games, during these visits. R1 expressed dissatisfaction with the activities offered, stating that she had not been provided with meaningful activities that matched her preferences, such as crocheting or playing cards. The director of life enrichment and the director of nursing both acknowledged that R1's care plan was not individualized and did not include her specific interests. The facility's policies required activities to be based on comprehensive assessments and tailored to residents' interests, but these were not followed in R1's case. The lack of individualized activities and failure to address R1's clothing concerns contributed to her non-participation in group activities, highlighting a deficiency in meeting her needs.
Failure to Follow Physician Orders for Cervical Collar Application
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring a cervical collar, leading to a deficiency in care. The resident, who had a history of transient ischemic attack, cerebral infarction, and a cervical fracture, was observed not receiving the required assistance from two licensed staff members when applying the cervical collar. Instead, a family member was involved in the process, which is against the facility's policy and physician's orders. The resident expressed discomfort when the collar was initially applied too tightly, indicating improper application by the staff. The resident's medical records indicated a need for the cervical collar to be worn continuously, including during bathing, and required the assistance of two people for any movement involving the collar. Despite this, during an observation, only one licensed practical nurse (LPN) assisted the resident, with the family member providing additional support. Interviews with the family member and staff confirmed that the facility's policy of using two trained staff members was not followed, and the family member was inappropriately relied upon for assistance. Interviews with various staff members, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Registered Nurses (RNs), revealed a lack of adherence to the established protocol for handling the resident's cervical collar. The staff acknowledged the requirement for two trained personnel to assist with the collar, yet this was not consistently practiced. The facility's policy and training materials emphasized the importance of two staff members for the safe application and removal of the cervical collar, but this was not implemented in practice, leading to the deficiency.
Failure to Follow Care Plan for Resident with Past Trauma
Penalty
Summary
The facility failed to adhere to the care plan for a resident who was reviewed for abuse. The resident, who had diagnoses of anxiety, depression, psychotic disorder, and a history of falls, was assessed to have moderate cognitive impairment and was dependent on staff for transfers. Her care plan, dated 5/21/24, specified that two female staff members were required for all personal care and transfers due to a history of past trauma. Despite this, a nursing assistant was observed transferring the resident and providing personal care without the assistance of another staff member, contrary to the care plan directives. The incident occurred after the resident had returned from the hospital following an allegation of sexual assault. The facility's policy required that the care plan and Kardex, which provided a brief overview of the resident's care plan, be followed. Both the nursing assistant and the director of nursing acknowledged the requirement for two female staff members for the resident's care and transfers. However, the care plan was not followed, as evidenced by the nursing assistant's actions, which were observed and confirmed by the facility's staff.
Failure to Properly Label, Store, and Sanitize Food and Dishware
Penalty
Summary
The facility failed to ensure food was labeled, dated, and stored properly to prevent foodborne illness. During an observation, it was noted that the refrigerator contained undated items such as a sandwich, a Styrofoam container of soup, an opened container of cucumber salad, and a bag of lettuce. The Director of Dining Services (CD) confirmed that these items were undated and from over the weekend. Additionally, a resident's salmon was found in the kitchen's refrigerator without a date, which was against the facility's policy. The CD admitted that leftovers and opened items should be dated and that the weekend staff were not as organized. The facility also failed to ensure that dishware was cleaned and sanitized properly. During an observation, a dietary aide (DA-B) was seen testing the dish machine with test strips that did not change color, indicating improper sanitization levels. The cook confirmed that the sanitizer level was between 10 and 50 ppm, which was below the required level. The cook admitted that the dishes were not properly sanitized and that prep dishes and utensils used for cooking were still being used despite the low sanitizer levels. The facility's Dishmachine/PPM Temperature Log showed inconsistencies in recording the sanitizer levels, and expired test strips were found in use. Additionally, the facility failed to maintain clean vents over clean dishes. During an observation, a vent above the clean silverware was noted to have gray and whitish fuzzy particles hanging from it. The Culinary Supervisor (CS) confirmed that the smaller vents above the clean dish area were not regularly cleaned and that there was no documentation of cleaning tasks. The CS admitted that the vent looked dusty enough to be concerned about dust falling onto the clean dishes. The facility's policies and procedures did not adequately address the dating of opened items or leftovers, and there was a lack of proper documentation for cleaning tasks.
Failure to Implement Transmission-Based and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) for a resident who had emesis and loose stools during an outbreak of confirmed rotavirus and norovirus cases. The resident was observed vomiting in their bathroom, and the nursing assistant assisting them did not wear a protective gown. Additionally, there was no personal protective equipment (PPE) cart or signage on the resident's door indicating TBP. The bathroom remained soiled with bodily fluids for an extended period, and the resident's roommate, who used the same bathroom, was not provided with adequate precautions to prevent cross-contamination. The infection preventionist (IP) and director of nursing (DON) acknowledged the oversight and the need for proper cleaning and isolation measures but failed to ensure timely implementation. Another resident with a history of MRSA was not placed on TBP despite having an indwelling foley catheter and a recent history of severe sepsis and recurrent urinary tract infections. The resident's room lacked TBP signs and PPE supplies, and staff were observed providing catheter care without wearing protective gowns. The infection preventionist admitted that the resident should have been on contact precautions to prevent the spread of MRSA but had not yet implemented the necessary measures. Two additional residents with indwelling catheters and wounds were not placed on enhanced barrier precautions as required. Staff were observed providing catheter care without wearing protective gowns, and the infection preventionist confirmed that the facility had not yet educated staff or developed policies for enhanced barrier precautions. The director of nursing acknowledged the need for enhanced barrier precautions and the importance of proper infection control practices but had not yet taken action to address the deficiencies. Additionally, the facility failed to ensure proper handling of linens, with clean personal items being delivered uncovered and placed on doorknobs outside rooms with contact and droplet precautions, further compromising infection control efforts.
Failure to Provide Discharge Notice and Notify Ombudsman
Penalty
Summary
The facility failed to provide a resident with a written discharge notice and the basis for discharge, and did not notify the Ombudsman Office for Long-Term Care (OOLTC) of the transfer or discharge. The resident, who had intact cognition and required supervision with bed mobility, transfers, and toileting, was discharged without proper documentation or notification. The resident was on parole due to a felony history, which the facility cited as the reason for discharge, but no formal notice or appeal rights were provided to the resident or their family member. The family member was only given a medication list via email and had to arrange temporary accommodation for the resident. The facility's social worker was unaware of the requirement to notify the OOLTC of resident discharges and had not been completing this task. The facility's policies indicated that the resident, family, and OOLTC should be notified within 72 hours of a transfer or discharge, but this was not followed. The facility's discharge and transfer notice form was also found to be incomplete, lacking the reason for discharge and information regarding the resident's rights to appeal.
Failure to Complete SAM Assessment and Monitor Oxygen Settings
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident (R19) who was observed with medications at bedside. R19, who had intact cognition and diagnoses of COPD, CHF, and CKD, was receiving oxygen therapy. Despite the physician's order for 2.5 liters per minute (lpm) of oxygen, R19 was observed receiving 4 lpm and admitted to adjusting the oxygen settings independently. The SAM assessment indicated that R19 did not want to administer her own medications and required assistance, and there was no physician's order allowing R19 to self-administer medications. Multiple staff members, including a registered nurse (RN), a trained medication assistant (TMA), and the director of nursing (DON), confirmed that residents should not adjust their own oxygen settings and that a SAM assessment and physician's order are required for self-administration of medications. The DON emphasized that nurses should intervene immediately if a resident is found adjusting their oxygen settings, educate the resident, discuss the risks and benefits, and update the care plan. The facility's policy on SAM requires a nurse to complete an assessment and obtain a physician's order for residents to self-administer their medications.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure a call light was accessible for a resident (R385) who was moderately cognitively impaired, had diagnoses of malnutrition and depression, and was dependent on staff for turning in bed. During an observation, the call light cord was found clipped to the fitted sheet with approximately four feet of cord hanging down onto the floor, making it inaccessible to the resident. Despite the resident calling out for help multiple times, no staff entered the room to assist. The Director of Nursing (DON) briefly looked into the room but did not notice the call light on the floor or respond to the resident's calls for help. When staff eventually entered the room, they confirmed that the call light was out of reach and the resident expressed a desire to be repositioned to face the window and lie on their side to alleviate pain. The facility's policy and procedure on call lights, dated June 2022, indicated that call lights should always be within the resident's reach and never on the floor. The DON acknowledged that call lights should be accessible and that staff should respond to residents' needs in a timely manner.
Failure to Document Basis for Resident Discharge
Penalty
Summary
The facility failed to include a physician-documented basis for the discharge of a resident (R82). R82 was admitted for short-term rehabilitation after a hospitalization for a bladder infection and required supervision with bed mobility, transfers, and toileting. Despite having intact cognition and no behaviors or rejection of care, R82 was discharged from the facility without a documented medical reason. The discharge was initiated after the facility was informed of R82's felony history by his parole officer. The physician provided discharge orders but did not document the reason for the discharge in the medical record. Interviews revealed that the facility's staff, including the PT, DON, and administrator, were aware of the discharge but did not ensure proper documentation. The administrator stated that the discharge was in accordance with the facility's Resident Protection Plan, but the required documentation was missing. R82's family member had to arrange alternative accommodation, as the facility did not provide a clear basis for the discharge. The facility's policy or procedure for facility-initiated discharges was requested but only a blank example of a discharge and transfer notice form was provided, which included a section for the reason for transfer or discharge and information regarding resident rights to appeal.
Failure to Complete Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident, specifically neglecting to evaluate cognitive and mood needs. The resident, who was admitted with anxiety disorder, depression, and schizoaffective disorder, had an incomplete MDS assessment. Sections C (Cognitive Patterns) and D (Mood) were marked as not assessed, indicating that the Brief Interview for Mental Status (BIMS) and the Resident Mood Interview were not conducted. This failure was attributed to the social worker responsible for these sections not being on campus during the assessment period and no other staff being authorized to complete the MDS in her absence. The social worker admitted to marking the sections as not assessed if she could not complete them by the due date and stated that the MDS process was new to her. Interviews with other staff members, including a registered nurse and the director of nursing, confirmed the importance of completing these sections to assess the resident's cognitive abilities and mood status. The registered nurse emphasized that any nurse could complete the assessment and that it was crucial to know the resident's status, especially given their mental health conditions. The director of nursing also highlighted the necessity of completing the MDS sections to ensure the resident received appropriate care and mental health referrals if needed. The facility did not have a specific policy for completing the MDS but followed the Resident Assessment Instrument (RAI) manual guidelines. The director of nursing confirmed that assessments were expected to be completed before the assessment range date (ARD). The failure to complete the MDS assessment as required led to a deficiency in evaluating and addressing the resident's cognitive and mood needs, which are critical for individualized care planning and appropriate mental health interventions.
Failure to Assess and Reassess Physical Devices for Resident
Penalty
Summary
The facility failed to ensure that physical devices were assessed and reassessed for continued appropriateness for a resident (R66) who had perimeter mattresses placed on their bed as a fall intervention. R66, who had Alzheimer's disease and was on hospice, required extensive assistance with transfers and bed mobility. Despite being identified as a high fall risk, the facility did not assess or reassess the perimeter mattress placed on R66's bed. The perimeter mattress was initially placed after R66 fell from bed without injury, but subsequent assessments and progress notes did not evaluate the continued need for the device. Observations and interviews with staff revealed that R66 had not attempted to get out of bed independently and required total assistance with bed mobility. The perimeter mattress was eventually removed, and R66's bed was positioned in the lowest position to the floor. The facility's policy required physical devices to be assessed on admission, re-admission, significant change of condition, and annually, but this was not followed in R66's case.
Failure to Provide Resident's Preferred Activities
Penalty
Summary
The facility failed to ensure a resident's preferred activities were available, as evidenced by multiple observations and interviews. The resident, who had Alzheimer's disease, anxiety, and a psychotic disorder, had specific preferences for activities such as listening to country music, playing with dolls, and attending religious services. Despite these preferences being documented in the resident's care plan, staff did not consistently provide these activities. Observations showed the resident often left without music or dolls, and staff were unaware of the resident's radio or did not use it to play music during care routines. The resident's activity attendance records indicated limited participation in preferred activities, especially during a lockdown period. The resident's care plan and life enrichment assessments highlighted the importance of music and other activities, but these were not consistently offered. Interviews with nursing assistants and the director of life enrichment revealed a lack of awareness and adherence to the care plan, with staff not playing music or providing dolls as required. The resident was often observed moaning and facing the wall without engagement in preferred activities. The director of nursing and other staff acknowledged the deficiencies, noting the importance of providing activities, especially during lockdowns. The facility's policy emphasized the responsibility of all staff to ensure residents could participate in life enrichment programs, but this was not effectively implemented. The failure to follow the care plan and provide the resident's preferred activities led to the deficiency identified in the report.
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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