Good Samaritan Society - Mountain Lake
Inspection history, citations, penalties and survey trends for this long-term care facility in Mountain Lake, Minnesota.
- Location
- 745 Basinger Memorial Drive, Mountain Lake, Minnesota 56159
- CMS Provider Number
- 245549
- Inspections on file
- 23
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Good Samaritan Society - Mountain Lake during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment, poor vision, unsteady gait, and high fall risk had a care plan requiring staff to toilet her during 4:00 a.m. rounds due to prior falls and need for extensive assistance with toileting and toilet transfers. A CNA checked on the resident during the night but did not offer toileting assistance, stating she was unaware of the toileting intervention because it was not on the Kardex and she had not reviewed the care plan. The resident later attempted to get up to use the bathroom independently, was found on the floor complaining of left leg pain, and was sent to the ED where a closed displaced left femoral neck fracture was diagnosed, requiring a left hip hemiarthroplasty. The NP stated the fall could have been prevented if the care-planned toileting intervention had been followed.
A resident with dementia and Alzheimer's disease ingested another resident's crushed medications after an RN prepared the medications in a glass, placed it in front of the intended resident, and walked away, leaving it unattended. The cognitively impaired resident took the glass, drank the contents, and became lethargic, with her pulse dropping from her usual rate to the 30s–40s bpm. She was sent to the ED, where it was determined she had ingested multiple medications, including metoprolol, and was diagnosed with a medication overdose and bradycardia requiring IV fluids and glucagon.
The facility failed to incorporate identified vulnerable adult risks into the care plans of three cognitively impaired residents, despite MVAA findings that they could not report abuse/neglect, defend themselves from verbal/physical attacks, or manage financial affairs. Staff, including NAs, reported relying on the care plan or Kardex to understand resident needs and interventions. One NA reported finding two residents in a room during an inappropriate physical interaction and did not immediately stop it, instead leaving to get a nurse. Social Services reported completing the MVAA but not specifically care planning vulnerabilities, assuming all residents were vulnerable adults, while the DON stated all identified vulnerabilities should be care planned under the facility’s comprehensive care plan policy.
A resident with a history of stroke and fragile skin developed a deep tissue injury on the coccyx. Although the provider was notified and wound care orders were obtained after the wound opened, there was no documentation of family notification until nearly two weeks later. The family only became aware of the wound after observing it during a visit, and the wound progressed to infection requiring hospitalization. Facility policy required immediate notification of significant changes, but this was not followed.
A resident with impaired mobility and poor nutritional intake developed an unstageable pressure ulcer to the coccyx after staff failed to promptly assess and implement pressure-relieving interventions when a red area was first noted. Despite risk factors and facility policy requiring immediate preventative measures, there was a delay in both assessment and intervention, resulting in the wound progressing to a severe, infected state requiring hospitalization.
A resident with diabetes type 1 was admitted to the ICU with a blood sugar level over 1000 mg/dl due to the facility's failure to properly assess and monitor blood sugar levels. The staff relied on inaccurate CGM readings without confirming with finger stick tests, leading to inappropriate treatment. The resident exhibited symptoms of hyperglycemia, which were not identified, resulting in a diagnosis of diabetic ketoacidosis.
The facility failed to ensure beverageware and metal pans were completely dry before storing, risking bacterial growth. Observations revealed wet metal steam table pans and drinking cups with condensation were improperly stacked. Staff acknowledged the items should have been dry before storage, contrary to the facility's warewashing policy.
A resident with colon cancer and other conditions was found with medications at her bedside without an assessment or physician's order for self-administration. Despite no cognitive impairment, the facility did not document her ability to self-administer medications, contrary to policy. Staff acknowledged the oversight, and the Director of Nursing confirmed the lack of required documentation.
The facility failed to follow professional standards during eye drop administration for two residents. An LPN did not ask the residents to tilt their heads back and placed the drops in the inner corner of the eyes instead of the conjunctival sac. The LPN confirmed she was not trained on proper instillation, and the DON acknowledged the lack of training. An undated document from Elsevier online training was provided, which included proper administration instructions.
A resident was not offered the PCV20 vaccine as recommended by the CDC, despite being eligible. The immunization record lacked evidence of shared clinical decision-making with the physician, and there was no documentation that the resident was informed about the vaccine. The resident expressed interest in receiving the vaccine, highlighting a lapse in the facility's immunization policy.
Failure to Follow Care-Planned Toileting Intervention Resulting in Fall and Hip Fracture
Penalty
Summary
The facility failed to follow a care-planned fall intervention for a resident with dementia, moderate cognitive impairment, poor vision, unsteady gait, and a high risk for falls. The resident’s MDS indicated a need for substantial to maximal assistance with toileting and partial to moderate assistance with toilet transfers. After an actual fall without injury, the care plan was revised to include an intervention for staff to toilet the resident during 4:00 a.m. rounds. On the date of the incident, progress notes documented that at 6:15 a.m. the resident was found on the floor after attempting to use the bathroom, and the resident later reported she had been trying to get up to go to the bathroom before the fall and did not think staff had offered to take her to the bathroom beforehand. A nursing assistant reported that between 2:00 a.m. and 4:00 a.m. she checked on the resident but did not offer toileting assistance and was not aware the resident needed to be toileted during 4:00 a.m. rounds because this intervention was not on the resident’s Kardex. The nursing assistant also stated she did not review the care plan prior to her shift. The DON stated that staff are expected to follow resident care plans and that the toileting intervention had been added to the care plan but was not on the Kardex. The NP stated that the fall could have been prevented if staff had followed the care plan and toileted the resident during 4:00 a.m. rounds. As a result of the fall, the resident sustained a closed displaced left femoral neck fracture requiring a left hip hemiarthroplasty.
Resident Overdose After Ingestion of Another Resident’s Crushed Medications
Penalty
Summary
The facility failed to ensure medications were administered to the correct resident, resulting in a resident with dementia and Alzheimer's disease ingesting another resident's medications. The resident was seated at a dining table across from another resident whose medications had been crushed and placed in a glass of liquid. The administering RN prepared the other resident's medications in the glass, set the cup in front of that resident, and then walked away, leaving the medications unattended. During this time, the resident with dementia took the glass containing the crushed medications and drank from it. After ingesting the medications, the resident became sleepy at the dining room table within about ten minutes. Vital signs showed the resident's pulse decreased to 47 bpm and then to 40 bpm, compared to her usual pulse of around 60 bpm. Poison control was contacted due to concern that the resident had received an unknown amount of high-dose blood pressure medication, and guidance was given to send her to the ED if her pulse dropped below 45 consistently. The resident's pulse continued to decrease, at times dropping into the upper 30s, and she was sent to the ED. In the ED, it was determined that she had ingested valproic acid, carbidopa/levodopa, glycopyrrolate, metoprolol, and mirtazapine, and she was diagnosed with a medication overdose with bradycardia consistent with metoprolol ingestion, requiring IV normal saline and glucagon therapy.
Failure to Integrate Vulnerable Adult Assessment Findings Into Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans that incorporated identified vulnerabilities from the Minnesota Vulnerable Adult Assessments (MVAA) for three residents with dementia or mild cognitive impairment. One resident’s face sheet showed dementia and mild cognitive impairment, and the MVAA documented that this resident was unable to report abuse/neglect concerns, defend herself from verbal or physical attacks, and manage financial affairs. Another resident with mild cognitive impairment was assessed as unable to defend himself from verbal and physical attacks and unable to manage financial affairs. A third resident with dementia, disorientation, and Alzheimer’s disease was assessed as unable to report abuse/neglect concerns, defend herself from verbal or physical attacks, and manage financial affairs. Despite these documented vulnerabilities, each resident’s care plan dated 4/29/26 did not include the specific MVAA findings related to inability to report abuse/neglect, defend against verbal/physical attacks, or manage finances. Nursing assistants reported that they rely on the care plan or Kardex to identify resident needs and how to meet those needs. One NA described entering a resident’s room and finding another resident in a wheelchair at the bedside, with the resident in bed having her pants down and brief to the side, while the other resident was touching her vaginal area; the NA stated she was surprised, left both residents in the room, and went to get the nurse without stopping the interaction. Social Services staff stated they complete the MVAA and then address the findings in the care plan, but acknowledged there was nothing in the care plans about vulnerabilities specifically, explaining it was assumed everyone was a vulnerable adult and treated as such. The DON stated that Social Services was responsible for completing the MVAA and that all vulnerabilities should be care planned, while the facility’s Comprehensive Care Plan policy required development of a person-centered care plan to meet residents’ physical, mental, spiritual, and psychosocial well-being.
Failure to Timely Notify Family and Provider of Deep Tissue Injury
Penalty
Summary
The facility failed to notify the resident's representative and medical provider in a timely manner following the discovery of a deep tissue injury (DTI) for a resident with a history of cerebral infarction and fragile skin. The resident was initially assessed as not being at risk for pressure ulcers, but developed a dark red area on the coccyx, which was first noted by an LPN. Documentation shows that the provider was notified and wound care orders were obtained after the wound opened, but there was no documentation of family notification until nearly two weeks later, despite the facility's policy requiring immediate notification of significant changes. Interviews and record reviews revealed that the family was not informed of the wound until they observed it themselves during a visit, and subsequent communication with the facility did not result in timely updates about the wound's progression. The resident's condition deteriorated, with decreased therapy progress, increased weakness, and decreased appetite, and the wound eventually became infected, requiring hospitalization. The DON confirmed that both the family and provider should have been notified at the initial discovery of the wound and again when it opened, but this did not occur as required. The facility's own policy mandates immediate notification of the resident, physician, and representative in the event of significant changes or injuries. However, documentation and interviews confirm that this protocol was not followed, resulting in a delay in communication regarding the resident's DTI and subsequent decline.
Failure to Implement Timely Pressure Ulcer Prevention and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to assess, monitor, and implement pressure-relieving interventions for a resident who developed an unstageable pressure ulcer to the coccyx area. The resident was admitted with a history of stroke, impaired mobility, and skin fragility, but was initially assessed as being at low to moderate risk for pressure ulcers, with no pressure injuries present on admission. Despite the presence of risk factors such as immobility, poor nutritional intake, and incontinence, the care plan did not include comprehensive pressure ulcer prevention measures until after a red area was discovered on the coccyx. When a red area was first noted on the resident's coccyx, there was a delay in both assessment and the implementation of preventative interventions. Documentation and interviews revealed that no interventions to prevent further skin breakdown were put in place between the initial discovery of the red area and the subsequent assessment, during which the wound had already opened. The facility's own policy required immediate preventative measures and individualized repositioning plans for residents unable to reposition themselves, but these were not initiated in a timely manner. Additionally, there was a lack of consistent wound assessment and documentation, with significant gaps between assessments and no evidence of a repositioning assessment being completed. As the resident's condition deteriorated, the pressure ulcer progressed to an unstageable wound with necrotic tissue and infection, ultimately requiring hospitalization for cellulitis and advanced wound care. Interviews with staff and providers confirmed that preventative measures were not implemented promptly after the initial signs of skin breakdown, and that the severity of the wound could have been mitigated with earlier intervention. The facility's failure to follow its own protocols for pressure ulcer prevention and timely intervention directly contributed to the development and worsening of the resident's pressure ulcer.
Failure to Monitor Blood Sugar Levels Leads to Resident's ICU Admission
Penalty
Summary
The facility failed to properly assess and monitor blood sugar levels for a resident with diabetes type 1, who was admitted to the intensive care unit with a blood sugar level exceeding 1000 mg/dl. The resident's continuous glucose monitor (CGM) showed low blood sugar readings, but these were not confirmed with finger stick tests as recommended by the CGM manufacturer. The resident exhibited symptoms of hyperglycemia, such as confusion and lethargy, which were not identified by the staff due to reliance on the CGM readings. The resident's care plan did not address the use of the CGM, and there was a lack of comprehensive assessments and monitoring for hypo/hyperglycemia. The facility's staff, including licensed practical nurses, were not adequately trained on the use of CGMs and did not follow the manufacturer's recommendations to confirm low or high readings with a finger stick test. This oversight led to the resident receiving inappropriate treatment, such as glucose tablets, based on inaccurate CGM readings. The situation escalated when the resident's condition deteriorated, showing increased confusion and somnolence. Despite the CGM indicating low blood sugar, manual blood sugar tests revealed extremely high levels. The resident was eventually sent to the emergency room, where they were diagnosed with diabetic ketoacidosis and admitted to the ICU. The facility's failure to properly monitor and respond to the resident's blood sugar levels resulted in immediate jeopardy to the resident's health.
Removal Plan
- Review policy on blood sugar monitoring to include the use of CGM's and management of CGM's per manufacturer's recommendations
- Educate staff on correct placement of CGM's that the facility uses
- Educate staff on the signs and symptoms of hyper- and hypo- glycemia
- Educate staff on when to do a finger stick BGM to verify the CGM's readings
- Review with staff when to alert the physician of low and high blood sugars
Improper Storage of Wet Beverageware and Pans
Penalty
Summary
The facility failed to ensure that beverageware and metal pans were completely dry before storing, which could promote bacterial growth. During an observation and interview, a cook was seen stacking wet metal steam table pans upside down on a wire shelving rack. The cook acknowledged that the pans should not have been put away while still wet. In another instance, a different cook was observed with multiple drinking cups stacked upside down on a plastic tray, with visible condensation inside the tumblers and water pooling on the tray. The cook confirmed that the tumblers should have been allowed to dry completely before stacking. The facility's policy on warewashing indicated that dishes are to air-dry before storage or use.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R196, was appropriately assessed and deemed suitable to self-administer medications. R196, who has diagnoses including malignant neoplasm of the colon, polyneuropathy, and pain, was found to have various medications at her bedside, including Tylenol, Systane eye drops, Voltaren gel, and Neosporin ointment. Despite having no cognitive impairment as per her admission Minimum Data Set assessment, there was no documentation in her care plan or physician's orders indicating her ability to self-administer these medications. During interviews, both a registered nurse and a licensed practical nurse acknowledged the presence of medications in R196's room but confirmed that there was no completed self-administration assessment or physician's order authorizing this. The Director of Nursing also verified the absence of such an assessment or order, which is contrary to the facility's policy that requires an interdisciplinary team to determine and document a resident's ability to safely self-administer medications, along with obtaining a physician's order and updating the care plan accordingly.
Improper Eye Drop Administration for Two Residents
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during the administration of eye drops for two residents. Resident R197, who was admitted with a primary diagnosis of pancreatitis, had a physician's order for Alphagen P ophthalmic solution eye drops to be administered three times a day. However, during an observation, the LPN did not ask R197 to tilt her head back and placed the eye drops at the inner corner of each eye instead of the conjunctival sac. Similarly, Resident R7, diagnosed with unspecified macular degeneration, had a physician's order for brinzolamide ophthalmic solution eye drops to be administered twice a day. The LPN also failed to ask R7 to tilt his head back and instilled the drops in the inner corner of each eye. During interviews, the LPN confirmed that she was taught to instill eye drops in the inner corner of the eye and had not received any education from her employer on proper eye drop instillation. The Director of Nursing (DON) stated that nurses are expected to instill eye drops in the pocket of the lower lid and not in the corner of the eye, as this could lead to infection or improper administration. The DON acknowledged that no training on eye drop instillation had been completed. The facility provided an undated document from Elsevier online training, which included instructions on proper eye drop administration, such as asking the patient to look at the ceiling.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the pneumococcal vaccine series as recommended by the CDC. The resident, who was over the age of 65, had previously received the PPSV23 and PCV13 vaccines but had not been offered the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. The immunization record lacked evidence of shared clinical decision-making with the physician regarding the PCV20 vaccine, and there was no documentation that the resident was offered or declined the vaccine. Interviews with the infection preventionist and the director of nursing revealed that immunizations are reviewed upon admission, and eligible vaccines are supposed to be offered to residents. However, in this case, there was no documentation to confirm that the resident was informed about the PCV20 vaccine. The resident expressed interest in receiving the PCV20 vaccine, indicating that she usually receives all recommended vaccines. The facility's policy stated that residents should be provided the opportunity to receive immunizations, but the process was not followed in this instance, leading to the deficiency.
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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