Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Waconia And Westview Acre during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a documented high risk for elopement and falls was admitted without appropriate safety interventions in place. Despite assessments identifying the risk, staff failed to apply a wanderguard or implement increased supervision due to lack of training, unclear responsibilities, and poor communication. The resident was able to leave the facility unsupervised and was found by police offsite, resulting in an immediate jeopardy deficiency.
A resident was discharged with another resident's medications, including a blood pressure-lowering drug not prescribed to her. Due to incomplete medication reconciliation and lack of verbal education, the resident ingested the incorrect medications, resulting in multiple falls, acute facial trauma, and hospitalization for orthostatic hypotension. The error was discovered during a follow-up clinic visit when the medications were reviewed and identified as belonging to another patient.
A resident with significant cognitive and physical impairments was left on a bedpan for over eleven hours after staff failed to follow care plan instructions for regular repositioning and toileting assistance. The lack of communication between staff and failure to check on the resident led to the development of multiple deep tissue injuries on the buttocks, as confirmed by wound assessments and hospital evaluation.
The facility did not update care plans to reflect current needs for several residents, including those with behavioral issues, toileting assistance, discontinued medications, changes in diet orders, and frequent falls. Staff observations and interviews confirmed that care plans were not revised to address changes in resident status or interventions, contrary to facility policy.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was receiving both routine and PRN quetiapine while on hospice care. The pharmacy consultant recommended a gradual dose reduction and required prescriber evaluation for continued PRN use, but this recommendation was not communicated to the hospice prescriber. Facility staff believed hospice was responsible for GDRs, and the hospice nurse confirmed the recommendation was never received, with no documentation showing it was addressed.
Two residents experienced significant incidents—one developing a deep tissue injury after being left on a bedpan for over eleven hours, and another sent home with and ingesting medications prescribed to someone else, resulting in multiple falls and a hospital visit. In both cases, the facility did not report the incidents to the State agency within the required timeframe, contrary to policy and regulatory requirements.
A resident with multiple health conditions was discharged with medications, some of which were prescribed for another individual. After taking these medications at home and experiencing falls and a hospitalization, the error was reported to facility staff by an external clinic. Despite this, there was no documentation of an investigation or protective measures, contrary to facility policy.
The facility did not accurately code the MDS for two residents, resulting in missing documentation of falls for one resident and an incorrect discharge status for another. Staff confirmed that the MDS assessments did not match the information in the electronic medical records, and no facility policy on MDS completion was provided when requested.
Three newly admitted residents with complex medical needs did not have baseline care plans developed within 48 hours of admission, as required by facility policy and regulations. Instead, their care plans were completed several days after admission, leaving staff without documented guidance for immediate care. This deficiency was confirmed by a nurse manager and supported by review of electronic health records.
A resident with a history of heart failure and edema had a physician order for PRN Torsemide if their weight exceeded a specified threshold. For several consecutive days, the resident's weight was above this limit, but the PRN medication was not administered or documented. Staff interviews revealed a lack of awareness of the PRN order, which was not readily visible in the electronic MAR, and the resident subsequently developed worsening symptoms and was hospitalized for fluid overload.
A nursing assistant did not perform hand hygiene or wear gloves while assisting a resident with moderate cognitive impairment and multiple medical conditions during meal set-up. The assistant used ketchup packets from the table to spread ketchup on the resident's sandwich, contrary to facility policy and infection control expectations.
The facility did not consistently post daily nurse staffing and census information in a location accessible to all, with postings sometimes missing, outdated, or placed too high for individuals in wheelchairs to read. This failure had the potential to affect all residents and visitors seeking staffing information.
A resident with severe cognitive impairment and a Stage 3 pressure ulcer did not receive consistent care as per the care plan and physician orders. The facility failed to apply an off-loading boot as required, and wound assessments were not completed regularly. Staff interviews and observations revealed a lack of adherence to wound care protocols and inadequate communication among staff regarding the resident's care needs.
A resident with multiple sclerosis and bilateral broken legs did not receive routine toenail care, leading to long, painful toenails. The care plan lacked toenail care instructions, and there was no documentation of care or refusal in the EMR. Staff interviews revealed confusion about documentation and responsibility for nail care, and the resident was on a list to see a podiatrist without a set date.
The facility failed to assess and prevent falls for two residents, R2 and R4, by not performing comprehensive assessments or implementing appropriate interventions. R2 was found on the floor without immediate intervention documented, and R4 experienced multiple falls despite existing care plan measures. Staff interviews revealed inconsistencies in completing fall huddle worksheets and risk management forms, hindering root cause analysis and effective intervention implementation.
The facility failed to thoroughly investigate quality of care concerns reported by two residents. The DON was informed of issues involving an LPN and a nursing assistant but did not interview other residents or staff, nor did she make schedule changes or speak directly with the implicated staff. The investigation lacked comprehensive interviews or assessments, and the DON did not follow up with the residents after the initial report.
A resident with Parkinson's disease did not receive their medication, Sinemet, within the required time frame on multiple occasions, leading to a deficiency. The medication was often administered late, particularly during the morning pass, causing the resident to experience increased stiffness and pain. The facility's policy required medications to be given within one hour of the scheduled time, but this was not consistently followed.
The facility failed to maintain cleanliness in the main kitchen, with significant lint buildup on three kitchen fans located in critical areas. The kitchen manager acknowledged the issue, and further investigation revealed no set cleaning schedule for the fans. Although a cleaning schedule existed, it was not adhered to, as confirmed by the director of environmental services and the director of nutritional services.
The facility failed to maintain cleanliness of wheelchairs for two residents and a tube feeding pump and pole for another resident. One resident's wheelchair was soiled with food debris, while another's motorized wheelchair had rust and torn armrests. A third resident's tube feeding equipment was covered in dried substances. Staff were unclear on cleaning responsibilities, and no policies were provided, leading to unsanitary conditions.
A resident with cognitive impairments reported feeling abused during toileting care, but the facility failed to report the allegation within the required two-hour timeframe. Staff interviews revealed a lack of immediate action, with the incident only being acknowledged days later. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to, resulting in a deficiency.
A resident with cognitive impairments and mood issues accused a nursing assistant of abuse during toileting care. Despite facility policies requiring immediate reporting and investigation of abuse allegations, no investigation was conducted, and the incident was not documented in the resident's health record. Interviews with staff revealed a lack of follow-up, highlighting a deficiency in handling abuse allegations.
A facility failed to monitor orthostatic blood pressure for a resident on psychotropic medications, risking increased falls due to dizziness. Additionally, another resident went ten days without a bowel movement, despite being on a constipation protocol, with no as-needed medications administered. The facility's policies on medication monitoring and bowel management were not followed, leading to these deficiencies.
A facility failed to maintain proper infection control practices for a resident with a urinary catheter and did not utilize enhanced barrier precautions (EBP) for another resident with a pressure ulcer. The catheter bag was repeatedly found on the floor, and staff did not wear gowns during high-contact care activities for the resident on EBP. Staff misunderstandings and lack of adherence to protocols contributed to these deficiencies.
Failure to Implement Elopement Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when a newly admitted resident with severe cognitive impairment, Alzheimer's disease, and dementia, who was identified as being at high risk for both falls and elopement, was not provided with adequate supervision or safety interventions. Upon admission, assessments documented the resident's high risk for elopement and falls, citing factors such as recent admission, disorientation, confusion, inability to communicate needs, and a history of wandering. Despite these documented risks, the resident's care plan did not include elopement or fall prevention interventions until after the resident had already eloped from the facility. Staff interviews and documentation revealed that although the need for a wanderguard device was identified, it was not applied because the admitting nurse did not know where the devices were kept or how to activate them, and believed it was the nurse manager's responsibility. The nurse manager was informed of the risk but left the facility, assuming the device would be applied later. Other staff members, including nurses and nursing assistants, were either unaware of the resident's risk status or did not know what the resident looked like, and increased safety checks were not implemented prior to the incident. The lack of communication and training regarding elopement prevention measures contributed to the failure to supervise the resident adequately. As a result of these failures, the resident was able to leave the facility unsupervised, travel through an attached assisted living area, cross a parking lot and a busy street, and was eventually found by police in a parking lot across the street. The facility's policy required individualized interventions for residents at risk of elopement, but these were not implemented in this case, leading to an immediate jeopardy situation.
Medication Error on Discharge Leads to Resident Harm
Penalty
Summary
A medication error occurred when a resident was discharged from the facility and sent home with another resident's medications, including a blood pressure-lowering agent not prescribed to her. The discharge documentation lacked verification of medication reconciliation, and the education provided to the resident was limited to paper handouts without verbal instruction. The resident, who had intact cognition and no memory concerns, assumed the medications were intended for her and ingested approximately 11 doses of the incorrect medications at home. As a result of taking the wrong medications, the resident experienced multiple falls at home, including one that caused acute facial trauma requiring sutures. She was hospitalized for orthostatic hypotension, which was likely exacerbated by the unprescribed blood pressure medication. Clinic records confirmed that the medication error contributed to her low blood pressure and subsequent hospital admission. Interviews with facility staff revealed that the discharge process involved sending all medications in the facility belonging to the resident, but there was no thorough review to ensure the medications matched the resident's current orders. The discharge summary and medication list were incomplete, and the error was only discovered after the resident's follow-up clinic visit, where medications labeled for another resident were identified and destroyed.
Failure to Prevent Pressure Ulcer Due to Prolonged Bedpan Use
Penalty
Summary
A resident with moderate cognitive impairment and multiple complex medical conditions, including depression, anxiety, cancer, muscle weakness, metabolic encephalopathy, diabetes, and acute kidney failure, was dependent on staff for all activities of daily living. The resident's care plan and kardex required staff to reposition the resident every two to three hours and provide assistance with toileting, including anticipating toileting needs and checking/changing as needed. Despite these instructions, a nursing assistant placed the resident on a bedpan and failed to return, neglecting to inform the next shift that the resident remained on the bedpan. During the following shift, another nursing assistant interacted with the resident, providing food, fluids, and repositioning, but did not check or change the resident or notice the bedpan. The resident, who was more fatigued and less communicative than usual, did not alert staff to her situation. The oversight continued for approximately eleven and a half hours until a registered nurse discovered the resident still on the bedpan during a routine check. The resident subsequently developed multiple deep tissue injuries on the buttocks, as confirmed by wound assessments and hospital evaluation, with the injuries corresponding to the outline of the bedpan. Interviews with staff revealed a lack of communication regarding the resident's status and care needs, as well as a failure to follow the care plan's directives for frequent repositioning and toileting assistance. The care plan did not specify the use of a bedpan, and staff assumptions about the resident's ability to communicate her needs contributed to the incident. The prolonged pressure from the bedpan resulted in actual harm, including the development and progression of deep tissue injuries.
Failure to Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs and conditions of several residents, as required by policy and regulation. For one resident with Alzheimer's disease and behavioral disturbances, the care plan did not address the resident's refusal of assistance with personal hygiene, such as nail trimming and shaving, despite staff observations and interviews indicating the resident was not independent and required reminders and cues. Staff reported repeated attempts to assist, which were refused, but this behavior and the need for partial assistance were not documented in the care plan. Another resident with a neurostimulator implant and recent back surgery required extensive assistance with toileting and had ongoing issues with bowel regulation. The resident expressed concerns about bowel management and was noted to refuse toileting and incontinence care, with staff making specific agreements to provide care. However, the care plan lacked any mention of these toileting needs or the interventions being provided. Similarly, a resident receiving hospice care had a discontinued medication (anastrozole) that remained listed in the care plan, even after the medication was stopped and hospice services began. Additional deficiencies included a resident with a feeding tube whose care plan was not updated after a significant change in diet order, allowing oral intake for quality of life, and a resident with a history of falls whose care plan was not revised to reflect frequent falls and new interventions. In each case, staff interviews confirmed that care plans were not updated in a timely manner to reflect changes in resident status, behaviors, or interventions, despite facility policy requiring such updates with each assessment or change in condition.
Failure to Communicate Pharmacy GDR Recommendation to Hospice Prescriber
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's (PharmD) recommendation for a gradual dose reduction (GDR) of an antipsychotic medication was communicated to the hospice prescriber for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, visual hallucinations, psychotic disturbance, mood disturbance, and anxiety. The resident was receiving hospice care for vascular dementia following a stroke and had active orders for quetiapine fumarate, both as a routine and as-needed (PRN) medication for agitation and hallucinations. The PharmD reviewed the resident's medication regimen and recommended either discontinuing the PRN antipsychotic, issuing a new order with a specified duration and rationale, or adjusting the routine order, in accordance with regulations that PRN antipsychotic orders cannot exceed 14 days without direct prescriber evaluation. Despite this recommendation, there was no documentation in the resident's electronic medical record or hospice communication folder indicating that the recommendation had been reviewed or addressed by the hospice prescriber. Interviews with facility staff revealed a belief that GDRs for hospice residents were the responsibility of hospice providers, but the hospice nurse confirmed that the recommendation had not been received. Facility policy required staff to facilitate communication between the resident, family, and hospice employees, but this process was not followed, resulting in the PharmD's recommendation not being communicated or acted upon.
Failure to Timely Report Suspected Abuse, Neglect, or Misappropriation to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of incidents to the State agency for two residents. In the first case, a resident with moderate cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living was left on a bedpan for approximately eleven and a half hours. The nursing assistant who placed the resident on the bedpan did not return to check on her, nor did she inform the next shift that the resident was still on the bedpan. The subsequent nursing assistant also failed to check or change the resident during her shift. The resident was eventually found by a registered nurse with a bedpan still underneath her, resulting in a deep tissue injury. The incident was reported to the State agency about twelve hours after discovery, exceeding the required two-hour reporting window for incidents involving harm. In the second case, another resident with intact cognition and several chronic conditions was discharged from the facility and later attended a clinic appointment, bringing all her medications with her. It was discovered that she had been sent home with medication cards containing drugs prescribed to another resident. The resident reported taking these incorrect medications at home, which led to episodes of dizziness, multiple falls, and a hospital visit for low blood pressure. The clinic notified the facility of the medication error, but the incident was not reported to the State agency as required. Facility staff acknowledged that the incident should have been reported immediately upon becoming aware of it. Interviews with facility staff and review of the facility's abuse and neglect policy confirmed that the expectation was to report incidents of abuse, neglect, or significant bodily harm to the State agency within two hours, and all other reportable incidents within twenty-four hours. However, in both cases, the facility did not adhere to these timelines, resulting in a failure to meet regulatory requirements for timely reporting of suspected abuse, neglect, or misappropriation of resident property.
Failure to Investigate and Protect Resident After Medication Error Allegation
Penalty
Summary
The facility failed to thoroughly investigate and protect a resident following an allegation of neglect related to a medication error. A resident with intact cognition and multiple diagnoses, including hypertension, atrial fibrillation, anemia, and depression, was discharged from the transitional care unit and later attended a clinic appointment. During this appointment, it was discovered that the resident had been given bubble medication cards at discharge, some of which contained medications prescribed for another resident. The resident reported taking these medications at home, which included a blood pressure medication, and had experienced falls and a recent hospitalization for low blood pressure. The incident was reported to the facility by an external clinic, and staff interviews confirmed that the information was relayed to a nurse and then to the nurse manager. However, a review of the resident's electronic health record revealed a lack of documentation regarding any investigation into the reported medication error. Staff acknowledged that the incident should have been reported to the state agency and that an investigation should have been initiated immediately upon learning of the event, but this did not occur. The facility's own Abuse and Neglect policy requires immediate reporting, assessment, and investigation of any allegations of abuse, neglect, or misappropriation of resident property. The policy outlines specific steps for protecting residents and notifying appropriate agencies, but these procedures were not followed in this case. The failure to initiate an investigation and ensure resident protection constituted a deficiency in responding to the reported allegation of neglect.
Inaccurate MDS Coding for Falls and Discharge Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in inaccurate documentation of falls and discharge status. For one resident, the quarterly MDS did not reflect two falls that had occurred since admission, despite these incidents being documented in the electronic medical record. Both the nurse manager and interim DON confirmed that these falls should have been included in the MDS assessment. For another resident, the discharge MDS was incorrectly coded as a transfer to a short-term general hospital, while the electronic medical record and progress notes indicated the resident was actually discharged home with family. Facility staff acknowledged the MDS was coded incorrectly and verified the actual discharge destination. No facility policy on MDS completion was provided when requested. These inaccuracies in MDS coding were identified through interviews and document review, with staff confirming the errors and the discrepancies between the MDS and the residents' medical records.
Failure to Initiate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for three residents who required varying levels of assistance with activities of daily living (ADLs) and had complex medical conditions. For each of these residents, the electronic health record (EHR) did not show evidence that a baseline care plan was initiated within the required timeframe after admission. Instead, the baseline care plans were developed several days after admission, as indicated by the dates in the EHR. The residents involved had diagnoses including end stage renal disease, heart failure, hypertension, cirrhosis, diabetes mellitus, arthritis, depression, dependence on renal dialysis, chronic pain, acute on chronic systolic heart failure, atrial fibrillation, coronary artery disease, localized edema, prosthetic heart valve, coronary angioplasty implant and graft, fracture, and anxiety disorder. During an interview, a registered nurse manager confirmed that baseline care plans should be completed within 24 hours of admission and acknowledged that this was not done for the three residents in question. The facility's own care plan policy required the development of a baseline care plan upon admission, in accordance with federal and state regulations, to provide effective and person-centered care. The lack of timely baseline care plans meant that staff did not have documented guidance on how to care for these residents immediately after admission.
Failure to Administer PRN Medication per Physician Order
Penalty
Summary
A deficiency occurred when the facility failed to administer a prescribed as needed (PRN) medication, Torsemide, according to physician orders for a resident with a history of congestive heart failure, atrial fibrillation, coronary artery disease, hypertension, renal failure, and localized edema. The resident had an order for daily weights and to receive PRN Torsemide if their weight exceeded 116.0 pounds. Over a seven-day period, the resident's weight was consistently above this threshold, but there was no documentation of the PRN medication being administered as ordered. Review of the electronic health record (EHR) and medication administration record (MAR) confirmed the absence of PRN Torsemide administration on the days when the resident's weight exceeded the specified limit. Observations during this period noted the resident had 2+ pitting edema in the lower extremities and later required oxygen for low saturations, eventually being hospitalized for pneumonia and fluid overload. Interviews with nursing staff revealed a lack of awareness of the PRN order, with some staff stating there were no parameters related to daily weights and others discovering the PRN order only upon review. The PRN order was not visible in the usual workflow of the electronic MAR, requiring staff to access a separate tab to view it. The facility's medication administration policy required correct and timely administration of medications and documentation of PRN medication efficacy. However, the process for entering and displaying PRN orders in the electronic system led to the order being overlooked, resulting in the resident not receiving the prescribed PRN Torsemide despite clear indications based on daily weight measurements.
Failure to Perform Hand Hygiene and Use Gloves During Meal Assistance
Penalty
Summary
A nursing assistant (NA) failed to perform proper hand hygiene and did not wear gloves while assisting a resident with meal set-up. The NA handled ketchup packets from the middle of the table, removed the top of the resident's hamburger bun, applied ketchup, and used the packet itself to spread the condiment before replacing the bun. The NA did not sanitize hands before or after assisting the resident, despite being expected to do so according to facility policy. The NA also confirmed during an interview that she did not follow the required hand hygiene or glove use protocols during this interaction. The resident involved had moderate cognitive impairment and required assistance with all activities of daily living, with multiple diagnoses including hypertension, neurogenic bladder, diabetes mellitus, arthritis, cerebral palsy, epilepsy, atrial fibrillation, and depression. Facility staff, including the infection preventionist and a registered nurse, confirmed that the expected practice was to wash hands and wear gloves when assisting residents with meals, and that using ketchup packets as utensils was inappropriate due to potential contamination. The facility's food handling policy also specified that food should not be touched with bare hands and that proper utensils and hand hygiene must be used.
Failure to Consistently and Accessibly Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently and properly post daily nurse staffing information, including the resident census, in a location and manner that was accessible to residents, staff, and visitors. Observations over several days revealed that the staff posting was sometimes missing entirely or not updated with the current date. When the posting was present, it was often clipped to the administration office doorframe at a height of about six feet, making it difficult for individuals in wheelchairs to access and read the information. On multiple occasions, the posting displayed outdated information or was not visible upon arrival at the facility. Interviews confirmed that the administrator was responsible for posting the staffing information, typically around 9:00 a.m. on weekdays and for the entire weekend at once. The administrator acknowledged that the posting's height was not accessible for all individuals, particularly those in wheelchairs. The facility's own policy required that the nurse staffing posting be prominently displayed daily in a clear, readable format where residents, staff, and the public could view it. These failures had the potential to affect all 69 residents and any visitors seeking this information.
Failure to Implement Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to comprehensively assess and manage the pressure ulcer care for a resident, identified as R3, who had a severe cognitive impairment and required substantial assistance with daily activities. R3 had a Stage 3 pressure ulcer on her left lateral ankle and was at risk for developing additional ulcers. The care plan for R3 included the use of a pressure-reducing mattress and cushion, and the application of an off-loading boot to her left foot while in bed, as per physician orders. However, the care plan lacked specific information about the off-loading boot, and the physician's orders were not consistently followed, as R3 was observed without the boot on multiple occasions. Interviews with staff revealed a lack of adherence to the prescribed wound care protocols. RN-B admitted to not applying the boot during the day shift, citing the absence of an order in the treatment administration record. Additionally, the wound data assessment, which should have been completed daily, was not consistently performed, leading to a lack of information on the wound's condition. The nurse manager and director of nursing confirmed that the wound data assessment and RN wound assessment were not completed as required, which hindered the ability to monitor the wound's healing process effectively. Observations and interviews with family members and nursing assistants further highlighted the inconsistency in following the care plan. R3 was seen without the off-loading boot while in bed, and there was confusion among the staff regarding the correct footwear for R3. The nursing assistants were not adequately informed about the need for the off-loading boot, as it was not documented in their shift documentation or R3's Kardex. This lack of communication and documentation contributed to the failure in providing appropriate pressure ulcer care and preventing the development of new ulcers.
Failure to Provide Routine Toenail Care
Penalty
Summary
The facility failed to provide ongoing, routine toenail care for a resident, leading to potential foot-related complications. The resident, who had intact cognition and diagnoses including multiple sclerosis and bilateral broken legs, required assistance for weekly bed baths. However, the care plan did not address toenail care, and the medical record lacked documentation of toenail care or any refusal by the resident. Interviews with staff revealed that nursing assistants were responsible for clipping nails on bath days unless the resident was diabetic or on blood thinners, which was not the case for this resident. Despite this, there was no documentation of toenail care in the electronic medical record, and the resident reported that her toenails were long and painful, with no action taken despite requests for care. Observations confirmed the resident's toenails were long, uneven, and jagged, with the great toe's nail thickened. Staff interviews indicated a lack of clarity on where to document nail care, and the resident was on a list to see a podiatrist, but no date was set. The facility's policy stated that residents unable to carry out activities of daily living should receive necessary services, including nail care, but this was not adhered to in this case. The deficiency was identified through a combination of resident interviews, staff interviews, and direct observation, highlighting a gap in the facility's care processes and documentation practices.
Failure to Assess and Prevent Falls
Penalty
Summary
The facility failed to perform a comprehensive assessment of falls and implement appropriate interventions to reduce the risk of falls for two residents, R2 and R4. R2's care plan indicated he was at risk for falls due to weakness and shortness of breath, with interventions such as using assistive devices and ensuring appropriate footwear. However, after R2 was found on the floor on 2/21/25, there was no immediate intervention documented to prevent future falls, and the fall huddle worksheet was not completed by the end of the shift. R4's care plan included interventions for fall prevention, such as keeping the door open for checks, using a reacher device, and ensuring appropriate footwear. Despite these measures, R4 experienced multiple falls, including one on 2/17/25 while reaching for a brief and another on 2/24/25 while attempting to sit on the toilet. The facility's documentation lacked immediate interventions and a root cause analysis for these incidents, and the fall huddle worksheets were not completed or located. Interviews with facility staff revealed that the fall huddle worksheets and risk management forms were not consistently completed or reviewed, hindering the ability to determine the root cause of the falls and implement effective interventions. The facility's policies required a comprehensive investigation and documentation process following falls, but these procedures were not followed, contributing to the deficiency in fall prevention and management.
Inadequate Investigation of Quality of Care Concerns
Penalty
Summary
The facility failed to conduct a thorough investigation into reported concerns related to the quality of care for two residents. The Director of Nursing (DON) was notified via email about issues involving two staff members, an LPN and a nursing assistant, who allegedly neglected their duties and behaved inappropriately towards residents. Despite being informed of these allegations, the DON did not interview other residents or staff to gather additional information about the reported incidents. The investigation lacked evidence of comprehensive interviews or assessments to substantiate the claims made by the residents. The facility's investigation was inadequate as the DON did not make any changes to the staff schedule or speak directly with the implicated staff members during their shifts. The DON only communicated with the two residents who reported the concerns and did not review any charting or follow up with them after the initial report. The facility administrator expected complaints to be addressed promptly, but the DON did not adhere to this expectation, resulting in an incomplete investigation into the quality of care concerns.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to consistently administer medication within the required time frame for a resident with Parkinson's disease, leading to a deficiency. The resident, who was cognitively intact and able to communicate needs, was prescribed Sinemet to be administered five times a day. However, the medication administration record revealed multiple instances where the medication was not given within the one-hour window before or after the scheduled time, as required by the facility's policy. The report highlights specific dates where the medication was administered late, ranging from 6 minutes to 1 hour and 49 minutes beyond the allowed time frame. The delays were particularly noted during the morning medication pass at 8:00 a.m., which the resident reported caused increased stiffness and pain. The clinical manager acknowledged these concerns and noted that other residents could potentially be affected by similar issues with time-sensitive medications. The consultant pharmacist confirmed that the delayed administration of Sinemet, a medication with a short half-life, could lead to side effects for the resident. The facility's policy on medication administration emphasized the importance of timely administration, yet the observed practices did not align with these guidelines, resulting in the identified deficiency.
Lint Buildup on Kitchen Fans
Penalty
Summary
The facility failed to maintain cleanliness in the main kitchen, specifically regarding the buildup of lint on three out of four kitchen fans. These fans were located in critical areas of the kitchen, including the dish return and cleaning area, the area near a refrigerator and freezer, and the kitchen prep zone. The lint buildup was significant, with strands measuring approximately 1 1/2 to 2 inches, and was observed on both the front and rear portions of the fan guards. This deficiency was confirmed during an observation and interview with the kitchen manager, who acknowledged the issue and indicated it was on their list of tasks to address. Further investigation revealed that there was no set schedule for cleaning the fans, as confirmed by the director of environmental services. The director of nutritional services also admitted that it had been a while since the fans were last cleaned and could not recall the exact timing of the last cleaning. Although a kitchen cleaning schedule was provided, it indicated that the fans were supposed to be cleaned during the third week of each month on Thursdays, suggesting a lapse in adherence to the schedule.
Failure to Maintain Cleanliness of Resident Equipment
Penalty
Summary
The facility failed to maintain wheelchairs in a clean and sanitary manner for two residents, R20 and R15, and did not ensure the cleanliness of a tube feeding (TF) pump and pole for resident R31. R20, who had diagnoses including cerebral hemorrhage and Parkinsonism, was observed with a soiled wheelchair covered in food debris. Despite a checklist for cleaning wheelchairs being presented to staff, R20's wheelchair had not been cleaned as scheduled. R15, diagnosed with ataxia, used a motorized wheelchair that was observed with rust and debris, and torn armrests secured with tape. The motorized wheelchair could not be cleaned in the wheelchair washer, and staff failed to notice or report its condition. For resident R31, who was dependent on staff for most activities of daily living and had a history of stroke and malnutrition, the TF pump and pole were observed with dried substances covering more than 50% of the legs and pump. Despite the resident's complaints, the equipment remained uncleaned. Staff, including a nursing assistant and a licensed practical nurse, were unaware of who was responsible for cleaning the TF equipment, and the director of nursing could not provide clarity on the responsibility. The facility did not provide policies for the maintenance of resident equipment or cleaning of the TF pump and pole when requested. The lack of clear responsibility and adherence to cleaning schedules contributed to the unsanitary conditions observed for the residents' equipment, indicating a failure to provide a safe, clean, and comfortable environment.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R5, within the required two-hour timeframe. R5, who had moderately impaired cognitive skills and required assistance with daily living activities due to conditions such as hemiplegia, dementia, and other mental health disorders, reported feeling abused during toileting care. The incident was noted in a progress note by a nursing assistant, but there was no documentation of an incident report or investigation in the resident's electronic health record or the Aspen Complaint/Incidents Tracking System. Interviews with facility staff revealed a lack of immediate action following the allegation. A registered nurse confirmed the incident and stated that the nurse manager was notified via email, but no follow-up was recalled. The director of nursing acknowledged awareness of the allegation only during a meeting two days later, attributing the resident's behavior to her known patterns. The facility's policy required immediate reporting of abuse allegations to the administrator or designated personnel, but this protocol was not followed. The administrator and social services staff emphasized the importance of adhering to the abuse reporting guidelines, stating that all allegations should be reported immediately to initiate an investigation. Despite this, the facility did not report the incident within the mandated timeframe, resulting in a deficiency in their handling of the abuse allegation.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as R5, who had moderately impaired cognitive skills and required assistance with daily living activities due to conditions such as hemiplegia, dementia, and other mental health disorders. R5's care plan indicated a preference for no male caregivers and noted mood problems, including unrealistic fears and resistance to care. On a specific date, a nursing assistant reported that R5 accused them of abuse during toileting care, but there was no documentation of an incident report or investigation in R5's electronic health record. Interviews with facility staff revealed that the registered nurse familiar with R5's care was aware of the allegation but did not recall any follow-up actions being taken. The nurse manager was notified via email, but no investigation was conducted. The social services staff expressed that it was unacceptable to disregard an abuse allegation based on a resident's behavior history and emphasized the importance of following procedures. The director of nursing acknowledged the lack of investigation and stated that staff were expected to report allegations immediately to initiate the investigation process. The facility's policy on abuse and neglect required prompt reporting and investigation of all alleged or suspected abuse incidents. However, the administrator confirmed that staff were expected to report allegations as soon as possible, regardless of their validity, to allow for a timely investigation. Despite this policy, the facility did not follow through with the necessary steps to investigate R5's allegation, resulting in a deficiency in handling abuse allegations appropriately.
Deficiencies in Monitoring and Care for Residents on Psychotropic Medications and Constipation Protocols
Penalty
Summary
The facility failed to ensure appropriate orthostatic blood pressure monitoring for a resident who was on psychotropic medications. The resident, who had a history of hemiplegia, high blood pressure, dementia, and several mental health disorders, was prescribed quetiapine fumarate, which required monthly orthostatic blood pressure checks. However, the treatment administration records for June and July 2024 showed checkmarks indicating the task was completed, but there was no documentation of the actual blood pressure readings. The director of nursing confirmed the absence of documented readings, acknowledging the risk of increased falls due to dizziness from unmonitored blood pressure. Additionally, the facility did not implement a bowel movement protocol for another resident who was dependent on staff for all activities of daily living and had a history of dementia and gastro-esophageal reflux disease. The resident's medication administration records indicated the use of laxatives and other medications for constipation, with instructions to contact a provider if there were three days without a significant bowel movement. Despite this, the resident went ten consecutive days without a documented bowel movement, and no as-needed medications were administered during this period. The director of nursing and infection preventionist confirmed the oversight, noting that the resident's care plan lacked documentation regarding constipation management. The facility's policies on psychotropic medication monitoring and bowel and bladder management were not adhered to, leading to these deficiencies. The psychotropic medication policy required monitoring for side effects and effectiveness, while the bowel management policy outlined interventions for constipation, including medication administration. The failure to follow these protocols resulted in inadequate monitoring and care for the residents involved.
Infection Control Deficiencies in Catheter and EBP Practices
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident with an indwelling urinary catheter. The resident, who was cognitively intact and dependent on most activities of daily living, was observed with their catheter bag placed on the floor without a barrier on multiple occasions. Despite the care plan indicating the need for catheter care every shift and monitoring for signs of infection, the catheter bag was repeatedly found on the floor, which was confirmed by both a licensed practical nurse and a nursing assistant. The director of nursing and the infection preventionist acknowledged the infection control risk associated with the catheter bag being on the ground, and the infection preventionist was unaware that the resident's behavior of placing the bag on the floor had returned. The facility also failed to utilize enhanced barrier precautions (EBP) for a resident with an unstageable pressure ulcer. The care plan did not address EBP, and during observations, staff did not wear gowns while performing high-contact care activities, such as wound care and perineal care, despite a magnetic sign indicating the resident was on EBP. Interviews with staff revealed a misunderstanding of when EBP should be applied, with some staff believing it was only necessary for wounds with active infections. The director of nursing confirmed that gowns and gloves should be worn during such care for residents on EBP. The infection preventionist noted that implementing EBP has been challenging for the facility, requiring constant reeducation of staff on the use of personal protective equipment. The facility's EBP protocol indicated that gowns and gloves are needed during high-contact care activities, but this was not consistently followed, leading to a deficiency in infection control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waconia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Auburn Home In Waconia | 0.3 mi | — | 4 | 0 |
| Lake Minnetonka Shores | 9.8 mi | — | 0 | 0 |
| Auburn Manor | 10.2 mi | — | 8 | 0 |
| Haven Homes Of Maple Plain | 11.7 mi | — | 4 | 0 |
| The Estates At Excelsior Llc | 12.1 mi | — | 18 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.