Knute Nelson Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Alexandria, Minnesota.
- Location
- 420 12th Avenue East, Alexandria, Minnesota 56308
- CMS Provider Number
- 245435
- Inspections on file
- 22
- Latest survey
- May 13, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Knute Nelson Care Center during CMS and state inspections, most recent first.
Resident rights were not reviewed verbally or in writing during resident council meetings, and the posted rights notice was outdated. Several residents stated the rights had not been reviewed, and the admin confirmed the meetings did not include this review and the poster was not current.
Incomplete Daily Staffing Posting: The facility failed to ensure the daily staffing posting included all required information. The posting showed the date and the total number of licensed staff with their designation, but it did not include the facility name, a clearly identified census, or the total actual hours worked by licensed staff. The senior manager of scheduling operations, RN-A, the DON, and the administrator gave differing accounts of who was responsible for updating weekend changes and acknowledged uncertainty about the exact posting requirements.
The facility failed to properly label, date, and discard food items in the kitchen, and did not maintain appropriate cold food temperatures during meal service on the Pines unit. Several food items were found without proper labeling or had expired, and potato salad was served at 51 degrees Fahrenheit, above the required 41 degrees Fahrenheit. This affected 59 residents receiving food from the refrigerators.
A resident with severe cognitive impairment and a stage 4 pressure ulcer on the left heel was not repositioned for over three hours, despite requiring repositioning every two hours as per the care plan. Staff interviews confirmed the resident's need for assistance and the failure to follow the care plan, increasing the risk of further skin breakdown.
The facility failed to serve food at the appropriate temperature, affecting four residents on the Pines unit. Observations showed that meals were served below the required 140 degrees Fahrenheit, with a test tray revealing significantly lower temperatures. The issue was linked to the warming cart not being plugged in during meal service, contrary to facility policy.
The facility failed to ensure that four residents received pneumococcal vaccinations according to CDC guidelines. The residents, aged 76 to 89, did not have documentation of being offered or receiving the PCV20 vaccine, despite CDC recommendations for adults 65 and older. The DON confirmed the oversight, which was contrary to the facility's policy to offer pneumococcal vaccines to all residents.
A resident with severe cognitive impairment and a history of pressure ulcers was not repositioned every two hours as required by their care plan. Observations showed the resident remained seated in a wheelchair for over three hours without repositioning. Staff interviews confirmed the resident's need for extensive assistance and the failure to follow the care plan, which increased the risk of skin breakdown.
A resident with severe cognitive impairment and a history of falls was observed with a Velcro belt fastened behind their wheelchair, which they could not remove independently. Despite staff believing the belt was not a restraint, a comprehensive assessment was not conducted, and the facility's policy on restraints was not followed. The deficiency was identified due to the lack of assessment and re-evaluation of the belt's use.
A facility failed to implement physician orders for a resident requiring daily weights to manage fluid retention. Despite having a process for recording weights, staff did not consistently obtain or document them, impacting the administration of Torsemide. Interviews revealed a lack of adherence to procedures, and the nurse practitioner was not informed of the missing weights, which were crucial for the resident's treatment plan.
A resident with cognitive impairment and a history of falls was not properly assessed for smoking safety, despite being a smoker. The resident managed cigarettes independently, disposing of butts in his room's garbage can, creating a fire risk. Staff interviews confirmed the lack of smoking assessments and interventions in the care plan, and the facility's policy required residents to smoke off-property without a designated area or supervision.
Resident Rights Not Reviewed or Posted Current
Penalty
Summary
The facility failed to ensure the resident bill of rights were provided verbally and in writing for all residents. During review of Resident Council Minutes Forms for 2/24/26, 3/26/26, and 4/16/26, the minutes did not document that the resident rights were reviewed. When seven residents attended a resident council meeting held by the surveyor, the residents stated the rights had not been reviewed. One resident said the rights were given at admission and posted in the facility, while another resident said they had been admitted years ago and were not coherent at that time. At 11:45 a.m., the poster near the nurses' station was reviewed and was dated 9/19, not the current 12/25 resident rights poster. During interview, the administrator stated the life enrichment supervisor was responsible for the resident council meetings and verified that the resident rights were not reviewed during those meetings and that the poster was not current. The facility policy for Resident and Family Council stated the facility would provide meeting space, inform residents of meeting opportunities, and respond to council concerns, but it did not include review of resident rights in the agenda.
Incomplete Daily Staffing Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting included all required information. Review of the staff schedule and facility staff posting documentation dated 4/13/26 through 5/13/26 showed that the posting included the date and the total number of licensed staff with their designation, but it did not include the facility name, the census number clearly identified as such, or the total number of actual hours worked by licensed staff. On 5/13/26, the senior manager of scheduling operations stated they were responsible for updating and posting the daily facility staffing information Monday through Thursday evenings and posting the whole weekend on Friday night, with weekend nurses responsible for updating any changes. The senior manager stated they were unsure of the exact requirements for the posting. That same day, RN-A stated weekend staffing changes would be emailed to the DON and scheduling team and updated on internal unit sheets, but RN-A was unaware of responsibility to update the daily facility posting. The DON stated they were unsure whether weekend updates were always being done and confirmed the charge nurse was responsible for weekend changes. The administrator confirmed the scheduling team was responsible for updating and posting the daily staffing information and stated the posting needed to include the census and how many nurses and nursing assistants were in the building each day.
Improper Food Storage and Temperature Maintenance
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food and beverages stored in the refrigerators, as well as maintaining appropriate food temperatures during meal service. During a kitchen tour, it was observed that several food items, including orange sauce, barbeque sauce, a chicken salad sandwich, pureed bread, and pork sausages, were either not labeled with an opening date or had expired. Additionally, a bottle of staff pop was found without a date. These practices were not in accordance with the facility's policy, which requires all foods to be labeled with contents, preparation date, and specific instructions. Furthermore, during meal service on the Pines unit, the facility failed to maintain proper cold food temperatures. Potato salad was observed being served at 51 degrees Fahrenheit, which is above the required 41 degrees Fahrenheit or lower, as per the facility's policy. The dietary aide acknowledged the error and stated that the potato salad should have been kept on ice to maintain a safe temperature. The dietary manager confirmed these findings and reiterated the expectation that all cold food should be held at 41 degrees Fahrenheit or lower to prevent foodborne illness. This deficiency had the potential to affect 59 residents who received food and beverages from the refrigerators.
Failure to Reposition Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident (R2) who had a current pressure ulcer and was at risk for further development of pressure ulcers. R2 had severe cognitive impairment and required extensive assistance with activities of daily living, including bed mobility and transfers. The resident had a stage 4 pressure ulcer on the left heel and was on a repositioning program that required repositioning every two hours while awake. However, during a continuous observation on March 4, 2025, R2 was not repositioned for over three hours while seated in a wheelchair, contrary to the care plan directives. Interviews with staff, including a nursing assistant (NA-A), a clinical manager (CM-A), and the director of nursing (DON), confirmed that R2 required staff assistance to reposition and that the care plan for repositioning every two hours was not followed. The facility's policy on repositioning, revised in January 2025, required staff to check the care plan or assignment sheet for resident-specific positioning needs. Despite this, R2 remained seated without repositioning for an extended period, increasing the risk of further skin breakdown.
Failure to Serve Food at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for four residents on the Pines unit. Observations and interviews revealed that residents frequently received meals that were not at the appropriate temperature. Specifically, residents reported that their food was often cold, and during a meal service, a test tray showed that the food items were below the required temperature of 140 degrees Fahrenheit. The cheese pizza was 88 degrees, mashed potatoes were 125 degrees, pureed pizza was 116 degrees, and pureed carrots were 114 degrees, all of which were below the facility's policy requirements. The deficiency was attributed to the improper use of the warming cart, which was not plugged in during meal service, as confirmed by a dietary aide. This resulted in the food being served at inadequate temperatures. The dietary manager stated that the expectation was for the warming cart to be plugged in to maintain food temperatures at or above 140 degrees Fahrenheit. The facility's policy on food temperature, revised in March 2020, indicated that all hot food items must be served at a minimum of 140 degrees Fahrenheit, which was not adhered to during the observed meal service.
Failure to Administer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that four out of five residents received pneumococcal vaccinations in accordance with the CDC recommendations. The CDC guidelines specify that adults aged 65 and older who have previously received the PPSV23 or PCV13 vaccines should receive a dose of the PCV20 vaccine at least one year after the most recent PPSV23 or PCV13 vaccine. Additionally, adults 65 and older who have received both PCV13 and PPSV23 should receive a dose of PCV20 at least five years after the last pneumococcal vaccine dose, based on shared clinical decision-making. However, the medical records for residents aged 76 to 89 lacked documentation that they had been offered or received the PCV20 vaccine as recommended. The Director of Nursing, who also serves as the infection preventionist, confirmed that the residents had not received the pneumococcal vaccinations as per CDC guidelines. The facility's policy, dated 2001, stated that all residents should be offered the pneumococcal vaccine to prevent pneumonia and pneumococcal infections, with eligibility assessed within five working days of admission. Despite this policy, the facility did not adhere to the updated CDC recommendations, resulting in a deficiency in the vaccination process for the residents involved.
Failure to Reposition Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident with a history of pressure ulcers and at risk for further development of pressure ulcers. The resident, who had severe cognitive impairment and diagnoses including Parkinson's, Diabetes Mellitus, and anxiety disorder, required extensive assistance with activities of daily living, including bed mobility, transfers, and toileting. The care plan directed staff to reposition the resident every two hours to prevent skin breakdown. However, observations revealed that the resident remained seated in a wheelchair for at least three hours without being repositioned, contrary to the care plan instructions. Interviews with staff, including a nursing assistant, LPN, RN, and the Director of Nursing, confirmed that the resident required extensive assistance to reposition and was at risk for skin breakdown. The staff acknowledged that the resident had not been repositioned as required, with the last repositioning occurring at 7:30 a.m., despite the care plan's directive for repositioning every two hours. The facility's policy on repositioning also emphasized the importance of following the care plan for each resident's specific needs, which was not adhered to in this case.
Failure to Assess Restrictive Device as Potential Restraint
Penalty
Summary
The facility failed to comprehensively assess the use of a restrictive device as a potential restraint for a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including Parkinson's, Diabetes Mellitus, and anxiety disorder, required extensive assistance for activities of daily living and used a wheelchair for mobility. Despite the resident's care plan indicating the use of a non-restraint belt, observations revealed the resident was consistently seated in a wheelchair with a Velcro belt fastened behind the chair, which the resident was unable to remove independently. Interviews with staff, including a nursing assistant, LPN, RN, and the director of nursing, revealed a lack of clarity and assessment regarding the use of the Velcro belt. The staff believed the belt was not a restraint because the resident had previously been able to remove it, although current observations and attempts showed the resident could not do so. The director of nursing confirmed that a restraint assessment had not been completed prior to the belt's use, and the need for the belt had not been reassessed. The facility's policy on identifying involuntary seclusion and unauthorized restraint defined a physical restraint as any device that a resident could not easily remove and that restricted their freedom of movement. The policy emphasized that restraints should not be used unless required to treat a medical condition and should be the least restrictive option. The use of the Velcro belt, which the resident could not remove, was not accompanied by ongoing re-evaluation, leading to the deficiency identified in the report.
Failure to Implement Physician Orders for Daily Weights
Penalty
Summary
The facility failed to implement physician orders for a resident, identified as R33, who was at risk for fluid retention due to conditions such as atrial fibrillation and hypertension. The resident had an active order for Torsemide, a diuretic, to be administered as needed based on specific weight gain parameters. However, the facility did not consistently record daily weights as required, which were crucial for determining the administration of the medication. The absence of recorded weights was noted on multiple days across March, April, and May 2024, and there was no documentation indicating that the resident refused to be weighed or that the nurse practitioner was informed of the missing weights. Interviews with various staff members, including nursing assistants, LPNs, RNs, and the director of nursing, revealed a lack of adherence to the process for obtaining and documenting daily weights. Staff members acknowledged the importance of daily weights for the administration of Torsemide but admitted that weights were not consistently obtained or recorded in the electronic medical administration record (EMAR). The nurse practitioner and pharmacist were not informed about the missing weights, which could have impacted the resident's health management. The nurse practitioner confirmed that the facility did not communicate the lack of daily weights, which was essential for the resident's treatment plan. The director of nursing also confirmed the expectation for staff to follow physician orders, including obtaining daily weights. Despite the facility's process for recording weights, there was a significant lapse in execution, leading to the deficiency in care for the resident. A policy regarding vitals and weights was requested but not provided, indicating a possible gap in procedural documentation.
Failure to Assess and Supervise Resident Smoking Safety
Penalty
Summary
The facility failed to comprehensively assess smoking safety for a resident who was moderately cognitively impaired and had a history of falls and weakness. The resident, who had a tracheostomy and other medical conditions, was not identified as a smoker in the initial assessments and care plans. Despite being a cigarette smoker prior to admission and resuming smoking shortly after, the resident's electronic health record lacked any smoking assessments or interventions until a care plan update. The resident managed his cigarettes and lighter independently, kept them in his room, and disposed of cigarette butts in his room's garbage can, posing a fire risk. Interviews with staff, including an LPN, clinical manager, and DON, confirmed the lack of smoking assessments and interventions in the resident's care plan. The facility's policy prohibited tobacco use on the premises, requiring residents to go off-property to smoke. However, the resident was observed propping open facility doors with a cane to exit and smoke off-property, without a designated smoking area or proper supervision. Staff were unaware of the resident's smoking habits and disposal methods, highlighting a significant oversight in ensuring the resident's safety and compliance with facility policies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
