Madonna Towers Of Rochester
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester, Minnesota.
- Location
- 4001 19th Avenue Northwest, Rochester, Minnesota 55901
- CMS Provider Number
- 245153
- Inspections on file
- 31
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Madonna Towers Of Rochester during CMS and state inspections, most recent first.
Surveyors found that food items in the kitchen refrigerators, such as mushrooms, celery, lettuce, and carrots, were either expired or undated and had not been discarded as required. Staff interviews confirmed that the facility's practice is to label and date opened food and discard it after one week, but this was not consistently followed.
A resident with a history of heart failure and lymphedema experienced ongoing significant swelling in the left upper extremity, but staff failed to consistently assess and document the edema as required by the care plan and facility policy. Despite visible symptoms and staff awareness of the chronic condition, weekly skin checks and medical records did not reflect the resident's edema, preventing evaluation of intervention effectiveness.
Three residents who had previously received PCV13 and PPSV23 were not offered the PCV20 vaccine as recommended by CDC guidelines, and there was no documentation of shared clinical decision-making regarding its administration. Facility records showed missing or incomplete immunization documentation, and staff confirmed that PCV20 had not been offered, despite facility policy requiring adherence to CDC recommendations.
Required nurse staffing information was not updated daily and did not include the facility name, as observed in the main lobby. Staff interviews revealed uncertainty about who was responsible for updating the posting during the staffing coordinator's absence, and it was confirmed that the omission of the facility name had persisted for several months.
The facility failed to respect the toileting preferences of two residents, both cognitively intact and dependent on mechanical lifts for transfers. One resident expressed dissatisfaction with being forced to use a bedpan instead of the toilet, while the other reported discomfort after the ceiling lift used for toileting became unavailable. Staff interviews confirmed that residents' preferences should be honored and reflected in care plans, but this was not done, leading to a deficiency in promoting resident self-determination.
A facility failed to create a comprehensive care plan for a resident with an indwelling urinary catheter and bowel incontinence. Despite the resident's ability to manage bowel movements at home, the care plan lacked specific interventions for catheter care and a toileting schedule. Interviews revealed that the facility did not discuss catheter risks or bowel patterns with the resident, and the DON confirmed the care plan's deficiencies.
A facility failed to reassess the need for an indwelling catheter for a resident who was previously continent, resulting in discomfort and pain. The care plan lacked justification for the catheter and did not include interventions for infection monitoring. Additionally, the facility did not provide services to maintain bowel continence, as the resident preferred using the toilet over a bed pan, but this preference was not consistently honored. The care plan did not reflect the resident's toileting preferences, and there was no assessment of bowel patterns to establish a toileting schedule.
A resident with cognitive impairment and a history of wandering eloped from the facility due to a failure in the alarm system. The door alarm did not sound because it was not reset after a previous incident, and the resident's wander guard was non-functional. Staff were not trained to reset the alarm, leading to the resident's unsupervised exit and subsequent return by police.
The facility failed to conduct regular inspections of bed frames, mattresses, and bedrails, potentially affecting 50 residents. Despite manufacturer guidelines for monthly inspections, the director of maintenance stated beds are inspected yearly, and only one bed is checked. Staff interviews revealed inconsistencies in inspection practices, with the director of nursing not considering the rails as bedrails. This led to a deficiency in ensuring bedrail safety and preventing possible entrapment.
The facility failed to attempt alternative devices before using bedrails for seven residents, who had varying degrees of cognitive impairment and required significant assistance with mobility. The facility did not accurately assess the risk of entrapment or provide ongoing assessments to ensure the bedrail use met the residents' needs.
Failure to Properly Label, Date, and Discard Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and discarding of food items stored in the kitchen refrigerators. During a kitchen tour, several food items, including mushrooms, celery, lettuce, and carrots, were found either expired or undated, with some showing signs of spoilage such as browning and softness. Interviews with the dietary manager, culinary director, and a cook confirmed that the facility's practice is to label opened food with the date and discard it after one week, with the evening shift responsible for removing expired or undated items. However, the observed items had not been discarded as required, contrary to the facility's stated policy and procedures for food storage.
Failure to Monitor and Document Edema Management
Penalty
Summary
The facility failed to comprehensively monitor and assess a resident with a history of heart failure and lymphedema for edema, which prevented the determination of intervention effectiveness and the development of new interventions as needed. The resident's care plan required staff to monitor for adverse reactions to diuretics, apply and assess edema wraps and compression devices, and document skin assessments. However, weekly skin checks over a two-month period consistently indicated no edema, and the medical record lacked further assessment of the resident's left upper extremity edema during this time. Observations and interviews revealed that the resident continued to experience significant swelling in the left upper extremity, with visible puffiness and limited hand movement. Nursing staff acknowledged the chronic nature of the resident's edema but were unable to identify where this was documented in the records. One nurse noted that the edema had persisted at its current level for almost a month without documentation, and another stated that documentation of the edema was expected but not present. The facility's policy required assessments to be documented in the electronic health record, but this was not done for the resident's ongoing edema.
Failure to Offer and Document PCV20 Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three out of five residents reviewed for immunizations were offered and/or provided the pneumococcal conjugate vaccine (PCV)20 as recommended by the Centers for Disease Control (CDC). Documentation revealed that these residents had previously received PCV13 and PPSV23 vaccines, but there was no evidence that PCV20 was offered or that a shared clinical decision-making process occurred between the provider and the resident or their responsible agent regarding the administration of PCV20. The facility's own immunization review forms indicated that pneumococcal vaccinations were not up to date for some residents, and the vaccines were not offered as required. For each of the three residents, medical records and immunization reports confirmed the absence of documentation related to the offer or administration of PCV20. Consent or refusal forms for pneumonia immunizations were present in some cases, but the dates of vaccination were left blank, and there was no record of shared decision-making discussions. The regional nurse consultant and the infection preventionist both confirmed during interviews that PCV20 vaccinations had not been offered to residents, and that documentation of shared decision-making was lacking. The facility's policy on pneumococcal vaccines stated that education and administration of vaccines should be provided according to CDC recommendations, including the use of PCV15 or PCV20 for adults 65 years or older. However, the policy was not followed in practice, as evidenced by the lack of offers and documentation for PCV20 vaccination for the residents in question.
Failure to Post Daily Nurse Staffing Information with Facility Name
Penalty
Summary
The facility failed to ensure that required nurse staffing information was posted daily and that the posting included the facility name, as mandated by policy. On observation, the staffing information displayed in the main lobby was found to be outdated by two days and lacked the facility name. Interviews with the administrator, health unit coordinator, and staffing coordinator revealed confusion regarding responsibility for updating the posting during the staffing coordinator's paid time off. The staffing coordinator also confirmed that the omission of the facility name on the posting had been ongoing since September 2024 and had not been noticed or addressed. The facility's policy required daily posting of nurse staffing information at the beginning of each shift, including the facility name, but this was not followed.
Failure to Honor Resident Choice in Toileting
Penalty
Summary
The facility failed to honor the residents' right to self-determination and choice regarding toileting preferences for two residents. Resident 1, who was cognitively intact and dependent on a mechanical lift for transfers, expressed dissatisfaction with being forced to use a bedpan instead of being assisted to the toilet, which she preferred. She reported feeling a loss of control over her daily activities, including toileting. Her family member also emphasized the importance of dignity in allowing her to use the toilet. Similarly, Resident 2, who was also cognitively intact and required assistance for toileting, reported that the staff had previously used a ceiling lift to help her use the toilet. However, since the lift became unavailable, she was only offered a bedpan, which made her feel uncomfortable. Interviews with facility staff, including the regional director registered nurse and the director of nursing, confirmed that residents' preferences for toileting should be respected and reflected in their care plans. The facility's policy on Activities of Daily Living also supports interventions that align with residents' assessed needs and preferences. Despite this, the facility did not provide the necessary support to allow these residents to use the toilet, as per their requests, leading to a deficiency in promoting and facilitating resident self-determination and choice.
Failure to Develop Comprehensive Care Plan for Catheter and Bowel Management
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter and bowel incontinence. The resident, who was cognitively intact, had a history of diabetes mellitus, a stress fracture of the left tibia, and chronic kidney disease. Despite the resident's admission Minimum Data Set (MDS) indicating the presence of an indwelling urinary catheter and frequent bowel incontinence, the care plan did not include specific interventions for catheter care or a toileting plan for bowel continence. The nursing assistant care guide acknowledged the presence of a catheter but lacked detailed instructions for its care or a toileting schedule. Interviews with the resident and their family member revealed that the resident was able to manage bowel movements independently at home and did not experience incontinence. However, the facility did not discuss the risks associated with the catheter or inquire about the resident's bowel patterns prior to admission. The Director of Nursing confirmed that the comprehensive care plan did not address necessary interventions for catheter care or bowel continence management, which was contrary to the facility's policy on comprehensive assessment and care planning.
Failure to Reassess Catheter Use and Maintain Bowel Continence
Penalty
Summary
The facility failed to comprehensively reassess and justify the continued use of an indwelling catheter for a resident who was previously continent of bowel and bladder. The resident, who had a history of incontinence and reduced mobility due to a fracture, was noted to have an indwelling catheter for skin care management. However, the care plan did not indicate a medical necessity for the catheter, nor were there interventions to monitor for signs and symptoms of infection. The resident experienced discomfort and pain related to the catheter, and there was no documentation of education provided to the resident about the risks and benefits of catheter use. Additionally, the facility did not provide services to maintain bowel continence for the resident, who was previously continent before hospitalization. The care plan lacked person-centered interventions and did not include a toileting plan to maintain bowel continence. The resident expressed difficulty in having bowel movements using a bed pan and preferred to use the toilet, but staff did not consistently honor this preference. The resident's care plan did not reflect her preference for toileting, and there was no assessment of her bowel patterns to determine a toileting schedule. Interviews with staff and family members revealed that the resident's requests to use the toilet were not consistently met, and the facility's policy on bowel assessment was not provided. The facility's failure to reassess the need for the catheter and to provide appropriate bowel continence care resulted in discomfort and unmet care needs for the resident.
Resident Elopement Due to Alarm System Failure
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, resulting in an immediate jeopardy situation. The resident, who had a history of wandering and was cognitively impaired, was able to leave the facility through a fire door without staff knowledge. The incident occurred when the door alarm did not sound, and the resident was found approximately two blocks away by police and returned to the facility. The resident's care plan included a wander guard system, but it was not functioning at the time of the elopement. The deficiency was attributed to the failure to reset the door alarm after the resident had previously triggered it earlier in the day. Staff were unaware that the alarm needed to be reset for it to function properly, leading to the resident's unsupervised exit. Interviews with staff revealed that the maintenance department was not notified to reset the alarm, and nursing assistants were not trained to do so. The resident's wander guard was also found to be non-functional, contributing to the lack of alert when the resident left the facility. The facility's policy on elopement was not effectively implemented, as staff were not adequately trained on the procedures to ensure resident safety. The resident's cognitive impairment and history of wandering behavior were not sufficiently addressed, leading to the elopement incident. The lack of proper alarm system functionality and staff training were key factors in the deficiency, resulting in the resident's temporary absence from the facility.
Removal Plan
- All staff were educated on how to reset all the doors at the facility
- The door alarm company checked all the tags for all the doors
- Equipment was added that allowed the staff to see any door that an alarm had gone off on the televisions
- The facility updated their camera system post motion on the video from the default of 3 seconds to 10 seconds
Inadequate Bedrail Inspection Practices
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bedrails as part of their maintenance program, which could potentially affect 50 residents. The bed manufacturer guidelines require monthly visual inspections for broken welds, cracks, and loose hardware, but the facility did not adhere to this schedule. Instead, the director of maintenance stated that beds are inspected yearly, and only one bed is checked because all beds and bedrails are the same. This discrepancy in inspection frequency and the lack of comprehensive checks for all beds led to a deficiency in ensuring the safety of bedrails and preventing possible entrapment. Interviews with facility staff revealed a lack of clarity and consistency in the inspection process. The regional nurse believed inspections were conducted quarterly, while the nursing department did not inspect bedrails and relied on maintenance to address any concerns. The director of nursing did not consider the rails to be bedrails, viewing them as grab bars, which contributed to the oversight. The facility's policy indicated that siderails and mattresses should be checked for entrapment concerns annually, but this was not aligned with the manufacturer's monthly inspection requirement, leading to a potential risk for residents.
Failure to Attempt Alternatives Before Bedrail Use
Penalty
Summary
The facility failed to attempt alternative devices before using bedrails on residents' beds, affecting seven residents. The facility did not accurately assess the residents for the risk of entrapment by considering their medical diagnoses, size and weight, cognition, communication, mobility, and risk of falling. Additionally, the facility did not provide ongoing assessments to ensure the bedrail use met the residents' needs. This deficiency was identified through observations, interviews, and record reviews. For Resident 1, the facility's documentation indicated the use of side rails, but no alternative devices were attempted. Interviews with staff and family members revealed that Resident 1 was dependent on staff for bed mobility and did not use the bedrails independently. Similarly, Resident 2's records showed the use of siderails and grab bars without any alternative devices being tried. The resident was cognitively impaired and had a history of wandering, yet there was no documentation of attempts to use other methods. Other residents, such as Residents 3, 4, 5, 6, and 7, also had bedrails or grab bars in use without documented attempts of alternative devices. These residents had varying degrees of cognitive impairment and required significant assistance with mobility. Interviews with nursing staff confirmed that alternative devices were not attempted, and there was a lack of consistent assessments to determine the appropriateness and safety of the bedrails for these residents.
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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