Mayo Clinic Health System - Lake City
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake City, Minnesota.
- Location
- 500 West Grant Street, Lake City, Minnesota 55041
- CMS Provider Number
- 245218
- Inspections on file
- 29
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Mayo Clinic Health System - Lake City during CMS and state inspections, most recent first.
A resident with dementia and a history of childhood sexual abuse, who had severe cognitive impairment and was confused and disoriented, was seated in a common TV lounge without specific protective measures in place. Another resident with dementia, severe cognitive impairment, and a documented history of sexually inappropriate touching and comments was brought to the same lounge and could self-propel his wheelchair. Staff care plans and the Kardex only directed general monitoring and awareness of nearby female residents, without clear, individualized supervision parameters or defined staff responsibilities. Some staff were unaware of the high-risk resident’s sexual behavior history, and no one was specifically assigned to supervise him when out of his room. In this context, the high-risk resident wheeled himself next to the cognitively impaired resident and placed his hand under her shirt, touching her breast, before an RN intervened and separated them. The deficiency centers on the facility’s failure to develop, document, and consistently implement individualized supervision and protective interventions to prevent this non-consensual sexual contact.
The facility failed to report an alleged incident of resident-to-resident sexual abuse to law enforcement as required by its abuse policy. A nurse observed a resident with dementia and severe cognitive impairment being touched under her shirt on her breast by another cognitively impaired resident in a TV lounge. Staff immediately separated the residents and documented the event in internal reports and progress notes, and the allegation was verified in a 5‑day investigative summary. However, the facility’s incident report left the law enforcement reporting section blank, there was no documentation of any law enforcement contact, and the administrator and DON later confirmed that the allegation was not reported to law enforcement despite policy requiring immediate reporting of suspected abuse and potential criminal conduct.
The facility failed to conduct a thorough investigation of a resident-to-resident sexual abuse allegation after a nurse observed a resident with dementia place his hand under another cognitively impaired resident’s shirt and touch her breast in a TV lounge. Although both residents had care plans identifying vulnerability and the need to report suspected maltreatment, the facility’s internal investigation did not include comprehensive interviews with all involved and potentially knowledgeable staff, such as the witnessing RN, the assigned RN, and a NA who had assisted and seated the residents, nor were other nearby residents interviewed. The DON and Administrator, who were responsible for the investigation, could not provide documentation showing that required elements of the facility’s abuse investigation policy—such as full staff and resident interviews and complete assessment of the circumstances—were completed.
A resident with dementia and a mood disorder, who had a history of sexually inappropriate behaviors, was care planned for behavioral issues, including prior incidents of inappropriate touching and comments. However, behavior monitoring and the medical record lacked complete and corroborating documentation of episodes such as the resident grabbing others, making sexually explicit comments to a NA during toileting, responding suggestively when offered assistance to bed, and being reported by night staff as very grabby during frequent bathroom use. These behaviors were not entered into behavior notes or otherwise recorded, despite expectations from the DON and facility policies requiring complete, accurate EHR documentation and systematic assessment and tracking of behavioral symptoms.
Two residents who required mechanical lifts for transfers did not receive comprehensive assessments to determine the correct sling or harness size, as required by manufacturer instructions. Instead, staff relied on weight-based charts and informal judgment, with no formal documentation or inclusion of sling size in care plans or Kardex. Multiple staff interviews confirmed the absence of a standardized assessment process and unclear responsibility for determining sling/harness size.
A resident with a history of stroke, cognitive impairment, and impulsivity experienced multiple unwitnessed falls, including one after being left unsupervised on the commode, resulting in two thoracic spinal fractures and hospitalization. The facility did not consistently analyze fall trends, update care plans with individualized interventions, or assess the required level of supervision, leading to actual harm.
A resident in a LTC facility was mistakenly given lisinopril, intended for another resident, by a new nurse on their first independent medication pass. The resident, with chronic kidney disease and hyponatremia, experienced dizziness, weakness, and hypotension, requiring emergency treatment. The facility's medication administration policy was not followed, leading to this significant error.
The facility failed to provide the required written SNFABN and NOMNC forms to three residents whose Medicare A coverage ended. The NOMNC and SNFABN for these residents lacked signatures from their representatives acknowledging receipt and understanding of the notices. The CSM confirmed responsibility for providing these notices but did not remember obtaining written signatures. The facility's policy requires these notices to be signed and dated to demonstrate receipt and understanding.
A facility failed to accurately complete the MDS for a resident with severe cognitive impairment and wandering behavior. The resident's quarterly MDS did not document wandering, despite a history of elopement attempts and increased wandering during delusional episodes. The MDS coordinator admitted to overlooking progress notes indicating the resident's attempts to leave the facility. The DON confirmed the importance of accurate MDS assessments for resident care and Medicare reimbursement.
A resident with chronic heart conditions did not receive Metoprolol Tartrate according to physician's orders, as staff failed to consistently check and document blood pressure and pulse before administration. Interviews with facility staff confirmed the oversight, highlighting the importance of these checks to prevent adverse effects. The facility did not provide a Medication Administration/Monitoring policy when requested.
A resident with a stage three pressure ulcer was not repositioned every two hours as required by their care plan, leading to a deficiency in care. Despite the resident's inability to reposition themselves and their preference to remain seated for activities, staff interviews and observations confirmed that the necessary repositioning was not consistently provided, contributing to stalled healing of the ulcer.
A resident with moderate cognitive impairment and dementia exhibited wandering and aggressive behaviors, but the facility failed to investigate and analyze the underlying causes. Despite interventions like verbal reminders and a wanderguard, the behaviors persisted. Staff interviews revealed a lack of documented analysis or comprehensive assessment, contrary to the facility's policy on behavioral health management.
A resident with dementia and delusional disorders experienced elopement attempts and behavioral issues. Despite provider orders for a psychiatric consult, the facility failed to schedule the appointment. Staff interviews revealed a lack of awareness and follow-up on the order, leading to a delay in securing necessary psychiatric care.
A resident with C-Diff was not properly managed during therapy sessions, as the therapist failed to change gloves after potential contamination and did not use PPE when entering the resident's room. Additionally, laundry staff did not wear gowns while handling soiled laundry, contrary to facility policy, increasing the risk of cross-contamination.
A resident was not offered the PCV20 vaccine despite being eligible, as the facility failed to ensure shared clinical decision-making and proper documentation. The resident, who had previously received PPSV23 and PCV13, was unaware of the PCV20 vaccine and expressed interest in receiving it. Interviews revealed that the facility's process for reviewing and offering vaccines was not followed in this case.
The facility failed to deliver mail to residents on weekends, affecting all residents who receive mail. Interviews revealed that mail was held until Monday due to the absence of staff to receive it on weekends. The activities director and receptionist confirmed the lack of weekend delivery, and the administrator noted that mail was delivered to an attached hospital, which stopped weekend delivery. No alternative arrangements were made, and a mail delivery policy was not provided.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from non-consensual sexual contact by another resident with a known history of sexually inappropriate behavior. One resident (R1) had dementia with severe cognitive impairment, anxiety disorder, and a documented history of childhood sexual abuse/molestation. R1’s care plan, initiated months before the incident, identified her past sexual trauma and directed staff to observe for changes in mood, behavior, sleeping, and eating, and to allow her to talk as she felt appropriate, but did not identify triggers or specific protective interventions. On the morning of the incident, R1 was very confused, disoriented, and already seated in the Country View TV lounge after being gotten up early due to inability to sleep. Staff were monitoring her for confusion and fall risk, but there were no individualized measures in place to protect her from potential sexual abuse by other residents. The other resident (R2) had dementia, an unspecified mood disorder, severe cognitive impairment, and a documented history of sexually inappropriate behavior. In 2023, R2 had inappropriately touched another female resident’s breast under her shirt in the Country View common area, and his care plan and Kardex noted that he occasionally made inappropriate comments to female staff that were usually redirectable. Interventions in the care plan and Kardex instructed staff to ensure awareness of females surrounding R2 when out of his room, ensure adequate space between R2 and the prior victim resident, and to address any concerns for inappropriate behaviors immediately. R2 was able to self-propel in his wheelchair and leave the unit for activities, with staff escort required only for distant locations. After a remodel in 2025, R2 was moved back from an all-male unit to Country View, where female residents were present, without documented comprehensive review or update of his care plan to ensure continued prevention of inappropriate sexual behaviors. Staff interviews showed inconsistent awareness of R2’s sexual behavior history; some NAs and RNs knew of his prior incident, while others stated they were unaware or that the Kardex did not clearly reflect his risk. On the day of the incident, R2 was brought to the TV lounge in his wheelchair around early morning and was able to wheel himself close to where R1 was seated. A nurse (RN-B), positioned at a medication cart with view of the lounge, observed R1 seated in her wheelchair on the left side of R2 and saw R2’s right hand inside the top of R1’s shirt, touching her left breast. RN-B immediately intervened, instructed R2 to remove his hand, and staff separated the residents and returned R2 to his room. R1 did not react during the incident but was later documented as confused, hallucinating, misidentifying a male resident as her father, and making statements such as “my dad just grabbed my boob.” Multiple staff, including NAs and RNs, stated that neither R1 nor R2 had capacity to consent to sexual activity due to dementia. Staff also reported that R2 had recently been “grabby” with staff during toileting and had made sexually suggestive comments, such as asking to kiss or lick a staff member’s belly, but he was generally redirected rather than placed under defined, continuous supervision. The facility’s own policies required individualized care planning, behavioral health assessment, and abuse protection for vulnerable adults, including residents lacking capacity to consent, yet R2’s Kardex and care plan did not establish a clear, individualized supervision system sufficient to prevent his unsupervised access to vulnerable female residents, relying instead on general monitoring and redirection. This lack of clearly defined, consistently implemented supervision and protective interventions led to R2 being able to place his hand under R1’s shirt and touch her breast in the common area. Interviews with the DON, nurse managers, and direct care staff confirmed that supervision expectations for R2 were vague, not consistently documented, and not translated into specific, enforceable directions on the Kardex. Staff at the nurses’ station were generally responsible for monitoring R2 when he was in common areas, but no staff member was specifically assigned to supervise him, and he could independently move throughout the unit in his wheelchair. The DON acknowledged that interdisciplinary reviews and documentation of supervision decisions were not consistently completed after R2’s transfer back to Country View and that the care plan did not clearly define the level of supervision required. As a result of these omissions and the failure to revise and implement individualized interventions despite R2’s known history of sexually inappropriate behavior, R2 was able to access and inappropriately touch R1, who had severe cognitive impairment and a history of childhood sexual abuse, in the Country View TV lounge.
Failure to Report Resident-to-Resident Sexual Abuse Allegation to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-to-resident sexual abuse to law enforcement as required by its abuse policy. A nurse observed one resident with dementia and severe cognitive impairment, who used a Wanderguard and had a care plan identifying vulnerability and the need to report any suspicion of maltreatment, sitting in the TV lounge when another resident placed his hand under her shirt and touched her left breast. The second resident also had dementia, severe cognitive impairment, and a care plan identifying vulnerability and the requirement that suspected maltreatment be reported per facility policy. Staff immediately removed the resident’s hand, separated the two residents, and returned the alleged perpetrator to his room. The incident was documented in a facility reported incident (FRI) submitted to the state agency, which noted that both residents did not believe the behavior was inappropriate. Despite the allegation being witnessed by staff and verified in the facility’s 5‑day investigative summary, there was no documentation that the incident was reported to law enforcement. The FRI form section for identifying the name and position of the individual who reported the incident to law enforcement was left blank, and the investigative summary did not indicate any law enforcement notification. Progress notes documented the event and subsequent internal notifications to the administrator, DON, and nurse manager, but did not reference any contact with law enforcement. In an interview, the administrator and DON, who were responsible for managing the investigation, confirmed that the incident was not reported to law enforcement, contrary to the facility’s Vulnerable Adult-Abuse Protection Plan policy, which requires all alleged violations involving abuse, including sexual abuse and potential criminal conduct, to be reported immediately to law enforcement and required state agencies.
Failure to Thoroughly Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of resident-to-resident sexual abuse involving two residents with dementia and severe cognitive impairment. One resident, who used a Wanderguard and had care plan interventions for vulnerability and reporting suspected maltreatment, was observed in the TV lounge when another resident placed his hand under her shirt and touched her left breast. Both residents had care plans identifying risk for vulnerability and interventions requiring that any suspicion of maltreatment be reported per facility policy and that a safe environment be maintained. The incident was documented in a facility reported incident and a 5‑day investigative summary submitted to the state agency, which verified the allegation based on staff witnessing the event but did not include detailed findings from a comprehensive investigation. Despite the facility’s written policy requiring immediate and thorough internal investigations of all alleged abuse—including interviews with staff, residents, and witnesses; collection of written statements; care observations; environmental review; and medical record review—the investigation lacked key components. The nurse who witnessed the incident reported it to the charge nurse but was not contacted by administration for a follow‑up interview. The nurse who completed post‑incident assessments was not directed to interview other residents or staff who might have additional information. The assigned nurse for both residents on the date of the incident and the nursing assistant who assisted both residents and placed them in the TV lounge were also not interviewed. During interviews, the DON and Administrator, who were responsible for managing the investigation, were unable to provide documentation showing that comprehensive interviews or a full assessment of the circumstances surrounding the incident had been completed, resulting in a failure to meet the facility’s abuse investigation policy requirements.
Failure to Accurately Document Sexually Inappropriate Behaviors in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident with dementia and an unspecified mood disorder, who had a history of sexually inappropriate behaviors. The resident’s care plan documented prior incidents of sexually inappropriate touching toward another resident and noted that the resident occasionally made inappropriate comments to female staff, which were usually easily redirected. Behavior monitoring records for a specified period showed an entry that the resident was “grabbing others” on one date, but there was no corroborating documentation in the medical record to further describe or support this behavior. Interviews and observations revealed additional sexually inappropriate comments and behaviors by the resident that were not documented in the medical record. A nursing assistant reported that on her first day working with the resident, he asked if he could lick her belly while he was on the toilet, and she redirected him. During an observation, when staff offered to assist the resident to bed, he responded, “With you?” An LPN reported receiving a night-shift report that the resident had been up approximately every hour using the bathroom and had been “real grabby” with staff while being toileted. None of these behaviors were documented in the resident’s medical record, despite the DON stating that staff were expected to document such behaviors in behavior notes for tracking and evaluation, and despite facility policies requiring complete, accessible, and accurate medical records and systematic assessment and documentation of behavioral symptoms.
Failure to Assess and Document Proper Sling/Harness Size for Mechanical Lift Transfers
Penalty
Summary
The facility failed to comprehensively assess and document the appropriate sling or harness sizes for residents requiring mechanical lifts for transfers, as required by manufacturer instructions. For two residents who utilized sit-to-stand and full-body mechanical lifts, there was no evidence of a formal assessment that included necessary measurements such as height, weight, distance from tailbone to base of neck, or torso circumference. Instead, staff relied primarily on the resident's weight and a laminated chart in the tub room to estimate sling or harness size, without documenting the specific size in the care plan or Kardex. Interviews with various staff members, including RNs, LPNs, nurse managers, and nursing assistants, revealed a lack of clarity and consistency regarding responsibility for assessing sling/harness size. Staff reported that there was no formal assessment process, and that the size was not routinely updated or included in care plans. Some staff indicated that therapy might be responsible for the assessment, while others believed it was the responsibility of nursing. The process described by staff involved using judgment and trial-and-error to determine if a sling or harness fit properly, rather than following a standardized assessment protocol. Manufacturer instructions for the mechanical lifts and slings used in the facility specify that a full patient assessment must be conducted to determine the appropriate accessory size and type prior to each use. The facility was unable to provide a policy or procedure for mechanical lift equipment, and documentation for the two residents reviewed did not include a Mechanical Lift Sling Assessment. The lack of a comprehensive and documented assessment process for determining sling/harness size led to the deficiency identified by surveyors.
Failure to Assess and Prevent Falls Resulting in Resident Harm
Penalty
Summary
The facility failed to assess or analyze trends in falls to determine causal factors or root causes and did not implement individualized interventions to prevent or reduce the risk of falls with major injuries for a resident who experienced multiple falls. The resident had a complex medical history, including a recent stroke with left-sided hemianopsia, hemiparesis, cognitive impairment, poor safety awareness, and impulsivity. Despite being identified as at moderate risk for falls and requiring extensive assistance with activities of daily living, the facility did not consistently update or revise the care plan with new interventions after each fall, nor did they conduct comprehensive assessments to determine the appropriate level of supervision needed, particularly during toileting and transfers. The resident experienced several unwitnessed falls, including incidents where he slid out of his wheelchair, attempted to self-transfer from bed to wheelchair, and was left unsupervised on the commode. Documentation revealed that after some falls, interventions were noted in progress notes but not incorporated into the care plan. There was also a lack of assessment regarding whether the resident could be left alone on surfaces other than the wheelchair, such as the commode or other chairs. Staff interviews indicated that therapy and nursing staff were aware of the resident's impulsivity and cognitive deficits, but there was no clear assessment or documentation regarding the level of supervision required during toileting tasks. Incident reports and fall scene investigations were incomplete or missing for several falls, and the facility's post-fall investigation process was not consistently followed. The director of nursing and nurse manager confirmed that fall huddle forms were not completed for all incidents, and root cause analyses were lacking, particularly regarding whether the resident's basic needs were met at the time of the falls. As a result of being left unsupervised on the commode, the resident suffered two thoracic spinal fractures and required hospitalization. The facility's failure to assess, analyze, and implement individualized interventions contributed to actual harm for the resident.
Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure medications were administered to the correct resident, resulting in a significant medication error for one resident. The resident, who had intact cognition and diagnoses of chronic kidney disease stage 3b and hyponatremia, was mistakenly given lisinopril, a medication intended for another resident. This error occurred on the first day a new nurse was independently passing medications. The resident experienced immediate adverse effects, including dizziness, weakness, and hypotension, which required emergency medical treatment. The resident's blood pressure dropped significantly after receiving the incorrect medication, leading to symptoms such as dizziness, nausea, and blurred vision. The resident was sent to the emergency department for further evaluation and treatment, where they received intravenous fluids and albumin to address the hypotension. The resident's condition was closely monitored, and they experienced ongoing symptoms, including weakness and leg pain, following the incident. Interviews with staff revealed that the nurse responsible for the error was new and had not realized the mistake until the resident exhibited symptoms of hypotension. The facility's director of nursing confirmed that the error was significant due to the adverse effects experienced by the resident. The facility's medication administration policy requires that medications be administered as prescribed, with proper resident identification and adherence to the five rights of medication administration, which were not followed in this instance.
Removal Plan
- the facility completed an investigation and causal analysis
- RN-B was immediately re-educated and supervised
- provided education to licensed and unlicensed staff regarding giving medications as ordered and medication administration policy
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to three residents whose Medicare A coverage ended. For Resident 2, the NOMNC indicated that the community support manager (CSM) called the family member, who was also the power of attorney, to notify them of the end of skilled services and the beginning of financial liability. However, the NOMNC lacked the signature of the family member acknowledging the notification. The SNFABN also lacked a signature, and the family member stated they did not receive or sign any written notice. Resident 2's payer source changed from Medicare Part A to Private Pay, and they remained in the facility. Similarly, for Resident 162, the NOMNC and SNFABN lacked signatures from the power of attorney acknowledging receipt and understanding of the notices. The family member stated they never received or signed the notices and were unaware of the care level and associated costs. Resident 258's NOMNC also lacked a signature, and the resident was discharged from the facility. The CSM confirmed that she was responsible for providing these notices and acknowledged that she did not remember offering or obtaining written signatures for these residents. The facility's Medicare A Denial policy requires that the NOMNC and SNFABN be signed and dated by the resident or their representative to demonstrate receipt and understanding of the notices.
Inaccurate MDS Completion for Resident with Wandering Behavior
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident reviewed for wandering. The resident, identified as R26, had an admission MDS indicating severe cognitive impairment, physical and verbal behaviors, and wandering with no significant risk, with a Wanderguard in place. However, the quarterly MDS did not document wandering, despite the resident's history of elopement attempts and increased wandering during episodes of delusional thoughts. Progress notes from 3/20/24 to 3/27/24 indicated that on 3/22/24, the resident attempted to leave the facility multiple times, refused medications, and required redirection and 1:1 care. During an interview, the MDS coordinator acknowledged using a reference sheet to confirm assessment dates and stated that she referenced task documentation and progress notes during the assessment period. She admitted to overlooking the progress note dated 3/22/24, which documented the resident's multiple attempts to exit the facility. The director of nursing confirmed the importance of accurate MDS assessments for appropriate resident care and Medicare reimbursement. The facility's policy on the MDS/Careplan Process emphasized the need for comprehensive assessments to identify care needs and develop a plan of care.
Failure to Administer Medication Per Physician's Orders
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident with multiple health conditions, including chronic heart failure, atrial fibrillation, hypertension, obstructive sleep apnea, and chronic obstructive pulmonary disease. The resident's physician had ordered Metoprolol Tartrate to be administered daily, with specific instructions to hold the medication if the resident's heart rate was below 50 or systolic blood pressure was below 100. However, the Medication Administration Record and Treatment Administration Record lacked documentation of the required blood pressure and pulse checks prior to administering the medication from May 17, 2024, to the present. Interviews with facility staff, including a trained medication aide, a registered nurse clinical manager, a consultant pharmacist, and the director of nursing, confirmed that the necessary monitoring was not consistently performed as per the physician's orders. The staff acknowledged the importance of these checks to prevent potential adverse effects, such as dizziness or dangerously low blood pressure, which could lead to life-threatening situations. Despite the expectation that these parameters be followed, the facility did not provide a Medication Administration/Monitoring policy and procedure when requested.
Failure to Reposition Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident, identified as R4, who had a stage three pressure ulcer. R4's care plan required repositioning every two hours while in bed or a wheelchair to promote healing and prevent further skin breakdown. However, observations revealed that R4 was left seated in a Broda chair for extended periods without repositioning, from 9:42 a.m. to 12:57 p.m., during which time R4 was moved only for lunch and toileting. Interviews with staff, including nursing assistants and a registered nurse, confirmed that R4 was unable to reposition herself and required staff assistance every two to three hours, as per the care plan. Despite this, R4 frequently refused to lay down, preferring to watch television and participate in activities, which contributed to the lack of repositioning. The report highlights that R4 had multiple medical conditions, including moderately impaired cognition, non-traumatic brain dysfunction, atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, non-Alzheimer's dementia, seizure disorder, depression, and muscle weakness. These conditions, along with the presence of a stage three pressure ulcer, increased R4's risk for further skin breakdown. The facility's failure to adhere to the care plan for repositioning, as confirmed by staff interviews and observations, resulted in a deficiency in providing appropriate pressure ulcer care for R4.
Failure to Investigate and Analyze Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to adequately investigate, review, and analyze the underlying causes of a resident's anxiety and agitation. The resident, identified as R24, exhibited behaviors such as wandering, exit-seeking, and aggression, which were potentially harmful to himself and others. Despite these behaviors being documented in progress notes, there was a lack of comprehensive assessment and analysis to determine the triggers or underlying causes of these behaviors. R24 had a significant change in their Minimum Data Set (MDS), indicating moderate cognitive impairment and diagnoses including dementia, repeated falls, and malignant neoplasm of the prostate. The care plan identified R24 as at risk for wandering and elopement, with interventions such as verbal reminders and a wanderguard. However, these interventions were often ineffective, as evidenced by multiple incidents of wandering, exit-seeking, and aggression documented between 5/15/24 and 6/11/24. Interviews with staff revealed that while behaviors were discussed in interdisciplinary team (IDT) meetings, there was no documented analysis of the behaviors to identify potential causes. The facility's policy required individualized behavioral care plan interventions and regular reviews by the IDT team, but the medical record lacked evidence of such reviews or analyses. The deficiency highlights a failure to adhere to the facility's policy on mood and behavior management.
Failure to Follow Up on Psychiatric Consult for Dementia Resident
Penalty
Summary
The facility failed to follow up on provider orders for a resident diagnosed with dementia, delusional disorders, and anxiety. The resident, identified as R26, had a history of severe cognitive impairment, elopement attempts, and behavioral issues such as verbal aggression and threats. Despite having a care plan in place that included a wanderguard and medication adjustments, the facility did not ensure a psychiatric consult was scheduled as ordered by the provider. Interviews with staff revealed a lack of awareness regarding the psychiatric appointment, and the unit secretary admitted to not documenting or following up on the appointment scheduling process. The resident's progress notes indicated ongoing behavioral episodes, yet there was no documentation of an increase in these behaviors. The unit secretary recalled attempting to make the psychiatric appointment but was unable to do so due to the order being in review. No follow-up actions were taken until prompted by a nurse manager, leading to a delay in securing the necessary psychiatric consultation. The director of nursing acknowledged the importance of following up on provider orders for the proper healthcare of residents, but a policy for provider orders was not provided upon request.
Infection Control Deficiencies in Therapy and Laundry Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during therapy sessions for a resident diagnosed with Clostridium difficile (C-Diff). The resident, who required moderate assistance with grooming and hygiene and was frequently incontinent of bowel, was observed in a therapy session where the physical therapist did not change gloves after touching potentially contaminated items. The therapist continued to assist the resident without changing gloves and did not adhere to contact precautions when entering the resident's room, despite clear signage indicating the need for gown and gloves. Additionally, the facility did not properly manage the sorting of soiled and potentially contaminated laundry, increasing the risk of cross-contamination. During a laundry tour, it was observed that laundry staff did not wear gowns while handling soiled laundry, including isolation gowns, which were frequently found loose in storage carts. The facility's policy required the use of gloves and gowns when handling contaminated laundry, but this was not followed, and there were no gowns available in the area for staff to use. Interviews with staff, including the infection preventionist and the director of nursing, confirmed that the observed practices were breaches in infection control. The infection preventionist acknowledged the need for staff to wear isolation gowns during laundry sorting to prevent contamination, and the director of nursing emphasized the importance of following infection control practices to prevent the spread of infection.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R40, was offered and/or provided the pneumococcal vaccine series as recommended by the CDC. R40, who was over the age of 65, had previously received the PPSV23 vaccine in 2012 and the PCV13 vaccine in 2015. However, there was no evidence of shared clinical decision-making with the physician regarding the administration of the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. The immunization record lacked documentation of offering or providing education about the PCV20 vaccine to R40. Interviews with the infection preventionist and the registered nurse clinical manager revealed that the facility's process involved reviewing immunization records upon admission and discussing eligible vaccines with residents. However, in R40's case, the PCV20 vaccine was not addressed, and the resident was not informed about its availability. R40 confirmed that she was unaware of the third pneumonia vaccine and expressed interest in receiving it. The facility's policy indicated that residents should be offered pneumococcal vaccines according to CDC guidelines, but this was not adhered to in R40's case.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure timely delivery of mail to residents on weekends, which has the potential to affect all residents who receive mail. Interviews with residents revealed uncertainty about mail delivery on Saturdays, with one resident stating that mail was delivered by the activities staff, and another indicating that mail was delivered to family members. The activities director confirmed that her department was responsible for mail delivery, but mail was not delivered on weekends as her staff occasionally worked on weekends and the mail was held until the following Monday. Further interviews revealed that the receptionist stated mail was not delivered on weekends due to the absence of staff at the desk to receive it, and the decision was made to hold mail to safeguard protected health information. The administrator explained that mail was delivered to an attached hospital and sorted by activities staff, but the hospital stopped weekend mail delivery, and the mailroom was locked on Saturdays. No alternative arrangements were made for weekend mail delivery, and a policy regarding resident mail delivery was requested but not provided.
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.
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