Oakland Park Communities, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Thief River Falls, Minnesota.
- Location
- 123 Baken Street, Thief River Falls, Minnesota 56701
- CMS Provider Number
- 245592
- Inspections on file
- 18
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Oakland Park Communities, Inc. during CMS and state inspections, most recent first.
A resident with recent stroke, right-sided hemiparesis, severe cognitive impairment, and high fall risk was care planned for Hoyer lift transfers with assist of two. Shortly after admission, family brought in a power lift recliner that staff began using without notifying administration or obtaining the required RN/therapy assessment for safe use. Multiple staff transferred the resident into the lift chair over several days, despite her dependence for all mobility and poor safety awareness, and the remote was left where she could potentially access it. The resident was later found on the floor next to the lift chair, which was in the full stand position, and was diagnosed in the ER with a trimalleolar ankle fracture with talar subluxation, attributed to an unwitnessed fall from the unassessed lift chair.
A resident admitted after a CVA with documented hypokalemia was discharged from the hospital on potassium chloride 10 mEq BID, with an e-prescription confirmed by the pharmacy and potassium tablets delivered to the facility. The potassium order was not entered on the EMAR at admission, and the resident missed multiple potassium doses over several days. Staff observed that the potassium card was untouched and that the medication was not on the EMAR, but the medication was set aside and no provider notification occurred at that time. Interviews with nursing staff, the DON, and the MD confirmed that the physician was not informed of the omissions or the low potassium level, despite facility policy requiring timely physician notification when treatment or medications are altered significantly. This failure to notify the physician of omitted potassium doses constituted the cited deficiency.
A resident with recent CVA, hypokalemia, and multiple comorbidities was discharged from the hospital with an e-prescribed order for potassium chloride 10 mEq BID, which the pharmacy confirmed and delivered to the facility. The potassium order was not included on the paper transfer orders and was not entered into the EMAR on admission. A TMA received the potassium, noted it was not on the EMAR, did not administer it, and left the medication on the medication room counter with a note, without documented communication to nursing leadership. The potassium remained unused through multiple shifts until a night-shift RN later discovered the untouched card, located the hospital order, and entered it into the resident’s record, at which point administration began. Facility documentation identified that at least six doses of potassium were missed during this period and classified this as a medication error, reflecting a failure to ensure the resident was free from significant medication errors.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was lacking, but does not specify further details about those involved.
A resident with cognitive impairment and multiple medical conditions sustained a third-degree burn due to improper use of a microwave-heated gel pack. The facility failed to follow the manufacturer's instructions, conduct a comprehensive assessment, and implement timely interventions. There was a significant delay in notifying the physician, and staff lacked training on the proper use of gel packs.
The facility failed to accurately submit licensed nursing staff hours on the PBJ, affecting all 32 residents. The PBJ report indicated low weekend staffing and lack of 24-hour coverage on several days, but payroll records showed otherwise. Discrepancies arose from salaried staff not using the timeclock and manual data entry errors by the administrator, who was unavailable due to a family emergency.
The facility failed to develop, monitor, and evaluate performance measures, affecting all 46 residents. The QAPI process lacked measurable goals and actions, with projects like fall reduction and infection control not showing evidence of effectiveness. Despite scheduled meetings, the facility did not track performance improvements, indicating a deficiency in their QAPI process.
The facility did not ensure that the Quality Assessment and Assurance (QAA) committee meetings included the required members, such as the medical director and director of nursing, on a quarterly basis. Meeting minutes showed their absence, and an RN confirmed this, although they believed the members were available by phone. This oversight potentially affected all 32 residents in the facility.
The facility failed to implement enhanced barrier precautions for two residents with wound care needs and did not ensure proper PPE use during soiled laundry sorting. A resident with a toe wound and another with a hip wound were not provided with appropriate PPE, and the facility's policy lacked guidance on EBP. In the laundry department, a single contaminated apron was used throughout the day, with no disposable gowns available.
A facility failed to notify physicians of incidents involving two residents. One resident, with cognitive impairment and multiple medical conditions, developed a burn from a heat pack, but the physician was not informed until weeks later. Another resident, on anticoagulant therapy, fell and sustained a large bruise, but the physician was not notified. The facility's policy required notifying physicians of such incidents, but this was not adhered to, resulting in delayed medical evaluation and intervention.
A resident with cognitive impairment and diabetes suffered a burn on the right hip due to improper use of a hot pack by an RN. The RN was unaware of the manufacturer's instructions and did not report the incident to the state agency. The burn, initially a blister, developed into a chronic full-thickness burn. Other staff members, including the DON, were unaware of the incident, and the facility's policy on reporting was not followed.
A resident with cognitive impairment and diabetes suffered a burn on the right hip due to improper use of a hot pack. The RN who applied the pack was not educated on its heating instructions and did not read them, leading to the resident lying on the pack and sustaining a full-thickness burn. The incident was not reported promptly, and no investigation was conducted to determine the appropriateness of the pack's use or staff awareness of its instructions.
A facility failed to accurately code the MDS for a resident with Type 2 Diabetes, who received Trulicity, a GLP-1 receptor agonist, weekly. A registered nurse incorrectly identified Trulicity as insulin on the MDS, despite acknowledging it was not insulin. This error occurred while the facility's MDS nurse was on medical leave, leading to a misunderstanding of medication classification.
A resident with severe cognitive impairment developed a pressure ulcer on the right great toe, which was not documented in the care plan. Nursing staff performed dressing changes, but there was a lack of comprehensive assessment and documentation of interventions to promote healing. Interviews revealed that staff were not fully aware of the wound's condition or interventions, and the facility's pressure ulcer protocol was not provided.
A resident with severely impaired cognition was administered oxycodone despite an allergy listed in their medical record, and received acetaminophen exceeding the recommended daily dose. The consultant pharmacist failed to identify the discrepancy, and the DON found that the provider had overridden the allergy alert without facility staff questioning it.
A consulting pharmacist failed to identify and report a discrepancy between a resident's documented allergy to oxycodone and its administration over several months. Despite the allergy being listed, the resident received oxycodone multiple times without documented adverse reactions. The pharmacist did not report this irregularity, and the facility's policy requiring such reporting was not followed.
A LTC facility failed to provide timely pain management for two residents. One resident, with severe cognitive impairment, experienced a delay in receiving as-needed oxycodone due to a medication shortage and insufficient use of emergency resources. Another resident, with chronic pain, faced a delay in receiving a Lidocaine patch, which was crucial for pain relief. These deficiencies highlight issues in medication availability and timely administration, impacting residents' comfort and care.
Failure to Assess and Safely Manage Use of Power Lift Chair Resulting in Fall With Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement its standards of practice for assessing and safely using a power lift chair for a resident with severe cognitive and physical impairments. The resident was admitted after a recent left PCA stroke with right-sided hemiparesis, expressive and receptive aphasia, severely impaired cognition, disorganized thinking, impaired vision, and dependence on staff for all ADLs and transfers. On admission, therapy evaluations and the care plan identified that the resident could not bear weight on the right lower extremity, had right knee buckling, poor trunk control, leaned to the right, and required a Hoyer lift with assistance of two for transfers. The Morse Fall Scale score placed the resident at high risk for falls, and the care plan directed staff to follow therapy recommendations, including use of a Hoyer lift for transfers. After admission, the resident’s family brought in an electric lift recliner that the resident had never used before and was not familiar with. The family did not explicitly notify administrative staff, but facility staff observed the chair being delivered and began using it for the resident within a day or two of admission. Multiple NAs and RNs reported transferring the resident into the lift chair using a Hoyer lift on several occasions over the following days. Staff interviews revealed that no lift chair assessment was completed by nursing or therapy prior to the resident’s use of the chair, despite an existing facility policy requiring evaluation of a resident’s ability to safely operate an electric recliner by therapy or an RN. Several staff members acknowledged they were aware that a lift chair assessment should have been completed before use, but they either assumed the chair was safe because it was in the room or did not verify whether an assessment existed. Therapy staff, including the PTA and PT, observed the resident seated in the lift chair during therapy sessions and used the remote themselves to adjust the chair, but no formal lift chair assessment was initiated. Interviews with the DON, care coordinator RN, MDS coordinator, therapy staff, and NAs consistently described the resident as confused, forgetful, unable to stand or walk, with right-sided paralysis and poor safety awareness, and indicated that the resident would not have been safe to use the lift chair or its remote independently. On the day of the incident, NAs transferred the resident via Hoyer lift from bed to the lift chair, elevated the feet with the remote, reclined the chair, covered the resident with a blanket, and placed the remote either over the left armrest or in the side pocket, in a manner that still allowed the resident potential access to the cord or remote. Shortly thereafter, the resident was found on the floor on her right side between the bed and the lift chair, with the chair in the fully upright stand position and the right foot in eversion with obvious ankle deformity. The resident was unable to provide a clear account of what happened. ER evaluation and x-rays confirmed a new trimalleolar fracture of the right ankle with lateral subluxation of the talus, which staff and providers attributed to the unwitnessed fall from the lift chair in the context of the resident’s inability to safely use or tolerate the lift mechanism.
Failure to Notify Physician of Omitted Potassium Doses After Admission
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident’s physician of omitted potassium doses following admission, despite existing orders and documented hypokalemia. The resident was admitted from an acute hospital with a recent CVA and multiple comorbidities, including hypokalemia attributed to Lasix use. Hospital records showed a potassium level of 3.1 mEq/L on the morning of discharge and discharge instructions that the resident was to receive potassium chloride 10 mEq by mouth twice daily for approximately one month, with the possibility of discontinuation if levels normalized. An e-prescription for potassium chloride 10 mEq CR twice daily was sent to the pharmacy and receipt was confirmed, and the pharmacy delivered a card of potassium tablets to the facility on the day of admission. On admission, the facility’s care plan directed staff to administer medications as ordered and report abnormal labs or vital signs to the primary care provider. However, the potassium order was not entered onto the facility’s EMAR at the time of admission, and the resident did not receive the ordered potassium doses from the evening of admission through several subsequent medication passes. The facility’s own Medication Error document later identified that the resident potentially missed three doses on the evening of admission and four additional doses over the next two days, with potassium therapy not started until several days after admission. During this period, there is no documentation that the resident’s physician or on-call provider was notified of the missed doses or of the resident’s low potassium level on admission. Staff interviews confirmed that the potassium medication was delivered and recognized as not appearing on the EMAR, but the issue was not escalated to a provider. The TMA who accepted the delivery noted that the potassium was not on the EMAR and placed the medication with a note in the medication room, consistent with what she stated she had done in similar situations in the past, but she did not administer the medication or contact a nurse or provider before going off work. A night-shift RN later discovered the untouched potassium card in the cart, identified this as a red flag, and located the hospital order in the hospital record, but did not notify a provider at that time because it was the middle of the night. The DON and the primary provider both stated in interviews that nursing staff would have been expected to notify the prescribing provider or on-call provider about the missed potassium doses and the low potassium level, and the facility’s policy on Notification of physician and family required timely notification of physicians when treatment or medications are altered significantly, including when existing medications are discontinued or not given as ordered. Despite this, there was no evidence that the physician was notified of the omissions, constituting the cited deficiency. The resident’s subsequent clinical course included an ED visit after an unwitnessed fall with a right ankle fracture, during which her potassium level was within normal limits, and a later ED visit for hyperkalemia, hypernatremia, acute renal failure, and severe dehydration, with a potassium level of 7.2 mEq/L. At both ED encounters, the outpatient medication list still reflected potassium chloride 10 mEq twice daily. The primary provider reported she was not aware of the missed potassium doses prior to her initial visit several days after admission and that she had not initiated provider coverage until that visit. The facility’s Medication Error document related to the missed potassium doses contained no documentation of any notifications to agencies or people, and sections for such notifications were left blank. This sequence of events demonstrates that the facility did not follow its own policy requiring timely physician notification when treatment is altered by missed medication doses, specifically failing to notify the physician of the potassium omissions for this resident with documented hypokalemia.
Failure to Transcribe and Administer Ordered Potassium Resulting in Multiple Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a prescribed potassium supplement was not properly transcribed and implemented, resulting in multiple missed doses. The resident was admitted from the hospital with a history of CVA, UTI, hypokalemia, hypertension, hyperlipidemia, arteriosclerotic disease, and recent stroke with severely impaired cognition, aphasia, and disorganized thinking. Hospital documentation showed hypokalemia with a potassium level of 3.1 mEq/L on the day of discharge and a plan for approximately one month of potassium supplementation, with an e-prescribed order for potassium chloride 10 mEq twice daily. The hospital pharmacy confirmed receipt of the e-prescription and delivered potassium tablets to the facility on the day of admission, and the facility’s care plan directed staff to administer medications as ordered and report abnormal labs. Despite the hospital’s e-prescribed order and delivery of potassium, the medication was not entered into the facility’s EMAR on admission and was not included on the interagency transfer discharge orders. A TMA received the potassium from the pharmacy, verified it against the packing slip, and noted that potassium was not listed on the EMAR. The TMA did not administer the medication and instead placed the potassium on the counter in the medication room with a sticky note, consistent with an informal practice she described, but there was no documented communication to the charge nurse, RCC, or DON. The potassium remained on the counter through multiple shifts without being investigated or reconciled with the resident’s orders, and the DON later confirmed that the medication stayed in the medication room and that there should have been follow-up when potassium arrived without a corresponding order. The missed potassium order was eventually discovered days later by a night-shift RN who, while checking the medication cart, found the potassium card untouched and recognized this as a red flag. This RN searched the hospital’s electronic record, located the provider’s potassium order, printed and scanned it into the resident’s chart, and entered it into the facility’s orders and EMAR on 1/18. Facility documentation, including a medication error report prepared by the DON, identified that the resident potentially missed at least six doses of potassium between the evening of admission and the start of administration on 1/18. The primary provider stated she was unaware of the missed doses and indicated that nursing staff should have followed facility protocol and notified a provider when potassium doses were missed in the context of a low potassium lab value. The DON acknowledged that multiple process failures occurred, including lack of follow-up when the potassium arrived without an order and failure to ensure the order was placed in the EMAR, and confirmed that missed doses of potassium constituted a medication error. Later clinical events documented in the record showed that the resident was sent to the ER on one occasion for a fall with a trimalleolar ankle fracture, at which time potassium was 3.8 mEq/L, and on another occasion for hyperkalemia, hypernatremia, acute renal failure, and severe dehydration, with a potassium level of 7.2 mEq/L. However, the deficiency cited in the survey focused specifically on the facility’s failure to transcribe and implement the potassium order upon admission and the resulting missed doses from the date of admission until the order was entered into the EMAR. The facility’s own medication error document characterized these missed doses as a medication error and noted that no notifications were documented on the error form and that the form was incomplete.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential accidents. Specific actions or omissions by staff or details about the residents involved are not provided in the report.
Failure to Follow Gel Pack Instructions Leads to Resident Burn
Penalty
Summary
The facility failed to follow the manufacturer's instructions for the use of a microwave-heated gel pack, leading to a resident, identified as R15, sustaining a third-degree burn. R15, who had a moderate cognitive impairment and various medical conditions including type 2 diabetes and chronic kidney disease, was at risk for pain due to several musculoskeletal issues. On the day of the incident, R15 complained of hip pain after a fall, and a registered nurse (RN-A) applied a gel pack heated in the microwave without following the manufacturer's instructions. The gel pack was placed on R15's hip, and R15 was positioned to lie on it, resulting in a burn. The nursing staff failed to conduct a comprehensive assessment of the burn and did not implement timely interventions to promote healing. The initial response to the burn was inadequate, as RN-A did not apply ice or cool water and left the burn open to air. The facility's documentation lacked a detailed assessment of the burn, and there was a significant delay in notifying R15's physician about the injury. The burn was not properly evaluated until several weeks later, and the physician was not informed until there was concern about a potential infection. Interviews with facility staff revealed a lack of awareness and training regarding the proper use of gel packs. The acting director of nursing (DON) and other staff members were not fully informed about the circumstances of the burn, and there was no formal education provided to staff on the use of gel packs. The facility also failed to investigate the incident thoroughly to ensure that the equipment was used correctly and to prevent similar occurrences in the future. The facility did not provide requested policies on first aid, wound monitoring, or the use of gel packs, indicating a lack of preparedness and protocol adherence in handling such incidents.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure that licensed nursing staff hours were accurately submitted on the payroll-based journal (PBJ), which had the potential to affect all 32 residents residing in the facility. The PBJ Staffing Report for fiscal year Quarter 4 2024 identified that the facility had excessively low weekend staffing and failed to have licensed nursing coverage 24 hours a day on multiple days throughout July, August, and September 2024. However, a review of the facility's payroll and working schedule for the same period showed that there was licensed nursing staff present 24 hours a day on all the days identified in the PBJ report. Interviews conducted during the investigation revealed that the discrepancies were due to salaried employees not using the timeclock system, even though they worked charge nurse shifts. RN-B, a salaried employee, confirmed that she did not use the timeclock during the period in question. Additionally, RN-D, the corporate nurse, stated that the administrator, who was responsible for submitting the PBJ data, was unavailable due to a family emergency and had difficulty submitting the data, leading to manual entry errors. The facility did not provide a policy or procedure regarding PBJ data submission when requested.
Deficiency in QAPI Process Due to Lack of Measurable Goals
Penalty
Summary
The facility failed to develop, monitor, and evaluate their identified performance measures, which had the potential to affect all 46 residents residing in the facility. The facility's Quality Assurance Performance Improvement (QAPI) process was not effectively implemented, as evidenced by the lack of measurable goals and actions taken in their performance improvement projects. Despite holding QAPI meetings on a scheduled quarterly basis and more often if indicated, the facility did not track performance to ensure that improvements were realized and sustained. The facility's QAPI meetings identified several performance improvement projects, including fall reduction and infection control. However, the data from these meetings failed to show that the facility developed and implemented action plans with measurable goals. For instance, the 'Walk to Dine' program and restorative programs were mentioned, but there was no evidence of measurable outcomes or actions taken to evaluate their effectiveness. Similarly, infection control projects focused on audits and training, but again lacked measurable goals and actions. During an interview, the RN-D acknowledged that while the minutes identified actions aimed at performance improvement, they did not include measurements of success or track performance. The facility's QAPI policy outlined the need for a comprehensive, data-driven program focusing on outcomes of care and quality of life, but the facility did not demonstrate evidence of meeting these requirements. The lack of measurable goals and tracking of performance improvements indicates a deficiency in the facility's QAPI process.
Failure to Ensure Required Attendance in QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee held meetings with the required members on at least a quarterly basis. Specifically, the meeting minutes from the Quality and Safety Meeting dated 7/18/24 did not indicate the presence or review participation of the medical director. Similarly, the meeting on 10/16/24 lacked attendance or review participation from the director of nursing, consultant pharmacist, and medical director. This oversight had the potential to affect all 32 residents residing in the facility at the time of the survey. During an interview, the registered nurse (RN-D) acknowledged that the meeting minutes reflected the absence of required members but believed they were available by phone if needed. The facility's policy on Quality Assurance and Performance Improvement (QAPI) outlines the necessity of a comprehensive, data-driven program focusing on care outcomes and quality of life. The policy mandates the presence of the director of nursing and the medical director or their designee in the QAA committee, which was not adhered to, as evidenced by the meeting minutes.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents with wound care needs. Resident R14, who had severe cognitive impairment and a right great toe wound, was not placed under EBP despite having a chronic wound. Observations revealed that nursing assistants and a registered nurse did not use gowns during high-contact activities and dressing changes, and there was no signage or personal protective equipment (PPE) available in R14's room. Similarly, Resident R15, who had a moderate cognitive impairment and a right hip wound, was not provided with appropriate PPE during transfers, despite the care plan indicating the need for EBP. The facility's infection prevention and control policy did not specify when EBP should be used. In the laundry department, the facility failed to ensure proper PPE was used during the sorting of soiled laundry. A single black fabric apron was used throughout the day by laundry staff, which was visibly contaminated and only washed at the end of the day. Disposable gowns were not available, and the facility did not provide a policy regarding infection prevention and control during soiled laundry sorting. Interviews with staff confirmed the expectation for laundry staff to wear long sleeve, impermeable gowns to prevent contamination, but this was not practiced due to the lack of available PPE.
Failure to Notify Physicians of Resident Incidents
Penalty
Summary
The facility failed to inform the physician of a burn incident involving a resident, R15, who had a moderate cognitive impairment and various medical conditions including type 2 diabetes and chronic kidney disease. On 10/19/24, R15 developed a blister on her right hip after a heat pack was applied, which was not overly warm but may have caused the blister due to R15's fragile skin. Despite the blister leaking fluid and increasing in size over the following days, the physician was not notified until 11/7/24, when there was concern about a potential infection. The delay in notifying the physician resulted in a lack of timely evaluation and treatment, which could have impacted the healing process of the burn. Another incident involved a resident, R29, who experienced a fall on 11/29/24 while trying to hang up a shirt in her closet. R29, who had intact cognition and was on anticoagulant therapy, fell and hit her right side, resulting in a large bruise and swelling on her right hip. Although a physical assessment was completed and the family was notified, the physician was not informed of the fall. R29 later complained of pain and was seen in urgent care, where a hip X-ray was performed and found to be negative. The facility's policy required notifying the physician of all resident falls, but this was not done in R29's case. The facility's failure to notify the physicians promptly in both cases highlights a deficiency in communication and adherence to policy. The delay in informing the physicians of the incidents involving R15 and R29 resulted in a lack of timely medical evaluation and intervention, which could have affected the residents' recovery and well-being. The facility's policy on incidents and accidents required the nurse to contact the resident's provider to inform them of any incidents or accidents, but this protocol was not followed in these instances.
Failure to Report Resident Burn Incident
Penalty
Summary
The facility failed to report a burn incident involving a resident, identified as R15, to the state agency. R15, who had a moderate cognitive impairment and medical conditions including type 2 diabetes and chronic kidney disease, suffered a burn on the right hip due to the inappropriate use of a hot pack. The incident occurred when a registered nurse (RN-A) applied a gel pack heated in the microwave for approximately 30 seconds, wrapped in a hand towel, and placed it under R15's right hip. R15 was positioned to lie on the gel pack, which led to the development of a blister that later evolved into a chronic full-thickness burn. The manufacturer's instructions for the gel pack emphasized the need for caution, especially for individuals with circulatory or diabetes issues, and advised against unattended use by elderly or incapacitated individuals. However, RN-A was not educated on these instructions and did not report the burn to the state agency, as she was unsure if the reddened area would persist. The burn was discovered during a routine skin assessment after R15 had a shower, but the incident was not reported to the state agency as required by the facility's policy. Interviews with other staff members, including RN-B and the Director of Nursing (DON), revealed a lack of awareness and follow-through regarding the incident. RN-B was informed of the burn but did not consider reporting it to the state agency. The DON, who assumed her role after the incident, was unaware of the circumstances surrounding R15's burn. The facility's policy mandates immediate reporting of suspected abuse, neglect, or exploitation to the appropriate authorities, but this protocol was not followed in this case.
Failure to Investigate Burn Incident from Hot Pack Use
Penalty
Summary
The facility failed to investigate a burn incident involving a resident who was reviewed for wound care. The resident, who had a moderate cognitive impairment and diagnoses including type 2 diabetes and chronic kidney disease, suffered a burn on the right hip due to the inappropriate use of a hot pack. The nursing assistant discovered a blister on the resident's hip, which was later identified as a chronic full-thickness burn. The burn was attributed to the resident lying on a hot pack that was not overly warm but may have caused the blister due to the resident's fragile skin. The registered nurse (RN) who applied the hot pack was not educated on the manufacturer's heating instructions and did not read them before use. The RN heated the gel pack in the microwave for approximately 30 seconds, wrapped it in a hand towel, and placed it on the resident's hip, positioning the resident to lie on it. The RN discovered the burn during a routine skin assessment after the resident's shower. The RN disposed of the gel packs, believing them to be defective, but did not verify their correct usage or document any verbal directions given to other staff. The incident was not reported to the acting director of nursing until two days later. The acting director of nursing confirmed that no investigation was conducted to determine if the gel pack was used appropriately or if it should have been used for the resident, given their diabetic condition. The facility's interdisciplinary team meetings and purchasing orders failed to address the causative factors of the burn or ensure staff awareness of the gel pack's heating instructions. The new director of nursing and another RN were unaware of the incident's circumstances, indicating a lack of assessment and follow-through to prevent similar occurrences. The facility's policy on abuse prevention and reporting required an investigation, which was not conducted in this case.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for a resident reviewed for MDS accuracy. The resident, identified as having a moderate cognitive impairment and a diagnosis of Type 2 Diabetes, received a weekly injection of Trulicity, a GLP-1 receptor agonist used to control high blood sugar. However, during an interview, a registered nurse (RN-D) assisting with MDS completion stated that Trulicity was incorrectly identified as insulin on the MDS, despite acknowledging that it was not insulin but a GLP-1 medication. The facility's policy on Resident Assessment, revised in January 2025, mandates standardized assessments of each resident's functional capacity, including medication administration. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual outlines the steps for assessing insulin injections, which include reviewing medication records and determining if insulin injections were received during the look-back period. The RN-D's misunderstanding of the medication classification led to the incorrect coding of the MDS, which is a tool used to assist in the resident's individualized plan of care.
Failure to Document and Address Pressure Ulcer
Penalty
Summary
The facility failed to comprehensively assess and implement interventions for a pressure ulcer on a resident's right great toe. The resident, who had severe cognitive impairment and was at risk for pressure ulcers, developed a pressure ulcer that was not documented in the care plan. The care plan did not include interventions to prevent the ulcer from worsening or to promote healing. Nursing progress notes indicated that the ulcer was first noticed when a nursing assistant removed the resident's socks, causing pain and bleeding. Despite the presence of the ulcer, the care plan and resident care sheet did not reflect this condition or any specific interventions. The nursing staff documented the presence of the ulcer and performed dressing changes, but there was a lack of comprehensive assessment and documentation of interventions to promote healing. Interviews with nursing assistants and a licensed practical nurse revealed that they were not fully aware of the wound's condition or the interventions being implemented. The registered nurse acknowledged that the wound was caused by pressure from the resident's shoe and that interventions were communicated verbally but not documented. The facility's pressure ulcer and wound dressing policies were requested but not provided. The director of nursing stated that staff were expected to follow the facility's pressure ulcer protocol, but the lack of documentation and comprehensive assessment indicates a deficiency in the facility's wound care practices. The report highlights the need for proper documentation and implementation of interventions to address pressure ulcers and prevent further complications.
Failure to Clarify Medication Allergy and Dosage Exceedance
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident, R27, who had severely impaired cognition and was receiving both scheduled and as-needed pain medications. Despite having an allergy to oxycodone listed in the medical record, R27 was administered PRN oxycodone multiple times from September to December 2024. The consultant pharmacist reviewed R27's medical record monthly but failed to identify the discrepancy between the oxycodone order and the listed allergy. There was no documentation that the potential drug interaction was identified or addressed by the facility staff. Additionally, on November 29, 2024, R27 was administered a total of 3,650 mg of acetaminophen, exceeding the recommended daily dose for elderly patients, which is 3,000 mg. The Director of Nursing (DON) acknowledged that the acceptable dose for the elderly would be 3,000 mg of Tylenol in a day. The trained medication assistant (TMA) who administered the PRN Tylenol was unaware that R27 was over the maximum limit and was instructed by a nurse to give the PRN Tylenol due to increased pain and awaiting a provider refill prescription for oxycodone. The consultant pharmacist, CP-H, stated that it was common practice to review a resident's allergy list during monthly medication reviews. However, CP-H was unable to find documentation that the previous pharmacist had identified the discrepancy of the ordered medication with R27's allergy list. The DON found that R27's provider had overridden the allergy alert when first ordering the oxycodone, but there was no evidence that the allergy had been questioned by the facility staff or discussed with the provider when it was ordered.
Consulting Pharmacist Fails to Identify Allergy Discrepancy
Penalty
Summary
The consulting pharmacist failed to identify and report irregularities related to a resident's allergies for a prescribed medication. The resident, who had severely impaired cognition, was administered oxycodone despite having an allergy to it documented in their medical record. Over several months, the resident received oxycodone multiple times, with no documentation of an allergic reaction occurring. The consultant pharmacist reviewed the resident's medical record monthly but did not identify the discrepancy between the oxycodone order and the allergy list. During interviews, it was revealed that the consultant pharmacist had not completed the reviews, as they were done by a recently retired pharmacist. The Director of Nursing (DON) found that the resident's provider had overridden the allergy alert when initially ordering the medication, but there was no evidence that the facility staff questioned the allergy or discussed it with the provider. The facility's policy required the consultant pharmacist to report findings and recommendations to the DON, which was not done in this case.
Pain Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that as-needed pain medications were available to treat acute breakthrough pain for a resident, R27, who had severe cognitive impairment and impaired range of motion. R27's care plan included administering pain medications as ordered and observing for pain using a non-verbal pain scale. However, the facility ran out of R27's as-needed pain medication, oxycodone, and there was a delay in obtaining a refill. During this time, R27 exhibited non-verbal signs of pain, such as crying and grimacing, and family members expressed concerns about the lack of pain management. The facility's staff attempted to manage R27's pain with non-pharmacological interventions and scheduled Tylenol, but these measures were insufficient. The facility's emergency medication kit contained pain medications with Tylenol, which R27 could not use due to already receiving the maximum allowed dose of Tylenol. The staff did not utilize the on-call doctor or the medical director to address the medication shortage promptly. As a result, R27 experienced increased pain until the medication was finally delivered. Another resident, R29, experienced a delay in receiving a Lidocaine patch for pain management. R29, who had intact cognition and chronic pain conditions, reported that the patch was usually applied in the morning but was delayed on one occasion. The nurse, RN-E, informed R29 that the patch was not due until later, resulting in a delay in pain relief. The facility's policy allowed for morning medications to be administered between 6:00 a.m. and 10:00 a.m., but the patch was applied later than usual, causing discomfort for R29.
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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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