Parkview Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Belview, Minnesota.
- Location
- 102 County State Aid Highway 9, Belview, Minnesota 56214
- CMS Provider Number
- 245475
- Inspections on file
- 19
- Latest survey
- May 6, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Parkview Home during CMS and state inspections, most recent first.
Failure to complete a bed hold for a resident after hospital admission. A resident with emphysema, heart disease, CHF, DM, dysphagia, and CKD became increasingly fatigued and weak, was taken to the clinic by family, and was later admitted to acute care for pneumonia. The facility received notice of the hospitalization, but there was no indication a bed hold was completed verbally or in writing, despite policy stating residents leaving for hospitalization and choosing to return were to complete a bed hold.
Failure to revise care plans for two residents left key safety and behavior needs undocumented. One resident with dementia had scissors removed after cutting clothing and hair, but the care plan did not include supervised scissor use. Another resident with a wander guard repeatedly wanted to go outside and attempted to go out on his own, but the care plan did not identify elopement risk or specific interventions for staff. Interviews confirmed staff knew about both residents’ needs, yet the care plans did not reflect those changes.
A resident with COPD, respiratory failure with hypoxia, and sleep apnea had nebulizer treatments documented as complete even though the nebulizer cup still contained medication during observations. Staff found the nebulizer left assembled on the resident’s end table, and an RN and LPN confirmed medication remained in the cup. A self-administration assessment stated the resident was not safe to self-administer inhalants without supervision, but the record was not updated to reflect that change, and the facility’s nebulizer policy required staff to remain with the resident and clean the equipment after use.
A resident with intact cognition and diagnoses including CHF, COPD, respiratory failure with hypoxia, O2 dependence, sleep apnea, and A-fib had inconsistent documentation about the ability to self-administer nebulizer treatments. The MAR stated the resident could self-administer meds and nebulizers after set-up, but a self-administration assessment found the resident was not safe to self-administer inhalants without supervision. Surveyors also observed a handheld nebulizer still connected with medication remaining in the cup, while the MAR showed the treatment as completed and signed off by an RN.
A resident with COPD, respiratory failure with hypoxia, and other cardiac and respiratory diagnoses had a handheld nebulizer left on her end table with medication still in the cup after treatments. Staff documented the treatment as completed, but an RN later observed the cup still contained a moderate amount of medication and stated the nebulizer should have been disassembled and rinsed after use. The next morning, the nebulizer was again found assembled with medication remaining while the resident was asleep, despite a prior self-administration assessment stating she was not safe to self-administer inhalants without supervision.
The facility did not ensure that data presented to the QAPI committee was analyzed or documented, nor were benchmarks or action plans established for most quality indicators. While department heads brought data on various topics, only falls and pressure ulcers had identified goals, and even these lacked analysis or follow-up actions, resulting in insufficient oversight for all residents.
The facility did not provide documentation of a required Performance Improvement Project (PIP) focused on high risk or problem-prone areas, as shown by a review of QAPI meeting minutes and confirmed by a regional administrator. No goal, action plan, or staff training was completed for the identified PIP, and the deficiency had the potential to affect all 18 residents.
The QAPI committee did not receive a required infection control program report from the infection preventionist for one quarter, as no data was presented at the April meeting despite the DON/infection preventionist being present. The administrator, who was new to the role and unaware of the omission, confirmed attendance at the meeting. No policy was available regarding infection preventionist reporting at QAPI meetings.
The facility did not adequately track employee illnesses or ensure proper documentation of symptoms, physician visits, and clearance before staff returned to work. Additionally, two new hires did not complete the required two-step TB testing, with only the first step documented in their files.
The facility did not ensure that the acting IP, who was also the interim DON, had completed specialized training or certification in infection prevention and control. Interviews and document review confirmed that there was no certified IP working at least part-time or onsite, and the facility was still recruiting for qualified staff to oversee the infection control program. This deficiency had the potential to affect all residents in the facility.
The facility did not provide mandatory training to staff on its specific QAPI program, including its goals, elements, and staff roles. Interviews showed that while some staff completed general QAPI training online, none received information about the facility's own QAPI initiatives, and no policy or evidence of such training was provided. This affected all residents.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall and had a swollen hand from a previous, undocumented injury. Facility staff did not complete required documentation or report the injury of unknown origin to the State Agency as mandated by policy. Interviews confirmed that the incident was neither adequately investigated nor reported within the required timeframe.
A resident with severe cognitive impairment and a history of falls and aggression sustained a right middle finger fracture of unknown origin. Staff were unaware of how the injury occurred, and there was no evidence of an internal investigation or incident report, nor was the injury reported to the State Agency as required by facility policy.
Failure to Complete Bed Hold After Hospitalization
Penalty
Summary
The facility failed to obtain a bed hold for 1 of 4 sampled residents, R24, after he was hospitalized. R24 had an unplanned short-term general hospital stay beginning on 4/2/26, and his 4/6/26 quarterly MDS showed his cognition was intact, he was independent with set-up assistance for ADLs except for lower-body dressing, and he ambulated independently without assistive devices. His diagnoses included emphysema, heart disease with high blood pressure, CHF, diabetes, difficulty swallowing, and CKD. Progress notes documented that on 4/2/26 he was increasingly fatigued, weak, and was taken to the clinic by family; later that day the facility received a phone call that he had been admitted to acute care for pneumonia. On 4/3/26, he remained hospitalized and was discharged from the facility with return anticipated. Interview with the nursing consultant and interim DON confirmed a bed hold should have been completed when the facility was notified of the hospital admission, and there was no indication that a bed hold had been completed verbally or in writing. The February 2024 Bed Hold Responsibilities policy stated residents leaving due to hospitalization or therapeutic leave and choosing to return were to complete a bed hold, but it did not identify the process for completion.
Failure to Revise Care Plans for Safety and Elopement Needs
Penalty
Summary
The facility failed to revise the care plan for 2 of 12 sampled residents, R15 and R18, after changes in condition and identified needs were documented. The report states the care plan was not updated within 7 days of the comprehensive assessment and was not prepared, reviewed, and revised by a team of health professionals as required. Review of the records and interviews showed that the existing care plans did not reflect the residents’ current assessed needs and behaviors. For R15, the 4/6/26 quarterly MDS showed severely impaired cognition, with independence in dressing, toileting, and ambulation using a walker, and diagnoses including Alzheimer’s disease, dementia, muscle weakness, hallucinations, anxiety disorder, and long-term pain medication use. On 5/4/26, R15 stated the facility had taken away her scissors and she could no longer use them for knitting, while a bag of yarn and string was observed near her recliner. A 4/15/26 progress note documented housekeeping staff reported R15 had been cutting her clothes and had cut her hair, and social services noted a plan for supervised scissor use. R15’s care plan addressed leisure preferences and one-to-one interactions, but it did not include supervised assistance with scissors for safety reasons. The IDON confirmed R15 had been cutting her clothing and hair, was not safe to use scissors unsupervised, and that the care plan should reflect that need. For R18, the 5/6/26 quarterly MDS showed a BIMS score of 13, indicating cognition intact, with independence in dressing, toileting, and ambulation using a walker, wandering noted during the assessment period, and use of oxygen and multiple medications including antipsychotic, antidepressant, hypnotic, anticonvulsant, pain, and antiplatelet drugs. On 5/4/26, R18 stated he had an alarm on, wanted to go outside, and believed it was illegal that he could not go out by himself; he also said staff told him he needed someone to go outside with him but there was never anyone available. His care plan noted cognition-related needs and a wander guard, but it did not identify elopement risk, a goal, or interventions for what staff should do if he attempted to leave or when he wanted to go outside. The elopement evaluation left the risk for wandering and/or elopement blank, and interviews confirmed staff knew he wanted to go outside, sometimes attempted to go out on his own, and that the care plan lacked detailed interventions.
Nebulizer Treatment Not Fully Supervised or Completed
Penalty
Summary
The facility failed to ensure medication administration was completed and supervised as ordered for one sampled resident who used a nebulized medication. The resident had an intact cognition and diagnoses of COPD, respiratory failure with hypoxia, and sleep apnea, and required moderate assistance with transfers, dressing, and hygiene. On one observation, the resident’s handheld nebulizer was found on the end table still connected to the machine with approximately half of the medication remaining in the cup, even though the MAR showed the treatment had been documented as completed hours earlier by an RN. The RN who observed the setup stated nursing should have followed up to ensure the medication was fully administered and that the nebulizer should have been disassembled and rinsed after use. A second observation the next morning again found the resident’s nebulizer assembled on the end table with about one-quarter of the medication still in the cup while the resident was asleep in bed. The LPN confirmed the nebulizer was still present with medication remaining and reviewed the MAR, which showed the last treatment had been given overnight. A self-administration assessment completed after the resident returned from the hospital stated the resident was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. The consultant who completed the assessment acknowledged the resident’s record was not updated to reflect that she was no longer safe to self-administer nebulizer treatments, and the interim DON stated staff were expected to follow the facility’s nebulizer policy requiring staff to remain with the resident during the procedure and clean the nebulizer after completion.
Inconsistent documentation of self-administration status for nebulizer treatments
Penalty
Summary
The facility failed to ensure documentation of one sampled resident’s ability to self-administer medication was consistent and accurate throughout the medical record. The resident’s quarterly MDS, accepted on 4/6/26, identified intact cognition and multiple diagnoses including heart failure, COPD, respiratory failure with hypoxia, dependence on supplemental oxygen, sleep apnea, and atrial fibrillation. The resident required moderate assistance from one staff member for transfers, dressing, and hygiene. On 5/4/26 at 5:30 p.m., surveyors observed a handheld nebulizer in the resident’s room still connected to the nebulizer machine, with approximately half of the medication remaining in the cup, while the resident was not present. The May 2026 MAR documented that the resident received an ipratropium/albuterol nebulizer treatment at 2:00 p.m. and that RN-B signed off the treatment as completed. The MAR also stated the resident was able to self-administer oral medications and nebulizers after set-up. However, the resident’s 4/13/26 self-administration assessment completed by RN Consultant-B stated the resident was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. During interview, RN Consultant-B acknowledged the assessment was accurate and agreed he did not update the MAR to show the resident was no longer safe to self-administer nebulizer treatments. The interim DON stated it was her expectation that the MAR be updated immediately following the change with re-assessment.
Nebulizer Cup Left Unrinsed With Medication Remaining After Treatment
Penalty
Summary
The facility failed to ensure a nebulizer medication cup was rinsed and left to air dry after medication administration for a resident with intact cognition and diagnoses including heart failure, COPD, respiratory failure with hypoxia, dependence on supplemental oxygen, sleep apnea, and atrial fibrillation. The resident required moderate assistance with transfers, dressing, and hygiene, and her quarterly MDS identified she was able to self-administer oral medications and nebulizers after set-up. However, a self-administration assessment completed on 4/13/26 stated she was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. On 5/4/26, the resident’s handheld nebulizer was observed on her end table still connected to the machine, with approximately half of the medication remaining in the cup, about 3 hours and 45 minutes after the scheduled 2:00 p.m. treatment. RN-A agreed the cup still contained a moderate amount of medication and stated nursing should have followed up to ensure the full dose was administered and the nebulizer should have been disassembled and rinsed after completion. On 5/5/26, the nebulizer was again observed on the end table with approximately one-fourth of the medication remaining in the cup while the resident was asleep in bed. LPN-A confirmed no medication had yet been given that morning and noted the last nebulizer treatment had been during the night at 1:20 a.m. The interim DON stated staff were expected to remain with the resident to ensure the entire dose was administered and to follow the facility nebulizer therapy policy, which required disassembly, rinsing with warm water, and air-drying after use.
Failure to Analyze and Document QAPI Data and Actions
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented. Although department heads regularly brought data on topics such as medication errors, falls, pressure ulcers, weight loss, pharmacy services, infection control, admissions and discharges, staff agency use, and adverse event monitoring to the QAPI meetings, only falls and pressure ulcers had benchmark goals identified. Even for these areas, there was no analysis of the data or documentation of actions the facility would take to achieve the goals, nor was there monitoring to determine if the goals were met or if continued QAPI oversight was needed. For all other areas, there were no documented benchmarks, data analysis, or action plans. Review of QAPI meeting minutes from multiple months confirmed the lack of documented benchmarks, analysis, and action plans across a range of quality indicators. An interview with the regional administrator confirmed that the facility had not identified goals, action plans, or analyzed data brought forth in the QAPI meetings. The facility's own QAPI policy required oversight, action plan development, and analysis, but these steps were not documented or implemented as required.
Lack of Evidence for Required Performance Improvement Project
Penalty
Summary
The facility failed to provide evidence of a Performance Improvement Project (PIP) that addressed high risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) policy. Review of QAPI meeting minutes over a five-month period showed that no PIP projects were documented. During an interview, the regional administrator confirmed that although a PIP project had been identified, no goal was set, no action plan was developed, the project was not discussed in QAPI meetings, and staff had not been trained. The facility's QAPI policy requires the committee to oversee improvement areas, develop action plans, and maintain documentation of ongoing QAPI activities, including at least one distinct PIP project annually. This deficiency had the potential to affect all 18 residents in the facility.
QAPI Committee Did Not Receive Required Infection Control Report
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee failed to receive a report from the infection preventionist regarding the infection control program for one of the three quarters reviewed. Specifically, during the April QAPI meeting, no data or report on the infection control program was presented for committee review, as confirmed by the meeting minutes. The sign-in sheet for the April meeting showed that the DON, who was also serving as the infection preventionist, was present. During an interview, the administrator stated he was unaware that the infection preventionist had not provided the required data or report and confirmed his own attendance at the meeting. He also noted recent staff turnover, including the resignation of the social service designee and the interim status of the DON, and indicated he had only recently obtained his administrator license. No policy was provided regarding the requirement for the infection preventionist to present infection control data at QAPI meetings.
Deficient Employee Illness Tracking and TB Testing
Penalty
Summary
The facility failed to properly track and document employee illnesses, resulting in incomplete surveillance of staff health status and return-to-work criteria. Employee Absence Report sheets reviewed for April 2025 showed missing or incomplete information regarding symptoms, physician visits, COVID testing, and resolution of illness for several staff members, including nurse aides, the activity director, the administrator, and an LPN. In multiple cases, there was no documentation of when or if symptoms resolved, whether staff were cleared to return to work, or if required testing was performed. The interim DON confirmed that employee illness surveillance was not adequately completed, and the existing policy required staff to report illness and obtain clearance before returning, but this was not consistently followed. Additionally, the facility did not ensure that two of five sampled employees, a certified nursing assistant and a dietary aide, completed the required two-step tuberculosis (TB) testing upon hire. Both employees had a baseline TB symptom screening and a first-step TST, but there was no evidence of a second TST as required by state guidelines. The facility's TB screening policy referenced CDC recommendations and required baseline risk assessment, symptom evaluation, and TB testing for all new hires, but these procedures were not fully implemented for the affected staff.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP), who also served as the interim director of nursing (DON), had completed specialized training or certification in infection prevention and control. During interviews, the interim DON confirmed that she was responsible for overseeing the infection control program but had not completed the required IP training and certification. Additional interviews with facility staff and the regional administrator revealed that there was no certified IP working at least part-time or onsite at the facility. Document review showed that the facility was actively recruiting for a permanent DON and an assistant director of nursing (ADON) to oversee the infection control program, with job postings specifying the need for education, training, experience, or certification in infection control. The facility's Infection Surveillance-Overview policy outlined the responsibilities of the IP, including leading surveillance, documenting and monitoring findings, providing staff training, and tracking communicable diseases among residents and staff. However, the lack of a qualified and certified IP had the potential to affect all 18 residents residing in the facility.
Lack of Facility-Specific QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training to all staff on its specific Quality Assurance and Performance Improvement (QAPI) program. Interviews with various staff members, including a nursing assistant, dietary aide, and activity aide, revealed that while some had completed general QAPI training through an online platform, none had received training specific to the facility's own QAPI program, its goals, elements, or implementation. Staff were unaware of what the facility was currently working on regarding QAPI, and there was no evidence or policy provided to show that such training had occurred. The regional administrator confirmed that no staff training specific to the facility's QAPI program had been conducted. This deficiency had the potential to affect all 18 residents in the facility.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its own policies and regulatory requirements for timely reporting of suspected abuse, neglect, or injury of unknown origin to the State Agency (SA) for one resident. A resident with severe cognitive impairment, dementia, and a history of falls experienced an unwitnessed fall from a Broda chair while unattended in the day room. Although no new injury was noted from this fall, the resident's right hand remained swollen from a previous finger fracture, the cause of which was undocumented and unwitnessed. Interviews with staff, including a nursing assistant and the DON, revealed a lack of awareness regarding the resident's recent falls and the origin of the hand injury. The DON was unable to provide documentation of the incident or evidence that it had been reported to the SA, as required by facility policy. The administrative consultant and facility administrator both acknowledged that the injury of unknown origin should have been investigated, documented, and reported to the SA, but confirmed that this process was not completed. Review of facility policies and posted guidance indicated that suspected abuse or reportable incidents, including injuries of unknown origin, must be reported to the SA within two hours of discovery. The facility's internal investigation policy outlined steps for conducting investigations, but in this case, there was no adequate investigation or timely reporting of the incident involving the resident's hand injury, resulting in noncompliance with both facility policy and regulatory requirements.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and a history of falls and physical aggression. The resident, who required extensive to total assistance with activities of daily living and had diagnoses including dementia and depression, was found to have swelling and discoloration in his right hand. Progress notes indicated that the resident was unable to communicate the cause of the injury, and staff were unaware of how the injury occurred. Despite documentation of the injury and subsequent diagnosis of a closed, displaced fracture of the right middle finger, there was no evidence of an internal investigation or incident report regarding the injury. Interviews with nursing staff and the DON revealed that the injury was not witnessed, and there was no documentation or report made to the State Agency (SA) as required by facility policy. The DON and consulting administrator both acknowledged that the injury should have been investigated and reported, but confirmed that no such actions were taken. The facility's risk management records and electronic medical record did not contain any documentation of an investigation or incident report related to the injury. The facility's policy on conducting internal investigations outlines steps such as reviewing documents, interviewing staff and residents, and collaborating with administration or outside authorities. However, these procedures were not followed in this case, as there was no evidence of an investigation or reporting of the resident's injury of unknown origin, despite the resident's vulnerability and inability to communicate the cause of the injury.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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