Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pathstone Living during CMS and state inspections, most recent first.
Two residents with diabetes received long‑acting insulin at widely varying times across the morning shift rather than at a consistent daily time, despite orders for daily dosing and internal policies and pharmacist guidance that long‑acting insulin should be given at approximately the same time each day. For one resident using a Dexcom CGM, staff relied on CGM readings without consistently confirming low values by fingerstick, did not follow the facility’s hypoglycemia protocol for 15‑minute BG rechecks, and allowed the resident to leave for outside appointments shortly after a documented low BG and glucagon administration without documented monitoring to ensure BG had returned to safe levels. Surveyors also observed this resident eating most of a meal before any BG was obtained, delayed insulin administration until after the meal, and noted that a dislodged CGM sensor had gone unnoticed, while staff interviews revealed uncertainty about CGM use and order transcription that created broad administration windows for insulin.
The facility failed to maintain an effective infection control program, with incomplete documentation and analysis of resident infections. The infection preventionist struggled to access reports and did not include essential data such as signs and symptoms or transmission-based precautions. Additionally, a resident with a nephrostomy tube did not receive proper Enhanced Barrier Precautions (EBP), as a nursing assistant entered the room without wearing the required PPE, despite being aware of the EBP policy.
The facility failed to effectively implement an antibiotic review process, impacting the monitoring of antibiotic use and resistance. The ADON, responsible for tracking infections and antibiotic use, faced challenges in accessing culture results and did not report on MDRO or prophylactic use at meetings. A review showed that many UTIs treated with antibiotics lacked culture results, and not all physicians followed infection testing criteria. The DON confirmed the lack of analysis and monitoring in the antibiotic stewardship program.
A resident with chronic conditions expressed dissatisfaction with the facility's food, which did not align with his cultural preferences. Despite the facility's policy on culturally competent care, the resident's care plan lacked cultural considerations, and staff interviews revealed uncertainty about responsibility for addressing these needs.
The facility failed to ensure cleanliness of ceiling vents in the 3400 wing, affecting three residents. Observations showed vents covered with a black substance due to dust and dirt buildup. The maintenance director admitted that vent cleaning was on a monthly checklist but was only done quarterly. The facility's policy required items to be free of visible soil, yet the vents were visibly dirty.
A resident with a history of cardiovascular issues experienced chest pain, but the facility staff failed to promptly assess and notify the physician, delaying treatment. Despite the resident's symptoms and family member's concerns, staff waited for physician rounds. The resident was eventually sent to the hospital, diagnosed with an acute anterior STEMI, and passed away after complications.
The facility failed to ensure proper infection control practices, including ongoing surveillance, correct PPE usage, and proper storage of PPE. Staff were observed doffing PPE incorrectly, and a meal tray was placed on the floor, posing an infection control risk. These deficiencies had the potential to affect all 56 residents in the facility.
The facility failed to implement a process for antibiotic review, lacking formal tracking and monitoring for residents on antibiotics. The DON and ADON confirmed that while symptoms were monitored and reported, there was no system to track antibiotic use, cultures, or ensure proper prescriptions.
The facility failed to report an allegation of misappropriation of property to the state agency within 24 hours. A resident reported missing cash, and while a police report was filed, the facility did not notify the state agency as required by their policies. The resident later found the cash, but the incident should have been reported within the required timeframe.
The facility failed to ensure accurate MDS assessments for two residents. One resident receiving hospice services was not correctly documented, and another resident with pressure ulcers had an MDS assessment indicating no such injuries. These inaccuracies were confirmed by the MDS coordinators and the DON.
The facility failed to provide a summary of the baseline care plan to newly admitted residents and/or their representatives. This deficiency was identified for three residents, with staff confirming that copies of the care plan were only provided if requested, contrary to the facility's policy.
A resident with moderately intact cognition and specific activity preferences was not offered individualized activities by the facility. Despite documented interests in playing cards, listening to music, and attending religious services, the resident and his family member reported no activities were offered. Staff confirmed the lack of engagement, and the facility did not adhere to its Activity Programs policy.
A resident receiving hospice services experienced missed visits and lack of communication from the hospice agency, leading to confusion and unmet care needs. The facility's director of nursing confirmed the communication issues, and a policy on hospice services was not provided.
A facility failed to implement a ROM program and properly apply a wrist brace and edema glove for a resident with hemiplegia and hemiparesis. Staff inconsistencies and improper application led to the resident's fingers curling and the splint losing its form, indicating a lack of proper care.
A facility failed to properly assess and manage the disposal of cigarettes for a resident with severe cognitive impairment. The resident was observed smoking across the street with the interim director of nursing (IDON) supervising, but the cigarette butt was improperly disposed of and later found inside the facility. The facility lacked a designated receptacle for cigarette disposal, and the IDON admitted to not knowing where the cigarette butt was disposed of, leading to a deficiency in managing the resident's smoking habits and ensuring safety.
The facility failed to maintain a sanitary environment in the kitchen's food preparation and drying areas, with vents, wire mesh, and a printer cord covered in debris. This was confirmed by the cook, maintenance director, and culinary director.
A resident with diabetes received both detemir and glargine insulin simultaneously over six days due to a lapse in the visibility of a hold order, leading to hypoglycemia and hospitalization. Nurses administered both insulins without questioning the orders, and significant changes in the resident's condition were observed.
A resident with a history of Parkinson's Disease, renal insufficiency, neurogenic bladder, seizure disorder, and muscle weakness experienced a significant decline in condition, including decreased appetite, facial pallor, blue lips, increased fatigue, lethargy, and decreased responsiveness. Despite multiple reports from nursing assistants, the licensed nursing staff failed to perform a comprehensive assessment, document observations, or notify a physician. The resident was found in severe respiratory distress and later died from acute respiratory failure.
Inconsistent Insulin Administration and Inadequate Hypoglycemia Management
Penalty
Summary
The deficiency involves the facility’s failure to administer long‑acting insulin at consistent times, failure to appropriately respond to abnormal blood glucose (BG) levels, and failure to monitor and follow up after hypoglycemia interventions for residents with diabetes. One resident with type 2 diabetes mellitus, diabetic retinopathy, and use of a Dexcom continuous glucose monitor (CGM) had a care plan and physician orders directing daily glargine insulin, sliding‑scale Novolog, hypoglycemia treatment, and specific notification parameters for BG values. However, the MAR showed glargine ordered as "every day shift" with an administration window of 6:30 a.m.–1:00 p.m., and actual administration times varied widely from early morning to early afternoon. On multiple days, glargine was given at different times (e.g., between about 9:00 a.m. and 2:45 p.m.), and on some days it was not administered at all with no explanation. Facility staff, including a nursing assistant who transcribed orders and nurses who confirmed them, acknowledged that the order was entered as a broad shift‑range rather than a specific time and that this could affect BG control. The same resident experienced multiple episodes of low BG where staff did not follow the facility’s hypoglycemia protocol or the physician’s orders. On one occasion, the Dexcom alarmed for a low reading in the dining room, and a family member obtained orange juice and notified staff. An LPN reported difficulty locating glucose tablets, did not clearly recall whether a manual fingerstick was obtained, and administered glucagon from the emergency kit based on the CGM reading. Documentation showed BG readings of 54 and 57, administration of orange juice and glucagon, and then the resident leaving the facility for appointments, with instructions to the family member to recheck BG later. There was no comprehensive assessment documented for signs/symptoms of hypoglycemia and no documented monitoring to ensure BG returned to safe levels after glucagon; the next recorded BG was not until several hours later. The van driver and clinic nurse reported they were not informed of the low BG event, and the physician later stated the BG should have been manually checked and that such low levels could lead to coma or death. Additional documentation for this resident showed repeated low BG readings (e.g., in the 50s, 60s, and low 70s) where interventions such as orange juice were given but follow‑up BG checks were delayed or incompletely documented, contrary to the facility’s diabetes and hypoglycemia protocols that called for rechecking every 15 minutes until BG was at least 70 mg/dL and the resident was without symptoms. The Dexcom order initially lacked clear instructions on how to change the sensor, verify readings with fingersticks, or set alarm parameters, and staff reported relying on internet videos to learn sensor changes. During surveyor observation, the resident’s Dexcom displayed a message to start a new sensor, and the resident ate most of his breakfast before any BG was obtained; a TMA later took a manual BG of 153 and then an LPN administered both long‑acting and short‑acting insulin after the meal. Family reported that the Dexcom sensor had fallen off the previous day and staff had not noticed. A second resident with type 2 diabetes and multiple diabetic complications also had glargine ordered daily, but MAR review showed long‑acting insulin administered at widely varying morning times, from just before 7:00 a.m. to after noon, despite staff and the consulting pharmacist stating that long‑acting insulin should be given at approximately the same time each day and BG should be checked before meals and insulin administration. The facility’s own Diabetes‑Clinical Protocol and Insulin Administration policies required assessment of diabetic residents, incorporation of orders and reporting parameters into the MAR and care plan, consistent monitoring of BG, and specific hypoglycemia treatment steps including 15‑minute rechecks and continued monitoring after glucagon. Standing orders for CGM use required setting alarms, verifying initial readings with fingersticks, and performing fingersticks when readings were <100 or >400 or when accuracy was in question. Interviews with nursing staff, the clinical manager, and the pharmacist confirmed that long‑acting insulin should not be administered at random times across a broad shift window and that BG should be checked before meals and insulin dosing. Despite these policies and professional expectations, the facility did not ensure consistent timing of long‑acting insulin for two residents, did not consistently verify or respond to abnormal BG readings according to protocol, and did not document timely reassessment after hypoglycemia interventions for one resident.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to ensure that its infection control program included ongoing surveillance, trending, and analysis of resident infections. The Assistant Director of Nursing (ADON-B), who also served as the infection preventionist, was responsible for tracking and documenting infections and antibiotic use. However, ADON-B experienced difficulties accessing reports and did not include essential information such as signs and symptoms, treatment, or the implementation of transmission-based precautions in the documentation. The facility's monthly resident infection statistics revealed incomplete documentation, with missing data on signs and symptoms, bacteria, outcomes, and whether infections were healthcare-associated. ADON-B acknowledged the challenges in accessing culture and x-ray reports and the lack of adherence to McGeer's criteria by physicians for ordering tests before treating infections. The facility's infection surveillance policy required the infection preventionist to conduct ongoing surveillance for healthcare-associated infections and other significant infections. However, the surveillance flow sheet lacked critical information, and ADON-B did not print out monthly or quarterly reports for infection analysis. Consequently, ADON-B was unable to report on the facility's current or past infection rates during infection control meetings and quality assurance and performance improvement meetings. The Director of Nursing (DON) confirmed that infection surveillance was incomplete and acknowledged the need for improvement in the process. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a nephrostomy tube, which posed a risk of infection. Despite the presence of a PPE cart and a sign indicating the need for gloves and gown, a nursing assistant (NA-A) entered the resident's room without donning the required PPE. NA-A admitted to being aware of the EBP requirement but did not think it was necessary if not directly handling the tube. The facility had conducted multiple trainings on EBP and created a pocket guide to assist staff, but compliance with the policy was inconsistent. The DON expected staff to adhere to the EBP sign on the door, but the deficiency in implementing EBP was evident in this instance.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective process for antibiotic review, which is crucial for determining appropriate indications, dosage, duration, and trends of antibiotic use and resistance. During an interview, the Assistant Director of Nursing (ADON), who also serves as the infection preventionist, revealed that while infections and antibiotic use were tracked and documented using a software program, there was difficulty in accessing and printing reports. A review of the facility's monthly antibiotic use data from May 2024 to February 2025 showed that 34 out of 37 urinary tract infections treated with antibiotics lacked culture results and analysis of antibiotic treatment. Additionally, six UTIs were documented as suspected without proper diagnosis, and five residents were on prophylactic antibiotics. The ADON indicated challenges in accessing culture results and noted that not all physicians adhered to the McGeer criteria for infection testing. Furthermore, the ADON did not report on multi-drug resistant organisms (MDRO), prophylactic use, or antibiotic use at infection control or quality assurance performance improvement (QAPI) meetings. The Director of Nursing (DON) confirmed that the antibiotic stewardship program lacked proper analysis and monitoring. The facility's Antibiotic Stewardship policy, last reviewed in October 2024, outlined the need for culture and sensitivity results to be communicated to prescribers to guide antibiotic therapy decisions, but this was not effectively implemented. The Prevention and Control Program policy also emphasized the inclusion of culture reports and antibiotic usage reviews in surveillance activities, which was not adequately followed.
Failure to Include Cultural Aspects in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan included cultural aspects, specifically related to food preferences, for a resident with chronic kidney disease, heart failure, and diabetes. The resident, who was moderately cognitively impaired, expressed dissatisfaction with the food provided, stating it was not prepared in a manner consistent with his cultural preferences. Despite the culinary team offering options within religious and cultural preferences, the resident reported a poor appetite and did not consume the offered supplements. The care plan, developed by a registered nurse, did not address the resident's cultural needs, and the nursing assistant's task sheet and kardex also lacked this information. Interviews with facility staff, including the director of nursing and a licensed social worker, revealed a lack of clarity regarding responsibility for incorporating cultural preferences into care plans. The facility's policy on comprehensive person-centered care plans emphasized culturally competent services, yet this was not reflected in the resident's care plan. The facility assessment indicated a commitment to person-centered care, including cultural and religious aspects, but this was not implemented in practice for the resident in question.
Failure to Maintain Clean Ceiling Vents
Penalty
Summary
The facility failed to maintain cleanliness in the 3400 wing, specifically regarding the ceiling vents in the rooms of three residents. Observations revealed that the vents were covered with a black substance, which was identified as dust and dirt buildup. The maintenance director acknowledged that the vents were dirty and needed cleaning, attributing the buildup to moisture causing dirt to stick. The maintenance director also admitted that although vent cleaning was on a monthly checklist, it was only performed quarterly, contrary to the facility's expectations. Interviews with residents and staff confirmed the presence of the black substance on the vents. One resident expressed uncertainty about whether the substance was dirt or mold. The facility's policy on maintenance of plumbing, HVAC, and related systems indicated that items should be free of visible soil, yet the vents were visibly dirty. The administrator confirmed that vents were expected to be cleaned regularly by maintenance and housekeeping staff, especially before new residents moved in, at resident discharge, and when visibly dirty.
Failure to Address Sudden Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to recognize and respond appropriately to a sudden change in condition for a resident, leading to a delay in treatment. The resident, who had a history of cardiovascular issues including non-ST elevation myocardial infarction, atrial fibrillation, and nonrheumatic aortic stenosis, experienced chest pain. Despite the resident's history and the care plan's directive to monitor for cardiac complications, the nursing staff did not conduct a comprehensive assessment or continuous monitoring of the resident's condition. On the morning of the incident, the resident reported chest pain to the nursing staff. However, the staff did not immediately notify the physician or take urgent action. Instead, they planned to wait for the physician's rounds later that morning. The resident's condition included symptoms such as pitting edema, wheezing, and nausea, which were not adequately addressed. The nursing staff's inaction persisted despite the resident's family member expressing concern and urging them to contact the physician. The delay in response resulted in the resident being sent to the emergency room only after the family member insisted on immediate action. Upon arrival at the hospital, the resident was diagnosed with an acute anterior STEMI and underwent a surgical procedure. Unfortunately, the resident suffered complications and passed away later that day. The facility's failure to promptly address the resident's chest pain and notify the physician contributed to the delay in receiving necessary emergency care.
Removal Plan
- re-education on change of condition with nurse management team
- posters of signs/symptoms of cardiac episodes posted at nurses stations and reviewed with all staff
- quiz for each nurse to take asking what do nurses do when a change of condition occurs, what is considered a change of condition
- review of like residents and no one else was at-risk
- nurse meeting scheduled to reiterate presented education
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure the infection control program included ongoing surveillance, trending, and analysis of resident infections. Staff were observed doffing personal protective equipment (PPE) incorrectly for one resident and PPE was stored improperly on the floor for multiple residents placed on enhanced barrier precautions (EBP). Additionally, a meal tray was placed on the floor for one resident, which posed an infection control risk. These deficiencies had the potential to affect all 56 residents in the facility. During observations, it was noted that plastic gowns were stored directly on the floor inside resident rooms, and there was no place to dispose of the gowns before leaving the rooms. Staff confirmed that PPE was donned inside the resident rooms, and it was suggested that mounting the gowns and gloves on the wall would be more efficient. The assistant director of nursing (ADON) and the director of nursing (DON) acknowledged that the current placement of PPE was an infection control risk and that there was no garbage or place to dispose of the gowns readily available next to the door for staff to doff PPE before exiting the rooms. The facility also failed to conduct ongoing infection surveillance. The ADON, who was responsible for infection surveillance, confirmed that tracking of infections was not currently taking place and was not aware of the last infection surveillance. The DON stated that discussions were held at daily meetings about residents showing signs of infection and on antibiotics, but ongoing surveillance had not been completed. The ADON verified that a monthly analysis of illnesses and infections was important to rule out any trends or patterns and that the facility was not currently tracking infection data. Additionally, staff were observed improperly doffing PPE, and a meal tray was placed on the floor, which the ADON acknowledged as an infection control breach.
Failure to Implement Antibiotic Review Process
Penalty
Summary
The facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, and trends of antibiotic use and resistance. This deficiency was identified during an interview with the DON and ADON, who confirmed that while the nursing staff monitored symptoms and reported potential infections to providers, there was no formal tracking or monitoring process for residents placed on antibiotics. The ADON, who was responsible for the infection control program, acknowledged that although he had completed education on infection control and antibiotic stewardship, the facility had not yet implemented a tracking system for antibiotic use. The DON and ADON verified that the facility did not have a formal process to track antibiotics for cultures, source, location of infection, or symptoms when placed on antibiotics. The health unit coordinator received culture results via fax and alerted the nursing staff, who would then contact the doctor if a change in the antibiotic was needed. However, the ADON confirmed that he did not review or track culture results to ensure proper antibiotics were prescribed and did not maintain a tracking log. The facility's Prevention and Control Program policy indicated that antibiotic usage reviews should be included in surveillance activities, but this was not being followed.
Failure to Report Allegation of Misappropriation of Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the state agency within 24 hours as required by their policies and procedures. A resident, who was cognitively intact and independent with most activities of daily living, reported that approximately $70 in cash was stolen from his room. The facility staff were informed of the missing money, and a police report was filed. However, the facility did not report the incident to the state agency within the required timeframe, relying instead on law enforcement to file a report with the Minnesota Adult Abuse Reporting Center (MAARC). The resident's care plan indicated a behavior problem of paranoia related to dementia, which may have influenced the staff's perception of the validity of the report. Despite the resident later finding the cash in his underwear drawer, the facility's regional nurse consultant acknowledged that the incident should have been reported to the state agency within 24 hours. The facility's policy clearly states that any suspected theft or misappropriation of resident property must be reported to the appropriate agencies within 24 hours, which was not adhered to in this case.
Inaccurate MDS Assessments for Hospice and Pressure Ulcers
Penalty
Summary
The facility failed to ensure the accurate identification of resident status in the Minimum Data Set (MDS) assessment for two residents. Resident R52, who was admitted with diagnoses including malignant neoplasms and heart failure, was receiving hospice services. However, the MDS assessment did not reflect this, as section O, K1 under special treatments and programs did not include hospice care services. This discrepancy was confirmed by the MDS coordinator, who acknowledged that the section was not coded correctly despite the resident's indication of receiving hospice services and a provider order for hospice evaluation. Similarly, Resident R21, with diagnoses of hemiplegia, hemiparesis, and diabetes mellitus type 2, had an MDS assessment that incorrectly indicated no pressure ulcers or deep tissue injuries. However, a skin assessment revealed a small open shallow area on the left buttock and a pressure ulcer on the left heel. The MDS coordinator confirmed the inaccuracy and admitted that the MDS would have been submitted incorrectly. The director of nursing also acknowledged that the MDS should have been completed accurately. The facility's policy requires an RN to be responsible for the accuracy of the resident assessment, which was not adhered to in these cases.
Failure to Provide Baseline Care Plan Summary to Residents
Penalty
Summary
The facility failed to offer or provide a summary of the baseline care plan to newly admitted residents and/or their representatives. This deficiency was identified for three residents who were newly admitted. One resident, who was cognitively intact, stated that she never received a copy of her care plan and would like to have one. The social worker confirmed that copies of the care plan were only provided if requested, and the Director of Nursing confirmed that a copy of the baseline care plan was not being offered to the resident or a family member. Another resident's family member also did not recall receiving a copy of the baseline care plan. A registered nurse stated that it was not current facility practice to provide the resident or resident representative a copy of the baseline care plan. The facility's policy and procedure for baseline care plans, dated March 2022, included the requirement to develop a baseline plan of care within 48 hours of admission and to provide a written summary of the baseline care plan to the resident and/or representative. This summary should include the stated goals and objectives of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility, and any updated information based on the comprehensive care plan. The provision of the summary to the resident and/or representative should be documented in the medical record. However, the facility did not adhere to this policy, resulting in the deficiency noted in the report.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to ensure individualized activities were provided for a resident (R29) who had moderately intact cognition and expressed interest in various activities. Despite the resident's care plan and baseline care plan indicating his preferences for activities such as playing cards, listening to music, and attending religious services, the facility did not offer these activities to him. The resident and his family member both reported that he had not been offered any activities, and the activity calendar posted in his room was not utilized to engage him in the listed activities. The activity coordinators (AC-A and AC-B) and nursing assistant (NA-F) confirmed that they had not offered R29 any activities based on his interests. AC-A stated that the resident's activity preferences were documented, but there was no follow-up to ensure he participated in these activities. AC-C mentioned that staff might have assumed the resident did not want to participate in activities because he had company, but this assumption was not verified with the resident. The director of nursing (DON) confirmed that residents were expected to be offered activities based on their interests and assessments, which did not occur in this case. The facility's Activity Programs policy outlined the importance of providing individualized and group activities based on residents' preferences and needs. However, the facility did not adhere to this policy for R29, as there was no documentation of his participation in activities, and staff did not actively engage him in the activities he enjoyed. This failure to provide individualized activities led to the deficiency identified in the report.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure services were coordinated with the hospice agency for a resident receiving hospice services. The resident required substantial to maximum staff assistance with all activities of daily living and had intact cognition. The resident's care plan indicated the need for coordination with hospice services, but there were discrepancies in the hospice visit schedule. The hospice agency's plan of care indicated visits from a registered nurse and a home health aide, but the facility's hospice binder did not have updated visit dates beyond a certain point. The resident reported missed visits and lack of communication from the hospice agency, leading to confusion and unmet care needs. Interviews with the resident, hospice staff, and the facility's director of nursing confirmed the lack of communication and coordination. The resident expressed frustration over not being informed about visit schedules and having to refuse care from facility staff because hospice was supposed to provide it. The hospice staff admitted to not notifying the resident or the facility in advance of visits, and the director of nursing acknowledged the communication issues. A policy on hospice services was requested but not provided by the facility.
Failure to Implement ROM Program and Properly Apply Splint and Edema Glove
Penalty
Summary
The facility failed to ensure a range of motion (ROM) program for a resident with limited upper extremity mobility, leading to improper application of a wrist brace and edema glove. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with a hand splint and edema glove incorrectly applied. The resident reported that staff did not perform ROM exercises and often applied the brace incorrectly, causing it to move out of place. Observations confirmed that the splint was not providing the intended support, and the resident's fingers were curled, indicating a lack of proper ROM exercises and splint application. Interviews with staff revealed inconsistencies in the implementation of the resident's care plan. Nursing assistants indicated they did not perform PROM on the resident's left hand due to discomfort and lack of clear instructions. The occupational therapist confirmed that the splint was not in the correct position and had lost its form, making it ineffective in preventing contractures. The therapist also noted that the resident's fingers were tight and required further therapy to regain flexibility. The resident's care plan and provider orders specified the need for ROM exercises and proper application of the splint and edema glove, but these were not consistently followed. The director of nursing acknowledged that the PROM should be performed by nursing assistants and that the hand splint should be applied correctly. However, the facility's documentation and staff interviews indicated a failure to adhere to the care plan, resulting in the resident's condition worsening. The facility's policy emphasized the importance of maintaining ROM and preventing contractures, but the lack of proper implementation and monitoring led to the deficiency observed by the surveyors.
Improper Cigarette Disposal and Supervision
Penalty
Summary
The facility failed to properly assess and manage the disposal of cigarettes for a resident with severe cognitive impairment and multiple health conditions, including aphasia, hemiplegia, and tobacco use. The resident's care plan indicated that he required supervision while smoking and that the facility would store his lighter and cigarettes. However, during an observation, the resident was seen smoking across the street with the interim director of nursing (IDON) supervising. The resident disposed of the cigarette butt improperly, and it was later found inside the facility, indicating a lapse in supervision and proper disposal procedures. The IDON admitted to not knowing where the cigarette butt was disposed of and confirmed that the facility did not have a designated receptacle for cigarette disposal. The director of nursing (DON) also acknowledged the lack of a proper plan or designated area for cigarette disposal, despite the facility's policy requiring metal containers with self-closing covers in smoking areas. The IDON, who was recently hired and still unfamiliar with the facility layout, confirmed that the facility allowed the resident to smoke off-property but did not have a well-thought-out plan for cigarette disposal. Further observations revealed multiple cigarette butts on the ground where the resident commonly smoked, and the DON stated that education would be provided to nursing staff and the resident regarding proper cigarette disposal. The facility's smoking policy emphasized the need for safe smoking practices and designated smoking areas, but the lack of a proper receptacle and supervision led to the deficiency in managing the resident's smoking habits and ensuring safety within the facility.
Unsanitary Conditions in Kitchen Areas
Penalty
Summary
The facility failed to provide a sanitary environment in the kitchen's food preparation and drying areas, potentially affecting all 56 residents. During an initial tour, a vent above the pots and pans dishwashing area was observed to have dark, fuzzy material. Additionally, wire mesh and a printer cord above the food serving area were covered in gray, fuzzy debris. These observations were confirmed by the cook and maintenance director, who acknowledged that the areas were dirty and needed cleaning. The culinary director also confirmed that there should not be any dirt or debris in these areas.
Failure to Administer Insulin Per Physician Orders
Penalty
Summary
The facility failed to ensure insulin was administered per physician orders for a resident (R1) with diabetes, leading to significant medication errors. R1, who was cognitively intact and required insulin daily, had physician orders to switch from detemir insulin to glargine insulin once the detemir was used up. However, due to a lapse in the visibility of the hold order for glargine insulin, R1 received both types of long-acting insulin simultaneously over a six-day period. This resulted in R1 experiencing hypoglycemia and being transported to the hospital after showing symptoms such as increased confusion and agitation. Licensed Practical Nurse (LPN)-A and Registered Nurse (RN)-A both administered the insulins without questioning the orders, despite knowing that both were long-acting insulins. The Director of Nursing (DON) acknowledged that the facility was transitioning from detemir to glargine insulin, and the hold order for glargine was not easily visible. Family members and staff observed significant changes in R1's condition, including increased confusion, agitation, and physical symptoms like being pale and clammy. The facility's Insulin Administration Policy required verification of insulin type, dosage, strength, and method of administration before administration, which was not adhered to in this case.
Failure to Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to comprehensively assess, implement interventions, and provide timely notification for a change in condition to a provider for a resident who was found unresponsive, which delayed care and resulted in death from acute respiratory distress. The resident had a history of Parkinson's Disease, renal insufficiency, neurogenic bladder, seizure disorder, and muscle weakness. Despite several nursing assistants reporting the resident's deteriorating condition, including decreased appetite, facial pallor, blue lips, increased fatigue, lethargy, and decreased responsiveness, the licensed nursing staff did not perform a comprehensive assessment or monitor the resident adequately. On the day of the incident, multiple staff members observed and reported significant changes in the resident's condition, such as very dark urine, red eyes, and lethargy. However, the licensed practical nurse (LPN) and registered nurses (RNs) involved did not take appropriate actions, such as conducting a full set of vital signs, documenting the observations, or notifying a physician. The resident's condition continued to deteriorate throughout the day and evening, with no significant interventions or assessments performed by the nursing staff. By the time the night shift staff assessed the resident, the resident was found to be in severe respiratory distress with critically low oxygen saturation and pulse rates. Emergency Medical Services (EMS) were called, but the resident was not provided with oxygen or other necessary interventions before their arrival. The resident was transported to the hospital, where they were diagnosed with acute respiratory failure and subsequently passed away. The facility's failure to follow protocols for assessing and responding to changes in the resident's condition directly contributed to the resident's death.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mankato
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Care & Rehabilitation Center | 1.1 mi | — | 0 | 0 |
| Laurels Peak Care & Rehabilitation Center | 1.7 mi | — | 19 | 0 |
| Oaklawn Care & Rehabilitation Center | 2.1 mi | — | 2 | 0 |
| Benedictine Living Community Of St. Peter | 13.3 mi | — | 8 | 0 |
| Whispering Creek | 16.1 mi | — | 0 | 0 |
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