Sauer Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Winona, Minnesota.
- Location
- 1635 West Service Drive, Winona, Minnesota 55987
- CMS Provider Number
- 245102
- Inspections on file
- 21
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Sauer Health Care during CMS and state inspections, most recent first.
A resident on blood thinners experienced a fall that reopened an existing wound, but the LPN on duty did not perform neurochecks or immediately notify a provider, instead documenting the event in a communication book for review the next day due to lack of on-call coverage. The next morning, an RN reported the resident had a severe headache and altered cognition and expressed concern for a possible brain bleed, confirming that neurochecks and timely provider notification had not occurred. Later, frank blood was noted in the toilet without immediate physician notification, despite the DON’s expectation that such findings, along with the resident’s anticoagulant use and cognitive impairment, should trigger neurochecks, prompt provider contact, and possible ED transfer. The DON and RN reported that the facility had not maintained 24-hour on-call physician services for several years, contrary to facility policy requiring continuous physician availability for emergencies.
A resident with cognitive impairment, multiple comorbidities, a pressure injury, and active warfarin therapy experienced an unwitnessed fall that reopened a coccyx wound, with bleeding noted. Post-fall assessments documented stable VS and no pain, but neuro checks were not initiated and the physician was not actually notified as recorded. Later that night, frank blood in the toilet was observed and documented without neuro checks or provider notification, and a subsequent note attributed the bleeding to a skin tear. The next morning, the resident was lethargic, oriented x2, reporting significant head pain and breakthrough bleeding, and was transferred non-emergently to the ED, where an elevated INR was found and warfarin dosing was adjusted. The care plan lacked anticoagulation management focus, and interviews with nursing staff and the DON confirmed that required neuro assessments and timely provider notification after the fall and subsequent bleeding did not occur, contrary to facility policies on change of condition and fall management.
Two residents who required mechanical lifts for transfers were transferred without comprehensive, documented assessments of sling and harness sizing or consistent use of required safety components. One resident with stroke‑related hemiparesis and impaired balance experienced an incident in a sit‑to‑stand lift when feet were not correctly positioned on the platform and the leg strap was not used, resulting in the resident hanging in the lift until assisted to the floor. Another resident with multiple sclerosis and generalized weakness was dependent on a Hoyer lift, but no individualized sling size assessment based on height, weight, girth, and tailbone‑to‑neck measurements was documented. Care plans and assignment sheets did not specify sling or harness sizes or leg strap use, CNAs reported they did not know how to determine correct sizes and that leg strap use was inconsistent, and the DON and RN acknowledged there was no formal, documented process for sling/harness sizing or monitoring for changes, despite manufacturer instructions and an OT and equipment representative stating that full assessments and leg strap use are required for safe transfers.
A resident with moderately impaired cognition, stroke, CHF, mobility limitations, and documented urinary incontinence was not provided an individualized toileting program despite facility policy requiring comprehensive bladder assessments and tailored interventions. On admission and thereafter, no comprehensive bowel/bladder assessment was completed, the CAA did not identify the type of incontinence, and the care plan lacked specific toileting interventions such as scheduled toileting or prompted voiding. Staff expected the resident to use the call light and did not routinely offer toileting assistance, while the resident reported walking to the bathroom independently, sometimes forgetting to use a walker and experiencing incontinence. Nursing staff and the DON confirmed that comprehensive assessments and individualized toileting plans were not performed, even though the resident was frequently incontinent.
A resident with intact cognition but significant post-stroke physical impairments, including hemiparesis, limited ROM, incontinence, impaired vision, and a history of falls, required extensive assistance from 1–2 staff for transfers and toileting using a gait belt, walker, or EZ Stand lift. Over a 14-day period, call light logs showed this resident’s call light remained active more than 15 minutes on 38 occasions, with an average response time of about 27 minutes and several waits exceeding 40 minutes, especially in early morning and other busy periods. The resident reported frequent waits of about an hour, inconsistent responses, and call lights being turned off without care, and described multiple incontinence episodes related to delayed assistance. NAs stated that call lights ideally should be answered within 5–10 minutes but acknowledged that residents could wait up to 30 minutes during busy times, and the DON confirmed repeated complaints of waits over 20–30 minutes while being unable to provide a facility call light response policy when requested.
A facility failed to ensure proper PPE use when staff moved between rooms of residents with and without COVID-19. A dietary aide entered a COVID-19 positive resident's room with only an N95 mask, then proceeded to other rooms without changing PPE. Staff interviews revealed confusion about PPE requirements, despite facility policies and CDC guidelines mandating full PPE for COVID-19 rooms.
A facility failed to implement person-centered interventions for a resident with a history of falls and cognitive impairment. Despite multiple falls, the care plan was not updated with specific strategies, relying instead on generic reminders. Staff interviews confirmed the absence of individualized interventions, contrary to facility policy requiring updates to care plans based on fall risks.
Failure to Provide 24-Hour On-Call Physician Coverage and Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide or arrange 24-hour on-call physician services and to ensure timely provider notification and appropriate post-fall assessment for a resident on blood-thinning medication. After the resident, who was new to the facility and taking blood thinners, fell at 7:15 p.m. on 2/4/26, an LPN assessed the resident, noted that an existing wound on the resident’s bottom had reopened, and applied a dressing. However, neurochecks were not performed, and the provider was not notified immediately. Instead, the LPN documented the fall in a communication book for the provider to review during rounds the next day, stating that there was no on-call provider available. The facility’s own policy required 24-hour physician coverage for emergencies, including contacting the primary physician first, then the on-call physician, and, if necessary, the medical director, and transporting the resident to the ED if no physician was reachable and immediate assessment was required. On the following morning, an RN caring for the same resident reported that the resident requested transfer to the ED for a headache rated 7/10 and expressed concern for a possible brain bleed due to the recent fall, use of blood thinners, and altered cognition. The RN confirmed that neurochecks had not been performed after the fall and that the provider had not been notified immediately. The DON stated that, per facility expectations, staff should assess for injury, take vital signs, initiate neurochecks, notify the provider, inform the family, and document in risk management after a fall, and confirmed that these steps were not followed for this resident, who also had moderate cognitive impairment. At 2:05 a.m. on 2/5/26, frank blood was observed in the toilet, but staff still did not notify the physician immediately, despite the DON’s statement that this finding should have prompted an ED transfer due to increased risk of bleeding and that normal vital signs alone could not rule out internal bleeding. The DON and RN both confirmed that the facility had not had 24-hour on-call physician coverage for the past four years, and local providers did not round at the facility, have access to records, or provide on-call coverage, affecting all residents.
Failure to Assess and Notify Provider After Fall in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and notify the physician of a change in condition for a resident on anticoagulant therapy following a fall. The resident had moderately impaired cognition and multiple diagnoses including stroke, chronic heart failure, gait and mobility abnormalities, and a stage 2 pressure injury on admission. The care plan identified a self-care deficit and moderate fall risk with interventions for assisted ambulation, ADLs, and call light use, but did not include a focus on anticoagulation management with individualized goals and treatment management, despite active warfarin orders. On the evening of the fall, the resident self-reported an unwitnessed fall and was found in a recliner with a reopened coccyx wound and bleeding from the bottom. The post-fall assessment documented normal range of motion, no pain, orientation to person, and the resident’s denial of head strike, with predisposing factors including impaired memory, gait imbalance, and ambulating without assistance. Although documentation indicated multiple notifications, the physician was not actually notified at the recorded time, and neurological checks were not initiated, contrary to facility expectations for unwitnessed falls and residents on anticoagulants. A follow-up note in the early morning hours documented stable vital signs and no new physical findings, stated that the provider did not need to be notified, and lacked any neurological assessment. Later that night, frank blood in the toilet was observed by a nursing assistant, and a progress note recorded this change along with stable vital signs, but again lacked a neurological assessment and provider notification. A subsequent note indicated no blood after toileting and attributed prior bleeding to a skin tear from the fall. Later that morning, the resident was documented as lethargic, oriented x2, with breakthrough bleeding on the right gluteal/thigh region and head pain rated 7/10, and was transferred non-emergently to the ED. In the ED, the resident was noted to have fallen while on blood thinners, complained of head pain, and had an elevated INR of 5.3, with CT scans negative for acute changes and warfarin dosing later adjusted. The DON and nursing staff interviews confirmed that neuro checks were not initiated after the unwitnessed fall, the provider was not notified at the time of the fall or when frank blood was first noted, and that these actions were inconsistent with facility policies on change of condition and fall management, particularly for residents on anticoagulants.
Failure to Assess and Communicate Proper Sling/Harness Sizing and Leg Strap Use for Mechanical Lifts
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and document appropriate sling and harness sizes, and to consistently use required safety components (leg strap) for mechanical lift transfers, as required by manufacturer instructions. Two residents who depended on mechanical lifts for transfers were affected. One resident had intact cognition with a history of ischemic stroke, left hemiparesis, hemiplegia, unsteadiness on feet, impaired balance, limited mobility, incontinence, impaired vision, and a history of falls. This resident required substantial to maximal assistance for transfers and used a motorized wheelchair. The care plan and group assignment sheet directed staff to use a gait belt and walker or an EZ Stand sit‑to‑stand lift, and later referenced use of a pivot/EZ Stand for transfers, but did not identify the required harness size or whether the leg strap was to be used. For this resident, the clinical record lacked any comprehensive assessment for harness size that incorporated the resident’s weight and torso circumference where the harness is applied, as required by the manufacturer. The record also did not address whether the leg strap should be used. A fall report documented that the resident was elevated in an EZ Stand lift with both feet under him and the leg strap not in use; his feet slipped off the platform, leaving him hanging in the lift until a nurse supported his weight and repositioned his feet so he could be lowered to the floor. The resident reported that his foot did not get all the way on the platform, both feet slipped off because his shoe slipped, and he was hanging on until help arrived. The record did not include a comprehensive assessment identifying the size of sling required for use of a full body mechanical lift. In subsequent interviews, the resident and the RN who responded to the incident both described that the resident’s left foot slipped out of his shoe, both legs were trapped underneath him, he was not strong enough to hold himself up, and the leg strap was not believed to have been used. The second resident had intact cognition with diagnoses of multiple sclerosis, generalized weakness, repeated falls, dependence on a wheelchair, and impaired range of motion in both lower extremities. This resident was dependent on staff for transfers, used a motorized wheelchair, and required assistance of two staff with a Hoyer full body mechanical lift. The care plan did not identify the size of sling required for safe transfers, and the record lacked a comprehensive sling size assessment including height, weight, girth, and the distance from tailbone to base of neck, as required by manufacturer guidelines. The resident reported that two staff transferred her with a Hoyer lift and that she did not know what size sling was used, assuming staff would know. Multiple nursing assistants reported that sling and harness sizes were not identified on care plans, Kardexes, or assignment sheets for residents requiring mechanical lifts. They stated that each resident had a sling or harness in the room, but they were unable or unsure how to determine the correct size, and if a sling became soiled they would obtain another from the supply or linen room without a reliable method to select the appropriate size, especially when tags were worn or unreadable. One nursing assistant reported inconsistent use of the EZ Stand leg strap among staff and expressed concern that the leg strap should be used to prevent legs from slipping out. Another assistant who performed EZ Stand transfers stated she had not received training on use of the leg strap and was unfamiliar with it. The RN and DON confirmed that the facility did not complete formal, documented sling or harness size assessments, relied on a weight‑based reference chart in the linen room, did not document sling/harness size in the medical record, care plan, or assignment sheets, and had no system to monitor weight changes that might require size adjustments. The occupational therapist and the EZ Way lift representative both stated that a full patient assessment is required to determine appropriate accessory size and type, that the leg strap is essential or policy for safe EZ Stand use, and that sizing must be based on manufacturer charts using resident‑specific measurements such as weight, torso circumference, and tailbone‑to‑neck distance.
Failure to Implement Individualized Toileting Program for Incontinent Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, and implement an individualized toileting program to maintain or improve bladder continence for a resident with urinary incontinence and multiple comorbidities. On admission, the resident’s MDS documented moderately impaired cognition, a history of stroke, chronic systolic and diastolic heart failure, muscle weakness, unsteadiness on feet, fatigue, gait and mobility abnormalities, and a cognitive communication deficit. The resident required partial to moderate assistance with toileting hygiene and dressing, used a walker and wheelchair, and had occasional urinary incontinence while remaining continent of bowel. Despite these findings and the resident’s use of diuretics, no trial of a toileting program such as scheduled toileting, prompted voiding, or bladder training was initiated on admission. The record lacked a comprehensive bowel and bladder assessment, and the CAA identified frequent urinary incontinence with modifiable factors but did not specify the type of incontinence or translate these findings into specific toileting interventions. The resident’s care plan identified a self-care deficit related to congestive heart failure and noted the need for one-person assistance with ambulation, dressing, hygiene, bed mobility, and toileting, as well as frequent bladder incontinence, but it did not address urinary incontinence with individualized interventions or a toileting program. Bladder records showed a mix of continent and incontinent episodes over several weeks. Observation and interview revealed the resident ambulated to the bathroom independently without using the call light, sometimes forgetting to use the walker and experiencing incontinence when trying to reach the bathroom, and reported not receiving staff assistance with toileting. A nursing assistant confirmed staff expected the resident to use the call light and did not routinely check or offer toileting assistance. The RN and DON both acknowledged that comprehensive bowel and bladder assessments, including three-day assessments, were not completed to develop individualized toileting plans, and that although the resident was frequently incontinent, no individualized toileting interventions were in place, contrary to the facility’s urinary incontinence policy requiring comprehensive assessment and individualized toileting programs.
Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet a resident’s needs, resulting in repeated delayed responses to call lights and delayed care. The resident had intact cognition but significant physical impairments, including a history of cerebral infarction, hemiparesis/hemiplegia, unsteadiness on feet, limited range of motion on one side of the body, incontinence, impaired vision, and a history of falls. The resident’s care plan identified an ADL self-care deficit related to these conditions and specified that the resident required substantial to maximal assistance from one to two staff for transfers using a gait belt and walker or a PRN EZ Stand lift. The resident reported relying on staff assistance for transfers and toileting and stated that call lights were used primarily to get in or out of bed or to use the bathroom. Over a 14-day period, the facility’s call light log for this resident showed that the call light remained active for more than 15 minutes on 38 occasions, with an average response time of approximately 27 minutes and 40 seconds. The longest delays, including multiple waits exceeding 40 minutes, occurred most frequently in the early morning hours between 5:00 a.m. and 9:00 a.m., with additional prolonged waits around midday and late afternoon to early evening. The resident reported that call lights often took about an hour to be answered, that staff had told him lights should be answered within 5–7 minutes, and that this did not occur in practice. He also reported that some call lights were turned off without assistance being provided and that he had experienced multiple episodes of incontinence related to these long response times. Staff interviews further described inconsistent and delayed call light responses. A nursing assistant stated that call lights ideally should be answered within five minutes but acknowledged that during busy times such as early mornings, after lunch, and shift changes, residents might wait up to 30 minutes, and confirmed that this resident frequently complained about long waits. Another nursing assistant reported that staff should aim to answer call lights within 10 minutes but that this did not always happen and confirmed the resident’s frequent complaints. The DON acknowledged that this resident regularly complained of long call light response times, considered waits over 20 minutes to be a problem, and noted that the resident’s complaints typically involved waits over 30 minutes, which she reviewed with him using the call light log. The DON and nursing assistants were unaware that the resident had experienced incontinence episodes due to delayed responses, and the facility was unable to provide a call light response policy when requested.
Inadequate PPE Use During COVID-19 Precautions
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) when staff moved between rooms of residents with and without COVID-19 diagnoses. During observations, a dietary aide (DA-A) was seen entering the room of a COVID-19 positive resident, identified as being on enhanced respiratory precautions, wearing only an N95 mask without additional PPE such as gloves, gown, or eye protection. DA-A then proceeded to enter the rooms of other residents, some of whom were not on COVID-19 precautions, without changing the N95 mask or donning additional PPE, despite having contact with potentially contaminated surfaces. Interviews with staff revealed a lack of understanding and training regarding the necessity of full PPE when entering rooms of COVID-19 positive residents. The dietary manager and other staff members, including a registered nurse, expressed uncertainty or incorrect beliefs about PPE requirements, contradicting the facility's COVID-19 Plan and CDC guidelines. The infection preventionist confirmed that all staff were supposed to be trained to use full PPE in such situations, highlighting a gap between policy and practice.
Failure to Implement Person-Centered Fall Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate, person-centered interventions to prevent further falls and potential injury for a resident who was severely cognitively impaired and had a history of repeated falls. The resident's care plan identified risks for falls related to gait and balance problems, incontinence, safety unawareness, use of psychotropic medication, and wandering. Despite these identified risks, the facility did not update the care plan with specific interventions after multiple falls occurred. The resident experienced several falls over a period of months, with each incident being documented in progress notes. However, the interventions following these falls were limited to generic reminders for the resident to use the call light for assistance. The care plan was reviewed multiple times, but no resident-specific interventions were implemented, even after the resident sustained a bruise from a fall. Interviews with facility staff, including a nursing assistant, registered nurse, and the director of nursing, confirmed that the resident only had generic fall interventions in place and lacked person-centered strategies. The facility's policy required that care plans be updated to reflect current fall risks and interventions, but this was not adhered to in the case of the resident. The director of nursing acknowledged that the resident should have had specific interventions due to the high risk for falls, such as physical therapy consults, direct supervision, and proper footwear. The lack of individualized interventions contributed to the ongoing risk of falls and potential injury for the resident.
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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