St Gertrudes Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shakopee, Minnesota.
- Location
- 1850 Sarazin Street, Shakopee, Minnesota 55379
- CMS Provider Number
- 245610
- Inspections on file
- 31
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at St Gertrudes Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident who required two-person assistance and a mechanical lift for transfers was physically abused by a nursing assistant who attempted to transfer the resident alone and without the required equipment. During the incident, the NA punched the resident in the knee after a verbal altercation, which was witnessed by an RN. The resident reported feeling unsafe and described the abuse, and the facility's investigation confirmed that the NA did not follow the care plan or established protocols.
A facility failed to thoroughly investigate an allegation of physical abuse when a cognitively intact resident was punched by a nursing assistant during care. Although staff interviews were conducted, no residents or families were interviewed about the incident, and the investigation did not include residents from other units where the staff member had worked. The facility's policy requiring comprehensive interviews was not followed.
A resident who required transfer with a Sara Steady lift and care in pairs due to behavioral and physical needs was transferred by staff without the required device and without a second staff member present. Staff interviews revealed confusion and lack of awareness regarding the care plan interventions, and documentation gaps contributed to inconsistent care. The resident had multiple medical conditions and was dependent on staff for daily activities.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by regulations.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
A resident with multiple health issues, including end-stage renal disease and severe osteoporosis, experienced a fractured clavicle after a transfer using a sit-to-stand lift. The facility failed to report the injury of unknown origin to the State Agency within the required timeframe. Staff interviews revealed inconsistencies in the incident's account, and the facility's administrator acknowledged the reporting failure.
A resident with bilateral amputations expressed feeling unsafe in a shower chair, preferring showers over bed baths. Despite available mechanical lifts and slings, the LTC facility failed to reassess or accommodate the resident's bathing preference, leading to a deficiency in promoting resident self-determination.
The facility failed to provide routine grooming for two residents dependent on staff for personal care. One resident with impaired cognition had unaddressed chin hairs, while another with intact cognition had two-inch throat hairs that were not trimmed or shaved since admission. Staff interviews confirmed that personal care, including shaving, should be offered daily, but these needs were neglected.
A resident with moderate cognitive impairment experienced ongoing constipation issues that were not adequately addressed by the facility. Despite being on medications like Miralax and Senna-S, the resident reported infrequent bowel movements and a lack of proactive management discussions with staff. Medical records were incomplete, and staff interviews revealed a failure to communicate and document the resident's bowel status, leading to a deficiency in bowel management.
A resident with intact cognition and urinary retention had an indwelling catheter since the previous fall, but the facility failed to assess its removal or consult urology. Despite the resident's goal to have the catheter removed, no toileting program or alternative methods were implemented. Interviews revealed a lack of documentation and discussion with the resident and family about the catheter's duration or alternatives, contrary to the facility's policy on catheter use.
A resident with dementia, anxiety, and depression experienced behavioral issues after discontinuing Zoloft. Despite repeated recommendations from the consulting pharmacist to consider restarting Zoloft or using Lexapro, the facility failed to act on these suggestions in a timely manner. The nurse practitioner did not provide a documented rationale for not following the pharmacist's advice, and Lexapro was only started after increased communication from the care team about the resident's symptoms.
A resident in an LTC facility did not receive prescribed medications due to unavailability, resulting in a 7.14% medication error rate. The resident was discharged with orders for droxidopa and metronidazole, but these were not administered as the medications were not in the cart. The LPN did not inform the RN, and the pharmacy was not contacted. The DON noted a lack of clarity on how the orders were missed, and the facility's policy did not define medication errors or actions for unavailable medications.
The facility did not ensure that survey results and the plan of correction for the past three years, including the most recent survey from December 2023, were accessible to residents, families, and visitors. A binder at the main entrance was missing these documents, and the administrator confirmed the oversight. No facility policy on posting survey results was provided.
Failure to Protect Resident from Physical Abuse During Transfer
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) physically abused a resident during care. The resident, who was cognitively intact and dependent on staff for most activities of daily living, required the use of a mechanical lift for transfers and was to receive care from two staff members at all times. Despite these care plan requirements, the NA attempted to transfer the resident alone and without the mechanical lift, leading to an altercation. During this incident, the NA was witnessed by a registered nurse (RN) punching the resident in the left knee after a verbal argument and alleged aggression from the resident. The resident reported feeling unsafe and described being punched by the NA while being transferred from bed to wheelchair. The resident demonstrated the action to interviewers and stated that he retaliated by hitting the NA back. The RN corroborated the resident's account, stating she heard yelling, entered the room, and observed the NA strike the resident. The NA admitted to being alone with the resident, not using the required lift, and not following the care plan, citing lack of time to read care plans and being unfamiliar with the resident's needs. The facility's investigation confirmed that the NA failed to follow the care plan, which required two staff for care and use of the mechanical lift. The NA was alone with the resident and did not adhere to established protocols for managing residents with behavioral concerns. The incident was substantiated as physical abuse, with both the resident and RN providing consistent accounts of the event.
Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of witnessed physical abuse involving a resident who was cognitively intact and dependent on staff for most activities of daily living. The incident occurred when a nursing assistant (NA) was observed by a registered nurse (RN) to punch the resident in the leg during care. The resident confirmed feeling unsafe and described being struck by the NA, and both the NA and RN provided statements regarding the incident. Despite this, the facility's investigation did not include interviews with other residents to determine if they had experienced or witnessed abuse. The investigation process involved interviewing staff members about general experiences with mistreatment but did not include specific questions about the incident or the staff involved. Sixteen staff members were asked if they had ever mistreated a resident or witnessed mistreatment, but there was no documentation of targeted questions regarding the alleged abuse involving the NA and the resident. Additionally, the investigation did not include interviews with residents from other units where the NA had worked, nor were families interviewed. The facility limited its resident assessment to skin and pain checks and baseline emotional and psychological observations, without directly asking residents about abuse or safety concerns. The director of nursing and the administrator indicated that residents on the cognitive unit were not interviewed due to concerns about their ability to provide accurate responses, and residents from other units were not interviewed because the incident was considered isolated. The facility's policy required interviewing all individuals who might have knowledge of the incident, including the alleged victim, perpetrator, witnesses, or others with related contact, but this was not followed in the investigation.
Failure to Implement Care Plan Interventions for Transfer and Supervision
Penalty
Summary
The facility failed to implement the care plan interventions for a resident who required specific transfer and supervision protocols. The resident's care plan indicated that all transfers from bed to chair or toilet were to be performed using a Sara Steady mechanical lift and that care was to be provided in pairs (two staff members present) due to previous behavioral concerns and accusations made by the resident. Despite these documented interventions, staff were observed transferring the resident without the required mechanical device and without a second staff member present. Additionally, there was confusion among staff regarding the specifics of the care plan, with some staff unaware of the need for paired care or the use of the Sara Steady lift. Interviews revealed that staff did not consistently read or follow the care plan, leading to inconsistent application of required interventions. One nursing assistant admitted to transferring the resident alone and without the mechanical lift, stating she had not reviewed the care plan prior to providing care. Other staff members, including nurses and therapy staff, expressed uncertainty about the requirements for paired care and whether these applied to their roles. Documentation and communication gaps were evident, as some staff relied solely on the treatment administration record (TAR) and did not routinely review the full care plan, resulting in missed interventions. The resident involved had a history of sepsis, alcohol-induced chronic pancreatitis, lymphedema, and osteoarthritis, and was dependent on staff for most activities of daily living. The care plan also noted behavioral concerns, including making accusations against staff of different ethnicities, which contributed to the requirement for care in pairs. Despite these needs, the facility did not ensure that all staff were aware of or adhered to the care plan interventions, leading to the observed deficiencies in care delivery.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency within the required timeframe for a resident who was assessed with a fractured clavicle. The incident involved a resident who was cognitively intact and dependent on staff for all transfers. The resident had a history of congestive heart failure, end-stage renal disease, malnutrition, respiratory failure, and morbid obesity. On the evening of the incident, the resident was assisted by staff using a sit-to-stand lift for toileting. During the transfer, the resident's legs became weak, and she was lowered to the toilet. Later, the resident experienced severe pain and was sent to the emergency department, where an x-ray revealed a fractured clavicle. Interviews with staff revealed inconsistencies in the account of the incident. The night nurse reported that the resident had slid in the sit-to-stand lift earlier in the evening, while the evening nurse stated that the resident was weak and requested the use of a ceiling lift due to fear of falling. The nursing assistants involved in the transfer did not recall the resident sliding or bumping her body during the transfer. The facility's assistant director of nursing and the medical director provided possible explanations for the fracture, citing the resident's severe osteoporosis and vulnerability to fractures with slight movements. The facility's administrator acknowledged that the injury should have been reported as an injury of unknown origin within 24 hours, but believed it was reasonable to assume the fracture occurred during the transfer. The facility's policy on abuse prevention required reporting serious bodily injury immediately, but no later than two hours after the event. The report highlights the facility's failure to adhere to this policy, as the injury was not reported to the State Agency within the required timeframe.
Failure to Assess and Facilitate Resident's Bathing Preference
Penalty
Summary
The facility failed to assess and accommodate a resident's preference for bathing methods, specifically showers, after the resident expressed feeling unsafe being transported in a shower chair. The resident, who had undergone bilateral below-knee amputations, was receiving weekly bed baths but preferred showers. The resident felt uncomfortable and unsafe being wheeled through public spaces in a shower chair due to his amputee status. Despite the resident's expressed discomfort, the facility did not reassess or explore alternative options to facilitate the resident's preference for showers. Interviews with staff revealed a lack of communication and assessment regarding the resident's discomfort with the shower chair. A nursing assistant mentioned offering showers, but the resident refused without explaining why. The unit manager acknowledged the resident's discomfort but did not investigate further, believing it was not her place to ask for more information. The director of nursing stated that an assessment should have been conducted to understand the resident's concerns and offer suitable options. The facility had mechanical lifts and slings available that could potentially address the resident's needs, but these were not utilized or considered in the resident's care plan.
Failure to Provide Routine Grooming for Residents
Penalty
Summary
The facility failed to ensure routine grooming was offered or provided to promote good hygiene for two residents who were dependent on staff for their care. Resident 1 (R1) was identified with impaired cognition and multiple diagnoses, including heart disease and diabetes, and was dependent on staff for personal hygiene. Observations revealed that R1 had multiple white hairs on her chin, which had not been addressed by the staff. Interviews with nursing assistants confirmed that personal care, including shaving, should be offered daily, but it appeared that R1's grooming needs had been neglected for at least a couple of weeks. Resident 25 (R25), who had intact cognition and required assistance with personal hygiene, was observed with two-inch white hairs extending from her throat. R25 expressed a desire to have the hairs removed and stated that no one from the facility had offered to trim or shave them since her admission. Interviews with staff, including a licensed practical nurse and the director of nursing, acknowledged that personal hygiene care should include shaving and be performed at least twice per day. However, it was evident that R25's grooming needs had been overlooked, as she had not been asked about the hairs or offered assistance with their removal.
Deficiency in Bowel Management for Resident
Penalty
Summary
The facility failed to adequately address and assess complaints of potential constipation for a resident, leading to a deficiency in bowel management. The resident, identified as having moderate cognitive impairment, reported ongoing issues with constipation despite being on medications like Miralax and Senna-S. The resident expressed that staff had not discussed proactive bowel management options with him, despite his history of colon polyps and repeated complaints to staff about constipation. The resident's medical records, including the Elimination - Bowel evaluation and Medication Administration Record (MAR), were incomplete and lacked comprehensive assessments or interventions for bowel management. The MAR showed multiple refusals or non-administrations of bowel-related medications, and a bowel assessment order was recorded late without further action. Nursing staff, including a nursing assistant and a registered nurse, acknowledged the resident's complaints but failed to ensure appropriate follow-up or documentation in the medical record. Interviews with facility staff, including a licensed practical nurse unit manager and the director of nursing, revealed a lack of communication and documentation regarding the resident's bowel status. The Elimination-Bowel tool was not completed, and standing orders for bowel management were not enacted or charted. The director of nursing confirmed the importance of assessing and acting upon bowel complications to prevent impaction, but the facility's records did not reflect such actions. Additionally, the facility did not provide a policy on bowel management when requested.
Failure to Assess and Remove Indwelling Catheter
Penalty
Summary
The facility failed to assess and remove an indwelling urinary catheter for a resident, identified as R27, who was admitted with intact cognition and required assistance with toileting. Despite having a Foley catheter since the previous fall due to urinary retention, the facility did not attempt to implement a toileting program or consult with urology to evaluate the necessity of the catheter. The resident expressed a desire to have the catheter removed to return home, but no assessment or alternative methods were pursued by the facility. Interviews with the health unit coordinator and the director of nursing revealed that there was no order for a urology consult in the resident's electronic medical record, and no discussion had taken place with the resident or their family regarding the catheter's duration or alternatives. The facility's policy on preventing catheter-associated urinary tract infections emphasized eliminating indwelling catheters whenever possible, yet this was not adhered to in R27's case.
Failure to Act on Pharmacist's Recommendations for Resident's Medication
Penalty
Summary
The facility failed to ensure that the consulting pharmacist's recommendations were fully addressed or acted upon for a resident, identified as R66, who was reviewed for unnecessary medication use. R66's quarterly Minimum Data Set assessment indicated no cognitive impairment, hallucinations, delusions, or behaviors during the seven-day look-back period, but the resident was diagnosed with dementia, general anxiety disorder, and depression. The consulting pharmacist made several recommendations to consider restarting Zoloft or using a different SSRI like Lexapro due to reported behavioral issues after Zoloft was discontinued. However, these recommendations were not acted upon in a timely manner, and there was a lack of documented rationale for not following the pharmacist's advice. The nurse practitioner acknowledged the pharmacist's recommendations but did not make changes to the medication regimen, citing previous side effects and a recent hospitalization for psychic behaviors. Despite repeated recommendations from the pharmacist in August and September, there was no provider response or documented rationale for not acting on the advice to consider Lexapro. It was only after increased communication from the care team about R66's symptoms of anxiety and depression that Lexapro was started at the end of October. Interviews with facility staff, including the director of nursing and the nurse practitioner, revealed that the process for reviewing and acting upon pharmacy recommendations was not followed. The director of nursing confirmed that the pharmacy recommendations should have been reviewed and addressed during the next month's pharmacy review, but this did not occur for R66. The consultant pharmacist also noted the absence of a documented rationale from the provider for disregarding the recommendations, highlighting a breakdown in communication and follow-up within the facility's medication management process.
Medication Unavailability Leads to Errors
Penalty
Summary
The facility failed to ensure medications were available in a timely manner for a resident, resulting in multiple omitted doses and a medication error rate of 7.14%. The resident, who was discharged from an acute care hospital with a diagnosis of orthostatic hypotension, was prescribed droxidopa and metronidazole. However, upon observation, the medications were not available in the medication cart, and the licensed practical nurse (LPN) confirmed that the medications had not been administered since the resident's admission two days prior. The LPN did not notify the unit manager about the unavailability of the medications, and the registered nurse unit manager (RN) confirmed that the pharmacy had not been contacted. The RN acknowledged that the nurse responsible was new and had not participated in recent training. The consulting pharmacist noted that metronidazole should have been readily available, and the dispensing pharmacy technician confirmed that they had not received the orders for the medications. The director of nursing (DON) explained that the health unit coordinator is responsible for faxing orders to the pharmacy, but it was unclear how the orders were missed. The facility's policy on administering medications lacked definitions of what constituted an error or actions to take when medications were unavailable. The deficiency was identified as a failure to provide medications as ordered, which is crucial to prevent negative outcomes for residents.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents, families, and visitors had access to the survey results and the plan of correction (POC) for the past three years, including the most recent survey from December 2023. During an observation at the main entrance, a binder labeled 'St Gertrude's State Survey Results' was found to be missing the survey results and POC from the recertification survey exited on December 14, 2023. The receptionist indicated that the administrator was responsible for maintaining the binder. Upon review, the administrator confirmed that the survey results from December 2023 were not included in the binder at the reception desk or in another binder that was supposed to contain results from the past year. The administrator acknowledged the oversight and the requirement to have three years of survey results available for review. A facility policy on posting survey results was not provided.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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