Sterling Park Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waite Park, Minnesota.
- Location
- 142 North First Street, Waite Park, Minnesota 56387
- CMS Provider Number
- 245375
- Inspections on file
- 24
- Latest survey
- August 1, 2025
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Sterling Park Health Care Center during CMS and state inspections, most recent first.
Two residents with clear wishes for resuscitation, as documented in their signed POLST forms, had conflicting code status information in the EHR and physician orders, which incorrectly indicated DNR/DNI. Staff interviews confirmed they would have followed the incorrect EHR information in an emergency, resulting in actions contrary to the residents' wishes. The facility's inconsistent process for updating and verifying code status led to these discrepancies.
The facility did not maintain required RN coverage for at least 8 consecutive hours daily, as staffing records showed an RN shift was filled by an LPN on one occasion, resulting in no RN on-site for that day. Staff interviews revealed reliance on scheduling apps, on-call rotations, and contingency plans, but a scheduling oversight led to the deficiency.
A resident with significant cognitive and physical impairments was found to have a parameter mattress in place for an extended period to prevent falls, despite being non-ambulatory and unable to get out of bed independently. Staff interviews revealed the mattress was not assessed or documented as a restraint in the required physical device assessment, and its continued use was not clearly justified. Facility policy prohibits the use of physical restraints for staff convenience or fall prevention without proper assessment and documentation.
A resident with multiple chronic conditions left the facility against medical advice without a comprehensive discharge plan or proper documentation of education regarding the risks of leaving AMA. The facility did not provide a discharge summary or recapitulation of stay at the time of discharge, and key information such as medication instructions and follow-up care was not given to the resident.
A resident with multiple complex diagnoses and moderate ADL assistance needs did not have a person-centered care plan with specific goals and interventions. The care plan contained only problem statements without measurable objectives or individualized actions, and facility staff confirmed the plan was incomplete and not tailored to the resident.
Staff did not consistently follow physician orders or honor a resident’s preferences and goals, resulting in care that was not individualized or aligned with the resident’s needs.
A resident with moderate cognitive impairment and multiple health conditions was not assessed for safe use of an electric recliner, despite being identified as a fall risk and requiring assistance for mobility. The electric recliner was not included in the physical device assessment, and staff had to intervene when the resident nearly slid from the recliner. Nursing leadership confirmed the assessment should have included the recliner, but it was omitted.
A resident was repeatedly observed handling the tops and rims of other residents' coffee cups during meal service without staff intervention, despite this being a regular occurrence. Staff did not redirect or stop the resident, and the Infection Preventionist confirmed this was not in line with infection control protocols.
A resident with a history of peripheral vascular disease and cerebrovascular accident experienced worsening pain and swelling in the right lower leg, which was not promptly communicated to a physician by the facility staff. Despite documentation of significant changes in the resident's condition, including a large swelling and pain, the delay in notifying the medical provider led to a hospitalization for cellulitis and a hematoma.
A facility failed to implement a resident's physician's orders for tube feeding and did not coordinate care for incontinence needs during cancer center appointments. The resident, requiring tube feeding due to tongue cancer, missed scheduled feedings during appointments, and the facility did not send necessary incontinence supplies or clothing. The care plan lacked interventions for these appointments, and staff did not consult the physician or revise the care plan, leading to a deficiency.
The facility failed to store and label food properly, dispose of undated and expired food items, and maintain cleanliness in the kitchen, affecting 34 residents. Observations included uncovered and undated food, outdated buns without signage, improperly thawed fish, and significant ice buildup in the walk-in freezer. Interviews revealed that contracted kitchen staff were not consistently following proper food storage procedures.
The facility failed to assess a resident for the ability to self-administer medications and did not obtain an order for medication self-administration. The resident was observed taking high-risk medications without staff supervision, and staff confirmed that medications were sometimes left in the room for the resident to take independently, despite the lack of a self-administration order or assessment.
A facility failed to document and communicate required information when a resident with multiple diagnoses was emergently transferred to a hospital. The medical record lacked essential details, and staff interviews confirmed that the transfer process was not followed correctly.
A facility failed to inform a resident or their legal representative of bed hold rights during hospitalization. The resident was sent to the emergency room, but no bed hold notification was documented. Interviews confirmed the oversight, and a review of the medical records showed non-compliance with the facility's transfer and bed hold notification procedures.
The facility failed to ensure proper coordination of care and communication between the facility and the dialysis center for a resident receiving hemodialysis. Despite having pre and post-dialysis assessments documented, the resident's record lacked a dialysis care plan and did not include the dialysis center's contact information. Interviews revealed no paperwork was exchanged between the facility and the dialysis center, and no clinical communication was documented.
A facility failed to ensure that a resident's prescribed medication, Vascepa, was available and administered, resulting in 19 missed doses over ten days. The issue was attributed to a change in the resident's payer source and a lack of communication between the facility staff and the pharmacy. The nurse practitioner was not informed of the missed doses despite being in frequent contact with the facility.
A resident with diagnoses including congestive heart failure, diabetes, and hypertension was eligible for the PCV20 vaccine beginning December 2023, but the facility's EMR incorrectly indicated eligibility for December 2024. The resident was not provided education, offered, or received the PCV20 vaccination. The DON stated that the facility followed CDC recommendations and used a CDC-based tool to track eligible residents, but the error in the EMR led to the deficiency.
Failure to Accurately Document and Update Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that advance directives, specifically code status and resuscitation wishes, were accurately documented and updated in the electronic health record (EHR) banner, physician orders, and the Physician's Orders for Life Sustaining Treatment (POLST) for two residents. For one resident with diagnoses including congestive heart failure, hypertension, renal failure, diabetes, and chronic respiratory failure, the POLST signed by both the resident and the medical provider indicated a full code status, meaning the resident wished to receive cardiopulmonary resuscitation (CPR). However, the EHR banner and physician orders incorrectly reflected a do not resuscitate/do not intubate (DNR/DNI) status. Multiple staff interviews confirmed that in the event of an emergency, staff would have followed the incorrect DNR/DNI status in the EHR and not performed CPR, contrary to the resident's expressed wishes. A similar issue was identified for another resident with diagnoses including diabetes with polyneuropathy, hypothyroidism, hypertension, and chronic kidney disease. This resident's POLST and Directives to Define Scope of Medical Care form, both signed by the resident and provider, indicated a wish to be resuscitated (full code). However, the EHR banner and order summary incorrectly listed the resident as DNR. Staff interviews revealed that in an emergency, staff would have referred to the EHR and not initiated CPR, again contrary to the resident's wishes. The process for updating and verifying code status orders was inconsistent, with reliance on both the EHR and physical binders, leading to discrepancies and confusion among staff. The facility's policy required that advance directives and code status be discussed at admission and reviewed at care conferences, but the process for ensuring that changes were accurately reflected in all relevant documentation was not followed. The case manager was responsible for entering provider-signed orders into the EHR, but this step was missed, resulting in outdated or incorrect information being available to staff. Staff training and understanding of where to find the most current code status information varied, contributing to the risk of not honoring residents' wishes regarding life-sustaining treatment.
Removal Plan
- Completed an audit of all residents' code status.
- Reviewed the process to ensure the entered POLST information into the EMR was accurate and updated.
- Educated licensed staff regarding the updated POLST procedure and where to find a residents' code status.
- Continued education for staff.
Failure to Ensure Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on-site for at least 8 consecutive hours on a daily basis, as required. Payroll Based Journal (PBJ) staffing data for a specific quarter revealed that there was no RN coverage on at least one weekend day. Specifically, on one Sunday, an open RN shift was posted but was ultimately filled by an LPN instead of an RN, resulting in a lack of required RN presence. The facility's assessment indicated the need for one RN for 40 residents, and staffing schedules showed RNs were typically scheduled for 12-hour shifts. However, the absence of an RN on the identified day was not recognized as an error at the time. Interviews with facility staff, including the Director of Operations (DOO), Staffing Coordinator (SC), and Human Resources (HR), confirmed the processes in place for managing RN coverage, such as using the OnShift app to post open shifts, maintaining an on-call rotation, and having contingency plans for emergency staffing. Despite these measures, the facility's scheduling and oversight failed to prevent a lapse in RN coverage, as the open shift was inadvertently assigned to an LPN. Staff interviews also revealed a misunderstanding regarding the allowable number of days without RN coverage per quarter, with the SC believing a maximum of three days was permitted, though the goal was zero.
Failure to Properly Assess and Document Use of Parameter Mattress as Restraint
Penalty
Summary
The facility failed to ensure that a parameter mattress, which is a type of mattress cover designed to create a gentle barrier around the edge of the bed, was not used in a manner that restrained a resident while in bed. The resident in question had moderate cognitive impairment, required assistance with all activities of daily living, and had multiple diagnoses including dementia, anxiety, and limited mobility. The resident's care plan indicated the use of a lipped mattress to decrease fall risk, but did not document the use of the parameter mattress as a restraint. The Minimum Data Set (MDS) and physical device assessment did not indicate the use of restraints or the parameter mattress for this resident. During observations and interviews, staff confirmed that the resident had a parameter mattress in place for several years to prevent falls, despite the resident being non-ambulatory and unable to get out of bed independently for approximately a year. The parameter mattress was not assessed or documented in the physical device assessment as required, and staff were unsure why it remained in use. The facility's policy defined physical restraints as any device that restricts freedom of movement and specified that such restraints should only be used for medical symptoms and not for staff convenience or fall prevention. The use of the parameter mattress in this case was not supported by assessment or documentation, leading to the deficiency.
Failure to Ensure Safe and Orderly AMA Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who left against medical advice (AMA). The resident, who had intact cognition and required minimal to limited assistance with activities of daily living, had multiple diagnoses including type II diabetes mellitus, major depressive disorder, hypertension, osteoarthritis, hypothyroidism, and hyperlipidemia. Although the resident had previously planned to discharge to an assisted living facility, she ultimately left the facility with her daughter, refusing to re-enter the building. The facility provided an AMA form for the resident to sign in a vehicle, but did not complete a comprehensive discharge plan or adequately document efforts to educate the resident about the risks of leaving AMA. There was no documentation of a recapitulation of stay or a discharge summary in the resident's electronic health record at the time of discharge. The discharge summary was only entered as a late entry after being requested by a surveyor. Interviews with facility staff confirmed that the usual process of providing a discharge summary, including information on medications, recent labs, and follow-up appointments, was not followed in this case. The facility also did not provide documentation of efforts to educate the resident about appeal rights or bed-hold policies at the time of the AMA discharge.
Failure to Develop Person-Centered Care Plan with Measurable Goals
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was reviewed for care planning. The resident had intact cognition and required moderate assistance with activities of daily living (ADLs). Diagnoses included acute respiratory failure with hypoxia, atrial fibrillation, hypertension, benign prostatic hyperplasia, diabetes mellitus, hyperkalemia, depression, obstructive sleep apnea, and mild cognitive impairment. The care plan for this resident included several problem statements such as ADL self-care performance deficit, diabetes management, altered cardiovascular and hematological status, use of antidepressant medication, pain management, vulnerability, altered respiratory status, and a wish to return to the community. However, each of these care plan entries lacked specific goals and interventions. During interviews, the DON and RN clinical coordinators confirmed that the MDS coordinator, who was responsible for entering and revising care plans, had left the facility several months prior, and the resident's care plan was neither completed nor individualized. The facility's policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, but this was not done for the resident in question.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that staff did not consistently follow prescribed care plans or honor the expressed wishes and goals of the resident. The lack of adherence to orders and resident preferences resulted in care that was not aligned with the individualized needs of the resident.
Failure to Assess Resident for Safe Use of Electric Recliner
Penalty
Summary
The facility failed to comprehensively assess a resident with moderate cognitive impairment and multiple medical diagnoses, including dementia, anxiety, and limited mobility, for safe use of an electric recliner. The resident's care plan indicated the use of a recliner to elevate her legs and identified her as a fall risk requiring assistance for bed mobility and transfers. However, the physical device assessment did not include the electric recliner, and there was no documentation that the resident's ability to safely use the recliner had been evaluated. Observations showed the resident using the electric recliner independently, with the remote consistently within reach. During one incident, staff had to intervene when the resident elevated the recliner to a point where she nearly slid to the floor. Interviews with staff revealed inconsistent understanding of the resident's ability to operate the recliner remote, with some stating she could use it and others noting confusion and fidgeting. Nursing leadership confirmed the recliner should have been assessed as part of the physical device assessment and acknowledged this was not done. The facility was unable to provide policies related to assistive device and physical device assessments.
Failure to Prevent Cross-Contamination During Meal Service
Penalty
Summary
During multiple dining observations, a resident was seen walking around the dining room and handling the coffee cups of other residents by touching the tops and rims while distributing them. This occurred during both lunch and breakfast meal services, with the resident picking up and handing out coffee cups to others, often gripping the cups around the top or rim. Staff members present in the dining area did not intervene or redirect the resident to prevent this contact, despite being aware that the resident regularly engaged in this behavior at every meal. Interviews with staff confirmed that the resident frequently assisted with coffee distribution and that staff did not take action to stop the resident from touching other residents' drinkware. The facility's Infection Preventionist acknowledged that such behavior was not in accordance with the facility's infection control protocols and that staff should have intervened to prevent possible transmission of infectious agents. The facility's infection prevention and control policy related to dining services was requested but not provided during the survey.
Failure to Notify Physician of Resident's Worsening Condition
Penalty
Summary
The facility failed to promptly notify a physician of a change in condition for a resident when a right lower leg abscess worsened and required hospitalization. The resident, who had a history of peripheral vascular disease, cerebrovascular accident, and was at risk for pressure ulcers, experienced significant pain and swelling in the right lower extremity. Despite the presence of a large, painful swelling on the resident's leg, the facility staff did not notify the physician in a timely manner, leading to a delay in appropriate medical intervention. The resident's condition was documented by various staff members, including physical therapy and nursing staff, who noted the presence of a softball-sized swelling, pain, and changes in skin integrity. However, there was a lack of communication and follow-up with the medical provider regarding these observations. The resident was eventually sent to the emergency room after the condition worsened, where he was diagnosed with cellulitis and a hematoma, requiring further medical treatment. Interviews with facility staff revealed inconsistencies in documentation and a failure to adhere to the facility's policy on notifying medical providers of changes in a resident's condition. Several staff members acknowledged that the provider should have been contacted earlier, and the resident's condition warranted immediate medical attention. The delay in notification and treatment highlights a deficiency in the facility's response to changes in resident health status.
Failure to Implement Physician's Orders and Coordinate Care
Penalty
Summary
The facility failed to implement treatment consistent with the resident's physician's orders and professional standards of practice for a resident who was not sent with sustenance to his appointment. The resident, who had diagnoses including acute respiratory failure, pneumonia, and adult failure to thrive, required tube feeding due to tongue cancer. The resident's Medication Administration Record indicated an order for Osmolite to be administered via gastrostomy tube four times a day. However, on two occasions, the resident did not receive the scheduled tube feeding while at the cancer center for appointments, and there was no evidence of staff notifying the resident's physician or adjusting the feeding schedule. Additionally, the facility did not adequately prepare for the resident's incontinence needs during appointments. The resident was reported to be incontinent multiple times during a cancer center visit, and the facility failed to send incontinence supplies or extra clothing, despite requests from the cancer center staff. The resident's care plan did not include interventions for these appointments, and staff did not revise the care plan or communicate the necessary adjustments to other staff members. The Director of Nursing confirmed that the resident did not receive the ordered tube feeding on specific dates and acknowledged the lack of documentation or consultation with the resident's physician. The facility's failure to coordinate care with the cancer center and to revise the resident's care plan to address these issues contributed to the deficiency. The facility also did not provide a requested policy for comprehensive care plans, indicating a lack of adherence to expected procedures.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store and label food properly, dispose of undated and expired food items, and maintain cleanliness in the kitchen, which had the potential to affect 34 residents who were provided meals from the kitchen. During an initial tour of the kitchen, surveyors observed multiple instances of improper food storage, including uncovered and undated jello and fruit cocktail in a cooler, outdated hamburger and hotdog buns stacked on the floor without signage, and improperly thawed fish in a sink with running water. Additionally, the dry storage area contained an open bag of breadcrumbs and loosely sealed bags of chocolate chips without labels. The walk-in cooler had several unlabeled and uncovered food items, including grated parmesan cheese, strawberries, cheese, apple pies, and hamburger logs. The walk-in freezer had significant ice buildup and improperly stored food items directly on the floor. In the food preparation area, a bin labeled as sugar was loosely covered with plastic wrap, leaving an open area exposed to potential contamination. During a second tour of the kitchen, surveyors observed similar issues, including unlabeled fruit cocktail cups in the three-door cooler and ice/frost buildup in the walk-in cooler. Several food items, including broccoli, shrimp, pumpkin pies, breaded chicken pieces, and beef sirloin, were stored directly on the floor of the walk-in freezer. Interviews with the dietary manager (DM) and the administrator revealed that the kitchen staff, who were contracted employees, had been trained on proper food storage procedures but were not consistently following them. The facility failed to provide a policy regarding food storage when requested by the surveyors.
Failure to Assess and Obtain Order for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications after staff set them up, and did not obtain an order for medication self-administration. The resident, identified as R27, was observed self-administering medications without staff supervision. R27, who had a BIMS score of 15 indicating cognitive intactness, was taking high-risk medications including opioids and anti-platelet medications. Despite this, there was no order for R27 to self-administer medications, nor was there a completed self-administration assessment. During an observation, R27 was seen taking pills from a medication cup left on the bedside table without knowing what the pills were or how long they had been there. Interviews with staff confirmed that medications were sometimes left in the room for R27 to take independently, despite the lack of a self-administration order or assessment. Facility guidelines require a self-administration assessment and a physician's order for residents to self-administer medications, but these procedures were not followed for R27.
Failure to Document and Communicate Transfer Information
Penalty
Summary
The facility failed to ensure adequate and required information was documented and communicated to a receiving healthcare facility when a resident was transferred emergently to a hospital. The resident, who had multiple diagnoses including essential hypertension, chronic kidney disease, and type 1 diabetes mellitus, was admitted to the facility after a brief hospitalization. The resident required significant assistance with daily activities and had intact cognition. On the night of the incident, the resident reported feeling nauseous, did not eat supper, and had one episode of vomiting. Later, the resident developed a moist non-productive cough and was placed on supplemental oxygen before being sent to the emergency room. However, the medical record lacked sufficient documentation that a notice of transfer had been provided or that communication with the receiving hospital had occurred, including essential information such as the reason for transfer, physician contact, and relevant medical details. Interviews with facility staff revealed that the process for transferring the resident was not followed correctly. A trained medication aide stated that the process should include getting an order from the provider, updating the family, and documenting the reason for the transfer in the electronic medical record (EMR). However, the registered nurse case manager and the registered nurse clinical reimbursement specialist both confirmed that there was no documentation in the EMR explaining why the resident was transferred to the emergency room or any communication with the provider and receiving hospital. The facility's documented process for notice of transfer/discharge, which includes providing a written notice and relevant medical information, was not adhered to in this case, leaving many questions unanswered.
Failure to Inform Resident of Bed Hold Rights During Hospitalization
Penalty
Summary
The facility failed to ensure that a resident or their legal representative was informed of bed hold rights at the time of hospitalization. The resident, who had intact cognition, was sent to the emergency room, but there was no documentation in the medical record indicating that a bed hold notification was provided to either the resident or her son, who was her emergency contact. The progress note indicated that the son was notified of the hospitalization, but there was no mention of a bed hold. Interviews with the registered nurse case manager and the registered nurse clinical reimbursement specialist confirmed that the bed hold form was not completed or documented in the resident's medical record. The facility's policy, updated in October 2021, required that residents and their representatives be given a Notice of Transfer for any transfer to acute care or an emergency department, including a bed hold notification. This notice should be provided prior to or within 48 hours of the transfer and documented in the resident's medical record. However, the review of the resident's electronic and paper medical records showed no evidence that this process was followed, resulting in a deficiency in the facility's compliance with its own transfer and bed hold notification procedures.
Failure to Ensure Coordination of Care for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper coordination of care and communication between the facility and the dialysis center for a resident receiving hemodialysis. The resident, who had diagnoses including atrial fibrillation, hypertension, peripheral vascular disease, and end-stage renal disease, attended dialysis three times per week. Despite having pre and post-dialysis assessments documented in the electronic medical record, the resident's record lacked a dialysis care plan and did not include the name, address, and phone number of the dialysis center. Interviews with facility staff and the dialysis center's registered nurse revealed that no paperwork was exchanged between the facility and the dialysis center, and no clinical communication was documented in the resident's records. The dialysis center's registered nurse confirmed that the resident never arrived with paperwork from the facility, and the facility's registered nurse case manager and trained medication aide corroborated that no documents were sent or received. The facility's policy indicated that dialysis patients should have a care plan including the dialysis location and schedule, but this was not followed. Additionally, a request for a copy of the contract with the dialysis center was not fulfilled, further indicating a lack of formalized communication and coordination between the two entities.
Failure to Ensure Medication Availability and Administration
Penalty
Summary
The facility failed to ensure that medications were available and administered as prescribed by the physician for a resident diagnosed with atherosclerotic heart disease, diabetes mellitus type II, chronic A-fib, and end-stage renal failure. The resident had orders to take Vascepa, a medication used to reduce the risk of heart attack or stroke, but missed 19 doses over a period of ten days. The pharmacy technician reported no documentation of communication from the facility regarding the missing medication, and the trained medication aide and registered nurse charge nurse were unaware of why the medication had not been delivered. The registered nurse case manager stated that the provider should have been notified early in the process when the resident was missing medication doses. The administrator was unaware of the missed medication doses until informed by the surveyor and indicated that a change in the resident's payer source was a primary reason for the medication not being sent. The nurse practitioner, who had been in frequent contact with the facility, was not notified of the missed doses and stated that her expectation was to be informed after the first missed dose. The facility's medication ordering and receiving policy indicated that medications should be reordered several days in advance to ensure an adequate supply, but this procedure was not followed in this case.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer or provide the pneumococcal vaccine to a resident who was eligible for it. The resident, who had diagnoses including congestive heart failure, diabetes, and hypertension, had received previous pneumococcal vaccinations (Prevnar 13 and Pneumo-PPSV23) and was eligible to receive the PCV20 vaccine beginning December 2023. However, the facility's electronic medical record (EMR) incorrectly indicated that the resident was not eligible until December 2024, which was outside the CDC recommendation of five years after the last dose of Pneumo-PPSV23. Additionally, there was no evidence in the EMR that the resident was provided education, offered, or received the PCV20 vaccination. During an interview, the Director of Nursing (DON) stated that the facility followed CDC recommendations for pneumococcal vaccinations and used a CDC-based tool to track eligible residents. The DON mentioned that newly admitted residents who were eligible for vaccines would see the provider on the next rounding date, and the facility would request orders to administer the vaccine at that visit. Monthly audits were also performed to catch eligible residents. Despite these procedures, the resident's EMR and facility policy, which reportedly followed CDC guidance, incorrectly indicated the resident's eligibility date, leading to the failure to offer the PCV20 vaccine in a timely manner.
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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