The Villas At Osseo Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Osseo, Minnesota.
- Location
- 501 Second Street Southeast, Osseo, Minnesota 55369
- CMS Provider Number
- 245629
- Inspections on file
- 38
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Villas At Osseo Llc during CMS and state inspections, most recent first.
A resident with a right femur fracture and chronic low back pain received PRN oxycodone-acetaminophen multiple times without consistent evidence that non-pharmacological (non-pharm) interventions were attempted or documented beforehand. The care plan and facility pain protocol called for measures such as repositioning, ice, heat, and massage, and the MAR included a task list for non-pharm options, but documentation showed only once-per-shift entries, mostly offering food and rarely repositioning, rather than entries tied to each PRN dose. Nursing notes lacked comprehensive pain assessments, including pain location and characteristics, and did not record which non-pharm interventions were offered, attempted, refused, or their effectiveness. In interviews, the resident reported that ice and repositioning helped when requested, and clinical staff and leadership described an expected process of assessing pain, trying conservative measures first, and documenting all interventions, which was not reflected in the resident’s record.
A resident with gas gangrene and a foot ulcer was discharged from the hospital with an order for amoxicillin-pot clavulanate to be given twice daily starting on the day of admission and stopping on a specified later date. Although the facility’s physician order matched the hospital discharge order, the MAR was transcribed with a start date one day later, so the medication did not populate for administration until the following evening. As a result, the resident missed two ordered doses. The pharmacist, RN staff, NP, and DON all confirmed that medications are expected to start on the day of admission unless a different start date is ordered, that the first dose was not given until the next day’s evening shift, and that the order had not been transcribed accurately in accordance with facility policy.
A resident with complex medical needs received five times the prescribed dose of Methadone over three days due to staff failing to verify the medication concentration and dosage on the prescription label, instead relying on outdated records. Multiple nurses administered the incorrect dose, resulting in the resident experiencing impaired speech, inability to verbalize needs, decreased oral intake, and increased lethargy.
A resident with multiple chronic conditions experienced a significant weight loss and decreased appetite over several weeks. Despite care plan directives and staff observations of declining intake, the resident's family was not promptly notified of the change in condition or related medical interventions. Documentation and interviews confirmed that the facility did not follow its policy for timely communication with the resident's representative.
A non-verbal resident with multiple serious health conditions did not receive appropriate pain management due to staff failing to use the correct pain assessment tool, discontinuing pain medication orders before new ones were entered, and not consistently monitoring or documenting pain. The resident experienced unmanaged pain, with family and hospice staff reporting distress and delays in receiving pain relief.
The facility failed to assess the safety and necessity of side rails for two residents before use. One resident with a history of falls and diabetes was observed with raised side rails without documented assessment or consent. Another resident with a lumbar fracture had assist bars without proper assessment or consent. Staff confirmed the lack of necessary evaluations.
A resident with cognitive and physical impairments suffered a fall and injury due to neglect and rough handling by a nursing assistant. The assistant failed to follow the care plan, which required a mechanical standing lift for transfers, and instead used a non-care planned approach. Despite the resident's voiced pain and distress, the assistant continued with unsafe handling, resulting in a fall and a distal femur fracture requiring hospitalization.
A resident with cognitive impairments and a history of elopement risk managed to remove her wanderguard and exit the facility without staff knowledge, remaining outside in cold weather for 30 minutes. The facility failed to ensure consistent monitoring and documentation of the wanderguard, and staff did not adhere to the elopement policy, resulting in a breakdown of communication and protocol adherence.
A resident with cognitive intactness and physical impairments was not treated with dignity when a nursing assistant refused to assist her to the smoking area, contrary to her care plan. The resident, who was at high fall risk, had previously fallen when unassisted. The DON acknowledged inappropriate communication and ongoing staff training.
A resident with dementia experienced two falls resulting in a hip and neck fracture. The facility failed to notify the resident's representative due to incorrect contact information, despite attempts to correct it. The facility's policy requires immediate notification of such incidents, which was not followed.
A resident with dementia and a history of falls did not receive a falls assessment upon admission, leading to multiple falls and a hip fracture. The facility staff acknowledged the oversight, as the assessment was only completed after the resident's hospital return.
A facility failed to update a resident's care plan with fall interventions after the resident, who had dementia and a history of falls, experienced a hip fracture and a subsequent neck fracture. The care plan included interventions like physical therapy and a toileting plan, but was not updated after the resident's hospital re-entry. Interviews revealed communication gaps and a lack of specific intervention suggestions, contrary to the facility's care planning policy.
The facility failed to provide medications as ordered for three residents, resulting in deficiencies. An LPN's error led to a missed INR test and Coumadin doses for one resident. Another resident did not receive niacin for hypertension due to stock issues, and a third resident missed nicotine patches. The LPNs did not notify supervisors or providers about the missing medications, and facility procedures for documenting and reporting errors were not followed.
The facility failed to follow proper infection control practices during blood glucose checks for two residents with diabetes. An LPN used an alcohol wipe instead of the required disinfectant wipe for cleaning the glucometer, and another LPN placed the glucometer directly on surfaces without proper disinfection. The clinical manager confirmed the facility's procedure required bleach wipes, which were not used.
The facility inaccurately reported staffing data to CMS for Q2 2024, showing low weekend staffing despite adequate levels. The administrator noted that contracted staff hours were not recorded as regular hours, causing the discrepancy. A policy on PBJ reporting was not provided.
A facility failed to use professional interpreter services for a resident who frequently experienced pain and spoke Ukrainian. Despite having a care plan that required interpreter use, staff relied on the resident's personal phone and a translator app, which was ineffective. The resident became distressed during care, and staff did not offer to contact the professional service, leading to communication breakdowns and increased frustration.
A facility failed to notify the Ombudsman of a resident's hospitalization, missing a required written notification. The resident had multiple health issues and was hospitalized, but the facility did not send the necessary notification to the Ombudsman. The oversight was acknowledged by the facility's administrator and social service director, who noted a reporting issue that led to the omission.
A facility failed to complete a Level II PASARR for a resident with anxiety disorder and schizophrenia. Although a Level I PASARR indicated the need for a Level II screening before admission, it was not completed. The social worker admitted to a lack of communication with the lead agency, and the administrator stressed the importance of completing the screening to meet the resident's needs. A policy on PASARR was requested but not provided.
The facility failed to implement interventions for two residents to prevent decreased range of motion and mobility. One resident with Parkinson's disease did not receive prescribed daily stretches, and documentation showed tasks were not completed. Another resident with multiple myeloma was not offered walking with a walker and brace as prescribed, and a standing recommendation was not relayed from therapy. The DON confirmed the lack of follow-up on incomplete tasks.
A resident with multiple medical conditions sustained a hematoma on the right leg during a transfer involving a defective lift. The facility failed to report the injury to the State Agency, despite policy requirements and a family member witnessing a rough transfer. The administrator was unaware of the injury's cause and did not report it, believing there was no intent to harm.
A resident with multiple medical conditions was found with a hematoma on her leg, but the facility failed to investigate the cause. Despite reports of a rough transfer and the resident's leg hitting a mechanical lift, no follow-up was conducted. The facility's policy requires immediate investigation, but this was not completed due to the unavailability of the DON.
A resident on hospice care experienced a seizure, and the facility nurse initially denied the seizure and attempted to administer Ativan instead of calling 911 as requested by the family. The family called 911, and the resident was transported to the hospital, where she continued to have seizures and later passed away. The facility failed to honor the family's treatment decisions and adequately address their concerns.
A facility failed to recognize and report a potential allegation of neglect to the State Agency in a timely manner for a resident with stage IV cancer. The resident's family reported concerns about unsanitary and unsafe room conditions, bruising and bleeding in the mouth, delayed patient care, and a nurse refusing to contact 911. Despite these concerns, no report was filed, and the facility did not take immediate action to investigate the allegations properly.
The facility failed to administer medications according to physician orders for 10 residents, resulting in late or missed doses. Staff did not update providers or managers about the delays, causing distress and potential health risks for the residents.
The facility failed to administer insulin according to physician orders for four residents, resulting in delayed and omitted doses. An LPN was responsible for 25 residents and was unable to administer insulin on time, leading to potential risks of hypo/hyperglycemia. The facility's policies for timely medication administration were not followed, and there was a lack of communication with providers and supervisors about the delays and omissions.
Failure to Use and Document Non-Pharmacological Interventions Before PRN Narcotics
Penalty
Summary
The facility failed to ensure non-pharmacological pain interventions were attempted, offered, and documented prior to administering PRN narcotic pain medication for one resident. The resident had diagnoses including a right femur fracture, hypotension, and low back pain, and her admission MDS indicated no cognitive impairment with occasional pain that interfered with daily activities, therapy, and sleep. Her care plan identified altered comfort related to the femur fracture and low back pain, with interventions such as positioning, rest, and massage. A provider order authorized oxycodone-acetaminophen 10-325 mg every six hours PRN for chronic pain, without specifying the pain location. The MAR for the month showed 17 administrations of oxycodone-acetaminophen and included a task to document non-pharmacological interventions each shift, such as ice, heated blankets, massage, repositioning, music, essential oils, food or drink, and relaxation breathing. However, documentation of non-pharmacological interventions was completed only once per shift rather than in relation to each PRN narcotic administration, and the entries showed the resident was offered food 20 times and repositioning once, with no other interventions recorded. Between admission and the survey review period, the record lacked comprehensive pain assessments that would identify pain location and characteristics. Nursing notes documented the date and time of PRN narcotic administration but did not indicate what, if any, non-pharmacological measures were attempted or offered beforehand, nor did they document the effectiveness of any such interventions when they were used. During interviews, the resident reported that ice and repositioning helped her leg pain and that staff would bring ice if she asked but did not offer it before giving a pain pill. Multiple nursing staff, the NP, and the DON all described an expected process that included assessing pain location and intensity, offering non-pharmacological measures first, and documenting interventions and effectiveness, and the DON confirmed that R3’s record did not show non-pharmacological interventions offered, attempted, or refused prior to PRN narcotic administration, despite the facility’s Pain Management Protocol requiring such comforting and complementary interventions.
Failure to Accurately Transcribe Antibiotic Order Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and initiate an antibiotic order as written by the physician for one resident. The resident had diagnoses including gas gangrene and a foot ulcer and was discharged from the hospital with an order for amoxicillin-pot clavulanate 875-125 mg, one tablet twice daily, to start on the day of discharge and stop on a specified later date. The facility’s physician order matched the hospital discharge order, including the start and stop dates. However, the January and February MARs listed the start date as the day after admission, with the first scheduled administration on the evening shift, resulting in the evening dose on the day of admission and the morning dose the following day not being given. The resident’s MDS indicated no cognitive impairment and documented that the resident was administered an antibiotic. Interviews confirmed that the antibiotic was delivered to the facility on the day of admission and that medications are expected to start on the day of admission unless a different start date is ordered. The pharmacist stated that medications should start on the day of admission in the absence of a specific alternate start date. Nursing staff reported that medications appear on the MAR based on the transcribed start date and confirmed that the first dose of the antibiotic was not given until the evening of the day after admission, acknowledging that it should have started the prior day. The NP stated that medications should start on the day of admission unless otherwise specified and that the provider should be notified of missed doses, but did not recall being notified of the two missed doses. The DON acknowledged that the order was not transcribed accurately, as the start date should have been the day of admission, which resulted in two missed doses, contrary to the facility’s policy requiring accurate and timely transcription of medication orders including correct start and stop dates.
Failure to Follow Five Rights of Medication Administration Leads to Significant Methadone Overdose
Penalty
Summary
Facility staff failed to follow the five rights of medication administration for a resident with multiple complex medical conditions, including Multiple Sclerosis, paraplegia, and chronic pain. The staff did not compare the written order on the Medication Administration Record (MAR) with the prescription label on the Methadone bottle before administration. As a result, the resident received five times the prescribed dose of Methadone over the course of three days, totaling nine incorrect administrations. The error occurred because staff administered Methadone based on outdated or incorrect information, specifically using the concentration and dosing instructions from a discontinued medication bottle rather than the current prescription. Multiple nurses, including agency staff, RNs, and LPNs, administered the incorrect dose, each failing to verify the medication concentration and dosage as indicated on the new prescription bottle. The MAR and narcotic record contained conflicting information, and staff relied on these records without cross-checking the actual medication label, leading to repeated overdoses. The resident experienced a significant decline following the medication errors, including impaired speech, inability to verbalize needs, decreased oral intake, lethargy, and increased weakness. Observations and interviews with staff and the resident's significant other confirmed these changes, noting that the resident was previously able to speak and eat but became largely nonverbal and unable to tolerate food or oral medications after the errors. The medication error was discovered during a medication count, and subsequent interviews revealed that staff had not recognized the change in medication concentration or the impact of the error until the resident's condition had significantly deteriorated.
Removal Plan
- Provide education to nurses on medication administration and transcription, the five rights of medication administration, ensuring medication labels match physician orders, and contacting pharmacy or physician for clarification.
- Educate all nurses on medication types, prevention of errors, high risk medications, and compliance with national safety standards.
- Review pain medication management for accuracy and ensure the label on the bottle matches the physician order in the medical record.
- Review orders and liquid medication labels for all like residents to ensure labels on bottles match the orders in the medical record.
- Initiate compliance audits.
Failure to Timely Notify Family of Resident's Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's representative in a timely manner following a significant change in the resident's condition, specifically an 8.9-pound weight loss over 27 days. The resident had multiple medical diagnoses, including cancer, diabetes, heart failure, seizure disorder, and depression, and was noted to be cognitively intact and independent with activities of daily living. The care plan included monitoring for nutritional problems and weight changes, but despite documented weight loss and decreased appetite, there was no evidence that the family was promptly informed. Medical records and staff interviews revealed that the resident experienced a notable decline in appetite and food intake, with staff observing the resident eating alone in her room, refusing dining room meals, and not wanting assistance. Orders were placed by the nurse practitioner for laboratory tests and medication adjustments in response to the weight loss and anorexia, but no new interventions were initiated based on the results. The registered dietician assessed the weight loss and communicated with the nurse practitioner but did not contact the family until much later, after the issue was identified during the survey. The resident's family member reported only being notified of the weight loss by the nurse practitioner and not by facility staff, and was unaware of the earlier changes in condition and medical interventions. The facility's policy required timely notification of changes in a resident's condition to the resident and/or their representative, but documentation and interviews confirmed that this did not occur in this case. Progress notes lacked evidence of communication with the family regarding the weight loss, and staff interviews indicated a lack of clarity about who was responsible for family notification.
Failure to Provide Safe, Appropriate Pain Management for Non-Verbal Resident
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and implement appropriate pain monitoring and management for a non-verbal resident receiving palliative and hospice care. The resident had multiple serious medical conditions, including pneumonia, obesity, hypertension, congestive heart failure, atrial fibrillation, and was on long-term insulin. The care plan directed staff to use non-pharmacological interventions and pain medications as ordered, and to monitor for pain and medication side effects. Despite these directives, staff did not consistently use an appropriate pain assessment tool for the resident's non-verbal status, instead documenting pain using a numerical scale that required verbal input, which the resident could not provide. A significant lapse occurred when the resident went nearly four hours without access to pain medication due to a medication transcription error. Previous pain medication orders were discontinued before new orders were entered into the system, leaving the resident without any pain management options during this period. Multiple staff interviews confirmed that the correct procedure would have been to continue the previous pain orders until the new medications were available, but this was not followed. The resident's family and hospice staff reported distress over the resident's unmanaged pain, and documentation showed the resident was observed to be in pain, with behaviors such as calling out, groaning, and agitation. Further review revealed that after the medication orders were changed, staff failed to document any pain assessments for the resident, and when assessments were documented, they were often done incorrectly using a numerical scale rather than a non-verbal pain assessment tool like PAINAD. Staff interviews indicated a lack of understanding and adherence to proper pain assessment protocols for non-verbal residents. The facility's own policies required timely and accurate transcription of medication orders and individualized pain management plans, but these were not followed, resulting in the resident experiencing unmanaged pain and discomfort.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that side rails were comprehensively assessed for safety and necessity before use for two residents. One resident, who had intact cognition and a history of repeated falls and type 2 diabetes with a foot ulcer, was observed with side rails raised on both sides of the bed. The resident's care plan did not include information about bed rails, and there was no evidence in the electronic medical record (EMR) of a side rail assessment or informed consent. The resident did not recall being informed about the risks associated with side rails. Another resident, also with intact cognition and diagnoses including lumbar fracture and muscle weakness, was observed with raised assist bars. This resident's care plan similarly lacked information about bed rails, and the EMR did not show evidence of a side rail assessment or informed consent. The resident remembered being asked about the use of assist bars but could not recall being informed of the risks. Staff confirmed the lack of assessments and the director of nursing stated that assessments were necessary to ensure safety and appropriateness of side rail use.
Resident Suffers Injury Due to Neglect and Rough Handling
Penalty
Summary
The facility failed to protect a resident from abuse and neglect, resulting in a fall and injury. The resident, who was moderately cognitively impaired and required extensive physical assistance for bed mobility and transfers, was deprived of her care-planned needs. Despite voicing pain and showing signs of distress, the resident was handled roughly by a nursing assistant who did not follow the care plan, which required the use of a mechanical standing lift for transfers. The resident's care plan indicated she needed assistance due to conditions such as a stroke, right-sided hemiplegia, severe morbid obesity, and chronic pain syndrome. However, the nursing assistant attempted to transfer the resident without the required mechanical lift, instead using a non-care planned approach. This resulted in the resident being placed in unsafe positions and ultimately falling, leading to a distal femur fracture that required hospitalization and surgical intervention. Video footage revealed the nursing assistant's rough handling and failure to communicate effectively with the resident, who was visibly struggling and in pain. The nursing assistant did not seek additional help or alter her approach, despite the resident's distress. The facility's investigation confirmed that the nursing assistant did not follow the care plan, contributing to the resident's fall and injury.
Removal Plan
- Internal investigation was initiated.
- Ad Hoc QAPI meeting was held.
- NA-B was placed on suspension.
- OHFC report was filed, along with a police report.
- Staff education with associated quiz was initiated regarding Abuse, Safe Patient Handling, Resident Rights, and Care Planning.
- Observation transfer and resident treatment audits were initiated.
- Like resident care plans and care guides were reviewed to ensure current reflection of transfer needs.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident who was at risk for elopement and had a history of removing her wanderguard. The resident, who was moderately cognitively impaired and had multiple medical conditions including COPD, diabetes, and schizophrenia, managed to remove her wanderguard and exit the facility without staff knowledge. She was outside in 17-degree weather for approximately 30 minutes before being found by staff. The resident was not immediately assessed upon reentry, and the provider, family, and managerial staff were not promptly informed of the elopement. The resident's care plan included the use of a wanderguard to alert staff of her movements, but there was a lack of consistent monitoring and documentation regarding the wanderguard's placement and functionality. Despite previous incidents where the resident had removed her wanderguard, staff failed to ensure it was properly secured and functioning. The resident's medical record lacked evidence of consistent monitoring of the wanderguard, and staff documented checks that were not actually performed. Interviews with staff revealed a lack of understanding and adherence to the facility's elopement policy. The LPN responsible for monitoring the resident's wanderguard admitted to not physically checking it and was unaware of where to find replacements. The DON and administrator were not informed of the missing wanderguard or the resident's elopement in a timely manner, indicating a breakdown in communication and protocol adherence within the facility.
Removal Plan
- Internal investigation initiated.
- LPN-A placed on suspension.
- OHFC report filed, Risk Management and Incident review and analysis initiated.
- R1's skin assessed (no injuries observed), elopement risk evaluation completed (score of 7), behavioral monitoring for emotional distress and exit seeking behavior initiated, care plan reviewed and updated, provider and family notification completed, placed on 15-minute checks, wanderguard placed on right wrist and w/c.
- All wanderguards tested for functionality.
- Staff education with associated quiz initiated regarding elopement policy and procedure, including interventions, response, and reporting.
- Wanderguard placement audits conducted on the 3 residents identified for wanderguard use.
- All resident Elopement Evals reviewed to ensure up to date.
- Ad Hoc QAPI meeting held.
Failure to Uphold Resident Dignity and Communication
Penalty
Summary
The facility failed to communicate in a dignified manner with a resident who was reviewed for dignity. The resident, who was cognitively intact and had conditions such as depression, paraplegia, hemiparesis, and hemiplegia, required maximum assistance with daily activities and used a wheelchair. The resident's care plan indicated that staff should accompany her to and from the smoking area after meals due to her high fall risk. However, during an observation, a nursing assistant was seen arguing with the resident about going outside to smoke, and the resident expressed that the nursing assistant was rude and refused to assist her, despite her care plan requirements. The incident was further corroborated by interviews with staff. A registered nurse confirmed that the resident had previously fallen while trying to return from the smoking area unassisted, leading to a plan for staff to assist her. The director of nursing acknowledged that the nursing assistant's tone and language were inappropriate and mentioned ongoing training on communication with residents. The facility's policy on resident rights emphasized the importance of treating residents with respect and dignity, which was not upheld in this instance.
Failure to Notify Resident's Representative After Falls
Penalty
Summary
The facility failed to notify a resident's representative in a timely manner following two separate incidents where the resident experienced falls resulting in injuries. The resident, who had a diagnosis of dementia and mild cognitive impairment, was hospitalized twice due to falls, first with a hip fracture and later with a neck fracture. Despite the care plan indicating the resident was at risk for falls and required assistance, the facility did not successfully contact the resident's power of attorney (POA) after these incidents. The first incident occurred when the resident fell while attempting to go to the bathroom, resulting in a hip fracture. Although staff attempted to contact the family, they were unable to reach them due to an incorrect phone number in the system. The resident was sent to the hospital for surgical repair without the family being informed. The second incident involved the resident falling and hitting their head, leading to a neck fracture. Again, staff attempted to contact the family but were unsuccessful due to the same incorrect phone number. Interviews with the family member revealed that they were upset about not being informed of the hospitalizations and had previously corrected the phone number with the facility. However, the business office manager had reverted the number back to the incorrect one, leading to repeated communication failures. The facility's policy requires immediate notification of the resident's representative in such events, which was not adhered to in these cases.
Failure to Conduct Initial Falls Assessment
Penalty
Summary
The facility failed to complete an initial comprehensive assessment for a resident upon admission, specifically neglecting to conduct a falls assessment. The resident, who had a diagnosis of dementia and mild cognitive impairment, experienced multiple falls after admission. The resident required partial assistance with activities of daily living and had a history of falls, yet the necessary fall risk evaluation was not performed upon admission. This oversight was confirmed by interviews with facility staff, who acknowledged that the falls assessment was only completed after the resident returned from the hospital following a hip fracture. The resident experienced several falls, including one incident where they were found on the floor outside the transitional care unit entrance, and another where they fell next to their bathroom, resulting in a hip fracture. The facility's failure to conduct a timely falls assessment upon admission contributed to these incidents. Despite the resident's known history of falls and cognitive impairment, the necessary precautions and assessments were not implemented, leading to repeated falls and subsequent injury.
Failure to Update Care Plan with Fall Interventions
Penalty
Summary
The facility failed to update the care plan with identified fall interventions for a resident (R3) who was at risk for falls. R3's admission Minimum Data Set (MDS) indicated a diagnosis of dementia, mild cognitive impairment, and a history of falls since admission. The care plan, dated 11/07/24, identified R3's risk factors for falls, including gall bladder surgery, muscle weakness, and dementia. Interventions included physical therapy, keeping the room clutter-free, and a toileting plan. However, the care plan was not updated with new interventions after R3's re-entry from the hospital following a hip fracture on 10/16/24, and an additional fall on 11/08/24 resulted in a neck fracture. Interviews with the Director of Nursing (DON) and a Certified Occupational Therapist Assistant (COTA) revealed gaps in communication and implementation of fall interventions. The DON stated that the toileting intervention was added after R3's hospital re-entry, but it was not effectively updated in the care plan. The COTA mentioned that R3 was impulsive and that the facility did not use bed or chair alarms, and she did not recall any specific intervention suggestions for R3. The facility's care planning policy requires that care plans be modified and updated as the resident's condition and care needs change, which was not adhered to in this case.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide medication as ordered by the physician for three residents, leading to deficiencies in pharmaceutical services. For Resident 1, a physician's order directed to hold warfarin on specific dates and recheck INR on a subsequent date. However, due to an error by an LPN in entering the lab order into the computer system, the INR test was missed, and the resident did not receive the prescribed Coumadin from August 23 to August 27. The case manager confirmed the error, and the LPN admitted to the mistake in entering the order. Resident 2 was prescribed niacin for hypertension, but the medication was not available in stock, and the resident did not receive it for two days. The LPN responsible did not inform her supervisor or the provider about the unavailability of the medication. Similarly, Resident 3 was prescribed a nicotine patch, but it was not administered on multiple occasions due to it being on order. The LPN did not notify the provider or her supervisor about the missing medication, nor did she start a medication error report. The facility's procedures for documenting and reporting medication errors were not followed, contributing to the deficiencies.
Inadequate Infection Control During Blood Glucose Checks
Penalty
Summary
The facility failed to maintain proper infection control practices during blood glucose checks for two residents diagnosed with diabetes mellitus. The first resident's blood glucose was checked by an LPN who placed the glucometer on the bed linens and then on the over-the-bed table without following the correct cleaning protocol. The LPN used an alcohol wipe to clean the glucometer, unaware of the requirement to use a designated disinfectant wipe that should remain in contact with the glucometer for two minutes. Similarly, another LPN conducted a blood glucose check for a second resident and placed the glucometer directly on the over-the-bed table. After the procedure, the LPN placed the glucometer back into the bin without disinfecting it, later using an alcohol wipe instead of the required bleach wipe. The clinical manager confirmed that the facility's procedure required the use of bleach wipes, with the glucometer wrapped in the wipe for one minute, which was not followed in these instances.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate staffing data to the Centers for Medicare and Medicaid Services (CMS) for the second quarter of the fiscal year 2024. The Payroll Based Journal (PBJ) report indicated excessively low weekend staffing levels, which contradicted the facility's daily staff schedules and staffing reports that showed adequate staffing on weekends. During an interview, the administrator acknowledged that the staffing levels did not change from weekdays to weekends and explained that contracted staff hours were not recorded as regular staff hours, leading to inaccuracies in the PBJ report. The facility was unable to provide a policy related to PBJ reporting when requested.
Failure to Utilize Professional Interpreter Services
Penalty
Summary
The facility failed to utilize professional interpretive services for a resident who was cognitively intact and frequently experienced pain. The resident, who spoke Ukrainian and had a care plan indicating the need for communication via an interpreter, was instead communicated with using a personal cell phone and a translator app, which was ineffective. During multiple interactions, the resident became tearful and agitated due to the inability of staff to communicate effectively, leading to distress during wound care and other personal care activities. Despite the availability of a professional interpreter service, staff relied on the resident's phone, which failed to translate correctly, and did not offer to contact the professional service. Interviews with staff revealed a lack of consistent use of the professional interpreter service, with some staff stating they only used it if they could not understand the resident's needs. The Director of Nursing acknowledged the expectation to use the service if the resident was upset and the phone was not working. A traveling nursing assistant was not informed about communication methods with the resident, highlighting a gap in staff training. The resident expressed that using the professional service would have reduced frustration, but felt staff were reluctant to use it due to perceived wait times.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a written notification of transfer or discharge was sent to the office of the Ombudsman for a resident who was hospitalized. The resident, identified as R30, had a significant change in their Minimum Data Set (MDS) which included diagnoses such as high blood pressure, renal insufficiency, diabetes, cerebral vascular accident, aphasia, hemiplegia, anxiety, depression, and chronic obstructive pulmonary disease. The resident was hospitalized from May 5 to May 10, 2024, but the medical record lacked evidence that a written notification of this transfer was sent to the Ombudsman. The facility's administrator and social service director acknowledged the oversight. The administrator provided a list of notifications sent from January through May, which was submitted on August 22, 2024, indicating an attempt to rectify the missed notification. The social service director explained that they were responsible for generating and sending the report to the Ombudsman but realized in May that not all appropriate residents were included in the report. They confirmed that no notification was sent for the resident in question, emphasizing the importance of such notifications as the Ombudsman serves as an advocate for residents. The facility's policy on Bed-Holds and Returns, updated in February 2023, requires that copies of notices for emergency transfers be sent to the Ombudsman.
Failure to Complete Level II PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed for a resident with a serious mental illness diagnosis. The resident, identified as R25, had diagnoses including anxiety disorder and schizophrenia. A Level I PASARR was completed prior to admission on 5/12/23, indicating that a Level II PASARR was required before the resident's admission to the nursing facility. However, no Level II PASARR was found in the resident's medical record. During an interview, a social worker stated that the normal process involved completing a Level II PASARR prior to admission, but acknowledged that there had been no communication with the lead agency regarding this requirement for several months. The facility administrator confirmed that it was the responsibility of the social services department to request and ensure the completion of the Level II screening before admission. The administrator emphasized the importance of having the Level II PASARR completed to ensure the facility could meet the resident's individual needs. A policy related to PASARR was requested but not provided.
Failure to Implement Mobility and ROM Interventions
Penalty
Summary
The facility failed to implement interventions to prevent further development of decreased range of motion and mobility for two residents. The first resident, diagnosed with Parkinson's disease and contracture of the left ankle and foot, was observed with feet not resting on wheelchair foot pedals and no brace or positioning device in use. Despite a physical therapy discharge summary recommending daily stretches and a restorative ROM program order, documentation showed the task was mostly marked as not applicable, indicating it was not completed. The care coordinator confirmed the lack of follow-up on the incomplete tasks. The second resident, diagnosed with multiple myeloma and arthritis, reported not being offered the opportunity to walk with a walker and brace as prescribed. The resident's care plan included instructions to walk with assistance three times per week, but documentation showed the task was mostly marked as not applicable. The LPN confirmed the absence of documentation for the therapy recommendation to stand daily, which was not relayed from therapy. The DON acknowledged the lack of follow-up on the incomplete tasks and the failure to start the standing recommendation due to missing documentation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency, involving a resident who sustained a hematoma on the right leg. The resident, who had intact cognition and multiple medical conditions including acute kidney disease and respiratory failure, was involved in an incident during a transfer from bed to wheelchair. The incident report indicated that a defective full-body lift was the root cause of the injury, leading to a bruise on the resident's left lower extremities. However, a subsequent assessment revealed a swollen lower right extremity, with the resident experiencing significant pain and requiring hospitalization. Interviews revealed that the facility administrator was unaware of how the injury occurred and did not report it to the State Agency, as they believed there was no intent to harm and no grievances were filed. However, a family member witnessed a rough transfer where the resident's right leg hit the mechanical lift, correlating with the location of the hematoma. The facility's policy requires reporting injuries of unknown sources, especially when the injury is suspicious due to its extent or location, but this was not adhered to in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was reviewed for abuse. The resident, who had intact cognition and multiple medical conditions including acute kidney disease and muscle weakness, was found with a hematoma on her right leg. The injury was discovered by a nursing assistant and reported to a registered nurse, who assessed the resident and sent her to the emergency department for evaluation. However, no measurements of the injury were taken, and there was no investigation conducted to determine how the injury occurred. Interviews with staff and family members revealed that the resident had experienced a rough transfer, during which her leg hit a piece of the mechanical lift, potentially causing the hematoma. Despite this information being shared with the facility administrator, no follow-up or investigation was conducted. The facility's policy requires an immediate investigation of such incidents, but this was not completed, as the director of nursing, who usually leads investigations, was unavailable. The facility's failure to investigate the injury violated their Abuse Prohibition/Vulnerable Adult Policy.
Failure to Allow Family Participation in Treatment Decisions
Penalty
Summary
The facility failed to allow a resident's legal representative to participate in treatment decisions for a resident who was on hospice care. The resident, who had a history of stage IV metastatic rectal cancer and other serious health conditions, experienced a seizure. Despite the family's insistence on calling 911, the facility's nurse initially denied the seizure and attempted to administer Ativan instead, as directed by the hospice nurse. The family ultimately called 911 themselves, and the resident was transported to the hospital, where she continued to have seizures and later passed away. The resident's care plan indicated she was on hospice care and had a do-not-resuscitate (DNR) order. The care plan also directed staff to maintain communication with hospice and involve them in care conferences. However, during the incident, the facility nurse did not immediately honor the family's request to send the resident to the hospital, leading to a delay in medical treatment. The family reported concerns about the resident's condition, including visible blood in her mouth, bruising, and allegations of mistreatment by staff, which were not adequately addressed by the facility. Interviews with the family, facility staff, and hospice personnel revealed inconsistencies in the facility nurse's account of the events. The hospice supervisor confirmed that the family had the right to call 911 and that the facility nurse should have complied with the family's wishes. The facility's investigation lacked evidence of timely communication with the family and corrective actions for the staff involved. The facility's policy on resident rights emphasizes the importance of upholding residents' rights and ensuring they are fully informed and involved in treatment decisions, which was not followed in this case.
Failure to Report Alleged Neglect and Abuse
Penalty
Summary
The facility failed to recognize and report a potential allegation of neglect to the State Agency in a timely manner for a resident who had a malignant carcinoid tumor of the sigmoid colon and malignant neoplasm of the rectum stage IV. The resident's family reported concerns about unsanitary and unsafe room conditions, bruising and bleeding in the mouth due to forceful medication administration, delayed patient care, and a nurse refusing to contact 911 at the family's request. Despite these concerns being communicated to the facility through an email and direct conversations, no report was filed with the State Agency, and the facility did not take immediate action to investigate the allegations of neglect and abuse properly. The resident's interdisciplinary progress notes indicated that the director of nursing (DON) contacted the hospital for an update and learned that the resident was admitted with seizures, emaciated skin, a coccyx wound, and mouth sores. The family member (FM) reported that the resident had been communicating concerns daily, including new bruising, delayed call light responses, and jerking movements that were dismissed by the nurse as a panic attack. The family member also reported wanting to call 911 but was told by staff that hospice needed to be contacted first. The family member eventually called 911 herself, and the resident was taken to the emergency room, where she continued to have seizures and later passed away. The facility consultant DON stated that he was not informed about the family's concerns until the next day and conducted an internal investigation, which found no signs of abuse. However, the facility lacked evidence of filing a report with the State Agency regarding the suspected abuse and neglect. The facility's abuse prohibition policy required prompt reporting and investigation of all incidents of alleged or suspected abuse/neglect, which was not followed in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for 10 residents. Medications were provided outside of ordered parameters by three staff members on three separate units. This included instances where medications were administered late, not administered at all, or administered without proper documentation and provider updates. For example, Resident 11 reported that her medications were often provided up to two hours late, which caused her significant distress, particularly with her Ativan, which she relied on to stay calm. Similarly, Resident 10 stated that her medications were frequently administered hours after she expected them, and she had communicated these concerns to the staff, but the issue persisted. During observations, it was noted that several residents had past due medications. For instance, LPN-D was observed to be behind schedule, with multiple residents' medications being past due. LPN-D failed to locate certain medications and did not update the provider or the unit manager about the delays. This included Resident 16, whose 8:00 a.m. medications were not administered until after 10:00 a.m., and Resident 13, who did not receive her 8:00 a.m. medications until 11:03 a.m. Additionally, Resident 11's 8:00 a.m. medications were administered at 11:17 a.m., and she was not given her Breo Ellipta inhaler as it could not be found. The facility's staff, including LPN-C and LPN-E, acknowledged the delays and the failure to update the provider or the unit manager. The Director of Nursing (DON) and the consulting pharmacist were also unaware of the extent of the medication administration issues. The DON stated that medications should be administered as ordered and that any deviations should be reported immediately. The consulting pharmacist expected medications to be administered as ordered and was unaware of any adverse effects experienced by the residents due to the delays. The nurse practitioner also emphasized the importance of following medication orders precisely and updating the provider when issues arise.
Insulin Administration Deficiency
Penalty
Summary
The facility failed to ensure insulin medication was administered in accordance with physician orders for four residents. The report details multiple instances where insulin was administered outside of the ordered parameters and manufacturer recommendations. For example, one LPN administered insulin to a resident approximately two hours after the blood sugar check without confirming the resident's breakfast intake status or rechecking the blood sugar. Another resident received insulin late because the LPN was too busy to follow up on the resident's breakfast status, leading to insulin being administered two hours after the blood sugar check without confirming food intake or rechecking blood sugar levels. Additionally, a resident's morning insulin was omitted entirely due to the LPN's inability to administer it on time and lack of communication with the provider or unit manager about the omission. The LPN documented the administered insulin for the next scheduled timeframe to avoid giving a double dose, but this resulted in the resident missing a dose of insulin. The report also highlights that the LPN was responsible for 25 residents and was the only nurse on the unit, which contributed to the delays and omissions in insulin administration. The facility's policies and expectations for timely medication administration were not followed, and there was a lack of communication with providers and supervisors about the delays and omissions. The report includes interviews with staff and the DON, who expressed concerns about the timeliness of insulin administration and the lack of provider updates, emphasizing the potential risks of hypo/hyperglycemia due to the observed deficiencies.
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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