The Villas At Robbinsdale
Inspection history, citations, penalties and survey trends for this long-term care facility in Robbinsdale, Minnesota.
- Location
- 3130 Grimes Avenue North, Robbinsdale, Minnesota 55422
- CMS Provider Number
- 245417
- Inspections on file
- 32
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at The Villas At Robbinsdale during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and newly identified elopement risk repeatedly attempted to leave, triggered exit alarms, and expressed a desire to go home, yet the care plan contained only a wander device and general alarm-response directions without specific supervision or individualized interventions. Over the course of an evening, video showed the resident making multiple exit attempts that staff redirected before ultimately leaving through an exit door unobserved and being found by police several blocks away. Agency NAs on duty were not informed which residents were at risk for elopement, and their care sheets did not list elopement risks or related interventions. Additional cognitively impaired residents assessed as elopement risks also had care plans limited to wander devices and general monitoring, with NA care sheets that either omitted elopement risk or lacked preventive interventions, demonstrating a broader failure to translate elopement assessments into clear, supervised care.
Surveyors identified that the facility’s written assessment did not include required elements for staffing recruitment, retention, and contingency planning, despite affecting all 71 residents. The documented assessment omitted a plan to maximize recruitment and retention of direct care staff and did not address how direct care nurse staffing or other care resources would be managed during non-emergency events that could impact resident care. During an interview, the administrator reported having a recruitment plan but confirmed it was not included in the facility assessment and that there was no documented staff retention or non-emergency staffing plan; a requested policy on the facility assessment process was not provided.
The facility failed to verify that an agency nurse aide had an active status on the Minnesota Nursing Assistant Registry before assigning her to a 7.5-hour day shift on a floor caring for multiple residents. The aide reported it was her first shift at the facility, and a registry search later showed her status had been inactive for over a year. The DON stated she relied on the staffing agency to send only registry-listed staff and acknowledged the facility did not verify active status for agency personnel, and the administrator confirmed that their process did not include checking current certification of agency aides. A requested facility policy related to this verification process was not provided.
Soiled linens, including towels and a shower curtain, were observed unbagged in a bin below the laundry chute. A laundry assistant confirmed that some items were sent down the chute without being bagged. Both the environmental director and infection preventionist stated that all soiled linens should be bagged before being sent down the chute to prevent contamination, but no facility policy was provided.
Surveyors identified failures in proper food labeling and dating in community refrigerators, inadequate maintenance of required food temperatures on a steam table, and unsanitary handling of serving dishes during food prep. The Dietary Manager confirmed that these practices did not meet facility policies for food storage, temperature control, and hygiene.
Two residents received meals that were not at safe or appetizing temperatures, with hot foods served below 135°F and milk above 41°F. Both residents and a family member reported that food was cold or warm by the time it was delivered. Staff interviews revealed uncertainty about required food temperatures, and observations confirmed that food was not held or served at appropriate temperatures, potentially affecting all residents on the unit.
A nurse failed to instruct a resident with cognitive impairment and asthma to rinse her mouth after receiving Budesonide via nebulizer, despite facility policy and medication instructions requiring this step to prevent infection. Staff interviews and observations confirmed the resident was able to rinse and spit, and that rinsing after steroid inhalation is standard practice.
A resident with moderate cognitive impairment and a history of falls did not consistently receive all care plan interventions intended to prevent falls. Staff failed to keep the resident's door open as required, and some were unaware of all necessary fall prevention measures. The care plan and documentation were not fully followed, and the facility could not provide a fall policy when requested.
A resident with COPD, asthma, and diabetes did not receive a newly prescribed inhaler because the medication order was not confirmed in the eMAR system, despite the medication being available in the facility. Staff interviews revealed a lack of awareness and follow-through, resulting in the resident missing doses as the order remained in 'Pharmacy Pending Confirmation' status.
A resident refused Lovenox injections on multiple occasions, but the facility failed to notify the medical provider as required. The resident's care plan did not mention anticoagulation therapy, and staff interviews confirmed the oversight in communication and documentation.
A resident with a surgical wound and fistula did not receive the ordered wound care due to the facility's failure to enter hospital discharge orders into the medical record. The care plan lacked necessary interventions for pouch changes and wound dressings, leading to skin irritation and bleeding. Staff interviews revealed that the process for entering hospital orders was not followed, resulting in incomplete wound assessments and care.
A resident with a surgical wound did not receive proper care due to an LPN's failure to perform hand hygiene between glove changes and after handling contaminated items. Despite recent staff education on hand hygiene, the LPN did not follow the facility's policy, which requires handwashing before and after treating wounds and handling waste.
A resident with peripheral vascular disease and diabetes experienced skin breakdown due to the facility's failure to conduct weekly skin inspections and inform the interdisciplinary team. Despite a care plan requiring daily monitoring, the resident returned from a leave of absence with excoriated skin, which was not documented or addressed. The occupational therapist was unaware of the issue, and the director of nursing did not report the excoriation as an open area. The facility's policy for skin assessment and wound management was not followed.
The facility failed to maintain cleanliness and regular maintenance of the fourth-floor dining room ice and water dispenser, which had visible sediment build-up. Despite the maintenance light indicating a need for cleaning, supplies were not ordered until after the observation. Staff continued to use the machine, raising infection control concerns.
A resident, dependent on staff for toileting, experienced a delay in incontinence care, waiting about an hour for assistance after activating their call light. Staff were occupied with other tasks, and the requirement for two staff members to assist contributed to the delay. The facility's policy on resident dignity and timely care was not followed.
A facility failed to reassess a resident's ability to self-administer medications and update their care plan. The resident, with multiple diagnoses including dysphasia, was found with unauthorized medications at their bedside, despite an order against it due to choking risks. Staff interviews revealed a lack of recent assessments and documentation regarding the resident's self-administration of outside medications.
A resident with cognitive impairment and multiple health issues was not adequately monitored for skin conditions and weight changes. Despite having a care plan that required regular skin assessments and weight monitoring, the facility failed to document and assess the resident's numerous skin sores and weight fluctuations. Staff interviews revealed inconsistencies in awareness and documentation of the resident's condition, highlighting a lack of proper monitoring and communication.
A resident with significant hearing loss did not receive timely follow-up for recommended hearing aids due to communication issues between audiology and medical records staff. The resident's care plan lacked documentation of communication needs, and there was a delay in obtaining medical clearance for the hearing aids.
Failure to Provide Adequate Supervision and Individualized Elopement Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized, care-planned interventions for residents at risk of elopement. One resident with severe cognitive impairment and a diagnosis of malnutrition was initially assessed on admission as non-wandering and completely dependent for mobility and personal care. However, an elopement assessment completed days later identified this resident as an elopement risk who was able to self-propel a wheelchair, was cognitively impaired, actively exit-seeking, and expressing a desire to go home. The resident’s care plan, initiated after this assessment, included use of a wander device, monitoring the device for proper functioning, and prompt response to door alarms, but it lacked specific supervision measures and individualized interventions tailored to the resident’s escalating exit-seeking behavior. In the days leading up to the elopement, multiple progress notes documented that this resident was wandering up and down the hallway, confused, disoriented, and repeatedly attempting to leave the facility despite staff redirection. On the day of the elopement, documentation indicated the resident was very agitated, wandering into other residents’ rooms, calling the police, stating staff were holding her hostage, and attempting to leave multiple times. Video surveillance from the floor exit area showed the resident making several attempts over the course of the evening to open the stairwell and exit doors, triggering alarms that were reset by staff who redirected her away from the doors. Despite these repeated attempts and clear evidence of escalating exit-seeking, no additional formal interventions beyond the wander device were implemented, and staff did not revise the care plan to include increased supervision or other individualized strategies. Later that evening, the video showed the resident successfully exiting through the floor door without staff present. A police report documented that the resident, who was not dressed for the weather and wearing all black, was later found about five blocks from the facility after knocking on a private residence’s door and asking for help. She was transported to the hospital for evaluation and was discharged in stable condition without injuries. Interviews with staff revealed that agency NAs working that shift were not informed which residents were at risk for elopement and that their care sheets did not identify elopement risks or related interventions. Additional residents assessed as elopement risks also had care plans that included wander devices and general directions to monitor for exit-seeking and answer door alarms, but these plans similarly lacked specific supervision measures and individualized interventions, and NA care sheets did not consistently reflect elopement risk status. The facility’s elopement policy directed staff to establish a process to check bracelet alarm/device batteries according to manufacturer directions, and the user guide for the wander management transmitters required at least weekly testing to verify proper operation. Interviews with nursing and management staff showed inconsistent understanding of responsibilities for testing and ensuring functionality of wander devices, as well as for updating care plans and communicating elopement risk to direct care staff. Some nurses believed only nurse managers or the DON could change care plans, while the DON stated all nurses could make care plan changes. Nurse managers reported that residents at risk for elopement should be noted on NA care sheets, but agency NAs reported they were not alerted to any residents at risk to wander or elope. These documented gaps in assessment translation to care plans, supervision, communication, and device management contributed to the resident’s elopement and the identified deficiency. Three additional residents identified as elopement risks had diagnoses including dementia, moderate to severe cognitive impairment, and conditions such as breast cancer and acute encephalopathy. Their elopement assessments indicated confusion, disorientation, and requests to go home. Their care plans directed use of wander devices, monitoring and documentation of exit-seeking behavior, prompt response to door alarms, and inviting them to activities, but similarly lacked explicit supervision requirements and individualized interventions to prevent elopement. NA care sheets for these residents either did not indicate elopement risk or did not include interventions to prevent elopement. These findings showed that the facility failed to consistently integrate elopement risk assessments into clear, individualized supervision strategies and to communicate those strategies to all staff responsible for resident care.
Removal Plan
- Audited the care plans of residents identified as elopement risks
- Provided education to staff regarding the elopement policy
- Provided education to staff regarding elopement assessments
- Provided education to staff regarding one-to-one supervision
- Provided education to staff regarding safety checks
- Provided education to staff regarding wander device management
- Developed and implemented individualized care plans with interventions including supervision for residents at risk for elopement
Incomplete Facility Assessment for Staffing Recruitment, Retention, and Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that included all required components related to staffing resources. The facility assessment dated 12/17/25 did not contain a plan to maximize recruitment and retention of direct care staff, despite this being a required element. The assessment also lacked a contingency plan for situations that did not trigger the formal emergency plan but could still affect resident care, such as issues with the availability of direct care nurse staffing or other care resources. During an interview on 3/13/26 at 3:32 p.m., the administrator acknowledged that while a recruitment plan existed, it was not incorporated into the written facility assessment, and further stated that the assessment did not include a staff retention plan or a plan to address direct care staffing needs outside of the emergency plan. A policy governing how the facility assessment should be conducted and documented was requested by surveyors but was not provided. This failure had the potential to affect all 71 residents in the facility, as the incomplete assessment did not fully address how necessary staffing resources would be ensured during routine operations, nights, weekends, or non-emergency events that could impact resident care.
Failure to Verify Active Nurse Aide Registry Status for Agency Staff
Penalty
Summary
The facility failed to ensure that a nurse aide had a current competency evaluation on the Minnesota Nursing Assistant Registry before allowing her to work, affecting 1 of 1 nurse aides reviewed for registry verification and potentially all 71 residents. On 3/12/26 at 11:46 a.m., a nursing assistant (NA-A) reported it was her first shift at the facility, and the facility schedule for that date showed she was assigned to work a 7.5-hour day shift on the third floor, where 26 residents resided, with a total facility census of 71 residents. A Minnesota Nurse Aide Registry search, dated 3/13/26 at 11:45 a.m. and provided by the facility, showed NA-A’s registry status as inactive since 12/7/24. During interviews, the DON stated she trusted the staffing agency to send only staff who were on the registry and acknowledged the facility did not verify active status for agency staff, and the administrator confirmed that their process did not include verifying current certification of agency aides and that she expected only currently certified NAs would be sent. A facility policy related to this process was requested by surveyors but was not provided.
Improper Handling of Soiled Linens in Laundry Process
Penalty
Summary
The facility failed to ensure that soiled facility linens were handled in a manner that prevented potential contamination during the laundry process. During an observation, three towels and a shower curtain were found unbagged and lying in a bin below the laundry chute. The laundry assistant confirmed that some laundry items were sent down the chute without being bagged. The environmental director and infection preventionist both stated that soiled linens should be bagged before being sent down the chute to prevent contamination and potential exposure to infection. The facility was unable to provide a policy regarding the proper handling of soiled linens in relation to the laundry chute.
Deficiencies in Food Labeling, Temperature Control, and Sanitary Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in community refrigerators on two of three floors where residents' personal food was kept. Observations revealed undated and unlabeled containers, including a plastic bag with a Tupperware container, a half-full plastic pitcher with orange liquid, and a container of ice cream dated nearly two months prior. Additionally, an unlabeled and undated container of cooked pasta was found. The Dietary Manager confirmed these items were for resident consumption and acknowledged they should have been labeled and dated according to facility policy. During food service, a dietary aide recorded a chicken temperature of 120°F on the steam table, which was below the required standard. The Dietary Manager verified the temperature and instructed the aide to reheat the chicken, confirming that no residents had been served the underheated food. In the kitchen, another dietary aide was observed prepping fruit without gloves and touching the inside of serving bowls with their thumb, which the Dietary Manager confirmed was not in line with sanitary practices. These actions were inconsistent with the facility's policies on food storage, temperature maintenance, and hygiene during food preparation.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for two residents on the second floor. Both residents, one with intact cognition and one with moderate cognitive impairment, reported that their meals were not at appropriate temperatures when delivered to their rooms. One family member also stated that food was usually cold by the time it reached the resident. Observations confirmed that food was plated and placed on a cart, then delivered to the second floor, where the last tray was served with food temperatures below required standards: chicken at 106°F, rice at 119°F, mashed potatoes at 127°F, and milk at 55°F. The surveyor noted that the hot foods were cold or lukewarm, and the milk was warm. Interviews with staff revealed a lack of knowledge regarding proper food holding temperatures. Both a nursing assistant and a dietary aide were unsure of the required temperatures for hot and cold foods. The dietary manager stated that hot foods should be held at a minimum of 135°F and cold foods at 41°F or lower, consistent with the facility's policy, which also identified the danger zone for food temperatures as between 41°F and 135°F. The failure to maintain appropriate food temperatures had the potential to affect all 24 residents on the unit.
Failure to Instruct Resident to Rinse Mouth After Steroid Nebulizer Administration
Penalty
Summary
A deficiency occurred when a registered nurse administered Budesonide inhalation suspension via nebulizer to a resident with cognitive impairment, dementia, anxiety, and asthma, but failed to instruct or assist the resident to rinse her mouth after the medication. The resident's care plan required staff to administer medications as ordered, and the medication's instructions specified that the mouth should be rinsed after inhalation to prevent fungal infections. During the observed medication administration, the nurse placed the nebulizer mask on the resident and returned after the treatment, but did not instruct or assist the resident to rinse her mouth. The nurse later confirmed she had not provided this instruction and was unsure if the resident was able to rinse and spit, despite the resident's demonstrated ability to do so during a subsequent observation with a nursing assistant. Interviews with facility staff, including a licensed practical nurse, pharmacy consultant, and director of nursing, all confirmed the importance of rinsing the mouth after steroid nebulizer use to prevent infections such as thrush. The facility's policy required all medications to be administered in a safe and effective manner. The failure to follow this standard of practice for medication administration resulted in the facility not meeting professional standards of quality for this resident.
Failure to Follow Fall Risk Interventions for High-Risk Resident
Penalty
Summary
Staff failed to consistently implement fall risk interventions for a resident identified as being at high risk for falls. The resident had moderate cognitive impairment, required extensive assistance with activities of daily living, and had a history of falls, as well as diagnoses including diabetes mellitus and depression. The care plan specified several interventions, such as keeping the bed in the lowest position, placing a fall mat next to the bed, keeping the door open when the resident was in the room, posting a 'do not fall' sign, and ensuring the call light was within reach. Additionally, staff were to check on the resident and offer bathroom assistance during specific hours. Despite these interventions, multiple falls occurred over several months, each time prompting additional interventions to be added to the care plan. Observations revealed that the resident was found in bed with the door closed, contrary to the care plan instructions. Interviews with nursing staff indicated a lack of awareness of all required interventions, with some staff only aware of the bed and mat requirements and not the need to keep the door open or other measures. The nursing assistant worksheet lacked comprehensive fall interventions, and the facility was unable to provide a fall policy when requested. The DON confirmed that staff were expected to follow care plans at all times, but this was not consistently done for this resident.
Failure to Administer Ordered COPD Medication Due to System Lapse
Penalty
Summary
The facility failed to implement a system to ensure that medications were available and administered as ordered for a resident with significant medical needs. The resident, who was cognitively intact and dependent on staff for dressing and toileting, had diagnoses including asthma, COPD, and diabetes mellitus. A physician order was placed for Anoro Ellipta, a medication used for COPD, but review of the electronic medication administration record (eMAR) showed that the medication remained in 'Pharmacy Pending Confirmation' status and was not administered as prescribed. The medication was present in the facility, but the order had not been confirmed in the system, resulting in the resident not receiving the medication since it was prescribed. Interviews with facility staff revealed a lack of awareness and follow-through regarding the medication order. The registered nurse acknowledged the medication was in the cart but had not been confirmed or given. The DON was unaware that the medication had not been confirmed or administered, and the consultant pharmacist stated that confirmation should have occurred promptly. The facility's policy required timely and accurate transcription of medication orders, but this was not followed, leading to the deficiency.
Failure to Notify Provider of Medication Refusal
Penalty
Summary
The facility failed to notify the medical provider of a resident's refusal to take Lovenox, a medication used to prevent blood clots following surgery. The resident, who was cognitively intact and had a surgical wound, was prescribed Lovenox to be administered daily. However, the Medication Administration Record (MAR) indicated that the resident refused the medication on multiple occasions, specifically from February 6 to February 8 and from February 11 to February 16. Despite these refusals, there was no documentation that the medical provider was informed, as required by the facility's procedures. Interviews with staff revealed that the registered nurse and the director of nursing acknowledged the oversight, confirming that the provider should have been notified immediately upon the resident's first refusal. The facility's Specific Medication Administration Procedure mandates that persistent medication refusals be documented and communicated to the physician or prescriber. The resident's care plan also lacked any mention of anticoagulation therapy, further highlighting the deficiency in communication and documentation regarding the resident's medication management.
Failure to Provide Ordered Wound Care for Resident
Penalty
Summary
The facility failed to provide wound care as ordered for a resident, identified as R2, who was admitted with a surgical wound and required non-surgical dressings. R2's hospital discharge orders included specific instructions for wound care management, which were not entered into the facility's provider orders upon admission. This oversight resulted in the absence of necessary wound care and pouch changes for R2's fistula, as indicated in the hospital discharge orders. R2's care plan did not reflect the required wound care and pouch changes, and the Skin and Wound Evaluation lacked comprehensive documentation of the wound's condition. The wound provider's progress note highlighted a treatment error, noting that R2 had not been receiving the required dressing changes every six hours, leading to skin irritation and bleeding. Despite the presence of a care plan indicating R2's ability to direct her stoma care, the interventions did not include assistance with pouch changes and wound dressings. Interviews with facility staff, including registered nurses and the director of nursing, revealed that the process for entering hospital orders was not followed correctly, resulting in the omission of R2's wound care orders. The director of nursing acknowledged that the admission wound care orders were not entered into the medical record, and staff did not perform the care as ordered. Additionally, the wound assessment conducted on 2/13/25 was incomplete, failing to assess R2's wound/fistula adequately.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to conduct appropriate hand hygiene during wound care for a resident who was cognitively intact and had a surgical wound requiring non-surgical dressings. During an observation of the wound care process, an LPN was noted to have washed his hands with soap and water before starting the procedure. However, the LPN did not perform hand hygiene between glove changes while handling a fistula collection bag containing stool, cleaning the resident's legs, and managing wound care supplies. The LPN also failed to perform hand hygiene after touching a receptacle that previously held stool and after leaving the resident's room. The LPN acknowledged during an interview that he did not perform hand hygiene as required, except before starting the wound care. The director of nursing confirmed that staff had been educated on hand hygiene recently and were expected to follow the facility's hand hygiene policy. The facility's handwashing policy indicated that proper handwashing should be performed before and after treating a wound, after cleaning up someone who has used the toilet, and after touching garbage. The policy also required handwashing before donning gloves and after removing them during procedures requiring glove use.
Failure to Monitor and Address Resident's Skin Breakdown
Penalty
Summary
The facility failed to ensure that a resident with peripheral vascular disease and diabetes with neuropathy received appropriate skin care and monitoring, leading to skin breakdown. The resident, who was dependent on staff for mobility and hygiene, had a care plan that required daily skin monitoring and weekly skin inspections. However, the facility did not complete these inspections or inform the interdisciplinary team of the resident's skin breakdown. During a care conference, a family member mentioned a wound, which was not previously noted by therapy staff. The resident returned from a leave of absence with excoriated skin on the thighs, but no further documentation of care for the skin breakdown was provided. Observations and interviews revealed that the resident experienced discomfort from sitting in a wheelchair and had excoriated areas on the buttocks and thighs. The occupational therapist was unaware of the skin breakdown, and the registered nurse noted the excoriation but did not measure it. The director of nursing acknowledged the excoriation but did not report it as an open area. The facility's nurse consultant stated that the director of nursing should have addressed the skin concerns in daily meetings and updated the care plan accordingly. The facility's policy required staff to notify the provider, update the care plan, and involve therapy for skin concerns, which was not followed in this case.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and regular maintenance of the fourth-floor dining room ice and water dispenser, which was observed to have white, speckled, crust residue on various surfaces. The maintenance director (DOM) acknowledged that the machine's maintenance light had indicated a need for cleaning, but supplies for cleaning and sanitizing were not ordered until after the observation. The DOM, who started working at the facility in March 2024, stated this was the first time they would be cleaning and sanitizing the dispenser. Despite the visible sediment, staff continued to use the machine, and the administrator confirmed the presence of sediment and expected maintenance to address it when triggered by the facility's communication system. The facility's policy required ice machines to be cleaned and sanitized per manufacturer's instructions, which recommended cleaning at least every six months or more frequently based on water mineral content and other factors. The last recorded cleaning of ice machines and bins was on 5/31/24. The administrator noted that the fourth-floor machine had two filters to counter hard water sediment build-up, with one filter dated 3/28/24. The failure to clean and sanitize the machine as required raised infection control concerns, as staff continued to use the machine for resident meal service.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for a resident, compromising their dignity. The resident, who was cognitively intact and dependent on staff for toileting due to frequent incontinence, reported not being changed since the morning and activated their call light for assistance. A trained medication aide responded but left the room after informing the resident that another staff member would assist them. However, the resident had to wait for approximately an hour before two nursing assistants arrived to change their incontinence brief. Interviews with staff revealed that the delay was due to other staff being occupied with different tasks or on break, and the requirement for two staff members to assist with the resident's care. The registered nurse and director of nursing acknowledged that the call light should remain on until the resident's needs are met and that the delay in care could impact the resident's dignity. The facility's policy emphasizes the importance of upholding residents' rights to dignity and timely care, which was not adhered to in this instance.
Failure to Reassess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to comprehensively reassess a resident's ability to safely self-administer medications, document resident education regarding the risks, and update the care plan accordingly. The resident, who was cognitively intact and had multiple diagnoses including dysphasia, malnutrition, ADHD, depression, and anxiety, was observed to have medications at their bedside. These included guaifenesin, eye drops, ear wax remover, and nystatin powder, which were not authorized for self-administration according to the facility's policy. The resident's medical record lacked additional assessments beyond an initial evaluation that deemed them capable of self-administering certain medications. Despite this, there was an order indicating that medications should not be left in the resident's room due to the risk of choking, as the resident preferred to lie in bed rather than sit upright. Staff interviews revealed that the resident had a history of obtaining medications from outside sources, and there was no recent assessment or documented risk/benefit discussion regarding these outside medications. The facility's policy required a comprehensive assessment by the interdisciplinary team to determine if self-administration was safe and appropriate, with periodic reassessments based on changes in the resident's status. However, the resident had not been recently reassessed, and the care plan was not updated to reflect the medications they could self-administer. The presence of unauthorized medications at the bedside was not addressed by staff, despite being in plain view, leading to concerns about potential interactions and safety risks.
Failure to Monitor Skin Conditions and Weights
Penalty
Summary
The facility failed to comprehensively assess and monitor non-pressure related skin conditions and resident weights for a resident identified as R40. R40, who was cognitively impaired and had a history of alcohol use disorder, depression, cellulitis, and incontinence, was admitted to the hospital with severe dehydration and other symptoms. Upon discharge, R40's care plan included monitoring skin integrity and performing weekly skin inspections, but the facility did not adequately document or assess R40's skin conditions, which included open abrasions and scabs on various parts of the body. Despite the care plan's instructions, the facility's documentation lacked consistent identification and assessment of R40's skin issues. Observations revealed numerous scabs and open sores on R40's body, which were not consistently documented or monitored. Interviews with staff indicated a lack of awareness and documentation regarding R40's skin conditions, with some staff unsure of the status of the sores and others acknowledging the absence of proper documentation and monitoring. Additionally, the facility failed to monitor R40's weight as required, particularly given the resident's use of diuretics and history of weight fluctuations. Although R40's weight was recorded at two points, there was no consistent monitoring or documentation of weight changes, which was crucial due to the resident's medical conditions and medication regimen. The lack of weight monitoring was attributed to agency staff not entering the order for weights, leading to a failure in triggering the necessary monitoring procedures.
Failure to Provide Timely Hearing Aid Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received proper follow-up for recommended hearing assistive devices. The resident, who had intact cognition and diagnoses including Alzheimer's dementia, anxiety, and high blood pressure, was identified as hard of hearing but did not wear hearing aids. An audiology exam revealed significant sensorineural hearing loss in both ears, and hearing aids were recommended. However, the resident's care plan lacked documentation of communication needs, and there was a delay in obtaining medical clearance for the hearing aids. The delay was attributed to communication issues between the audiology staff and the facility's medical records (MR) staff. The MR staff acknowledged missing the notification for medical clearance and stated that the request was only sent to the resident's provider months after the audiology exam. Interviews with staff, including the MR staff, social services, a registered nurse, and the director of nursing, confirmed the breakdown in communication and the lack of timely action on the audiology recommendations. The facility did not provide a policy on appointment follow-up or hearing and communication when requested.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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