The Villas At St Paul
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Paul, Minnesota.
- Location
- 445 Galtier Avenue, Saint Paul, Minnesota 55103
- CMS Provider Number
- 245340
- Inspections on file
- 28
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Villas At St Paul during CMS and state inspections, most recent first.
A resident with multiple serious medical conditions and intact cognition received PRN Oxycodone on several occasions without documentation of the specific pain indication, symptoms, or non-pharmacologic interventions attempted prior to administration. Although the care plan and facility staff (including an LPN, RN, NP, and DON) described an expected process of assessing pain using a 0–10 scale, identifying pain location and characteristics, offering measures such as repositioning, ice, heat, food, or distraction, and then documenting the PRN narcotic administration and its effectiveness, the MAR and progress notes lacked this required information. The facility’s own Medication Administration policy requiring documentation of complaints or symptoms, date and time, dose, route, and results of PRN medications was not followed for these Oxycodone doses.
A resident with multiple chronic conditions had provider orders for daily cranberry capsules for UTI prophylaxis and daily lactobacillus for diarrhea, but the facility failed to administer numerous doses over an extended period. MARs showed repeated missed doses of both medications, with nursing notes documenting that the medications were on order, not available, or awaiting pharmacy or house stock delivery. An LPN described the process for documenting unavailable medications and contacting the pharmacy, and the DON described the house stock request process and defined missed doses as medication errors. The NP reported she was not notified about the missed doses, despite expecting to be contacted when medications were not administered as ordered.
A resident with hypomagnesemia and multiple serious diagnoses had an order for oral magnesium 250 mg daily that was not administered for five consecutive days, with MAR entries coded as unavailable and nursing notes stating the medication was on order or awaiting pharmacy delivery. Magnesium was an OTC item stocked in the facility, but the correct strength was not requested via house stock procedures, and the provider was not notified of the missed doses. During this time, labs showed persistently low magnesium, and documentation noted fatigue, lethargy, nausea, poor intake, and leg pain. An NP later documented that the resident’s magnesium supplement had not been started due to tablet strength issues, the pharmacy reported no request for the ordered dose, and the DON learned of the omissions only on later chart review. The Pharm-D characterized the five missed doses, in the context of the resident’s symptoms and lab values, as a significant medication error.
Surveyors identified deficiencies in food storage and labeling, with multiple undated and expired food items found in both kitchen and resident refrigerators, improper storage of chemical buckets near food, and ice packs stored with food. Staff interviews revealed confusion over responsibility for monitoring and discarding expired items, and dishwashing procedures were inadequate, with blank temperature logs and staff lacking training on required sanitization temperatures.
A resident with latent TB was not tracked on the infection line listing despite being prescribed antibiotics, and two residents on contact isolation for MRSA did not have consistent enforcement of transmission-based precautions. Staff entered the room without required PPE, and there was confusion among staff about when PPE was necessary, despite clear signage and care plan instructions.
A resident with cognitive impairment and multiple diagnoses was observed wearing TED stockings incorrectly, with the stockings rolled down and causing skin indentations and redness. Although the resident preferred to apply the stockings independently, nursing staff acknowledged their responsibility to ensure proper application, which was not documented in the care plan. Facility policy on TED stocking use was not provided when requested.
Several residents with cognitive and physical impairments did not receive necessary assistance with oral hygiene, as required by their care plans. Observations showed unopened or missing oral care supplies, and residents reported not being helped with oral care. Staff interviews revealed confusion about oral care procedures and inconsistent provision of services, despite facility policy requiring support for activities of daily living.
Several residents, including those with cognitive and physical impairments, did not have water or other fluids readily available outside of meal and medication times. Observations and interviews showed that residents often lacked access to drinks in their rooms and sometimes relied on staff or visitors to obtain water, despite care plans and facility policy requiring regular hydration support.
Staff with facial hair prepared food without wearing beard nets due to a supply shortage, despite knowing the requirement and facility policy mandating beard restraints to prevent hair contamination. The issue was observed and confirmed by staff interviews, and the administrator noted that the supply issue should have been communicated.
A nursing assistant delayed responding to a resident's call light and instructed the resident to use it only for emergencies, resulting in the resident's needs not being addressed promptly. Other staff were unaware of this practice, which was inconsistent with facility policy and expectations regarding timely response to resident requests.
A facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and personal needs. One resident's care plan lacked focus on incontinence and dental care, another's was incomplete regarding fall risk and pain management, and the third's did not address skin integrity or communication needs. Staff interviews highlighted a lack of detailed and updated care plans, increasing the risk of neglect.
A resident developed an avoidable stage II pressure ulcer due to the facility's failure to reassess pressure ulcer risk and update the care plan. Despite being at moderate risk, the resident's care plan lacked specific interventions for pressure ulcer prevention. Staff interviews revealed a lack of awareness and documentation regarding the resident's condition and necessary interventions. The facility's policy required a pressure ulcer risk assessment and preventative measures, which were not adequately implemented.
The facility failed to verify the nurse aide registration for an agency nursing assistant before allowing him to work with residents. The staffing coordinator was unable to confirm the registration due to a last-minute shift request and reliance on an agency portal system. The director of human resources and the administrator expected the staffing coordinator to handle agency paperwork, but the confirmation of the aide's registration was received only after he had already worked with residents.
A resident with a fungal skin infection did not receive prescribed Nystatin powder due to a transcription error, leading to a lack of treatment for several days. The medication order was not confirmed and revised until days later, resulting in the resident's condition deteriorating. Staff interviews revealed a lack of awareness and communication regarding the missed applications, and facility policies were not followed.
A resident reported that staff placed a pillow over her roommate's mouth to silence her during morning care. Despite being informed, an LPN and a nursing assistant did not report the allegations to management. The resident allegedly abused denied the incident when questioned. The Director of Nursing was unaware of the allegations until informed by the surveyor, and the facility did not provide a policy on abuse reporting.
A resident with intact cognition and specific bathing preferences did not receive showers as per their preference, leading to neglect in personal hygiene. The facility failed to assess and document the resident's preferences in the MDS, resulting in inconsistent bathing schedules and lack of proper care. Staff interviews revealed confusion and inconsistency in following the bath schedule, and the facility lacked a policy on preferences.
Two residents were not provided adequate privacy during personal care due to malfunctioning privacy curtains. Despite the doors being shut, the curtains were not pulled, leaving the residents exposed when staff entered the rooms. The nursing assistant acknowledged the issue and had requested repairs, but they were not completed. The DON confirmed the expectation for privacy, but the facility's privacy policy was not provided.
A resident dependent on staff for daily living and receiving nutrition via a feeding tube had dried enteral feeding liquid on the support legs of their tube feeding pump pole. Despite multiple observations over several days, the substance remained uncleaned. Nursing staff acknowledged their responsibility to clean the equipment, but the facility lacked a specific cleaning policy for tube feeding pump poles.
A facility failed to complete a comprehensive assessment and implement a resident's preferences for bathing. The resident, who had intact cognition and required assistance for bathing, did not receive showers as preferred and had inconsistent documentation of bathing schedules. Staff interviews revealed that the MDS section for preferences was not consistently completed, and the resident's care plan lacked specific information on bathing preferences.
A resident with mobility issues and a prosthetic leg was not provided with the restorative nursing program (RNP) as planned after discharge from physical therapy. Despite the care plan's directive for daily ambulation assistance, the resident reported not using the prosthetic due to pain and had not walked for weeks. Staff interviews revealed inconsistencies in the RNP's implementation, with some staff unaware of the resident's ambulation status and others noting refusal to wear the prosthetic. The facility lacked a formal RNP policy.
A resident with severe cognitive impairment and a history of falls did not receive consistent fall prevention interventions, such as a floor mat, as outlined in their care plan. Despite being at high risk for falls, the facility failed to maintain necessary safety measures, leading to multiple falls. Observations and staff interviews revealed a lack of adherence to the care plan and inadequate communication, contributing to the deficiency in providing a safe environment.
A facility failed to monitor and assess a resident's respiratory status, leading to improper oxygen use and lack of medication administration. The resident, with COPD and impaired cognition, had no documented interventions for oxygen use in their care plan. Observations showed the resident's nasal cannula was often misplaced, and no respiratory assessments were conducted. Staff interviews revealed confusion about oxygen orders and the use of PRN inhalers, with no specific guidelines provided for respiratory assessments.
A resident with a history of stroke and diabetes, dependent on tube feeding, did not receive care in accordance with enhanced barrier precautions (EBP). An LPN was observed performing tube feeding care without wearing a gown, despite EBP signage and facility policy requiring PPE for high contact care. The LPN was misinformed about the necessity of EBP, contrary to the facility's policy and the director of nursing's guidance.
A resident with multiple pressure ulcers did not have wound care orders properly documented in the EMR, leading to a lack of continuity in care. Despite having a care plan, it lacked specific directions for dressing changes. Observations showed that dressing changes were not documented, and the director of nursing confirmed the absence of orders in the EMR, indicating a breakdown in communication and documentation processes.
Failure to Document Indication and Non-Pharmacologic Measures Before PRN Narcotic Use
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management for a resident receiving PRN narcotic medication by not identifying the indication for use and not documenting non-pharmacological interventions prior to administration. The resident had intact cognition and multiple serious diagnoses, including retroperitoneal abscess, acidosis, malnutrition, acute kidney failure, and sepsis. The care plan identified an alteration in comfort related to pain and included interventions such as positioning, rest, and massage as non-medical pain relief. A provider order directed that Oxycodone 5 mg be given by mouth every six hours as needed for pain, but did not specify any further indication. Review of the MAR showed that the resident received PRN Oxycodone on three occasions, with effectiveness recorded as “E” for two doses and “U” (unknown) for one dose. For each of these three administrations, there was no corresponding progress note documenting that the medication was given, the symptoms or pain characteristics the resident was experiencing, or any non-pharmacological interventions that were attempted or offered before administering the narcotic. Interviews with an LPN, an RN, the NP, and the DON all described an expected process that included assessing pain location and intensity using a 0–10 scale, offering and documenting non-pharmacological interventions such as repositioning, ice, heat, food, distraction, and then, if needed, administering PRN pain medication and documenting the time, pain rating, location, characteristics, and effectiveness. The DON confirmed that the electronic medical record for this resident’s Oxycodone administrations did not identify the pain location or any non-pharmaceutical interventions offered or attempted. The facility’s Medication Administration policy required documentation of date and time of PRN administration, dose, route, the complaints or symptoms for which the medication was given, and the results and timing of those results, which were not present in the records reviewed.
Failure to Obtain and Administer Ordered Cranberry and Probiotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer routine medications as ordered by the provider for one resident. The resident had diagnoses including thoracic aortic aneurysm, neurogenic bowel, and neuropathic bladder, with intact cognition on admission. A provider order dated 2/13/26 directed that cranberry 250 mg be given orally once daily for UTI prophylaxis. The February 2026 MAR showed eight missed doses of cranberry on multiple dates, each coded with a “9” indicating “see nursing note.” Nursing notes for those dates documented that the cranberry capsules were on order, not available, that the pharmacy had been called, and that staff were waiting for delivery or house stock. The same resident had a provider order dated 2/14/25 for lactobacillus (probiotic), one capsule once daily for diarrhea. The February and March 2026 MARs showed a total of 20 missed doses of lactobacillus on multiple dates, again coded as “9,” with corresponding nursing notes stating the medication was on order and that staff were awaiting medication from the pharmacy or pending delivery. LPN-A explained that unavailable medications were charted with code 9 and that he would check for re-orders and call the pharmacy if needed; OTC medications and supplements were reportedly available as house stock with a process to request appropriate doses. NP-A stated she should be contacted when residents miss medications and confirmed she had not been notified about the missed cranberry and lactobacillus doses. The DON stated that OTC medications or supplements could be requested via a house stock request form and that a medication error occurs when a medication is not administered as prescribed, consistent with the facility’s Medication Administration policy requiring medications to be given in accordance with written prescriber orders.
Failure to Administer Ordered Magnesium Resulting in Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when an ordered magnesium supplement for hypomagnesemia was not administered for multiple days. The resident had diagnoses including retroperitoneal abscess, acidosis, malnutrition, acute kidney failure, sepsis, and hypomagnesemia, with a low magnesium lab value of 1.3 and instructions from the hospital to monitor and treat accordingly. A provider order dated 3/19/26 directed magnesium 250 mg by mouth daily for hypomagnesemia, but the March MAR showed the resident did not receive magnesium on five consecutive days, each omission coded with a “9” and nursing notes indicating the medication was on order or awaiting delivery from the pharmacy. During this period, nursing documentation repeatedly stated that the magnesium was awaiting medication from the pharmacy, despite magnesium being an OTC supplement stocked in the facility, though not in the 250 mg strength. Staff interviews clarified that when an ordered dose differs from stocked OTC strength, nurses are to complete a house stock OTC request form and contact the provider if the pharmacy cannot provide the ordered medication. In this case, the pharmacy confirmed it had not received a request for magnesium 250 mg, and the DON confirmed she was not notified about the missing doses and only discovered the error later during chart review. The facility’s Medication Administration policy required medications to be administered in accordance with written prescriber orders, and the DON stated that a medication error occurs when a medication is not administered as prescribed. While the resident was not receiving the ordered magnesium, clinical information and provider notes documented ongoing low magnesium levels and related symptoms. A magnesium lab on 3/20/26 was 1.2, and an NP note on 3/23/26 stated the NP did not see that the magnesium had been replaced and ordered magnesium to be added to the next lab draw. Social services notes recorded concerns from therapy and family about the resident’s tiredness, lethargy, poor intake, nausea, and difficulty arousing. On 3/24/26, a critical low magnesium value of 1.0 was reported, and an NP telephone note documented that the resident was on a magnesium supplement but that nursing had not started it because only 400 mg tablets were available and the 250 mg tablets had not been delivered. The Pharm-D stated that, given the resident’s leg pain, fatigue, nausea, and missed five doses of magnesium, this constituted a significant medication error, and the MD and NPs confirmed they had not been contacted about the missed doses as required when medications are unavailable or missed.
Deficiencies in Food Storage, Labeling, and Dishwashing Procedures
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and handling within the facility. In the main kitchen, a stand-up freezer contained a pan of beef roast with loose plastic wrap and visible ice crystals, and a refrigerator held cut pineapple and turkey lunch meat without dates, as well as sour cream past its best-by date. The dry storage area had empty chemical buckets with residual contents and holes in the lids stored on the floor. Staff interviews confirmed that open food items should be dated and expired items discarded, and acknowledged that chemical buckets should not be stored near food. On resident care floors, refrigerators and freezers contained several unlabeled and undated food items, including milk, sandwiches with visible mold, thawed frozen meals, bread past its best-by date, and take-out containers. Ice packs were stored alongside food, contrary to staff expectations. Staff interviews revealed uncertainty about responsibility for monitoring and cleaning resident refrigerators, with some believing it was the kitchen staff's duty, while others were unsure or thought it might be activities or housekeeping. The DON confirmed that all food should be labeled with the resident's name and date, and that expired or open items should be discarded after three days. Dishwashing procedures were also found deficient. The dishwasher temperature log was blank, and dietary aides were unaware of the required wash and rinse temperatures or proper monitoring procedures. Observed wash and rinse cycles did not consistently reach the temperatures indicated on posted signage. Staff reported a lack of formal training on dishwashing temperatures, and the Corporate Dietary Director acknowledged that only some staff had received education on this process. Facility policy required labeling and dating of resident food and proper disposal after three days, but a food storage policy was not provided when requested.
Failure to Track Latent TB and Enforce Contact Precautions for Residents on Isolation
Penalty
Summary
The facility failed to properly identify and track a potential infection for a resident diagnosed with latent tuberculosis (TB). The resident, who had cognitive impairment and chronic lymphocytic leukemia, was prescribed rifampin for latent TB, but this diagnosis and antibiotic use were not documented on the facility's Monthly Line Listing Infection Report. The infection preventionist confirmed that the resident was not included in the infection tracking system and was unaware of the need to monitor this case. Additionally, the facility did not ensure that transmission-based precautions were consistently implemented for two residents on contact isolation for MRSA. Observations revealed that staff, including nursing assistants, an LPN, and a social services staff member, entered the shared room of these residents without donning the required personal protective equipment (PPE), despite clear signage on the door instructing staff to wear gowns and gloves. Staff interviews indicated confusion about when PPE was necessary, with some believing it was only required for direct care and not for other interactions such as delivering meal trays or asking questions. The care plans for the residents on contact precautions directed staff to follow enhanced barrier precautions and to don and doff PPE as indicated. However, the observed practices did not align with these instructions or with CDC recommendations, which require PPE for all interactions that may involve contact with the resident or their environment. The facility's infection prevention and control policy also required the use of surveillance tools to recognize infections and the implementation of appropriate isolation precautions, which was not consistently followed.
Failure to Ensure Proper Application of Compression Stockings
Penalty
Summary
The facility failed to ensure that a resident's compression stockings (TED stockings) were applied correctly, as required by physician orders and the resident's care needs. The resident, who had moderately impaired cognition and diagnoses including spondylosis with myelopathy, muscle weakness, and dementia, was noted to be independent with activities of daily living but had a physician's order for TED stockings to be worn during the day and removed at night. Observations on multiple occasions revealed that the resident's TED stockings were rolled down to the ankles, with excess material hanging off the toes, causing indentations and a red area on the right ankle. The resident stated he put on his own TED stockings, but staff were responsible for ensuring they were applied correctly. Interviews with nursing staff and the director of nursing confirmed that, even when a resident prefers to apply their own TED stockings, it is the responsibility of nurses and nursing assistants to ensure the stockings are worn correctly and according to orders. The resident's care plan did not include any information about the use of TED stockings or the resident's preferences regarding them. Additionally, a facility policy regarding the use of TED stockings for edema was requested but not provided.
Failure to Provide Oral Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary oral hygiene services for five out of six residents reviewed for activities of daily living. Multiple residents with cognitive impairments and significant medical conditions, such as severe mental impairment, alcoholic cirrhosis, failure to thrive, schizophrenia, and autistic disorder, were observed to lack assistance with oral care. Observations and interviews revealed that oral care supplies were often unopened or missing from residents' rooms, and residents reported not receiving assistance with oral hygiene. Staff interviews indicated uncertainty regarding the use of oral care supplies and the frequency of oral care, with some staff unfamiliar with residents' needs or care plans. Care plans for these residents indicated a need for assistance with personal hygiene, including oral care, but this assistance was not consistently provided. Residents dependent on staff for oral hygiene either did not receive help or only received it sporadically, and some were unaware of how to use the provided supplies. The facility's policy required staff to maintain residents' abilities in activities of daily living, including oral hygiene, but this standard was not met for the residents reviewed.
Failure to Provide Adequate Hydration Consistent with Resident Needs
Penalty
Summary
The facility failed to provide drinks, including water, consistent with the needs and preferences of five out of six residents reviewed for hydration. Multiple residents with varying degrees of cognitive and physical impairment did not have water or other fluids readily available in their rooms outside of meal and medication times. Observations and interviews revealed that residents often relied on staff or visitors to obtain water, and some expressed a desire for water throughout the day. In several cases, residents were dependent on staff for assistance with drinking, but water was not present or accessible in their rooms. One resident's friend provided water during a visit, and another resident reported only receiving fluids with meals and medications. Staff interviews indicated uncertainty about hydration protocols, and one nursing assistant noted the lack of reusable water mugs on the floor, with staff using small disposable cups instead. The care plans and physician orders for these residents included specific instructions for hydration, such as offering fluids between meals and monitoring for signs of dehydration. Despite these directives, observations showed that water was not consistently available, and staff were not always aware of or following hydration protocols. The DON stated that water should be readily available and that staff were expected to check rooms, but this was not observed in practice. Facility policy required maintaining adequate hydration for all residents, but the observed practices did not align with this policy.
Failure to Ensure Beard Nets Worn by Food Preparation Staff
Penalty
Summary
The facility failed to follow infection control guidelines by not ensuring that staff with facial hair wore beard nets while preparing food in the kitchen. During an observation, a cook with a full beard was seen working in the kitchen without a beard net and confirmed that he had prepared food on multiple days without one because the facility was out of beard nets. The cook acknowledged awareness of the requirement to wear a beard net to prevent hair from contaminating food. A dietary aide reported that the kitchen manager was not present because she had left to purchase beard covers. The administrator stated that staff were expected to wear beard covers and should have communicated the supply shortage so that arrangements could be made to obtain more. Facility policy required the use of hair nets and beard restraints to prevent hair from contacting exposed food and clean equipment.
Neglect Due to Delayed Call Light Response and Staff Discouragement
Penalty
Summary
A nursing assistant (NA) failed to respond promptly to a resident's call light and instructed the resident to limit the use of the call light to emergencies only. The resident, who had recently been admitted and was alert and oriented, used the call light frequently for various needs, including personal care, water, pain medication, and wound care. The NA admitted to intentionally delaying responses, sometimes waiting up to ten minutes before checking on the resident, and prioritized other residents' needs over this resident. The NA also communicated to the resident that unless it was an emergency, he should not use the call light as often, citing the resident's confusion and frequent requests as justification. Other staff, including registered nurses and the administrator, were unaware of the NA's actions and stated that such behavior was unacceptable and not in line with facility expectations. The facility's policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, mental anguish, or emotional distress. The incident was identified as neglect, as the resident's needs were not addressed in a timely manner, and the resident was discouraged from seeking assistance through the call light system.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to ensure comprehensive, person-centered care plans were developed and adjusted as needed for three residents, leading to deficiencies in care planning. Resident 1's care plan lacked focus areas for bowel and bladder incontinence and dental care, despite these issues being identified in the Minimum Data Set (MDS) and Care Area Assessments (CAAs). The resident required substantial assistance for toileting and oral hygiene, experienced occasional bladder incontinence, and was free of natural teeth, yet these needs were not adequately addressed in the care plan. Resident 2's care plan was incomplete, with several focus areas left blank or not completed, including fall risk, alteration in mobility, and self-care deficit. The resident had a history of falls, used high-risk medications, and experienced frequent pain impacting daily activities. Despite these concerns, the care plan lacked specifics and did not address pain management, toileting, or high-risk medication usage. The care plan also failed to reflect the discontinuation of occupational and physical therapy, which were initially included as interventions. Resident 3's care plan was similarly deficient, with several focus areas left blank or not completed, such as alteration in skin integrity, self-care deficit, and alteration in communication. The resident was severely cognitively impaired, required physical assistance, and had multiple medical conditions, including diabetes and a pressure ulcer. Despite these needs, the care plan did not address the resident's right arm pain, activities, or high-risk medication usage. Interviews with staff revealed a lack of comprehensive care planning, with expectations for detailed and updated care plans not being met, increasing the risk of neglect and unmet needs.
Failure to Reassess and Update Care Plan for Pressure Ulcer Risk
Penalty
Summary
The facility failed to comprehensively reassess the pressure ulcer risk and adjust the care plan for a resident who developed an avoidable stage II pressure ulcer on the coccyx. The resident, who was admitted from an acute care hospital, was severely cognitively impaired and required physical assistance with care and mobility. The resident was at risk for pressure ulcers due to total bowel and bladder incontinence, diabetes, aphasia, cerebrovascular accident, dementia, hemiplegia, and seizure disorder. Despite being assessed as at moderate risk for pressure ulcers, the resident was initially free of pressure ulcers upon admission. The resident's care plan included interventions such as using an incontinent product, repositioning every two hours, and routine skin care. However, after the pressure ulcer was identified, the facility did not comprehensively reassess the resident's pressure ulcer risk or update the care plan to reflect the new condition. The care plan lacked specific interventions related to the pressure ulcer, and the nursing staff did not document a comprehensive assessment of the pressure ulcer risk after its discovery. Interviews with staff revealed a lack of awareness and documentation regarding the resident's pressure ulcer and the necessary interventions to prevent further skin breakdown. The facility's policy required a pressure ulcer risk assessment and appropriate preventative measures, such as mobility and repositioning plans, to be implemented. However, the resident's care plan did not include individualized interventions for pressure ulcer prevention, and the staff did not update the care plan or resident care lists after the ulcer was identified. The Director of Nursing acknowledged that the pressure ulcer was avoidable and that the resident's care plan should have included specific interventions to prevent skin breakdown.
Failure to Verify Nurse Aide Registration for Agency Staff
Penalty
Summary
The facility failed to verify the nurse aide registration for an agency nursing assistant (NA-A) before allowing him to work directly with residents. This oversight occurred on NA-A's first shift at the facility, where he provided care to residents, including hygiene, dressing, feeding, and mechanical lift transfers. The staffing coordinator (SC) acknowledged that the shift request for NA-A was last minute, which prevented her from verifying his registration before he began working. The SC relied on an agency electronic portal system to request and verify licensure or nurse aide registration, but due to the specific agency's process, this information was not immediately available. The director of human resources (DHR) stated that she only managed paperwork for facility staff, not agency staff, and expected the SC to handle agency paperwork. The administrator expected both DHR and SC to ensure agency staff met all requirements, including licensure verification, to maintain resident safety. The SC eventually received confirmation of NA-A's active nurse aide registration via email from the agency on the same day, but this was after NA-A had already worked with residents. The facility did not maintain agency staff employee files, as they accessed information through the agency's portal.
Failure to Transcribe and Administer Medication for Fungal Infection
Penalty
Summary
The facility failed to ensure that a medicated powder for a fungal skin infection was transcribed and applied according to provider orders for a resident with skin breakdown. The resident was assessed by a nurse practitioner for moisture-associated skin damage and a rash, and an order was made for Nystatin powder to be applied to specific areas three times a day. However, the order was not transcribed correctly, and the medication was not administered as scheduled, leading to a lack of treatment for several days. The resident's Medication Administration Record (MAR) showed that the Nystatin order was scheduled to start the day after it was ordered, but there were multiple instances where the medication was not administered. The order was not confirmed and revised until several days later, which resulted in the medication not being applied until then. The resident's condition deteriorated during this period, with the rash spreading and requiring more aggressive treatment. Interviews with staff revealed a lack of awareness and communication regarding the missed medication applications. The Director of Nursing and the administrator were unaware of the issue until it was brought to their attention, and the Health Information Assistant and Licensed Practical Nurse involved in the order process could not recall details about the order. The facility's Medication Error Procedure and Medication and Treatment Orders policy were not followed, contributing to the deficiency.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to immediately report allegations of physical abuse to the State Agency within the required two-hour timeframe. A resident, R3, reported that during morning care, staff placed a pillow over her roommate R2's mouth to stop her from screaming. R3 had previously witnessed a similar incident but did not report it because another staff member intervened. On the day of the incident, R3 informed both an LPN and a nursing assistant about her concerns, but neither reported the allegations to management. R2, the resident allegedly abused, was unable to complete a mental status assessment and was dependent on staff for daily activities. Despite R3's report, R2 denied any abuse when questioned by the LPN. The LPN, who spoke Hmong, did not report the allegations because R2 denied them. The nursing assistant also failed to report, assuming the LPN would handle it. The Director of Nursing was unaware of the allegations until informed by the surveyor. The facility did not provide a policy on abuse reporting when requested.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing bathing preferences for a resident, identified as R74. The resident's admission Minimum Data Set (MDS) indicated that an interview for preferences, including bathing preferences, should have been conducted, but it was not assessed. The resident was dependent on staff for showering and bathing, and the care plan indicated a weekly bath schedule. However, the care sheet lacked information on when or what type of bath the resident would receive. The resident's medication administration record and treatment administration record showed a bath was to be given within 24 hours of admission and then follow a bath day schedule, but documentation was inconsistent. Interviews and observations revealed that the resident had not received a shower since admission and had only received sponge baths twice. The resident expressed dissatisfaction with the lack of showers and had visible signs of neglect, such as an odor and long, dirty fingernails. Staff interviews indicated that the resident had a bath schedule, but there was confusion and inconsistency in following it. The resident preferred to sleep in and did not like to get up early, which was not accommodated in the bath schedule. The facility's staff, including the director of social services, nursing assistants, and therapists, acknowledged the resident's preferences but failed to document refusals or adjust the care plan accordingly. The director of reimbursement and registered nurse involved in completing the MDS admitted that section F, which includes resident preferences, was not consistently completed. The director of nursing confirmed the importance of knowing resident preferences and updating care plans accordingly but acknowledged the MDS was not completed. The facility lacked a policy regarding preferences, contributing to the oversight in honoring the resident's bathing preferences.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain privacy for two residents during personal care activities. Resident R42, who is cognitively impaired and dependent on staff for various activities of daily living, was observed receiving care with the door shut but the privacy curtain not pulled. This left R42 exposed when an unidentified staff member entered the room, despite the resident being undressed and facing the wall. Similarly, Resident R64, who is cognitively intact but always incontinent and dependent on staff for personal hygiene, was also observed receiving care without the privacy curtain pulled. This resulted in R64's private areas being exposed when several staff members entered the room. The nursing assistant (NA-A) involved in the care of both residents acknowledged that the privacy curtains in the rooms were stuck and not functioning properly, which prevented them from being used to ensure privacy. NA-A had submitted a work order for the repair of the curtains, but the issue had not been resolved at the time of the observations. The Director of Nursing (DON) confirmed that it was the facility's expectation for staff to provide privacy for residents during personal care by using the curtains. However, the facility's resident privacy policy was not provided upon request.
Failure to Maintain Cleanliness of Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident who was dependent on staff for all activities of daily living and had a feeding tube through which they received more than 50% of their nutrition. The resident had a history of traumatic brain injury, hemiparesis, and aphasia. Observations revealed that the support legs of the tube feeding pump pole had a dried brown substance, identified as enteral feeding liquid, adhered to them. This substance was noted on multiple occasions over several days, indicating a lack of timely cleaning by the nursing staff. Interviews with the nursing staff, including a registered nurse and the nurse manager, confirmed that the pole was dirty and should have been cleaned. The staff acknowledged that it was their responsibility to clean the equipment once a spill was identified. Despite this, the dried substance remained on the pole for several days. The director of nursing also confirmed that the expectation was for nursing staff to clean equipment immediately if it was dirty. However, the facility was unable to provide a cleaning policy regarding tube feeding pump poles when requested.
Failure to Complete Comprehensive Assessment and Implement Resident Preferences
Penalty
Summary
The facility failed to ensure a comprehensive assessment was developed, completed, and implemented for a resident, identified as R74, upon admission and periodically as required. The resident's Minimum Data Set (MDS) indicated intact cognition and dependency on staff for showering and bathing. However, the MDS lacked an assessment of the resident's preferences for bathing, as required under Section F of the Resident Assessment Instrument (RAI) manual. The resident's care plan and care sheet also lacked specific information regarding the type and timing of baths. Interviews and observations revealed that the resident had not received a shower since admission and had only been given sponge baths twice. The resident expressed dissatisfaction with the lack of showers and had an odor and untrimmed fingernails. Staff interviews indicated that the resident had a bath schedule, but documentation of baths or refusals was inconsistent or missing. The resident's preferences for bathing were not incorporated into the care plan, and the MDS section F was not consistently completed. The facility's staff, including the Director of Reimbursement, Registered Nurse, and Licensed Practical Nurse, acknowledged the importance of completing the MDS and incorporating resident preferences into the care plan. However, they admitted that section F of the MDS was not consistently completed, and there was a lack of documentation regarding the resident's bathing schedule and preferences. The Director of Nursing confirmed the absence of a policy regarding the MDS and emphasized the importance of knowing resident preferences.
Failure to Implement Restorative Nursing Program for Resident with Mobility Issues
Penalty
Summary
The facility failed to ensure that a restorative nursing program (RNP) was completed for a resident with mobility issues. The resident, who has a history of peripheral vascular disease, muscle weakness, difficulty in walking, and an acquired absence of the right leg above the knee, was discharged from physical therapy with a plan to continue ambulation through an RNP. Despite the care plan directing staff to assist the resident in ambulating daily with a prosthetic leg, the resident reported not using the prosthetic due to pain and had not walked for four weeks. Interviews with staff revealed inconsistencies in the implementation of the RNP, with some staff unaware of the resident's ambulation status and others noting the resident's refusal to wear the prosthetic. The resident's treatment administration record (TAR) indicated that the RNP order was being completed, but an interdisciplinary team (IDT) note later identified the resident as not appropriate for the program due to refusal to participate, citing pain with the prosthetic fitting. Despite this, the resident expressed a desire to walk and was able to ambulate with assistance after the IDT meeting. The facility's director of nursing stated that staff should follow orders and document refusals appropriately, but there was no restorative nursing program policy provided upon request, indicating a lack of formal guidance for staff.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident with a history of repeated falls. The resident, identified as R19, had severe cognitive impairment and required extensive assistance for mobility and toileting. Despite being at high risk for falls due to impaired mobility, unsteady gait, and a history of seizures, the facility did not consistently implement or maintain necessary safety interventions, such as a floor mat next to the bed, as outlined in the resident's care plan. R19 experienced multiple falls, including one on 6/12/24, where the resident was found on the floor next to the bed. The interdisciplinary team (IDT) reviewed the incident and added a floor mat as an intervention. However, subsequent observations revealed that the floor mat was not consistently in place, and staff were not following the care plan. On 6/24/24, R19 was observed trying to get out of bed without a floor mat present, despite the care plan indicating its necessity. Interviews with staff, including a licensed practical nurse manager and the director of nursing, revealed a lack of communication and adherence to the care plan. The facility's policy on fall prevention and management was not effectively implemented, as evidenced by the lack of consistent interventions and documentation. The resident's fall risk evaluations and risk management reports highlighted the need for interventions, yet these were not adequately addressed. The failure to maintain the floor mat and ensure staff followed the care plan contributed to the resident's continued risk of falls, demonstrating a deficiency in providing a safe environment for the resident.
Failure to Monitor and Assess Respiratory Status
Penalty
Summary
The facility failed to ensure ongoing monitoring and assessment of a resident's respiratory status and did not provide respiratory medications as indicated. The resident, identified as R50, had a significant change in their Minimum Data Set (MDS) indicating severely impaired cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). Despite the resident's care plan identifying a potential for respiratory distress, it lacked specific interventions for oxygen use. The resident's physician orders included an albuterol inhaler for wheezing or shortness of breath, but the Medication Administration Record (MAR) showed no administration of the inhaler. Observations and interviews revealed that the resident's oxygen use was not properly documented or monitored. On multiple occasions, the resident was found with the nasal cannula improperly placed or on the floor, and there was no respiratory assessment conducted before or after oxygen therapy. The resident's oxygen saturations and respiratory rate had not been checked since a previous date, and there was no order for oxygen use in the electronic medical record, despite a verbal order being given earlier in the month. Staff interviews indicated a lack of awareness and adherence to proper procedures for oxygen use and respiratory assessments. Nursing staff were unsure about the necessity of orders for oxygen use and the appropriateness of using the PRN inhaler for shortness of breath. The facility's standing house orders lacked specific guidelines for respiratory assessments with oxygen use, and a policy for respiratory assessments was not provided upon request.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
The facility failed to ensure staff utilized enhanced barrier precautions (EBP) for a resident during tube feeding care. The resident, who had a history of stroke, aphasia, diabetes, malnutrition, and was dependent on tube feeding for nutrition, was observed receiving care without the proper use of personal protective equipment (PPE) as required by EBP. The resident's care plan and active orders specified the need for EBP, including the use of gloves and gowns during high contact care activities such as tube feeding. During an observation, an LPN was seen entering the resident's room, wearing gloves but not a gown, and performing tube feeding care, which included handling the feeding tube and associated equipment. Despite the EBP signage on the door and the facility's policy requiring gowns and gloves for residents with indwelling medical devices, the LPN did not adhere to these precautions. The LPN later stated she was informed by an unidentified person that EBP was not necessary for tube feeding care, contradicting the facility's policy and the director of nursing's statement that PPE should be worn in accordance with EBP for device care.
Failure to Document Wound Care Orders
Penalty
Summary
The facility failed to ensure that the wound care provider's treatment orders were properly transcribed into the medical record for a resident with multiple pressure ulcers. The resident, who had severely impaired cognition and required total assistance for bed mobility and transfers, was at risk for developing pressure injuries. Despite having a care plan in place, the plan lacked specific directions for wound care dressing changes. The wound care provider's orders for the resident's left gluteus pressure ulcer were not documented in the electronic medical record (EMR) or the medication and treatment administration records, leading to a lack of continuity in care. Observations revealed that the dressing changes for the left gluteus pressure ulcer were not being documented as ordered. During wound care rounds, it was discovered that the dressing was wet with drainage, prompting a change in the wound care orders. However, these orders were not entered into the EMR, as expected by the nurse practitioner. The director of nursing confirmed the absence of these orders in the EMR, highlighting a breakdown in communication and documentation processes. The facility's policy required that treatment orders be updated in the care plan, which was not adhered to in this case.
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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