Tweeten Lutheran Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spring Grove, Minnesota.
- Location
- 125 5th Avenue Southeast, Spring Grove, Minnesota 55974
- CMS Provider Number
- 245429
- Inspections on file
- 25
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Tweeten Lutheran Health Care Center during CMS and state inspections, most recent first.
A resident with dementia and Parkinson's Disease was not properly monitored or assessed for pressure ulcer risk, and interventions such as heel boots and offloading were delayed or inconsistently documented. Wound assessments were incomplete, lacking key details and timely updates, and weekly comprehensive assessments by an RN were not consistently performed, contrary to facility policy.
A resident with cognitive impairment and a history of wandering was able to exit the facility in extremely cold weather after activating an exit alarm, with staff failing to immediately retrieve her despite visual confirmation. Additionally, another resident experienced multiple falls without comprehensive root cause analysis or timely updates to care plans and interventions. Staff interviews indicated insufficient training and inconsistent implementation of safety protocols.
The facility did not ensure an RN was on duty for at least eight consecutive hours in a 24-hour period, as required. Although posted staffing information indicated RN coverage, the actual schedule showed only LPNs were present, and the DON confirmed the absence of RN coverage. The facility's staffing policy did not specify the need for eight consecutive hours of RN coverage, potentially affecting all residents.
The facility did not immediately investigate suspicious bruises of unknown origin found on two residents, as required by its abuse prohibition policy. One resident with cognitive and physical impairments was found with a breast bruise, and another with multiple medical conditions had a bruise near the rectum. In both cases, there was no documentation of how the injuries occurred or evidence of staff interviews, and the DON confirmed that investigations should have been initiated but were not.
Two residents with significant medical conditions were found with bruises of unknown origin in suspicious locations. In both cases, the LPN who discovered the injuries did not immediately notify the administrator or DON, and reporting to the State Agency was delayed or not completed, contrary to facility policy requiring prompt reporting of potential abuse.
A resident with severe cognitive impairment and a history of falls was admitted and experienced two additional falls. The baseline care plan did not identify the resident's fall risk or include updated interventions from fall investigations, despite new measures being identified after each incident. The DON confirmed the care plan was incomplete and not updated as required.
Two residents experienced multiple falls and pressure ulcer events, but their care plans were not promptly updated to include new interventions identified during investigations and IDT reviews. Despite specific recommendations such as increased assistance, safety checks, and offloading devices, these were not consistently added to the care plans. Staff interviews revealed confusion about responsibility for care plan updates, contributing to the deficiency.
A resident with cognitive impairment and a history of wandering did not receive ordered occupational therapy evaluation, treatment, or cognitive testing due to a breakdown in communication and follow-up between nursing and therapy staff. The order was transcribed but not relayed to the therapy department, resulting in the services not being provided as directed.
The facility posted inaccurate nurse staffing information by listing an RN for a day shift when, in fact, an LPN worked that shift. The DON discovered the error after verifying the nurse's license, resulting in a staff posting that did not reflect the actual personnel on duty. This inaccuracy had the potential to affect all residents in the facility.
The facility failed to ensure proper hand hygiene practices among staff, affecting multiple residents. Nursing assistants and an LPN were observed not performing hand hygiene before and after resident contact, between glove changes, and after touching potentially contaminated surfaces. Additionally, the facility lacked an infection surveillance system, with no tracking of infections since July 2024, contrary to the facility's Infection Prevention and Control Plan.
The facility failed to maintain a clean and sanitized kitchen environment, potentially leading to cross-contamination or foodborne illness. During inspections, several kitchen items were found unclean with crusted food and debris. The dietary manager confirmed the issues and stated that all staff are trained on proper cleaning procedures, but the presence of dirty items indicates a failure to adhere to these procedures.
A facility failed to complete a Level II PASARR for a resident with mental disorders, including schizoaffective and bipolar disorders. Despite the resident's need for psychiatric care and psychotropic medications, the facility did not request the necessary screening, as confirmed by staff interviews and the facility's policy requirements.
The facility did not document that three staff members, including two LPNs and a housekeeper, were offered or educated about the COVID-19 vaccine. Interviews revealed a lack of awareness and documentation regarding vaccine offers and education, despite the facility's policy requiring such actions.
A resident with congestive heart failure and hypernatremia experienced harm due to the facility's failure to conduct a comprehensive nutritional assessment and monitor for dehydration. Despite being on diuretics and a pureed diet with thickened liquids, the resident's fluid intake was inadequately monitored, leading to multiple hospitalizations for severe health issues. Staff interviews revealed a lack of awareness and systems to monitor fluid intake, and facility policies on dehydration were not effectively implemented.
A facility failed to create a comprehensive care plan for a resident with acute respiratory failure with hypoxia. The care plan lacked specific goals and interventions for respiratory assessment and monitoring, despite the resident's recent hospitalization for severe hypotension and respiratory failure. Staff interviews confirmed the absence of necessary interventions in the care plan.
A resident with intact cognition and diagnoses of hypernatremia and hyperosmolality experienced frequent loose stools while receiving scheduled bowel medications, including docusate sodium. Despite documentation of large, loose stools and staff reports, the facility continued administering the medication without proper evaluation. Interviews revealed that bowel medications were not consistently held, and the provider was not notified promptly, contrary to the facility's bowel management policy.
A resident with Alzheimer's and psychotic disorder reported an incident of physical abuse by staff, which was not reported to the administration or State Agency within the required timeframe. The resident felt unsafe during the incident but has since felt secure. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to in this case.
A resident with Alzheimer's and other conditions reported an incident of physical abuse by two staff members, which was not thoroughly investigated by the facility. The investigation lacked interviews with all relevant parties and did not implement protective measures, contrary to the facility's policy.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, as required by their care plan. Observations showed no signage or PPE available, and staff were unaware of EBP requirements. Interviews confirmed that EBP was not implemented for any residents, despite the facility's policy outlining the need for staff training and PPE availability.
Failure to Monitor and Manage Pressure Ulcers
Penalty
Summary
A resident with diagnoses of dementia and Parkinson's Disease was not properly monitored or assessed for pressure ulcer risk, despite being identified as at risk for pressure injuries and requiring maximum assistance for mobility. The resident's care plan included interventions such as an air mattress, skin inspections, and heel protectors, but documentation showed inconsistencies and delays in implementing these interventions. For example, heel boots were not added to the care plan until eight days after a left heel wound was identified, and there was no documentation of offloading measures prior to the appearance of redness on the heel. Wound assessments for the resident were incomplete and lacked comprehensive details such as wound characteristics, pain, drainage, and surrounding skin condition. Several wound management reports failed to include necessary information or to document the use of pressure-relieving interventions. Additionally, weekly comprehensive wound assessments by a registered nurse were not consistently performed or documented, and the care plan was not promptly updated to reflect new or worsening wounds. Interviews with nursing staff and the DON confirmed that comprehensive wound assessments were not being reviewed to ensure wounds were not worsening and that appropriate treatments were being used. The facility's own policy required weekly head-to-toe skin inspections and comprehensive wound assessments for residents with wounds, but these procedures were not followed, resulting in delayed identification and management of pressure ulcers for the resident.
Failure to Prevent Elopement and Inadequate Fall Risk Management
Penalty
Summary
The facility failed to immediately respond to an elopement incident involving a resident with mild cognitive impairment, chronic kidney disease, and a history of wandering. The resident, identified as an elopement risk and equipped with an exit alarm bracelet, was able to leave the facility without appropriate clothing for extremely cold weather. When the exit alarm sounded, staff initially searched the wrong area and did not immediately pursue the resident outside, despite visual confirmation of her location. The resident was eventually found by a staff member approximately 15 minutes later, outside and exposed to cold temperatures, with red face and very cold hands. Additionally, the facility did not conduct comprehensive investigations or root cause analyses for multiple falls experienced by another resident with cognitive impairment and impaired mobility. The fall investigations often lacked thorough assessments of contributing factors such as toileting needs, call light placement, and footwear. Interventions were inconsistently implemented or documented, and care plans were not promptly or adequately revised to address the identified risks and causal factors for repeated falls. Staff interviews revealed gaps in training and understanding of elopement prevention and response protocols. Documentation and care planning for fall prevention were incomplete, with delays in updating interventions and a lack of comprehensive analysis following each incident. The facility's policies required individualized interventions and ongoing evaluation, but these were not consistently followed, resulting in repeated deficiencies in accident prevention and resident supervision.
Failure to Provide Required RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of eight consecutive hours within a 24-hour period on one day during the review period. Specifically, on 12/13/25, posted nurse staffing information indicated that an RN was scheduled for the day shift, but the actual daily schedule showed only licensed practical nurses (LPNs) were present, with no RN coverage documented for that 24-hour period. During an interview, the director of nursing (DON) confirmed that there was no RN coverage on that date, despite the posted information. Review of the facility's Nurse Staffing Hours policy revealed that while it required posting of total and actual hours worked by nursing staff, it did not specify the requirement for RN coverage for eight consecutive hours in a 24-hour period. This deficiency had the potential to affect all thirty-six residents residing in the facility.
Failure to Immediately Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to immediately investigate injuries of unknown source in accordance with its abuse prohibition policy for two residents. One resident with Alzheimer's and Parkinson's disease, who was dependent for transfers and had moderate cognitive impairment, was found with a bruise of unknown origin on the right breast. There was no documentation in the resident's record or incident reports regarding how or when the bruise occurred, nor evidence that staff interviews were conducted. Another resident with heart failure, diabetes mellitus, and atrial fibrillation, who was dependent with toileting hygiene and transfers and had intact cognition, was found with a dark bruise near the rectum. The resident attributed the bruise to a recent bowel movement and denied abuse or pain, but again, there was no further information or staff interviews documented in the records or incident reports. During an interview, the DON confirmed that bruises found on the breast or anal region are considered suspicious for abuse and should trigger an immediate investigation, which did not occur in these cases. The facility's policy requires that all reports of abuse, including injuries of unknown source, be promptly and thoroughly investigated, with results documented. The policy specifically lists bruising in areas such as the inner thigh, chest, face, and breast, or bruises of unusual size or in atypical locations, as requiring immediate investigation to rule out abuse. Despite these requirements, investigations were not initiated for either resident after their injuries were discovered.
Failure to Timely Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to immediately report injuries of unknown origin to the administrator and did not notify the State Agency (SA) within the required reporting guidelines for two residents. One resident with Alzheimer's and Parkinson's disease, who was dependent for transfers and had moderate cognitive impairment, was found to have a bruise on the right breast of unknown origin. The LPN who discovered the bruise believed it was caused by a sit-to-stand lift and, since the resident denied abuse, did not report the injury to the administrator immediately, instead sending an email notification several hours later. The bruise was not investigated or reported to the SA as required. Another resident, with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation, and who was dependent with toileting and transfers, was found to have a dark bruise near the anal region. The LPN who identified the bruise did not notify the DON or administrator immediately, as the resident believed the bruise was from a bowel movement and denied abuse. Notification to administration was delayed and sent via email at a later time. The facility's policy required that allegations involving abuse be reported no later than two hours after the allegation is made, but this protocol was not followed in either case.
Failure to Update Baseline Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a baseline care plan for falls was continuously evaluated and updated to reflect interventions identified as a result of fall investigations for a resident with neurocognitive disorder with Lewy bodies and polyneuropathy. Upon admission, the resident was noted to have severe cognitive impairment, a history of falls, and required supervision for transfers. The initial baseline care plan did not identify the resident's level of fall risk or include appropriate fall prevention interventions. Following two witnessed falls in the dining area, additional interventions such as one-to-one supervision, increased staff assistance, and specific instructions for transfers and ambulation were identified during fall investigations. Despite these incidents and the identification of new interventions, the baseline care plan was not updated to reflect the changes. The DON confirmed that although the resident was recognized as high fall risk at admission and a baseline care plan was created, it did not specify the risk level or include the necessary interventions to mitigate future falls. The facility's policy requires that a baseline care plan be developed and implemented within 48 hours of admission to address health and safety concerns, but this was not followed in the resident's case.
Failure to Timely Revise Care Plans After Falls and Pressure Ulcer Events
Penalty
Summary
The facility failed to revise and update care plans in a timely manner for two residents who were reviewed for falls and pressure ulcers. For one resident with diagnoses of malignant neoplasm of the lung and brain, and moderate cognitive impairment, multiple falls occurred over a period of time. Each fall investigation identified specific interventions such as increased assistance during transfers, regular toileting intervals, use of call lights, 15- or 30-minute safety checks, and environmental modifications like fall mats and visible signs. However, these interventions were not consistently or promptly incorporated into the resident's care plan following each incident, despite being identified as necessary in fall investigations and interdisciplinary team (IDT) reviews. Additionally, another resident with dementia and Parkinson's Disease, who was at risk for pressure ulcers and had existing skin breakdown, did not have their care plan updated to reflect new interventions after a skin integrity event. The event identified the need for offloading heels with pillows and boots, but these interventions were not added to the care plan. The care plan also lacked clarity regarding the measurement units for wounds and did not specify all required interventions for pressure ulcer prevention and management. Interviews with facility staff revealed a lack of clarity and accountability regarding who is responsible for updating care plans after new interventions are discussed or implemented. Both nursing and administrative staff indicated they were either unaware of their responsibilities or had not received training on revising care plans, resulting in delays and omissions in care plan updates. The facility's own policy requires timely care plan revisions when there are changes in condition or interventions, but this was not followed in the cases reviewed.
Failure to Implement Physician Orders for Occupational Therapy and Cognitive Testing
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for occupational therapy evaluation, treatment, and cognitive testing was implemented according to professional standards for one resident. The resident had diagnoses including mild cognitive impairment, chronic kidney disease, and a history of breast cancer, and was noted to have daily wandering behaviors and moderate cognitive impairment. The physician assistant issued an order for occupational therapy and cognitive testing, with instructions for therapy to provide the results to the provider. Despite the order being transcribed and placed in the therapy box by the registered nurse case manager, it was not communicated to the therapy director or followed up on by nursing staff. Interviews revealed that the occupational therapy department had not received the order, and the director of nursing confirmed that the order was not communicated as required. The physician assistant stated that her expectation was for orders to be processed promptly and communicated to the appropriate staff. A policy for following physician orders was requested but not provided.
Inaccurate Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the accuracy of its daily nurse staffing posting on 12/13/25. The posted information indicated that a registered nurse (RN) worked the day shift, but a review of the nursing schedule and subsequent verification by the director of nursing (DON) revealed that an LPN actually worked that shift. The DON initially believed the scheduled nurse was an RN, but upon checking the license, discovered the error, resulting in an inaccurate staff posting. The facility's policy requires accurate posting of the names, hours, and roles of nursing staff for each shift, but this was not followed on the date in question. This discrepancy had the potential to affect all 36 residents in the facility.
Inadequate Hand Hygiene and Lack of Infection Surveillance
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were implemented by staff, affecting six residents observed for handwashing/hand hygiene. Nursing assistants and an LPN were observed not performing hand hygiene before and after resident contact, between glove changes, and after touching potentially contaminated surfaces. For instance, a nursing assistant assisted multiple residents with meals without washing hands between interactions, and another did not perform hand hygiene after transferring residents. An LPN was seen touching her face with gloved hands and then proceeded to care for a resident without washing hands. These actions were contrary to the facility's stated expectations for hand hygiene. Additionally, the facility lacked a system for infection surveillance to identify possible communicable diseases or infections. The Director of Nursing admitted that no infection surveillance had been conducted since July 2024, and the medical director expressed concern over this oversight. The facility's Infection Prevention and Control Plan required an infection control surveillance system, but this was not being implemented, leaving the facility without a mechanism to track and respond to infections among residents and staff.
Failure to Maintain Clean and Sanitized Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean and sanitized kitchen environment, which could potentially lead to cross-contamination or foodborne illness affecting all residents, staff, and visitors. During an initial tour of the kitchen, several large pans, mixing bowls, and containers were found to be unclean with dry crusted food on them. The dietary manager acknowledged the dirty items and removed them from the storage area. Additionally, several dirty utensils were found in storage drawers. A follow-up observation revealed more dirty kitchen items, including large pans with dried food and a baking pan with paper debris, which were confirmed by a cook to be dirty and in need of cleaning. The dietary manager explained the facility's sanitary policy and confirmed that the dishwasher was functioning properly. The manager acknowledged the unclean items found during the initial tour and stated that they were discussed with the staff and removed for cleaning. The facility employs about 10 kitchen staff, some of whom are new, and all are trained on proper cleaning and sanitization procedures. The facility's policy requires all kitchen items to be cleaned, rinsed, and sanitized after each use, with staff expected to inspect items for cleanliness before storage. Despite this policy, the presence of dirty kitchen items indicates a failure to adhere to these procedures, potentially leading to foodborne illness.
Failure to Complete PASARR Level II Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed or clarified for a resident with a mental disorder. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, narcissistic personality disorder, and anxiety, was on a medication regimen that included psychotropic medications. Despite these conditions, the facility did not initiate a request for a PASARR Level II screening, which was necessary due to the resident's mental health concerns and extended stay. Interviews with facility staff, including the social services worker and the director of nursing, revealed a lack of awareness and action regarding the resident's PASARR status. The social services worker acknowledged the need for a Level II assessment, and the director of nursing was unaware of the resident's PASARR status and the missed psychiatric appointments. The facility's policy required a Level I PASARR prior to admission and a referral for a Level II screening if necessary, but this process was not followed, leading to the deficiency.
Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to maintain documentation that staff were offered or provided education regarding the benefits and potential risks associated with COVID-19 vaccination for three staff members, including two Licensed Practical Nurses (LPN-A and LPN-B) and a housekeeper (HSK-A). During interviews, the Human Resources Director stated there was no documentation of the COVID-19 vaccine being offered or education provided to these staff members. The Director of Nursing was unaware if employees were offered the COVID-19 vaccine, and the Medical Director expected the facility to ensure staff were educated on the risks and benefits and offered the vaccine. The facility's policy, dated November 2024, required that each staff member be offered the vaccine and provided education, with documentation maintained, but this was not followed.
Failure to Monitor and Address Dehydration Risk
Penalty
Summary
The facility failed to ensure a comprehensive nutritional assessment and monitoring for signs of dehydration for a resident, leading to harm. The resident, who had intact cognition and diagnoses including congestive heart failure and hypernatremia, was on diuretics and required a regular diet. However, the nutritional assessment did not account for the resident's diuretic use or specify daily fluid needs. The resident's fluid intake was consistently low, and there was no comprehensive assessment or care plan addressing the risk of dehydration. The resident experienced multiple hospitalizations due to severe health issues, including profound hypernatremia and hypovolemia, which were attributed to poor oral intake and inadequate fluid monitoring. Despite being on a pureed diet with thickened liquids, the resident's fluid intake was not adequately monitored, and the care plan did not include interventions to prevent dehydration. Interviews with staff revealed a lack of awareness and systems in place to monitor fluid intake and dehydration risk. The facility's policies on dehydration and nutrition interventions were not effectively implemented, as evidenced by the resident's low fluid intake and frequent loose stools, which increased the risk of dehydration. The registered dietician admitted to not comprehensively assessing the resident's fluid needs, and the interim director of nursing acknowledged the absence of a monitoring system for fluid intake. The physician assistant highlighted the need for close monitoring of residents with low fluid intake and chronic loose stools to prevent dehydration and related complications.
Failure to Develop Comprehensive Care Plan for Respiratory Condition
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with acute respiratory failure with hypoxia. Upon review, it was found that the resident's care plan, spanning from October 8 to November 13, did not include a respiratory plan of care with specific goals and individualized interventions to manage the resident's respiratory condition. The resident had been hospitalized for severe hypotension and acute respiratory failure with hypoxia due to a choking/aspiration event and was discharged with new dietary orders. Despite these significant health issues, the care plan lacked interventions for respiratory assessment and monitoring. Interviews with facility staff, including an LPN and the interim director of nursing, confirmed that the resident's care plan did not address the necessary interventions for the resident's respiratory condition. A physician assistant also stated that a resident with such a diagnosis should have a care plan with person-centered interventions, including a full respiratory assessment twice a day and monitoring for changes. The facility's policy on care planning emphasized the need for comprehensive, person-centered care plans with measurable objectives and timetables, which were not reflected in the resident's care plan.
Failure to Monitor and Evaluate Necessity of Bowel Medications
Penalty
Summary
The facility failed to adequately monitor and evaluate the necessity of bowel medications for a resident, leading to the administration of unnecessary drugs. The resident, who had intact cognition and was diagnosed with hypernatremia and hyperosmolality, was frequently incontinent of bowel and received scheduled bowel medications, including docusate sodium, Citrucel, and Miralax. Despite having loose stools throughout her stay, the facility continued to administer these medications without proper evaluation of their necessity. The resident's bowel movements were consistently documented as large and loose, with frequent episodes of incontinence. Despite these observations, the medication administration record indicated that docusate sodium was given twice daily, except on a few occasions due to hospitalization or loose stools. Progress notes highlighted that the resident experienced loose stools and stomach upset, yet bowel medications were not consistently held, and the provider was not notified promptly. Interviews with nursing staff revealed that the resident's loose stools were reported to nurses, but bowel medications were still administered. The interim director of nursing confirmed that the docusate sodium was unnecessary and should have been given only as needed. The facility's bowel management policy emphasized the importance of assessing individual needs and holding medications in cases of diarrhea, but these guidelines were not followed, resulting in the continued administration of unnecessary bowel medications.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the administration and State Agency (SA) within the required timeframe. A resident, who was admitted with diagnoses including Alzheimer's disease and psychotic disorder, reported an incident where two staff members allegedly attempted to force her into bed against her usual routine, causing her distress and bruising on her arms. The resident reported feeling unsafe during the incident but has since felt secure as the staff involved have not been seen again. The incident was not reported to the administration or the SA immediately, as required by the facility's policy. The social worker and former Director of Nursing (DON) were aware of the allegation but did not report it to the administrator or the SA within the mandated two-hour window. The administrator was only informed of the incident several days later, highlighting a failure in the facility's abuse reporting protocol. The facility's policy clearly states that all allegations of abuse must be reported immediately, but this protocol was not followed in this case.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a resident with Alzheimer's disease, auditory hallucinations, and a psychotic disorder. The resident, who required partial to moderate assistance with daily activities, reported an incident where two staff members allegedly attempted to force her into bed against her usual routine, resulting in her feeling disrespected and sustaining bruises on her arms. The resident identified the staff involved as two black females and mentioned that two white female staff intervened after she called for help. The facility's investigation was inadequate as it only included interviews with the resident and two staff members who typically worked the evening shift. It did not involve interviews with other residents, additional staff fitting the description of the alleged perpetrators, or the staff who intervened. Furthermore, the investigation did not identify or implement any protective interventions to ensure the safety of the resident or others. The facility's policy on abuse prevention and investigation was not followed, as it requires a comprehensive investigation process, including interviews with all relevant parties and a thorough documentation of findings. The social worker and administrator acknowledged the shortcomings in the investigation, noting that it should have been more thorough to ensure resident safety.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, which is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms. The resident's care plan identified the need for EBP due to wounds, requiring the use of gowns and gloves during high-contact resident care activities. However, observations revealed that there was no signage indicating EBP on the resident's door, and no personal protective equipment (PPE) was available outside the room. Nursing assistants were observed transferring the resident without using gowns or gloves, and they were unaware of the requirement to use EBP for residents with wounds. Interviews with staff, including a licensed practical nurse (LPN) and a registered nurse (RN), confirmed that EBP was not being implemented for any residents in the facility. The LPN verified the absence of signage and PPE carts, while the RN mentioned that the previous infection preventionist was aware of the EBP regulation but did not implement it. The interim director of nursing (IDON) also indicated a lack of awareness regarding the regulation and confirmed that EBP had not been implemented during her tenure. The facility's policy on Enhanced Barrier Precautions, dated November 2023, outlined the requirements for implementing EBP, including staff training, availability of PPE, and proper signage. Despite this policy, the facility did not adhere to these guidelines, resulting in a failure to protect residents from potential infection risks associated with wounds and indwelling medical devices. The lack of implementation and awareness among staff contributed to the deficiency in infection control practices.
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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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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