Woodlake Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Crystal, Minnesota.
- Location
- 8000 Bass Lake Road, Crystal, Minnesota 55428
- CMS Provider Number
- 245518
- Inspections on file
- 36
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Woodlake Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean and odor-free environment, as evidenced by persistent musty and urine odors in hallways and resident rooms, stained and inadequately cleaned carpets, and improper cleaning of urine spills. Multiple residents and family members reported unpleasant smells and unclean conditions, and staff confirmed challenges with housekeeping due to staffing shortages.
Two residents were not provided with timely pain management, mobility equipment, or personal care upon admission. One resident with multiple fractures waited hours for pain medication and was left bedbound without necessary devices, while another with a new colostomy experienced significant delays in assistance and care. Staff interviews revealed delays in therapy assessments and a lack of preparedness to meet residents' immediate needs.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights was upheld.
A resident alleged sexual abuse by a nursing assistant during pericare, but the facility failed to report the incident to the state agency within the required timeframe. Despite the resident's cognitive intactness and clear communication of the incident, the nurse manager did not report it, and the director of nursing and administrator were unaware until the survey. The facility's policy requires reporting within two hours, which was not adhered to, leading to a deficiency.
A resident with moderately impaired cognition was found with unsecured and expired medications in her room, without a proper assessment or physician order for self-administration. Staff interviews revealed that a nursing assistant applied the medication, despite not being trained or authorized to do so, and the facility's policy requiring evaluation for self-administration was not followed.
A resident with dementia, requiring extensive assistance, was frequently observed in a hospital gown with uncombed hair, contrary to her preference for wearing her own clothes. Staff were unaware of her clothing preferences, and her care plan lacked this information. The DON emphasized the importance of maintaining residents' dignity through appropriate dressing and grooming, as per facility policy.
A resident with dementia in an LTC facility did not receive adequate assistance with activities of daily living (ADL), including dressing, grooming, and oral care. Despite the care plan indicating the need for extensive assistance, the resident was often observed in a hospital gown with unkempt hair and without dentures. Staff interviews revealed a lack of adherence to the care plan and the resident's preferences, leading to a deficiency in care.
A resident with dementia and a history of falls was found without access to a call light, which was lying on the floor out of reach. Despite the care plan requiring the call light to be within reach, staff interviews confirmed it was not secured properly. The DON emphasized the importance of call light accessibility for resident safety, but the facility's policy was not followed, resulting in a deficiency.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a clean and odor-free environment for three residents reviewed for environmental concerns. Observations on multiple occasions revealed musty and urine odors in hallways and outside resident rooms, with no trash or linen carts present to explain the odors. One family member reported persistent foul odors in a resident's bathroom even after cleaning. Another resident, with a history of muscle weakness, diabetes, hypertension, and falls, stated that the carpet was stained, musty, and had not been properly vacuumed, leading her to use her own fungicide to improve the smell. She also reported that a recliner brought from the basement had an unpleasant odor. A third family member described incidents where urine from a catheter was spilled onto the carpet and not properly cleaned, with staff using a paper towel to rub the urine into the carpet. A facility grievance form documented complaints about dirty floors and insufficient garbage cans. The social service designee confirmed awareness of concerns regarding urine on the carpet and the lack of a recliner, noting that these issues contributed to a negative impression of the facility's cleanliness. The environmental services director acknowledged being short-staffed, lacking a floor technician, and stated that hallway cleaning was not occurring as frequently as desired. These findings demonstrate a failure to provide a clean, odor-free, and comfortable environment for residents, staff, and visitors.
Failure to Accommodate Resident Needs and Preferences Upon Admission
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences upon admission for two residents. One resident, admitted with multiple fractures and severe pain, did not receive prescribed pain medication for approximately seven hours after arrival, despite orders for oxycodone and documented severe pain. The resident was also left without necessary mobility devices, such as a walker or wheelchair, and was unable to transfer out of bed or access the commode due to the lack of equipment. Staff informed the resident and family that therapy assessments and equipment provision would not occur until the next day, resulting in the resident remaining bedbound and experiencing significant discomfort. The resident and family reported that staff were unprepared to assist with mobility and pain management, and that communication regarding medication availability was lacking. Another resident, admitted with a new colostomy and chronic pain, experienced delays in care and assistance. The resident was found lying in urine with the call light on and waited an hour for help on the first night. On another occasion, the resident waited two hours for assistance with a colostomy bag change, leading a family member to perform the task themselves. When a nurse eventually arrived, she was unfamiliar with how to change the colostomy bag, indicating a lack of staff preparedness and training for the resident's needs. Interviews with staff revealed that therapy assessments and equipment provision were often delayed on weekends, and that nursing staff were hesitant to provide mobility devices without therapy input. Staff also indicated that pain medication could be accessed from the emergency kit, but this was not done promptly for the resident in pain. The facility's processes and communication breakdowns resulted in residents not receiving timely pain management, mobility support, or personal care upon admission.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency within the required timeframe. The incident involved a resident who claimed that a nursing assistant had assaulted him during pericare. Despite the resident's cognitive intactness, as indicated by a BIMS score of 14, and his clear articulation of the incident to the nurse manager, the allegation was not reported to the state agency as required by the facility's policy. The nurse manager, upon being informed by the resident, discussed the incident with the social services director and the director of nursing but did not report it to the state agency. The resident's care plan was updated to include 'cares in pairs' as a protective measure, but the allegation itself was not documented in the progress notes. The director of nursing and the administrator were unaware of the allegation until the day of the survey, indicating a breakdown in communication and reporting procedures within the facility. Interviews with various staff members, including the nurse manager, director of nursing, and executive director, revealed a lack of clarity and adherence to the facility's abuse reporting policy. The director of nursing stated that she would have reported the allegation immediately had she been informed. The facility's policy mandates that all alleged violations be reported to the appropriate authorities within two hours, but this protocol was not followed, resulting in a deficiency.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications. The resident, identified as having moderately impaired cognition and requiring assistance with activities of daily living, was observed with various medications unsecured in her room. These included a tube of Asper Creme, a container of petroleum jelly, and two bottles of Nystatin powder, some of which were expired. The resident indicated that a nursing assistant applied the cream for her, but there was no documented assessment or physician order for self-administration of medications in the resident's medical record. Interviews with staff revealed that the nursing assistant applied the cream at the resident's request, despite not being trained to do so. The nurse manager confirmed that the resident did not have an order for self-administration and was not supposed to have medications in her room without an order. Additionally, the director of nursing stated that only nurses, not nursing assistants, were authorized to apply creams and powders. The facility's policy required an evaluation to determine if a resident could safely self-administer medications, which was not conducted in this case.
Failure to Maintain Resident Dignity in Dressing and Grooming
Penalty
Summary
The facility failed to maintain the dignity of a resident with severely impaired cognition and a diagnosis of dementia, who required extensive assistance for dressing, grooming, and toileting. The resident was frequently observed wearing a hospital-type gown instead of her own clothes, with uncombed and matted hair, and without proper footwear. The care plan did not specify the resident's preference for wearing her own clothes or a hospital gown, and staff members were unaware of her preferences, as they relied on a care sheet that lacked this information. Interviews with staff and a family member revealed that the resident preferred to wear her own clothes and took pride in her appearance. However, she was often dressed inappropriately, with pants that were too short and without a bra, which was not in line with her usual standards. The Director of Nursing acknowledged the importance of residents feeling good about their appearance and stated that staff should assist residents in wearing clean, neat clothing and grooming their hair. The facility's policy emphasized considering the resident's former lifestyle and personal choices when providing care, but this was not reflected in the care provided to the resident.
Deficiency in ADL Assistance for Resident with Dementia
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident with severely impaired cognition and a diagnosis of dementia. The resident required extensive assistance for dressing, grooming, bathing, oral care, and toileting, as indicated in their care plan. However, observations revealed that the resident was often left in a hospital gown, with messy and uncombed hair, and without dentures. Certified Nursing Assistants (CNAs) responsible for the resident's care did not consistently follow the care plan, failing to assist with hand hygiene before meals and neglecting oral and hair care. Interviews with staff and family members highlighted a lack of awareness and adherence to the resident's preferences and care needs. The resident's family member expressed that the resident preferred to wear her own clothes and took pride in her appearance, which was not respected by the staff. The Director of Nursing confirmed the resident's need for assistance and the expectation for staff to provide such care, yet the staff did not consistently meet these expectations, leading to a deficiency in the resident's ADL care.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that care plan interventions were being utilized for a resident with severely impaired cognition and a diagnosis of dementia, who required extensive assistance for daily activities. The resident's care plan, revised on September 15, 2024, indicated a risk for falls and included interventions such as ensuring the call light was within reach before staff exited the room. However, during an observation on October 25, 2024, the resident's call light was found lying on the floor, approximately two feet away from the resident and outside of her reach. There was no clip to attach the call light to the resident's bed or clothing, and no other call light was available in the room. Interviews with CNAs revealed that the resident was functionally able to use the call light to summon assistance, but the call light was not secured as required. CNA-B mentioned that the resident primarily used a specific type of call light and that it should be clipped to the blankets or wheelchair. CNA-C confirmed the call light was on the floor and stated it had been clipped to the blankets before her break. The Director of Nursing emphasized the importance of having the call light within reach for resident safety and communication. The facility's policy required staff to ensure the call light was accessible and secured, but this was not adhered to in the case of the resident, leading to a deficiency in providing adequate supervision to prevent accidents.
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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