Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ramsey Village during CMS and state inspections, most recent first.
A resident with chronic pain and multiple comorbidities was ordered a 75 mcg fentanyl patch to be applied every 72 hours with removal per schedule, and facility policy required removal of old transdermal patches before applying new ones. Pharmacy, MAR, and controlled drug records showed repeated administration of fentanyl patches, with documentation indicating prior patch removal; however, on two separate occasions the resident was transferred to the ED with altered mental status, and EMS/ED staff found two fentanyl patches on the resident’s shoulders and administered naloxone for suspected opioid overdose. The DON later acknowledged that extra patches had been present on the resident and described this as sloppy nursing and a need to re-educate staff on proper patch removal and application.
Surveyors observed multiple instances where staff failed to follow proper procedures for using mechanical lifts and wheelchairs during transfers, including not locking wheelchair wheels, not attaching foot pedals during transport, and inconsistent use of lift wheel locks. These deficiencies involved residents with severe cognitive and physical impairments who required significant assistance, and staff interviews revealed inconsistent understanding of safety protocols.
A resident with severe cognitive impairment and total dependence for ADLs was left in a wheelchair without repositioning or incontinence care for several hours after breakfast. Multiple CNAs and LPNs confirmed no assistance was provided during this period, despite care plan and policy requirements for frequent checks and hourly repositioning.
Staff failed to disinfect a mechanical lift between uses for two residents, did not perform proper hand hygiene during perineal care for a resident with dementia and incontinence, and exited a room on Enhanced Barrier Precautions without removing PPE, all in violation of facility infection control policies.
A resident with an indwelling urinary catheter did not receive enhanced barrier precautions during toileting and catheter care, with CNAs using the same gloves through multiple tasks and no observed hand hygiene during glove changes. Two other residents also had toileting and incontinence care provided without proper hand hygiene between dirty and clean tasks. In addition, a mechanical lift was moved from one resident’s room to another without being sanitized between uses, contrary to facility policy.
Failure to notify the physician of low blood sugars for a resident with severe cognitive impairment who was receiving Lantus and Humalog. The MAR showed repeated BG readings below 60 mg/dL, but there were no documented interventions, repeat checks, or provider notifications, and staff confirmed the resident could not report symptoms and that protocol required notification for BG <60 mg/dL.
Failure to Identify Resident-Specific Target Behaviors for Psychotropic Medications: Two residents receiving psychotropic medications lacked resident-specific target behaviors in their care plans and orders. One resident with dementia, anxiety, depression, and severe functional dependence had no documented behaviors or nonpharmacological interventions, while the other resident with severe cognitive impairment had documented episodes of scratching, swatting, refusing care, and throwing water at staff, but the behaviors were not tied to a diagnosis or specific target behaviors. Staff and the DON confirmed the target behaviors were not clearly identified in the EHR, MAR/TAR, or care plan.
Incomplete Care Plans for Residents Receiving Psychotropic Medications: The facility failed to fully develop comprehensive care plans for three residents. One resident's care plan did not include communication or behavioral symptoms or the target behaviors tied to antianxiety, antipsychotic, and antidepressant use. Two other residents' care plans listed psychotropic medications but did not identify resident-specific target behaviors or nonpharmacological interventions, despite MDS findings of severe cognitive or communication impairment and progress notes describing behaviors such as scratching, swatting, refusing cares, and verbal outbursts.
Care Plan Not Updated After Diuretic Discontinued: A resident with severe cognitive impairment, Alzheimer's dementia, HTN, and seizure disorder had a care plan that still listed diuretic therapy for edema even though Lasix had been ordered only briefly for lower-leg edema and was no longer on the MAR. The UM acknowledged the resident was not currently receiving a diuretic and that the care plan was not removed in a timely manner.
A resident with CHF, chronic respiratory failure with hypoxia, and OSA had oxygen therapy documented, but the care plan lacked the oxygen flow rate, delivery method, and assessment of self-administration. Staff notes did not clearly document the oxygen flow to CPAP, respiratory assessments, or pulse oximetry while the resident used CPAP with oxygen, and the DON gave inconsistent statements about the resident’s CPAP and oxygen use.
Insufficient staff were available to assist residents with meals, leaving multiple residents with food in front of them and no CNA at the table during observed meals. A resident on a puree diet with honey-thick liquids was seen coughing while feeding herself, and another resident repeatedly asked to eat while waiting for help. Staff also delayed incontinence care for a resident with impaired cognition and dependent toileting needs, despite repeated call light use and requests for cleaning.
An LPN administered insulin Aspart to a resident with DM without priming the FlexPen first. The resident had orders for scheduled and sliding-scale insulin, and the LPN dialed the pen to the ordered total dose but did not prime it, stating he believed the current needles did not require priming. The DON stated insulin pens should be primed with 2 units per the manufacturer’s instructions.
A resident with multiple comorbidities, including diabetes and functional quadriplegia, was admitted with a wound on the left foot that was identified by the ADON but not assessed or reported to a provider by the nurse for 48 days. The wound was only addressed after a CNA discovered it during a transfer, by which time it had worsened. Facility policy required prompt assessment and intervention for new wounds, but these steps were not followed, resulting in a significant delay in care.
A facility failed to accurately complete an MDS assessment for a resident with coronary artery disease, incorrectly documenting anticoagulant use during the 7-day look-back period. The resident's Care Plan and MAR indicated that the anticoagulant Eliquis was discontinued prior to the assessment period. The MDS Coordinator confirmed the discontinuation, highlighting a deficiency in ensuring accurate resident assessments.
A facility failed to include necessary interventions for a resident's PICC line and Mediport in their care plan, despite the resident receiving IV antibiotic therapy. The care plan lacked details on managing these devices, contrary to the facility's policy for comprehensive care plans.
A resident with a gastrostomy tube did not receive care according to professional standards, as staff failed to verify g-tube placement and did not flush the tube with water between medications. The resident, with multiple diagnoses including sepsis and dysphagia, required tube feedings. Despite facility policy and care plan directives, an LPN administered medications and enteral feeding without checking tube placement or performing necessary water flushes, as confirmed by interviews with facility staff.
A resident with multiple health conditions had a skin lesion that was not assessed or documented by staff, despite being observed for over a week. The facility's policy requires staff to document new wounds, but this was not followed, leading to a deficiency.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with indwelling medical devices, as staff did not use gowns during procedures involving a g-tube and a PICC line. Additionally, the infection control manual was not updated annually, lacking necessary approvals and documentation. The DON acknowledged the absence of a specific EBP policy, relying on CDC guidelines.
A facility failed to complete and submit a discharge MDS assessment for a resident within the required timeframe. The resident was discharged, and the assessment was completed late and not submitted to CMS. The MDS Coordinator did not submit the assessment due to the resident's private insurance status, contrary to facility policy and RAI Manual requirements.
A resident with severe cognitive loss was subjected to undignified treatment by a CMA, who allegedly attempted to place a glove in the resident's mouth and made demeaning comments. The incident was witnessed by a CNA, who reported it to an LPN the following day. The facility's policy emphasizes immediate reporting of such incidents.
A resident with Permanent Atrial Fibrillation did not receive Warfarin as ordered due to unavailability, and the physician was not notified. The MAR showed missed doses, and the Progress Notes lacked documentation of physician notification. The DON confirmed Warfarin is not in the Emergency Kit and expected physician notification, but the facility had no policy for this.
A facility failed to report suspected abuse within the required two-hour timeframe. A resident with severe cognitive loss was involved in an incident where a CMA allegedly attempted to place a glove in the resident's mouth and spoke unkindly. The incident was not reported immediately by the witnessing CNA, leading to a delay in filing with the appropriate authorities.
A resident with Permanent Atrial Fibrillation did not receive Warfarin as prescribed due to transcription errors in the EHR. The initial hospital orders were not administered, and subsequent physician orders were incorrectly transcribed, leading to a lower dosage being given. The DON confirmed the error, which violated the facility's medication policy.
Failure to Remove Old Fentanyl Patches Before Applying New Ones
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards and physician orders for transdermal fentanyl patch administration, specifically the removal of old patches prior to applying new ones. The cognitively intact resident involved had multiple diagnoses including coronary artery disease, respiratory failure with hypoxia, chronic pain from a history of polio, muscle wasting and atrophy, anxiety, depression, and PTSD, and was care planned for opioid pain medication therapy with instructions to administer pain medications as ordered and monitor for side effects and effectiveness. The physician’s order specified a 75 mcg fentanyl patch to be applied every 72 hours with removal per schedule, and the facility’s own policy for administering topical medications required removal of the old patch before applying a new one. On one occasion in March, pharmacy records showed that three 25 mcg fentanyl patches (totaling 75 mcg) were removed from the emergency kit for the resident, and a nursing progress note documented that three 25 mcg patches were applied to the resident’s shoulders. Subsequent documentation showed that 75 mcg fentanyl patches were delivered and administered per the MAR and controlled drug record, with entries indicating removal of previously applied patches and application of new patches every 72 hours. However, on a later date in March, the resident was noted in a nursing progress note to have altered mental status and not at baseline, leading to transfer to the ED. The ED provider note documented that two fentanyl patches dated three days prior were found on both shoulders, with EMS having administered Narcan en route and an additional dose given in the ED, and the resident was admitted to the ICU for further workup and management. In April, additional 75 mcg fentanyl patches were delivered and administered to the resident, with the MAR and controlled drug record again documenting removal of previously applied patches and application of new patches on multiple dates. Despite this documentation, a nursing progress note later in April recorded that the resident was unresponsive to verbal stimulation and was sent to the ED. A hospital progress note stated that the resident presented with altered mental status potentially in the setting of unintentional opioid overdose, and that two fentanyl patches were removed en route to the hospital, with naloxone administered. During an interview, the DON reviewed and acknowledged that extra patches had been documented on the resident when transported to the hospital and characterized the situation as sloppy nursing and an opportunity to re-educate nurses on removing and applying patches, confirming that the facility’s practice did not consistently align with its policy and the physician’s orders.
Improper Use of Mechanical Lifts and Wheelchairs During Resident Transfers
Penalty
Summary
Surveyors identified multiple deficiencies related to the improper use of mechanical lifts and wheelchairs during resident transfers. In several observed instances, staff failed to follow manufacturer instructions and facility protocols for safe transfer practices. For example, staff did not consistently lock wheelchair wheels during transfers, and mechanical lift wheels were sometimes locked or unlocked contrary to manufacturer recommendations. In one case, staff raised a resident from a toilet using a sit-to-stand lift without locking the lift's wheels, and staff provided conflicting statements about the correct procedure. Manufacturer documentation specified that the sit-to-stand lift's wheels should be unlocked after the resident is raised, but staff were inconsistent in their application of this guidance. Additionally, staff failed to ensure that wheelchair foot pedals were attached while transporting a resident who was unable to self-propel, and a staff member acknowledged that foot pedals should be used when pushing a resident in a wheelchair. Another observation revealed that a resident was transferred using a total body mechanical lift with the legs closed and the wheelchair unlocked, contrary to manufacturer instructions that require the legs to be open for stability and the wheelchair to be locked during transfer. Staff interviews confirmed a lack of consistent understanding and application of these safety procedures. The residents involved had significant cognitive and physical impairments, including severe dementia, end-stage renal disease, history of stroke, and incontinence, requiring varying levels of assistance with activities of daily living and mobility. Care plans specified the need for mechanical lifts, transfer discs, and assistance from multiple staff members, yet these plans were not always followed as observed. The facility also lacked a policy regarding wheelchair safety, as confirmed by the administrator, contributing to inconsistent practices among staff.
Failure to Provide Timely Repositioning and Incontinence Care
Penalty
Summary
A deficiency was identified when staff failed to provide timely repositioning and incontinence care for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had diagnoses including renal disease, Alzheimer's disease, and was always incontinent of bowel and bladder, required maximal to total assistance for mobility and personal care. The care plan specified that the resident should be checked and provided incontinence care 2-4 times per shift and as needed, with peri-area cleaning after each episode, and repositioned every hour when in a chair. On the day in question, the resident was observed being placed in a wheelchair in the TV lobby after breakfast and remained in the same position until lunchtime, with no evidence of repositioning or toileting assistance during that period. Multiple staff members confirmed they had not assisted the resident with repositioning or toileting after breakfast. Documentation in the electronic health record indicated care was provided before breakfast, and staff statements conflicted regarding the timing of incontinence care. The facility's policy required hourly repositioning for residents in chairs, which was not followed in this instance.
Infection Control Failures: Equipment Disinfection, Hand Hygiene, and PPE Use
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control practices. Staff did not disinfect a mechanical lift after use between two residents. Specifically, after transferring one resident from a wheelchair to a bed, the mechanical lift was pushed into the hallway without being sanitized. Later, another staff member used the same lift to transfer a different resident without disinfecting it before or after use. Additionally, during perineal care for a resident with Alzheimer's disease and incontinence, a CNA failed to perform hand hygiene or change gloves after handling a trashcan and before providing direct care, contrary to facility policy. The resident required extensive assistance with personal care and was always incontinent of bowel and bladder. Further, a CNA failed to remove PPE before exiting a room where both residents were on Enhanced Barrier Precautions due to invasive devices. The staff member exited the room wearing a gown and walked to another unit, which was not in accordance with the facility's policy that requires gowns to be discarded in the room. Staff interviews confirmed knowledge of the correct procedures, but the observed actions did not align with established infection control policies.
Infection Prevention and Control Failures During Resident Care and Equipment Use
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter. Resident #4’s admission MDS dated 6/14/25 documented the resident required substantial/maximal assistance for toileting hygiene, and the care plan dated 6/10/25 documented an indwelling urinary catheter. During an observation of transfer, toileting, and catheter care on 8/27/25, two CNAs assisted the resident from a wheelchair to a toilet using a standing mechanical lift. Both staff wore the same gloves through multiple steps of care, including positioning the resident, lowering clothing, emptying the catheter drainage bag into a graduated cylinder, and assisting the resident back to the wheelchair. Hand hygiene was not observed when gloves were removed and replaced during the care. An isolation cart with gowns was present outside the room, and one CNA stated she was not aware what enhanced barrier precautions meant and that the cart had been outside the room for quite a while without being used. The facility also failed to perform appropriate hand hygiene during personal care for residents requiring toileting assistance. Resident #61’s annual MDS dated 8/10/25 documented full dependence for toileting hygiene and bed mobility, and that the resident was always incontinent of bowel and bladder. During an observation beginning at 3:00 AM on 8/28/25, a CNA entered the room to provide incontinence care while the resident’s call light was out of reach. At 4:30 AM, the CNA donned gloves without observed hand hygiene, cleaned the resident after a heavily saturated brief was removed, then removed gloves and put on new gloves again without hand hygiene before applying barrier cream. A second staff member assisted with repositioning and incontinence care, and both staff handled soiled and clean items during the process. Resident #3’s admission MDS indicated substantial/maximal assistance for toileting hygiene, dressing, and transfers, and the care plan identified a self-care performance deficit requiring assist of one. During morning cares on 8/27/25, two CNAs provided peri-care and transfer assistance, and both failed to perform hand hygiene between glove changes when moving from dirty to clean care. The facility additionally failed to sanitize a full body mechanical lift between residents. On 8/25/25, two CNAs removed a mechanical lift from one resident’s room and transported it into another resident’s room without sanitizing it. When asked, the staff stated there was not a reason why the lift was not sanitized between uses. The facility policy for cleaning and disinfection of resident-care items and equipment stated reusable items are cleaned and disinfected or sterilized between residents, and the DON stated the lift should have been sanitized before use on the next resident.
Failure to Notify Physician of Low Blood Sugars
Penalty
Summary
The facility failed to notify the physician of blood sugars below 60 mg/dL for Resident #22, who had severe cognitive impairment, diabetes, stroke, seizure disorder, and non-Alzheimer's dementia and was receiving both long-acting and short-acting insulin. The resident's MAR documented multiple low blood sugar readings in July and August 2025, including 59 mg/dL, 55 mg/dL, 60 mg/dL, 56 mg/dL, and 60 mg/dL, all occurring at scheduled evening checks. No documented interventions were found in the electronic or paper record to address the low blood sugars, including repeat blood sugar checks to confirm improvement before the next scheduled check. There was also no documented communication to the physician or designee about the low readings. Staff interviews confirmed the resident could not report symptoms of low blood sugar and typically did not show physical signs, and the Unit Manager acknowledged the lack of documented interventions and stated the physician should have been notified when blood sugar was below 60 mg/dL per facility protocol.
Failure to Identify Resident-Specific Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to identify resident-specific target behaviors for psychotropic medication use for two residents. One resident had diagnoses including cerebral infarction, non-Alzheimer's dementia, anxiety, depression, sarcopenia, and quadriplegia, with severe functional dependence and no established BIMS score because the resident was rarely or never understood. Although the resident received antianxiety and antidepressant medications, the care plan did not include resident-specific target behaviors for staff to monitor or nonpharmacological interventions to attempt. Progress notes stated the resident did not have behaviors or mood symptoms, but the documentation still did not identify target behaviors. The second resident had severe cognitive impairment with diagnoses including heart failure, non-Alzheimer's dementia, and COPD, and received antianxiety and antipsychotic medications. The care plan did not include resident-specific target behaviors or nonpharmacological interventions. Notes documented episodes of scratching, swatting, refusing care, becoming verbal, and throwing water at staff, but the documentation did not identify which diagnosis the behaviors were associated with. A pharmacist recommended a GDR for the antipsychotic, but the physician declined due to psychotic disorder with delusions related to a known physiological condition and still did not include resident-specific target behaviors. Staff interviews confirmed they could not locate resident-specific target behaviors, and the DON stated staff should have clarified the target behaviors with the prescribing providers.
Incomplete Care Plans for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to fully develop comprehensive care plans for 3 of 17 residents reviewed. For Resident #4, the admission MDS dated 6/14/25 documented mood symptoms including feeling down, depressed, or hopeless, trouble concentrating, and moving or speaking slowly or being fidgety or restless during the prior 2-week look-back period. The MDS also listed diagnoses of Alzheimer's Disease, anxiety, and depression, and recorded use of antipsychotic, antianxiety, and antidepressant medications during the prior 7 days. Section V of the MDS identified communication, behavioral symptoms, and pressure ulcer/skin integrity as care areas to be included on the care plan, and the RN coordinator signed V0200B2 on 6/16/25. Review of Resident #4's care plan on 8/26/25 showed that potential for skin breakdown and pressure ulcers had been added, but the care plan did not include communication or behavioral symptoms. It also did not document the use of antianxiety or antipsychotic medications, and while psychotropic medications and an antidepressant were listed, the care plan did not identify the target behaviors being addressed. The MDS Coordinator stated on 8/28/25 that the care plan should be developed within 14 days of completing the MDS and said she had not been informed that the resident had been started on an antianxiety medication. The Administrator stated triggered CAAs should be listed on the care plan. For Resident #28, the quarterly MDS dated 8/10/25 showed severe communication impairment, diagnoses including cerebral infarction, non-Alzheimer's dementia, anxiety, depression, sarcopenia, and quadriplegia, and dependence for most ADLs and mobility. The resident received antianxiety and antidepressant medications in the 7-day look-back period. The care plan included the medication use but did not identify resident-specific target behaviors or nonpharmacological interventions, and progress notes dated 5/13/25 and 8/19/25 stated the resident did not have behaviors or mood symptoms but did not identify target behaviors. For Resident #50, the MDS dated 5/31/25 showed a BIMS score of 3, diagnoses of heart failure, non-Alzheimer's dementia, and COPD, dependence for most ADLs and mobility, and use of antianxiety and antipsychotic medications. The care plan did not include resident-specific target behaviors or nonpharmacological interventions, and progress notes described scratching, swatting at staff, refusing cares, and becoming verbal without identifying the diagnosis associated with those behaviors. Staff and the DON stated the residents' target behaviors should have been included in their care plans, and an LPN stated he could not locate those target behaviors on either resident's care plan.
Care Plan Not Updated After Diuretic Discontinued
Penalty
Summary
The facility failed to update the Care Plan for Resident #9 for the discontinued use of a diuretic. Resident #9 had a Quarterly MDS completed on 6/8/25 showing a BIMS score of 3, indicating severe cognitive impairment, with diagnoses including Alzheimer's dementia, hypertension, and seizure disorder/epilepsy. The Care Plan, with a target date of 9/14/25, still listed diuretic therapy for edema even though the resident had only received Lasix for three days beginning 9/19/24 due to edema and tenderness to the lower legs, and the medication order history showed the Lasix order ended on 9/22/24. The Order Summary Report obtained on 8/28/25 did not list a current diuretic order. During interview, the Unit Manager stated care plans are initiated and updated on the CCDI unit upon admission, quarterly, and as needed, and acknowledged the resident was not currently on a diuretic and that this was not removed from the Care Plan in a timely manner.
Inadequate Documentation and Monitoring of Oxygen and CPAP Use
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with anemia, CHF, chronic respiratory failure with hypoxia, and OSA who had oxygen therapy documented in the MDS and a BIMS score of 14 out of 15. The care plan identified altered respiratory status and difficulty breathing requiring oxygen, but it did not document the oxygen flow rate, delivery method, or assessment of the resident’s ability to self-administer oxygen or CPAP. The physician’s orders initially allowed oxygen to be titrated to keep saturations above 90% on nasal cannula, but there was no CPAP order until after surveyor inquiry, and the orders did not clearly match the resident’s reported use of CPAP with oxygen. Progress notes documented the resident wearing CPAP during the night shift on multiple occasions, but they did not document the oxygen flow rate to the CPAP, respiratory assessments, pulse oximetry while using CPAP with oxygen, or that the resident wore oxygen while sleeping during the day. Vital signs showed oxygen saturations were never below 90% on room air, with only limited pulse oximetry documented while CPAP was on and one reading when oxygen was on at an unknown flow rate via nasal cannula. During observation, the resident was resting in bed wearing a CPAP mask with 1 liter of oxygen running to the CPAP machine, and staff and the DON gave inconsistent statements about the resident’s oxygen and CPAP use and documentation.
Insufficient Feeding Assistance and Delayed Incontinence Care
Penalty
Summary
The facility failed to provide sufficient staff to safely feed residents who required feeding assistance during three observed meals. During an evening meal, Resident #61 was being fed by a family member while Residents #8, #17, #23, and #64 had meals in front of them and no staff present to assist all of them. Staff L, a CNA, was initially the only staff member actively feeding at the table, while Staff M briefly arrived and left, and Staff N was seen entering and exiting the dining room without assisting any of the residents who needed feeding help. Resident #64 was observed eating only 10-15% of her meal, although charting later documented 75-100% intake, and the documentation was entered before meal service by a CNA who was not observed in the dining room. During later meal observations, the same residents again had meals in front of them without staff present at the table. Resident #8, who had an order for a puree diet with honey thickened liquids and a care plan for supervision and cueing at meals, was observed feeding herself and lightly coughing while staff were elsewhere in the dining room. Resident #17 stated loudly that he wanted to eat his breakfast while his food sat in front of him without assistance. Staff eventually arrived and assisted, but Resident #8 continued coughing and later had an intensified cough during breakfast, after which the MDS Coordinator removed her from the dining room and assessed her, stating she likely aspirated some during breakfast. The facility also failed to complete incontinence care for Resident #2 in a timely manner. Resident #2, who had moderately impaired cognition and required dependent assistance with toileting and pericare after each incontinent episode, told staff he had a bowel movement and had not been changed. He activated his call light multiple times and repeatedly stated he still had not been cleaned, yet staff did not provide care until more than an hour later. The care plan directed staff to check the resident per schedule, assist with toileting as needed, and provide pericare after each incontinent episode, but the resident remained unchanged despite repeated requests and call light use.
Failure to Prime Insulin FlexPen Before Administration
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when insulin Aspart was administered without priming the insulin FlexPen. Resident #72 had a diagnosis of Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene, and the EHR showed physician orders for insulin Aspart 10 units subcutaneously twice daily and additional sliding-scale insulin three times daily based on blood sugar results. The MAR documented that Staff B, LPN, administered 10 units of Aspart insulin plus an additional 2 units for a blood sugar of 234 mg/dL. During observation, Staff B attached a needle to the Aspart insulin FlexPen and dialed the pen to 12 units, but did not prime the pen before giving the dose. In interview, Staff B stated he does not prime insulin pens because someone told him the current needles do not require it, and he did not know who told him that. The DON stated insulin pens should be primed with 2 units to remove air that might alter the dose and said the facility had no policy for insulin pens and followed the manufacturer’s guidelines. The manufacturer’s instructions for the FlexPen included priming steps before selecting and administering the ordered dose.
Delayed Assessment and Intervention for Resident Wound
Penalty
Summary
A deficiency occurred when the facility failed to provide timely assessment and intervention for a wound identified on a resident's left foot. Upon admission, the resident, who had multiple diagnoses including diabetes, Alzheimer's disease, functional quadriplegia, bipolar disorder, and polyneuropathy, was noted by the Assistant Director of Nursing (ADON) to have a wound on the left foot. However, the admitting nurse did not conduct a wound assessment or notify the provider for intervention at that time. The resident's care plan directed staff to check for skin breaks and treat promptly as ordered, but the Medication and Treatment Administration Records for the following months did not reflect any intervention for the wound. For 48 days after admission, there was no documented assessment or provider notification regarding the wound. The wound was only re-identified when a CNA noticed blood on a transfer device and the resident's sock, at which point the wound was found to be black, foul-smelling, and measured 3 cm x 3 cm. The nurse then cleansed the wound, applied a protective foam boot, and notified the physician, who ordered antibiotics. Further assessments and wound care were initiated only after this delayed recognition, and the wound was later determined to be an in-house acquired wound of unknown duration. Interviews with staff revealed that the ADON had expected the nurse to notify the physician and family and initiate treatment upon initial identification of the wound, but this did not occur. The facility's policies required prompt assessment, provider notification, and treatment implementation for new skin areas, but these steps were not followed. The delay in assessment and intervention was attributed in part to communication challenges and the use of agency nurses during the period in question.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #4, who was readmitted to the facility from the hospital with a diagnosis of coronary artery disease. The MDS assessment, completed on September 13, 2024, incorrectly documented that the resident took an anticoagulant medication during the 7-day look-back period. However, the resident's Care Plan indicated that anticoagulant therapy was resolved and removed from the Care Plan on April 30, 2023. The Order Summary showed that the resident's anticoagulant medication, Eliquis (Apixaban), was discontinued on July 9, 2024, and the Medication Administration Record (MAR) confirmed this discontinuation. During an interview, the MDS Coordinator, identified as Staff C, reported that she gathered information from the resident's record, interviews with the resident and family, and her own observations while providing care. Staff C confirmed that Resident #4 no longer took Apixaban, as it was discontinued on July 9, 2024. The RAI Manual Version 3.0 specifies that MDS assessment section N0410E should only be marked when a resident took an anticoagulant during the 7-day look-back period, excluding antiplatelet medications like aspirin. The inaccurate completion of the MDS assessment for Resident #4 represents a deficiency in ensuring accurate resident assessments.
Failure to Include Medical Device Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was admitted with diagnoses of cancer and pleural effusion. The resident was receiving IV antibiotic therapy and had both a PICC line and a Mediport for medication administration. However, the care plan did not include information or interventions related to the management and monitoring of these medical devices. This omission was identified through clinical record review, observation, and staff interviews. The resident's care plan was initially created upon admission and revised later, but it still lacked critical details about the resident's PICC line and Mediport. Staff interviews revealed that the MDS Coordinator and the Director of Nursing were responsible for updating care plans based on changes in the resident's status. Despite this, the care plan did not reflect the necessary interventions for the resident's medical devices, which was a deviation from the facility's policy that required comprehensive care plans to include measurable objectives and time-frames.
Failure to Verify G-Tube Placement and Flush Between Medications
Penalty
Summary
The facility failed to adhere to professional standards of quality in the administration of medications and enteral feeding for a resident with a gastrostomy tube (g-tube). The resident, who had diagnoses including sepsis due to e-coli, gastroesophageal reflux disease, diabetes, and dysphagia, required tube feedings as per their care plan. The care plan directed staff to check the g-tube placement and gastric contents before each feeding, but these steps were not followed. During an observation, a Licensed Practical Nurse (LPN) administered medications and enteral feeding through the g-tube without verifying the tube's placement or checking for residuals, as required by the facility's policy and the resident's care plan. Additionally, the LPN did not flush the g-tube with water between each medication administered, which is a necessary step to ensure proper medication delivery and prevent tube blockage. The facility's policy on administering medications through an enteral tube, dated 2001, clearly outlines the need to administer each medication separately and flush the g-tube with at least 15 ml of warm water between medications. Interviews with the MDS Coordinator and the Director of Nursing confirmed the expectation that g-tube placement should be checked before administering medications or feedings, and that water flushes should be performed between medications. These omissions in care represent a failure to meet the professional standards of quality required for safe medication administration in residents with g-tubes.
Failure to Assess and Document Resident's Skin Condition
Penalty
Summary
The facility failed to provide timely assessments and interventions for a resident's skin condition, leading to a deficiency. The resident, who has a history of cancer, heart failure, diabetes, cerebrovascular event, non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, and depression, was observed with a red lesion and a dark scab on her right cheek bone. Despite the care plan requiring staff to check for skin breaks and treat them promptly, the wound was not assessed or documented in the resident's medical records. Staff interviews revealed that the registered nurse was aware of the wound for over a week but had not performed a skin assessment or informed the medical director. The unit manager confirmed that the skin assessment was not completed and emphasized the expectation for staff to document new or reopened wounds. The facility's policy requires all staff to participate in resident assessments, but this was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions and Update Infection Control Manual
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for residents with indwelling medical devices, as observed in two cases. Resident #117, diagnosed with sepsis due to E. coli and requiring tube feeding, did not have EBP directives in their care plan. During a medication and enteral feeding procedure, a Licensed Practical Nurse (LPN) did not use a gown and placed supplies on an over-bed table without a barrier, contrary to EBP guidelines. The Director of Nursing (DON) acknowledged the absence of a specific EBP policy, relying instead on CDC guidelines. Similarly, Resident #54, diagnosed with cancer and undergoing antibiotic therapy via a PICC line and Mediport, lacked EBP information in their care plan. An LPN accessed and flushed the resident's PICC line and port without wearing a gown, despite handling these medical devices. The DON confirmed the facility's lack of a formal EBP policy, expecting staff to follow CDC guidelines for residents with medical devices. Additionally, the facility's infection control manual was not updated annually as required. The manual lacked a cover page indicating annual review and approval, and the Record of Adoption form was incomplete, missing details on approved policies, the medical director's signature, and a date of approval. The DON admitted that the January 2024 QAPI meeting minutes did not reflect the approval of the infection control manual, highlighting a gap in the facility's policy review process.
Failure to Timely Complete and Submit MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) assessment for a resident upon discharge within the required timeframe. Specifically, the MDS assessment for a resident who was discharged on 5/22/24 was not completed until 6/2/24, and it was not submitted to the Centers for Medicare & Medicaid Services (CMS) as required. The Director of Nursing (DON) signed the assessment as completed on 6/2/24, which was beyond the 14-day completion requirement after the discharge date. Additionally, the 5-day MDS assessment completed on 5/15/24 was also not submitted to CMS. During an interview, the MDS Coordinator, who had been in the role since March 2024, reported that the discharge MDS was not submitted because the resident had a private insurance plan and did not have a Medicare Part A policy. The facility's policy, revised in March 2022, and the Resident Assessment Instrument (RAI) Manual Version 3.0, both require that discharge assessments be completed and submitted for all residents, regardless of their insurance status. The failure to submit the discharge MDS assessment was a violation of these requirements.
Resident Dignity Violation by Staff
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving a Certified Medication Aide (CMA) and a resident with severe cognitive loss. The resident, who had diagnoses including non-traumatic brain dysfunction, dementia, high blood pressure, and stroke, required maximum assistance for transfers and total dependence for care. During an interaction, the resident became verbally aggressive, and the CMA allegedly attempted to place a glove in the resident's mouth while responding to the resident in an unkind and demeaning manner. This incident was reported by a Certified Nurse Aide (CNA) who witnessed the event. The CNA reported that the CMA made a demeaning comment to the resident about his children not caring for him, which was followed by the CMA's aggressive behavior with the glove. The CNA initially did not report the incident immediately due to a busy shift but informed a Licensed Practical Nurse (LPN) the following day. The facility's policy on abuse prevention and reporting was referenced, highlighting the importance of reporting any allegations of abuse, neglect, or mistreatment immediately to the charge nurse, who is then responsible for notifying the Administrator or designated representative.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify the physician when medication was unavailable and not administered to a resident diagnosed with Permanent Atrial Fibrillation. The resident had specific orders for Warfarin, a blood-thinning medication, to be taken in varying doses throughout the week. However, the Medication Administration Record (MAR) indicated that the resident did not receive Warfarin on the 20th of March as ordered, and it was also not administered on the 23rd and 24th of March. The Progress Notes did not document any notification to the physician regarding the missed doses, and the notes for those dates only mentioned that the medication was on order from the pharmacy. The Director of Nursing (DON) confirmed that Warfarin is not stocked in the facility's Emergency Kit and stated that his expectation is for the physician to be notified when a medication is not administered as ordered. However, the facility lacked a policy regarding physician notification in such situations. This oversight in communication and policy led to the deficiency, as the physician was not informed about the resident not receiving the prescribed medication, which is critical for managing the resident's condition.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to report suspected dependent adult abuse within the required two-hour timeframe for a resident with severe cognitive loss and multiple health conditions, including dementia and stroke. The incident involved a Certified Medication Aide (CMA) who allegedly attempted to place a glove in the resident's mouth during a care interaction, while also responding to the resident in an unkind manner. The incident was initially reported incorrectly and was not filed with the appropriate authorities until the following day, exceeding the mandated reporting timeframe. The incident was reported by a Certified Nurse Aide (CNA) who witnessed the event but did not report it immediately due to a busy shift. The CNA reported the incident the next day to a Licensed Practical Nurse (LPN), who then informed the facility manager. The facility's policy requires that all allegations of abuse be reported to the state agency within two hours, which was not adhered to in this case, leading to the deficiency.
Medication Transcription and Administration Error
Penalty
Summary
The facility failed to transcribe and administer medication as ordered by the physician for a resident diagnosed with Permanent Atrial Fibrillation. The resident's Electronic Health Record (EHR) initially reflected a correct transcription of the hospital's admission orders for Warfarin, a blood-thinning medication. However, the medication was not administered as per the original orders. The physician later adjusted the Warfarin dosage based on an INR test result, but the new orders were incorrectly transcribed into the EHR, leading to a decrease in the prescribed dosage. The Medication Administration Record (MAR) showed that the resident received a lower dose of Warfarin than ordered by the physician, specifically a 1 mg tablet instead of the prescribed 2.5 mg tablet on certain days. This error was confirmed by the Director of Nursing, who acknowledged the incorrect transcription and administration of the medication. The facility's Medication and Treatment Orders Policy, which emphasizes safe and effective order writing, was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 386 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Calvin Community | 1.2 mi | ★★★★★ | 12 | 0 |
| Scottish Rite Park Inc | 1.4 mi | ★★★★★ | 1 | 0 |
| Wesley On Grand | 1.8 mi | ★★★★★ | 0 | 0 |
| Iowa Jewish Senior Life Center | 1.8 mi | ★★★★★ | 20 | 0 |
| University Park Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ramsey Village.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.