Above 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 Anoka Rehabilitation And Living Center during CMS and state inspections, most recent first.
A resident with chronic pain conditions experienced significant pain during daily care, but staff did not administer prescribed PRN morphine sulfate for breakthrough pain. Despite clear signs of pain and a care plan requiring pain management interventions, staff were unaware of the medication regimen, did not inform the resident about PRN options, and lacked a system to monitor PRN medication use. The resident's pain was not effectively managed or documented, and the physician was unaware the PRN medication was not being given.
The facility failed to ensure proper PPE use for infection control, as staff did not consistently wear N95 masks or eye protection when caring for COVID-19 positive residents. Observations showed nursing assistants wearing surgical masks and lacking eye protection, contrary to facility policy and CDC guidelines. Interviews revealed a lack of awareness or adherence to PPE protocols, despite staff training and signage indicating necessary precautions.
The facility failed to maintain proper food temperatures and sanitary ice machines, affecting residents' meals and water quality. A dietary aide was unaware of the required holding temperatures, leading to cold food being served. Additionally, calcium buildup on ice machines resulted in poor-tasting water, with no cleaning logs available to verify maintenance.
The facility failed to properly reconcile medications during the discharge of several residents, leading to medication errors. One resident received another's medication due to incomplete discharge summaries that lacked documentation of medications sent home. Staff interviews revealed inconsistencies in the discharge process, with time constraints leading to incomplete forms. The director of nursing and administrator acknowledged the deficiencies, highlighting a failure to adhere to the facility's discharge planning policy.
The facility failed to maintain cleanliness in the Cornerstone unit kitchenette, with significant residue buildup on the ice and water dispenser and refrigerator. Family members and residents reported concerns about the water's taste and cleanliness, which were not adequately addressed despite daily cleaning attempts by staff. No facility policy was provided for cleaning procedures.
The facility failed to maintain proper food storage, labeling, and sanitation in the kitchen, risking foodborne illness for residents, staff, and guests. Observations revealed dietary staff without hairnets, unsealed and undated food items, and unsanitary conditions. The CDM cited multiple roles and policy changes as reasons for missed tasks, with no set cleaning schedule in place. A follow-up visit confirmed ongoing issues, and the administrator acknowledged the lack of a cleaning log, indicating systemic non-compliance with food safety regulations.
The facility failed to assess residents for self-administration of medications, resulting in five residents having medications at their bedside without necessary assessments or physician orders. Observations revealed residents using medications independently, such as nasal sprays, eye drops, and nebulizers, without staff supervision or proper authorization. Interviews with staff indicated a lack of adherence to the facility's policy, which requires assessments and orders for safe medication management.
The facility failed to conduct and document care conferences for several residents, despite having multiple MDS submissions. Interviews revealed that residents and family members could not recall attending any care conferences, and the facility's records lacked documentation. The licensed social worker confirmed the absence of required care conferences, which are essential for resident rights and care collaboration.
The facility failed to ensure that four residents were offered, educated, and/or provided the pneumococcal vaccination series as recommended by the CDC. The residents' records lacked evidence of shared clinical decision-making with a physician for the PCV20 vaccine, which should be considered at least five years after the last pneumococcal dose. The infection preventionist and RN believed the residents were up to date, but there was no documentation of discussions, education, or consent regarding the PCV20.
A facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) after their Medicare Part A coverage ended. Although the resident received a Medicare-A Non-Coverage form, there was no evidence of the SNFABN-CMS-10055 form in their medical record. Registered nurses and the facility administrator confirmed the oversight, which was against the facility's policy revised in September 2022.
The facility failed to notify the Ombudsman of hospital transfers for two residents, R106 and R107, who had various medical conditions. Despite sending bed hold policies with the residents, there was no evidence of written notification to the Ombudsman. The facility's documentation did not list R106, and the report for R107 could not be located. An email from the Ombudsman confirmed no notification was received for either transfer.
A resident with severe cognitive impairment and multiple medical conditions experienced several unwitnessed falls. Although neurological assessments were initiated, they were not completed as required by the facility's protocol. Interviews with staff confirmed missing documentation for these assessments, highlighting a failure to monitor for potential head injuries.
A facility failed to coordinate dialysis care for a resident with end-stage renal disease, who reported never receiving necessary paperwork for dialysis appointments. An LPN confirmed the absence of communication sheets, and a health unit coordinator noted no communication with the dialysis center for five years, contrary to facility policy requiring ongoing collaboration and documentation.
The facility failed to limit PRN psychotropic medications to 14 days or have a physician-specified order for two residents in hospice care. One resident with moderate cognitive impairment and another with severe cognitive impairment had open-ended orders for Lorazepam without reassessment or stop dates. Interviews with staff revealed a lack of adherence to the facility's policy requiring reevaluation of PRN psychotropic medications every 14 days.
A resident, who was cognitively intact and able to express her needs, did not receive assistance in obtaining routine dental services. Despite expressing interest in seeing a dentist, her medical record lacked an oral assessment or referral for a dental evaluation. The facility's policy required dental needs assessment upon admission, but this was not followed, leading to a deficiency in care.
A resident with multiple diagnoses, including MRSA and chronic ulcers, required enhanced barrier precautions. However, a nursing assistant failed to don a gown while providing care, and a registered nurse did not remove their gown before exiting the room. Both actions were contrary to the facility's infection control policy, which required PPE removal before leaving the work area.
The facility did not post required daily staffing information, affecting all 112 residents and visitors. Documentation review revealed missing postings on specific dates, including weekends and a holiday period. The staffing manager confirmed the lapse, and the administrator was unaware, expecting daily postings per policy.
A facility failed to implement care-planned interventions for a resident at risk for pressure ulcers. Despite orders for heel-protecting boots, staff did not consistently apply them, leading to inadequate management of the resident's pressure ulcers. Interviews revealed a lack of awareness and adherence to the care plan, and the Director of Nursing acknowledged gaps in communication and responsibility.
A resident with a history of stage 3 pressure ulcers did not receive consistent comprehensive assessments and interventions to prevent recurrence. The care plan lacked a turning/repositioning program, and there were discrepancies in care, such as improper floating of heels and inadequate repositioning. Observations noted issues like redness and tissue damage, with gaps in documentation and incomplete wound assessments. These lapses led to the development of new pressure ulcers on the resident's right heel.
The facility failed to ensure a dignified living experience for two residents, as observed through video footage and interviews. One resident was seen crying during care and exposed to the hallway and courtyard while on the commode. Another resident was left in the same nightgown and socks for several days and had her nonverbal expressions of discomfort ignored by staff. The facility's policies on resident rights and dignity were not adequately enforced.
The facility failed to implement a comprehensive toileting care plan for a resident, leading to missed toileting times and the use of incorrect incontinence products. Despite clear directives in the care plan, staff did not consistently follow the scheduled toileting routine or use the specified briefs, resulting in prolonged periods without being changed.
The facility failed to use mechanical standing lifts correctly for two residents, leading to unsafe transfer practices and significant discomfort. Additionally, the wander-guard system was not operational, allowing three residents to elope. Staff did not follow proper procedures, and the system's auditory alert was insufficient.
Failure to Administer PRN Pain Medication and Monitor Pain Management
Penalty
Summary
The facility failed to identify, treat, monitor, and manage pain for a resident with multiple chronic pain conditions, including rheumatoid arthritis, polymyalgia rheumatica, and chronic pain, as outlined in the resident's care plan and physician orders. Despite the resident experiencing and expressing significant pain during routine care activities such as dressing, cleaning, and transferring, staff did not administer the prescribed PRN (as needed) morphine sulfate for breakthrough pain. Observations showed the resident wincing, screaming, and flailing in pain during care, and interviews with staff confirmed that pain was reported but not adequately addressed with medication. The resident's care plan included specific interventions for pain management, such as administering pain medication per physician order for breakthrough pain and monitoring pain characteristics. However, the medication administration records indicated that while scheduled morphine was given, the PRN morphine sulfate was not administered at all during the review period, despite clear evidence of pain. Staff interviews revealed a lack of awareness regarding the resident's pain medication regimen and an absence of a system to monitor PRN medication usage. Nursing staff and management were not certain why the PRN medication was not used, and the resident was not informed that he could request pain medication when experiencing pain. Family members and staff expressed concern about the resident's uncontrolled pain, and the primary care physician was unaware that the PRN morphine was not being administered. The facility's pain management policy required a systematic approach to pain recognition, assessment, treatment, and monitoring, but this was not followed in the resident's case. The deficiency was further compounded by the lack of documentation and communication regarding the resident's pain and the absence of a process to ensure PRN pain medications were utilized as ordered.
Inadequate PPE Use for Infection Control
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection among residents. Specifically, two residents under COVID-19 transmission-based precautions and one resident under enhanced barrier precautions were not provided with the necessary PPE by the staff. Observations revealed that nursing assistants did not consistently wear eye protection or N95 masks when caring for COVID-19 positive residents, despite the facility's policy and CDC guidelines requiring such measures. During the observations, one nursing assistant was seen wearing a surgical mask instead of an N95 mask and lacked eye protection while caring for a COVID-19 positive resident. Another nursing assistant also failed to wear eye protection and did not change the surgical mask between resident rooms, which is against the recommended PPE protocol. Interviews with the nursing assistants confirmed a lack of awareness or adherence to the PPE guidelines, despite the presence of precaution signs on the residents' doors. The director of nursing and other staff members acknowledged that the facility's policy required the use of N95 masks, eye protection, gowns, and gloves for COVID-19 positive residents. They also confirmed that staff were educated on proper PPE use and received updates on residents' precautionary statuses. However, the observations and interviews indicated a failure in the implementation and monitoring of these infection control practices, potentially affecting all residents in the facility.
Deficiencies in Food Temperature and Ice Machine Sanitation
Penalty
Summary
The facility failed to maintain proper holding temperatures for food served to residents in the Reflections unit. During an observation, it was noted that the food temperatures were significantly below the required range, with spaghetti noodles at 102 degrees F, hamburger meat sauce at 114 degrees F, and peas and carrots at 115 degrees F. A dietary aide, who was on his first day of work, was unaware of the proper holding temperatures for hot food, which should have been between 135 and 165 degrees F according to the dietary manager. This failure to maintain appropriate food temperatures was confirmed by a family member who reported that a resident refused to eat the cold food, leading the family member to bring in food from outside the facility. Additionally, the facility did not maintain the ice machines in a sanitary manner, affecting residents in multiple units. Observations revealed a white flaky substance, identified as calcium buildup, on the ice and water spouts of the machines. A resident reported that the ice and water tasted terrible and had to discard several glasses before obtaining drinkable water. Despite notifying a licensed practical nurse about the issue, the ice machines remained uncleaned, and there were no available cleaning logs to verify maintenance. The dietary manager acknowledged the potential for residents to become ill from the calcium buildup breaking off into the ice or water.
Medication Reconciliation Failure at Discharge
Penalty
Summary
The facility failed to provide a proper medication reconciliation process during the discharge of several residents, leading to medication errors. Specifically, the discharge summaries for seven residents did not include a reconciliation of pre-discharge medications with post-discharge medications. This omission resulted in one resident receiving another resident's medication, Mirtazapine, which was not prescribed to them. The discharge summaries lacked documentation of the medications and their quantities sent home with the residents, which is a critical step in ensuring safe transitions of care. Interviews with staff revealed inconsistencies in the discharge process. A registered nurse and a licensed practical nurse described a protocol where medications should be reviewed and explained to the resident before discharge. However, it was noted that due to time constraints, the section of the discharge form detailing the medications sent home was often left incomplete. This lack of thoroughness in the discharge process contributed to the medication error experienced by the residents. The director of nursing and the facility administrator acknowledged the deficiencies in the discharge process. The director of nursing stated that the medication disposition should be documented in the discharge summary, but this was not consistently done. The administrator expressed the expectation that the discharging nurse should provide a list of medications to the resident and document the details in the discharge summary. Despite these expectations, the facility's failure to adhere to its own discharge planning policy resulted in significant lapses in medication management during resident discharges.
Sanitation Issues in Cornerstone Unit Kitchenette
Penalty
Summary
The facility failed to maintain the ice and water dispenser and refrigerator in the Cornerstone unit kitchenette in a clean and sanitary manner, affecting the potential health of 60 residents. Observations revealed a significant buildup of whitish-gray residue on the ice and water dispenser, including the drip tray, stainless steel surface, and chutes. Additionally, the refrigerator had a light brown substance in the rubber door seal grooves and a white substance at the base. Family members and residents expressed concerns about the cleanliness and taste of the water, which were reported to management in August 2024. Despite attempts by the maintenance and dietary staff to clean the equipment, the residue remained. The director of maintenance acknowledged the difficulty in removing the hard water buildup, while the dietary aide and assistant culinary director confirmed that the equipment was supposed to be cleaned daily. However, there was no facility policy provided regarding the cleaning of kitchenette equipment, indicating a lack of clear guidelines or procedures for maintaining sanitation standards.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and sanitation in the kitchen, which posed a risk of foodborne illness to all 112 residents, staff, and guests. During an initial kitchen tour, several issues were observed, including dietary staff not wearing hairnets, unsealed and undated food items in the refrigerator, and unsanitary conditions such as dried food particles on shelves and debris in floor drains. The walk-in cooler and freezer contained undated and improperly stored food items, with some showing signs of spoilage and contamination. The Certified Dietary Manager (CDM) acknowledged the poor condition of the kitchen, citing multiple roles and recent policy changes as reasons for missed routine tasks. The CDM was responsible for directing kitchen staff and ensuring food sanitation and preparation were conducted to minimize foodborne pathogens. However, there was no set cleaning schedule, and the CDM was unaware of the current policies. The facility's food storage policy required proper labeling, dating, and storage to prevent contamination, but these standards were not met. During a follow-up visit, additional concerns were noted, including a cook without a hairnet and unchanged unsanitary conditions. The administrator confirmed the lack of a cleaning log and stated that the staff was in the process of deep cleaning the kitchen and discarding undated food items. The facility's policies required maintaining cleanliness and sanitation through a comprehensive cleaning schedule, which was not provided, indicating a systemic failure in adhering to food safety regulations.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were comprehensively assessed for self-administration of medications, as evidenced by observations and interviews with staff and residents. Five residents were identified as having medications at their bedside without the necessary assessments or physician orders to self-administer. For instance, one resident, R3, was found with a nasal spray and arthritis pain-relieving cream in his room, which he used independently despite not having an order to self-administer these medications. Similarly, R14 had multiple bottles of eye drops at his bedside, which he used frequently without an order for self-administration. Another resident, R74, who had moderate cognitive impairment, was observed using a nebulizer without staff supervision, despite not having an order to self-administer the treatment. Staff confirmed that they set up the nebulizer and left the room, returning only to turn off the machine. This practice was inconsistent with the facility's policy, which requires an assessment and a physician's order for residents to self-administer medications safely. Additionally, R36 and R95 were found with medications at their bedside, including topical creams and Tylenol, without the necessary assessments or orders, indicating a systemic issue in the facility's medication management practices. Interviews with nursing staff and management revealed a lack of awareness and adherence to the facility's policy on self-administration of medications. Staff members, including LPNs and RNs, acknowledged that no residents had current orders for self-administration, and they were unaware of any residents who were permitted to self-administer medications. The facility's policy requires an interdisciplinary team assessment and a physician's order to ensure residents can safely manage their medications, but this process was not followed, leading to potential safety risks for the residents involved.
Failure to Conduct and Document Care Conferences
Penalty
Summary
The facility failed to conduct care conferences for five out of seven residents reviewed for care planning. These residents, identified as having either intact cognition or severe cognitive impairment, did not have documented care conferences in their medical records despite having multiple Minimum Data Set (MDS) submissions. Interviews with residents and family members revealed that they could not recall attending any care conferences, and the facility's records corroborated the absence of such documentation. The licensed social worker confirmed that care conferences were not held as required by the facility's policy, which mandates quarterly conferences or more frequently if needed, within seven days of MDS completion. The social worker acknowledged that regular care conferences are crucial for resident rights and care collaboration, and even if residents or their families chose not to attend, the conferences should still have been conducted and documented. The facility's policy emphasizes the importance of involving residents and their representatives in care planning to promote autonomy and dignity.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that four out of five residents reviewed for immunizations were offered, educated, and/or provided the pneumococcal vaccination series as recommended by the CDC. Specifically, residents R24, R56, R80, and R102 did not have evidence of shared clinical decision-making with a physician regarding the administration of the PCV20 vaccine, which should be considered at least five years after the last pneumococcal dose. The immunization records for these residents lacked documentation of being offered, educated on, or receiving the PCV20 vaccine. The infection preventionist and RN stated they believed the residents were up to date with their vaccinations and did not require the PCV20. However, there was no documentation in the medical records of discussions, education provided, or consent obtained or declined for the PCV20. The assistant director of nursing expected that upon admission, residents' vaccination records would be reviewed, and appropriate vaccinations offered and administered. The facility's policy indicated that for adults who have received PCV13 and PPSV23, shared clinical decision-making should occur regarding the administration of PCV20.
Failure to Provide SNFABN-CMS-10055 Form
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) to a resident, identified as R86, who was reviewed for beneficiary notification. R86 was admitted to the facility and had their Medicare Part A coverage end on May 23, 2024. Although R86 received a Medicare-A Non-Coverage (CMS-10123) form indicating the end of covered services, there was no evidence in R86's medical record that the SNFABN-CMS-10055 form was provided as required. On July 18, 2024, registered nurses confirmed the absence of the SNFABN-CMS-10055 form, and the facility administrator acknowledged the expectation that the form should have been provided to ensure residents were aware of the end date of their services and their right to appeal. The facility's policy, revised in September 2022, indicated that the SNFABN-CMS-10055 should be issued before providing care or services that do not meet Medicare coverage criteria.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that a written notification of transfer was sent to the office of the Ombudsman for long-term care for two residents who were transferred to the hospital. Resident R106, who had intact cognition and multiple medical diagnoses including a displaced bimalleolar fracture, anemia, hypertension, and chronic kidney disease, was transferred to the emergency room for evaluation of new concerns. Although a bed hold was signed and sent with the resident, and the family was notified, there was no evidence that a written notification of transfer was sent to the ombudsman. Similarly, Resident R107, with moderately impaired cognition and medical conditions such as osteoarthritis, hypertension, and atrial fibrillation, was transferred to the ER due to new concerns. A bed hold policy was sent with the resident, but the family declined it. Again, there was no evidence of notification to the ombudsman. The facility's documentation, referred to as the Monthly Notice to the MN Office of Ombudsman for Long-Term Care for Emergency Acute Care Transfers and Discharges, did not list R106 for the month of May, and the facility was unable to locate the fax or report for April to confirm R107's notification. The Licensed Social Worker (LSW) confirmed that no fax confirmation pages were retained and acknowledged that if the report is not generated correctly, the information is not accurate. An email from the Ombudsman confirmed that no notification was received for either resident's hospital transfer. The facility's policy requires that in emergent situations, notice to the LTC Ombudsman must be sent as soon as practicable, including in the form of a monthly list of residents.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments following unwitnessed falls for a resident with severe cognitive impairment and multiple medical conditions, including a progressive neurological condition and repeated falls. The resident experienced several unwitnessed falls over a period of time, and although neurological assessments were initiated, they were not completed as required. The facility's protocol for neurological assessments following unwitnessed falls includes checks at specific intervals, but documentation was missing for these assessments on multiple occasions. Interviews with facility staff, including an LPN manager and the assistant director of nursing, confirmed that the neurological assessments were not thoroughly completed, with missing documentation on the flow sheets. The staff acknowledged the importance of completing these assessments to monitor for potential head injuries, especially in cases of unwitnessed falls. Despite the facility's policy requiring comprehensive neurological assessments, the policy document was not provided upon request.
Failure in Dialysis Care Coordination
Penalty
Summary
The facility failed to ensure proper coordination of dialysis care for a resident who required such services. The resident, identified as having intact cognition and independence in all activities of daily living, had diagnoses including end-stage renal disease and was dependent on renal dialysis. Despite having a provider order indicating dialysis treatments three times a week, the resident reported that the facility never sent any paperwork with him to his dialysis appointments. This was confirmed by an LPN who stated that although a communication sheet was usually sent with residents, there were no such sheets for this resident, and none had been sent with him. Further investigation revealed that the health unit coordinator confirmed the absence of communication between the facility and the dialysis center for the past five years. The resident reportedly refused to take or bring back any communication sheets, considering dialysis his personal responsibility. The facility's policy required ongoing communication and collaboration with the dialysis facility, including sending a dialysis binder with essential information to each appointment. However, this protocol was not followed, leading to a lack of documented evidence of collaboration and communication as required by the facility's agreement with the dialysis services.
Failure to Reassess PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the use of PRN psychotropic medications was limited to 14 days or had a physician-specified, time-limited order for two residents under hospice care. Resident R74, who had moderate cognitive impairment and multiple diagnoses including anxiety disorder and depression, had an open-ended order for Lorazepam 0.5 mg PRN every four hours for anxiety, initiated on June 14, 2024. The medication was used four times in July without a reassessment or a stop date. Similarly, Resident R85, with severe cognitive impairment and various diagnoses including depression and anxiety, had an open-ended order for Lorazepam 0.5 mg PRN every four hours, initiated on June 21, 2024, and used twice in July without reassessment or a stop date. Interviews with facility staff, including a registered nurse case manager, a licensed practical nurse case manager, the assistant director of nursing, and a consultant pharmacist, revealed a lack of awareness and adherence to the requirement for reassessment and documentation of PRN psychotropic medications every 14 days. The facility's Psychoactive Medication Use policy, reviewed in August 2023, stipulated that PRN psychotropic medication orders must be reevaluated after 14 days, with a documented rationale and specified duration. However, this policy was not followed, leading to the deficiency in medication management for the residents involved.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist in obtaining routine dental services for a resident who was cognitively intact and able to express her needs. The resident's quarterly Minimum Data Set (MDS) indicated she required supervision and verbal cues for oral care, but did not show any dental concerns. Despite expressing interest in seeing a dentist and not recalling any dental appointments since admission, the resident's medical record lacked an oral assessment or referral for a dental evaluation. The care plan directed staff to assist with oral care and schedule dental exams as needed, but these actions were not taken. Interviews with facility staff revealed that the facility had an in-house dental provider, and the process for dental referrals involved obtaining consent from the resident or family. The Licensed Practical Nurse (LPN) responsible for coordinating dental referrals confirmed that the resident's record lacked a dental consent and that the resident had not expressed a desire to see the dentist. However, the resident later signed the consent, and her family was contacted. The Assistant Director of Nursing (ADON) confirmed that the resident had not received a dental referral or examination since admission, despite the facility's policy to assess dental needs upon admission and make appropriate referrals.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were used for a resident reviewed for infection control. The resident, who had intact cognition, required assistance with dressing and transfers, and had multiple diagnoses including surgical amputation, diabetes, osteomyelitis, MRSA, a colostomy, and chronic ulcers. The care plan indicated the resident met the criteria for enhanced barrier precautions, requiring staff to don gown and gloves during high-contact activities. However, a nursing assistant was observed entering the resident's room without donning a gown, despite signage indicating enhanced barrier precautions and gowns being available outside the room. The nursing assistant provided morning hygiene care without wearing a gown, believing it was only necessary if the resident had an active infection like COVID. Additionally, a registered nurse was observed failing to remove their gown before exiting the resident's room after completing a medication pass. The nurse acknowledged the mistake when prompted, admitting they should have removed both gloves and gown before leaving the room to prevent infection spread. The assistant director of nursing and the infection preventionist both stated that staff were expected to remove gloves and gowns before exiting rooms with enhanced barrier precautions. The facility's policy indicated that personal protective equipment should be removed before leaving the work area.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the required staffing information was posted daily, which had the potential to affect all 112 residents and their visitors. During a review of staff posting documentation from June 3, 2024, through July 18, 2024, the facility could not provide evidence of staff postings for several specific dates, including weekends and a holiday period. On July 18, 2024, the staffing manager confirmed that staff postings were not being done on weekends. The administrator was unaware of this lapse and stated that their expectation was for the postings to be completed daily, as per the facility's Staffing Hours Posting Policy, which was last revised in January 2015.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to ensure that assessed and/or care-planned interventions for pressure ulcer care were implemented for a resident who was at risk for additional and/or worsened pressure ulcers. The resident, who was cognitively intact and required substantial assistance with mobility, had a stage 3 pressure ulcer on the left heel and a deep tissue injury on the right heel. Despite care plans and treatment orders directing the use of heel-protecting boots while the resident was in bed and in a wheelchair, these interventions were not consistently followed by the staff. On multiple occasions, the resident was observed without the required heel-protecting boots while seated in a wheelchair, with his feet resting on the wheelchair pedals. Interviews with staff revealed a lack of awareness and adherence to the care plan. One LPN was unsure of the resident's ulcer treatments and interventions, and a nursing assistant admitted to not replacing the boots after morning care, despite knowing the resident had skin integrity concerns. The group sheets used by the nursing assistants did not include all necessary interventions, and the staff did not consistently review the care plans or Kardexes. The Director of Nursing acknowledged that the nursing assistants were updated on pressure ulcers during daily huddles but admitted that not all interventions were included on the group sheets. The responsibility to ensure the implementation of the care plan and treatment orders was placed on the nurses. The failure to consistently apply the heel-protecting boots as directed in the care plan and treatment orders led to the resident's pressure ulcers not being adequately managed, increasing the risk of further skin breakdown and complications.
Inconsistent Pressure Ulcer Prevention and Care for At-Risk Resident
Penalty
Summary
The facility failed to ensure comprehensive assessments were consistently completed and interventions were provided to prevent recurrent pressure ulcers for a resident (R13) with a history of facility-acquired stage 3 pressure ulcers. Despite being identified as at risk for pressure ulcers, R13's care plan did not include a turning/repositioning program, which is crucial in preventing pressure ulcers. The resident had multiple pressure ulcers, including on the right heel, left coccyx, and right buttock, with varying stages of healing and recurrence. The facility's lack of consistent interventions, such as floating heels in bed, off-loading the wound, and implementing a turning/repositioning program, led to the development of new pressure ulcers on R13's right heel. Documentation revealed discrepancies in the care provided to R13, with instances where the resident's heels were not properly floated or protected, despite physician orders and care plan directives. Family members raised concerns about lapses in care, including prolonged periods without diaper changes or repositioning, indicating a failure to adhere to the established care plan. Observations on multiple occasions showed inadequate positioning of R13's heels, leading to pressure on the affected areas and potential harm. The facility's policies emphasized the importance of daily skin observations, weekly skin audits, and individualized turning and repositioning schedules to prevent pressure ulcers, all of which were not consistently implemented in R13's care. During assessments and observations, healthcare providers noted issues such as redness, scabbing, and tissue damage on R13's heels, indicating the progression of pressure ulcers. Despite these findings, there were gaps in documentation, with incomplete wound assessments and lack of reporting on skin issues in the weekly skin checks. The facility's failure to accurately document and address R13's pressure ulcers, provide appropriate interventions, and ensure consistent monitoring and care in line with the established protocols resulted in the recurrence and development of new pressure ulcers, particularly on the right heel.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure a dignified living experience for two residents, R1 and R13, as observed through video footage and interviews. R1, who has multiple sclerosis, vascular dementia, and hemiplegia, was seen crying and grimacing during care. The LPN attending to R1 spoke loudly and used strong body language, which was distressing to R1. Additionally, R1 was exposed to the hallway and courtyard while on the commode, compromising her privacy and dignity. R1 expressed frustration that staff did not listen to her preferences, including proper leg positioning during care. R1's family member also reported concerns about staff yelling and not respecting R1's needs and preferences, further highlighting the lack of dignified care provided to R1. R13, who has severe cognitive impairment and requires maximal assistance for daily activities, was also subjected to undignified care. R13's family member reported that R13 was left in the same nightgown and socks for several days and that staff failed to follow the care plan. Video footage showed that R13 was left with an unopened breakfast tray for over an hour, and when the tray was finally placed within reach, the food was cold. Additionally, R13's nonverbal expressions of discomfort during a transfer were ignored by staff, further compromising her dignity and care. The facility's policies on resident rights and dignity were not adequately enforced, as evidenced by the repeated grievances and care concerns reported by the residents' family members. The Director of Nursing acknowledged that staff should follow up-to-date care plans and treat residents with dignity and respect, but the facility failed to ensure that these standards were consistently met. The lack of individualized care and respect for residents' preferences and needs led to a failure in maintaining a dignified living experience for R1 and R13.
Failure to Implement Toileting Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive toileting care plan for a resident (R13) who was always incontinent of both bowel and bladder. Despite the care plan specifying a routine for toileting and the use of specific incontinence products, staff did not consistently follow these directives. Observations and interviews revealed that R13 was not toileted according to the scheduled times, and the appropriate incontinence products were not used, leading to prolonged periods without being changed and the use of incorrect briefs that did not meet the resident's needs. R13's care plan included detailed instructions for toileting and incontinence management, such as offering toileting/bedpan at specific times throughout the day and night and using green overnight briefs for better moisture absorption. However, documentation and staff interviews indicated that these interventions were not consistently implemented. For instance, R13 was observed to be left unchanged for extended periods, and staff admitted to missing scheduled toileting times due to being busy. Additionally, the correct type of briefs specified in the care plan was not used, as staff reported using gray briefs instead of the green overnight briefs. Family members also expressed concerns about the lack of adherence to the care plan, noting instances where R13 was not checked or changed for several hours. Video footage and email communications from the family corroborated these concerns, showing significant gaps in care. The facility's management acknowledged the discrepancies and the potential for skin breakdown due to missed toileting times and improper use of incontinence products. Despite the care plan's clear directives, the facility failed to ensure that staff followed through with the necessary interventions to meet R13's needs.
Improper Use of Mechanical Lifts and Wander-Guard System Failures
Penalty
Summary
The facility failed to use mechanical standing lifts in accordance with manufacturer recommendations for two residents, leading to unsafe transfer practices. One resident with multiple sclerosis and hemiplegia was observed being transferred with an incorrect harness size and left unattended on a commode while attached to a mechanical lift. The resident was also seen struggling to reach a call light, and the commode used was unstable due to improper setup. Staff failed to follow proper procedures, leaving the resident in a potentially dangerous position and using equipment that was not fit for use. Another resident with severe cognitive impairment was also subjected to improper use of mechanical lifts. The resident's family member reported ongoing issues with the use of mechanical lifts, including a specific incident where the resident was left in pain due to incorrect strap placement. Video footage confirmed that staff did not follow proper procedures, leading to the resident being in a V-like position and experiencing significant discomfort. The facility's staff were observed not applying the lower leg strap and not ensuring the resident's feet were on the platform of the lift. Additionally, the facility failed to ensure the wander-guard system was operational to prevent elopement for three residents. One resident was able to elope from a secured unit due to the wander-guard doors not locking when alarmed. Another resident's wander-guard was found to have a low battery, and the system did not trigger when the resident approached the door. The maintenance director demonstrated that the system's auditory alert was only audible at the nurses' station and not throughout the unit, leading to a failure in preventing elopement. Staff were not adequately checking the functionality of the wander-guard devices, relying solely on the blinking light indicator, which was inconsistent with the system's actual performance.
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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.
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Nursing homes near Anoka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At Twin Rivers Llc | 1 mi | ★★★★★ | 2 | 1 |
| Park River Healthcare And Rehabilitation Center Ll | 5.9 mi | ★★★★★ | 22 | 2 |
| The Villas At Osseo Llc | 6.6 mi | ★★★★★ | 2 | 0 |
| Saint Therese At Oxbow Lake | 7.1 mi | ★★★★★ | 16 | 0 |
| Maranatha Care Center | 9.2 mi | ★★★★★ | 3 | 0 |
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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.