Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Aurora On France during CMS and state inspections, most recent first.
A cognitively intact resident was directed by an NA to roll onto his side and have a bowel movement in his brief instead of receiving toileting care consistent with his needs and preferences. The record contained conflicting toileting directions, with one assessment identifying him as continent while the care plan and Kardex directed brief-based incontinence care; the resident reported accidents while waiting for staff and said having a bowel movement in bed was deeply demoralizing. Staff interviews showed differing descriptions of his toileting status and use of a bedpan, urinal, or lift-assisted toileting.
A resident with multiple diagnoses, including diabetes and hypertensive heart failure, had clobetasol ointment kept at bedside and was applying it without a completed SAM assessment or provider order. The resident said the facility lost the cream, the husband brought in a replacement from home, and the cream was observed on the nightstand. Staff and the DON stated a SAM assessment and physician order were required before a resident could self-administer and keep medication at bedside, and the facility policy required the same.
Missing Transfer and Bed-Hold Notices: The facility failed to provide written transfer notices that included appeal rights and Ombudsman contact information, and failed to provide written bed-hold information for two residents transferred to the hospital/ED. Staff said they typically sent the face sheet, orders, and MAR, but did not give the required transfer or bed-hold forms, and the records did not show that these notices were provided.
Failure to Transmit Discharge MDS Assessments to CMS: The facility failed to transmit a DRA MDS for one resident and a DRNA MDS for another resident to CMS. Both assessments were completed, but the submit section indicated not to submit to CMS, and the MDS coordinator confirmed neither assessment had been sent. One resident was discharged to the ED after a fall, and the other was discharged with family to an ILF.
A resident with intact cognition and diagnoses of anxiety and bipolar disorder was admitted without evidence in the record that the PASARR screening had been finalized by the lead agency. The admissions coordinator said the hospital usually completed the PAS and that she would follow up for the final PAS, but she did not keep documentation of attempts to obtain it; the administrator stated admissions was responsible for receiving and following up on the PAS.
Failure to Provide Routine Nail Care: A resident with paraplegia and extensive ADL assistance needs was found with fingernails over 1/4 inch past the fingertips and brown substance under the nails. The resident stated no one had offered nail care, and the aide confirmed he had not offered to trim or clean the nails. The RN and DON stated nail care should be checked and provided on bath days and as needed, but the record did not show completed nail care before the survey.
A resident with CHF returned from the hospital with orders for daily weights, provider notification for significant weight gain, and a low-sodium diet, while Lasix was to remain on hold pending provider direction. The facility did not document daily weight monitoring, notification instructions, or the ordered diet, and the care plan did not address CHF management, fluid monitoring, sodium restriction, or signs of worsening HF. Staff interviews showed inconsistent understanding of where weights should be documented and who was responsible for carrying out the discharge recommendations.
Medications were not available for ordered administration for two cognitively intact residents. An RN found four ordered meds missing for one resident, including vitamins and supplements, and an LPN found missing cyclosporine eye drops and losartan for another resident, with only a lower-strength losartan on hand. Staff described reordering expectations of about 5-7 days before supply ran out, but the medications were still unavailable during the passes.
Surveyors found that food was stored on racks less than six inches from the floor in the freezer and that boxes were placed directly on the refrigerator floor after delivery. Additionally, clean dishes and food storage containers were stacked while still wet, contrary to facility policy requiring air drying before stacking. Staff confirmed these practices did not meet infection control and food safety standards.
Staff did not consistently follow infection prevention protocols, including proper use of PPE and hand hygiene, for residents on enhanced barrier or contact precautions. Multiple staff members entered precaution rooms without required gowns and gloves, performed high-contact care without full PPE, and failed to perform hand hygiene after resident contact, despite facility policies and posted signage.
Two residents who required assistance with personal hygiene were not provided care in a manner that preserved their dignity, as staff failed to address unwanted facial hair despite resident preferences and facility policy. Both residents were observed with visible facial hair, expressed discomfort or embarrassment, and staff interviews revealed inconsistent practices and lack of awareness regarding grooming needs.
The facility failed to implement new medication orders for a resident with heart failure and did not administer PRN antihypertensive medication or notify the provider for another resident with hypertension, despite multiple elevated blood pressure readings. In both cases, staff did not follow facility policies for order transcription, verification, and response to changes in condition.
A resident with cognitive impairments and aphasia was allegedly subjected to an inappropriate gesture by a staff member, which was reported by the resident's family member to the social worker. The social worker did not report the incident to the State Agency, believing it was not a reportable event. The DON and administrator were informed of the resident's distress but did not identify it as an abuse allegation, resulting in a failure to report the incident within the required timeframe.
A resident with cognitive impairments and aphasia was allegedly subjected to an inappropriate gesture by a staff member, which was reported by a family member. The social worker and DON failed to investigate the allegation, leaving the alleged perpetrator with continued access to vulnerable residents. The facility's policy on abuse prevention and response was not followed.
The facility failed to ensure proper sanitization of dishware, with dish machine temperatures not consistently reaching required levels, potentially affecting all 42 residents. Observations showed wash temperatures between 140 to 174 degrees and rinse temperatures between 165 to 192 degrees, below the manufacturer's minimum requirements. Staff inconsistently checked and recorded temperatures, and there was a lack of adherence to the facility's policy, which required wash temperatures between 140 to 160 degrees and rinse temperatures of at least 180 degrees.
A resident with impaired cognition and mobility was not repositioned every two hours as required, leading to the development of a pressure ulcer. Despite being at high risk for skin breakdown, the facility failed to implement necessary interventions upon admission. Observations showed the resident remained in the same position for extended periods, and staff misunderstood proper repositioning practices.
A resident admitted with an indwelling Foley catheter did not receive a voiding trial as ordered by the physician, leading to a deficiency in care. The facility's documentation lacked any record of the trial, and staff interviews revealed unawareness of the order. The resident's care plan included catheter care and monitoring for infection, but the voiding trial was missed, contrary to the facility's catheter care policy.
The facility failed to monitor side effects and implement non-pharmacological interventions for two residents prescribed psychotropic medications. One resident, with depression, lacked side effect monitoring in their care plan despite recommendations from a pharmacist. Another resident, with dementia and anxiety, was prescribed an antipsychotic without documented side effect monitoring. The facility's policy requires such monitoring and interventions, but these were not in place.
A facility failed to ensure staff wore appropriate PPE for a resident with a Foley catheter, as required by Enhanced Barrier Precautions (EBP). The resident's care plan indicated the need for EBP, but there was no signage or isolation cart to alert staff. Observations showed nursing assistants did not wear gowns while handling the catheter, and interviews confirmed staff were unaware of the EBP requirement due to the absence of signage.
The facility failed to ensure that three residents were offered or received pneumococcal vaccinations per CDC guidelines. Their records lacked documentation of shared clinical decision-making for the PCV-20 vaccine. Staff interviews revealed gaps in tracking and decision-making processes, with one resident not listed on the vaccine spreadsheet and another's vaccination status uncertain. The facility's policy required adherence to CDC guidelines and documentation of refusals, which were not consistently followed.
A facility failed to ensure a resident received or was offered the COVID-19 vaccination, as required by their preparedness plan. The resident, with a history of multiple health conditions, had received previous COVID-19 vaccinations, but the facility's EHR lacked documentation of the latest immunization and whether a second dose was offered. Staff interviews revealed inconsistencies in the vaccination process, and the resident was not listed on the infection preventionist's tracking spreadsheet.
The facility failed to develop comprehensive care plans for two residents prescribed antipsychotic medications, lacking measures for side effect monitoring. One resident with dementia was prescribed quetiapine fumarate, and another with intact cognition was on fluoxetine for depression. Despite recommendations from the pharmacist, the care plans did not include necessary interventions for side effect monitoring, which was acknowledged by the DON.
Failure to Preserve Resident Dignity During Toileting
Penalty
Summary
The facility failed to promote and maintain dignity for a cognitively intact resident when staff directed him to roll onto his side and have a bowel movement in his brief rather than providing toileting care consistent with his needs and preferences. The resident’s admission MDS indicated he was cognitively intact with a BIMS score of 15, and the record contained conflicting toileting information: one bowel and bladder assessment identified him as continent of bowel and bladder, while the toileting care plan and Kardex directed staff to use a bedpan and/or brief, provide incontinence care, and noted he needed assistance with a urinal. The resident reported he used a urinal with staff assistance, had accidents while waiting for staff to respond, and described having a bowel movement in bed as “the most demoralizing part of my whole life.” During interviews, a nursing assistant stated the resident had a bowel movement in his brief and was told he would have an easier time if he rolled onto his side in bed. Other staff described him as continent and said he called for a bedpan or urinal, while the nurse manager stated toileting expectations depended on the resident’s preferences and that he preferred a bedpan for bowel movements and a urinal for bladder needs. The DON stated dignified toileting practices included use of a bedpan when needed and that telling a resident to roll over and have a bowel movement in bed was not the facility’s standard of care. The facility’s dignity policy stated it promoted care in a manner that enhanced each resident’s dignity and respect in full recognition of individuality.
Failure to Complete SAM Assessment Before Bedside Medication Use
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed before allowing a resident to keep and apply clobetasol propionate external ointment at bedside. The resident’s MDS indicated the resident was cognitively intact but required substantial to maximal assistance with toileting hygiene, upper and lower body dressing, bed mobility, and transfers, and moderate assistance with oral and personal hygiene; the resident was also dependent on staff for bathing. The resident had diagnoses including pneumonia, acute respiratory failure with hypoxia, hypertensive heart failure, diabetes, anxiety disorder, and chronic low back pain. Physician orders included clobetasol ointment for lichen planus, and the MAR showed the medication was administered by staff as ordered. The nursing admission assessment documented the self-administration question as not applicable. During interview, the resident stated the staff had lost the medicated cream and that the resident’s husband brought in the clobetasol from home; the cream was observed on top of the nightstand in the resident’s room. The resident stated the cream was being applied every day and as needed. Staff interviews showed RN-E stated residents could self-administer medications only if alert and oriented, after a SAM assessment, and with a doctor’s order. RN-H stated she was not aware the resident had the cream in the room, retrieved it from the room, and stated a SAM assessment and provider order were needed for self-administration and that the medication would need to be reordered from the pharmacy. RN-F and the DON both stated a SAM assessment, provider order, and proper procedure were required before medication could be left at bedside. The facility policy also required a SAM assessment, physician order, and bedside storage in a locked box.
Missing Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer that included the resident's appeal rights and the contact information for the Office of the State Long-Term Care Ombudsman, and also failed to provide written information about bed-hold duration and reserve bed payment for 2 of 3 residents reviewed for hospitalization. One resident had intact cognition and diagnoses including congestive heart failure, heart disease, arthritis, depression, and chronic lung disease, and was hospitalized after a fall in his room before returning to the facility. During interviews, nursing staff stated they expected to send a face sheet, orders, and a medication list with the resident, but were unaware of providing a written transfer or bed-hold form, and the resident stated he was not offered or provided a verbal or written transfer or bed-hold form. For the second resident, the record showed intact cognition with no hallucinations, delusions, or behaviors, and she was transferred to the emergency department by ambulance after stating she was ready to go. The medical record did not show that she received a written transfer notice with ombudsman information and appeal rights, or a written bed-hold notice with the state bed-hold policy, reserve bed payment policy, or the facility's bed-hold policy. Staff interviews indicated that documents such as the order summary and MAR were sent, but that a written transfer notice or bed-hold notice was not given, and that social services would later follow up with residents about holding the bed. The facility policy stated that the transfer notice and bed-hold notice were to be given at the time of transfer and documented in the record.
Failure to Transmit Discharge MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that a discharge return anticipated (DRA) MDS for one resident and a discharge return not anticipated (DRNA) MDS for another resident were transmitted to CMS. For one resident, the admission MDS indicated the resident had a discharge-return anticipated status and that the discharge was unplanned, but the assessment was marked completed without showing that it had been submitted to CMS. The resident’s census listing showed the resident was admitted to the nursing home and later changed to STOP BILLING, and a progress note documented discharge to the emergency department after a fall. For the second resident, the DRNA MDS indicated the assessment was completed but did not show submission to CMS, and the submit section stated not to submit to CMS. The resident’s census listing showed admission to the nursing home and later a STOP BILLING status, and a progress note documented discharge with family to an ILF. During interview, the MDS coordinator confirmed that both assessments had been completed but never sent to CMS. The facility policy stated that MDS forms are completed on the facility computer and signed and dated after review for accuracy, but it did not include the expected time frame for submitting DRA or DRNA MDSs to CMS.
PASARR Screening Not Finalized for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Level I PAS and, if needed, a Level II PASARR were completed and finalized for one resident reviewed for PAS, R45. R45’s admission MDS indicated the resident was admitted to the facility with intact cognition and had diagnoses of anxiety and bipolar disorder. The resident’s PAS notice dated 4/22/26 stated that a copy of the PAS was included, but that the PAS was not final until the lead agency sent a final determination to the nursing facility. R45’s medical record lacked evidence that a final determination from the lead agency had been received. During interview, the admissions coordinator stated that when a resident was admitted from the hospital, the hospital would complete a PAS and send it to the facility, and that she would generally contact the lead agency for the final PAS. She confirmed that the final PAS from the lead agency, Medica, was found after review of R45’s record, but stated she did not keep documentation of attempts to contact the lead agency for the final PAS. The administrator stated admissions was responsible for receiving the PAS and following up as needed to obtain the final PAS. The facility policy stated that prior to admission, the admissions coordinator or designee would ensure the PASARR Level I screening was completed and received, work with the appropriate community provider to ensure completion and verification, and scan the Level I into the resident’s medical record.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to ensure routine and as-needed nail trimming and cleaning were completed for one resident who required staff assistance with ADLs. The resident had intact cognition, was diagnosed with paraplegia and not diabetes, and required setup/clean-up assistance with eating, supervision or touching assistance with oral hygiene and personal hygiene, and was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. The care plan called for a weekly body audit, and the Weekly Bath and Skin Sheets on several dates documented the resident's fingernails as short and smooth and not needing trimming, with no further completed sheets found and no documentation showing the resident received nail care before the survey start. During observation and interview, the resident was seen in bed with fingernails over 1/4 inch beyond the fingertips and brown substance underneath the nail tips. The resident stated no one had offered to help cut or clean the fingernails, and the aide assisting the resident stated he had not offered to help with nail care and did not think the resident could cut the nails independently. The RN stated aides should assist with trimming and cleaning nails on shower days and as needed, and the DON stated nursing staff should be checking nail status and trimming and cleaning as needed and on bath days if indicated. The facility policy stated nail care should be completed on bath days and as needed.
Failure to Follow CHF Discharge Orders and Standing Weight Monitoring
Penalty
Summary
The facility failed to implement hospital discharge recommendations and its own standing orders for a resident with CHF after the resident returned from the hospital. The resident’s admission MDS identified mild cognitive impairment and a primary diagnosis of chronic CHF. The hospital discharge paperwork included orders for daily weights, provider notification for a 2-pound weight gain in one day or 5 pounds in one week, and a low-sodium diet. The discharge summary also stated the resident had received IV Lasix during the hospital stay and was transitioned to oral Lasix for edema, but the medication was to be paused until a provider directed otherwise. After readmission, the resident had a documented weight of 153 pounds, but the medical record lacked evidence of daily weight monitoring, notification instructions, or the ordered diet being implemented.
Medications Unavailable for Ordered Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure medications were available for two residents reviewed for medication administration. One cognitively intact resident with a BIMS score of 15 had four medications unavailable during a medication pass: ginkgo biloba, a multivitamin with minerals, vitamin B12, and vitamin E. The nurse checked the medication cart and house stock but could not locate the medications, and stated she would need to fax and call the pharmacy to have them delivered that day. She also stated the assistant administrator, acting as the supplier, reordered house stock medications, and that she would need to notify the provider because the missing medications were vitamins and not urgent. A second cognitively intact resident with a BIMS score of 13 had cyclosporine ophthalmic drops unavailable during a medication pass, and the nurse stated the medication should have been reordered when the supply reached the last package. During the same pass, the resident’s ordered losartan 75 mg was unavailable and only losartan 50 mg was present; the nurse stated the resident should have had one 50 mg tablet and one 25 mg tablet available, and reported she had called the pharmacy twice during her previous shift about the missing medication. Later, the nurse obtained a one-time order to give losartan 50 mg in place of the prescribed 75 mg because the ordered dose was unavailable. The nurse manager and another RN stated the expectation was to reorder medications when about seven days of supply remained, and a pharmacy policy stated refill requests should be placed 5-7 days before the current supply runs out to avoid gaps in medication administration.
Improper Food Storage and Wet Dish Stacking Identified
Penalty
Summary
Surveyors observed multiple deficiencies in food storage and dish handling practices within the facility. During a kitchen tour, it was noted that food items, including a prep pan of raw whole turkeys, were stored on racks in the walk-in freezer that were less than six inches from the floor, with one rack's bottom shelf touching the floor. Additionally, boxes of food were found sitting directly on the floor of the first-floor refrigerator following a recent delivery. The culinary manager and dietary manager confirmed that these storage practices did not comply with facility policy, which requires food to be stored at least six inches off the floor. Further observations revealed that clean dishes, including plastic glasses and food storage containers, were stacked while still wet, with visible moisture present between and inside the items. Both the culinary manager and dietary aide acknowledged that dishes should be completely air dried before stacking, as per facility policy, to prevent infection risks. These practices were confirmed through interviews and direct observation, indicating a failure to adhere to established food storage and dishwashing protocols.
Failure to Adhere to Infection Control Standards and PPE Use
Penalty
Summary
Staff failed to adhere to infection prevention and control standards, specifically regarding the use of personal protective equipment (PPE) and proper hand hygiene, for three residents under enhanced barrier precautions (EBP) or contact precautions. For one resident with a chronic right foot ulcer and multiple comorbidities, a therapy assistant was observed wearing gloves but not a gown during high-contact care activities, and also wore gloves outside the resident's room, contrary to facility policy. The therapy assistant acknowledged receiving infection prevention training and recognized the error in PPE use and glove handling. Another resident, with a history of recurrent Clostridium difficile infection and other medical conditions, was on contact precautions. Multiple staff members, including a physical therapy aide and nursing assistants, entered the resident's room without donning the required gown and gloves, and failed to perform hand hygiene after leaving the room. Staff interviews revealed awareness of the precautions but lapses in compliance, with some staff citing being in a hurry or believing PPE was unnecessary if the resident was not touched. A third resident, on EBP following joint replacement surgery and with several chronic conditions, received high-contact care from a nursing assistant who wore gloves but not a gown, and was unaware of the specific reason for the precautions. The facility's policies required gowns and gloves for high-contact care in EBP and contact precaution rooms, and mandated hand hygiene after glove removal and before leaving resident rooms. The director of nursing confirmed that staff were expected to follow these protocols and acknowledged the observed lapses.
Failure to Preserve Resident Dignity in Personal Grooming
Penalty
Summary
The facility failed to ensure that care was provided in a manner that preserved the dignity of two residents who required assistance with personal hygiene and had preferences regarding facial hair removal. One resident, who was moderately cognitively impaired and had multiple diagnoses including impaired vision, was observed on multiple occasions with several long chin hairs. The resident was unaware of the facial hair and stated they would have wanted it removed if they had known. Staff interviews revealed inconsistent practices and a lack of initiative in addressing unwanted facial hair, with some staff stating they would not offer to remove chin hairs and others indicating it was a personal issue. The resident's care plan included instructions for personal hygiene assistance and reminders to wear glasses, but did not address facial hair preferences. Another resident, who had intact cognition and required assistance with personal hygiene, was observed with significant facial hair despite a care plan indicating a preference for facial hair removal to maintain dignity. The resident expressed embarrassment and discomfort about the facial hair, stating that at home they would have removed it themselves. Staff were unaware of the resident's concerns and did not address the issue until after it was brought to their attention. Facility policies indicated that residents should be groomed as they wish and that both men and women should have facial hair shaved as part of morning care, but these policies were not consistently followed for the residents involved.
Failure to Implement Provider Orders and Respond to Abnormal Clinical Findings
Penalty
Summary
The facility failed to implement and document new medication orders and to recognize and respond to abnormal clinical findings for two residents. For one resident with a history of heart failure, hypertension, and other significant comorbidities, a provider issued a new order to increase the dose of furosemide due to weight gain and fluid retention. The order, sent via fax and email, was not entered into the electronic medical record (EMR) or administered as prescribed. Facility staff did not clarify the order with the provider or follow up over the weekend, resulting in the resident not receiving the intended increased dose. Documentation and interviews confirmed the order was missed, and the facility's policy requiring double verification and communication of new orders was not followed. For another resident with hypertension and renal insufficiency, the facility failed to administer as-needed (PRN) antihypertensive medication despite multiple blood pressure readings that met the criteria for intervention. The resident's medication administration record showed that the PRN medication was never given, and there was no documentation of provider notification or alternative interventions for the elevated blood pressures. Staff interviews confirmed that the process for responding to abnormal blood pressure readings was not followed, and the director of nursing acknowledged that each missed dose constituted a medication error. Facility policies required prompt transcription and verification of new orders, as well as immediate provider notification and intervention for changes in resident condition. In both cases, the facility did not adhere to these policies, resulting in failures to provide care and treatment according to provider orders and the residents' clinical needs.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency within the required two-hour timeframe. The incident involved a resident with cognitive impairments and aphasia, who required extensive assistance with activities of daily living. The resident's family member reported that the resident was upset after a staff member allegedly made an inappropriate gesture towards them. Despite the family member notifying the social worker about the incident, the social worker did not report it to the State Agency, believing it was not a reportable event since the allegation was not directly heard from the resident. The Director of Nursing and the administrator were informed that the resident was upset, but neither determined that an allegation of abuse had occurred. Consequently, the incident was not reported to the State Agency. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but this protocol was not followed. The policy also defines verbal abuse to include gestured language that is disparaging or derogatory, which was relevant to the incident in question.
Failure to Investigate Alleged Abuse and Protect Resident
Penalty
Summary
The facility failed to complete an investigation and ensure protection for residents following an allegation of staff-to-resident abuse involving a resident with cognitive impairments and aphasia. The resident, who required extensive assistance with activities of daily living, was reported by a family member to have been upset after a staff member allegedly made an inappropriate gesture towards her. The family member reported the incident to the social worker, who attempted to discuss the matter with the resident but was unable to understand her due to her aphasia. The social worker reported the allegation to the director of nursing but did not conduct further investigation. The director of nursing was unaware of the specific allegation of abuse and assumed the resident's distress was related to a previous hospital stay. Consequently, no investigation was initiated, and the alleged perpetrator continued to have access to the resident and other vulnerable individuals. The facility's administrator confirmed that no investigation had been conducted, and the facility's policy on abuse prevention and response was not followed. This policy required immediate reporting, protection of the resident, and suspension of the employee in question pending investigation.
Dishware Sanitization Deficiency
Penalty
Summary
The facility failed to ensure that dishware was cleaned and sanitized properly, which could potentially affect all 42 residents. During observations, it was noted that the dish machine temperatures were not consistently reaching the required levels for effective sanitation. The wash temperatures recorded were between 140 to 174 degrees, and rinse temperatures were between 165 to 192 degrees, which did not always meet the manufacturer's minimum requirements of 150 degrees for wash and 180 degrees for rinse. Staff members, including dietary aides and the director of culinary, were observed using the dish machine with temperatures below the required levels, and there was inconsistency in checking and recording these temperatures. The facility's policy required wash temperatures to be between 140 to 160 degrees and rinse temperatures to be at least 180 degrees, with staff instructed to monitor and record temperatures for each meal service. However, the logs showed discrepancies, and the dish machine's temperatures for dinner had not been recorded at the time of observation. Staff members were expected to notify supervisors if temperatures were not as specified, but there was a lack of consistent adherence to this protocol. The director of culinary acknowledged the importance of maintaining proper temperatures to prevent foodborne illness but relied on staff to report issues, which did not always occur promptly.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement interventions to prevent pressure ulcers and ensure timely repositioning for a resident with existing pressure ulcers. The resident, identified as R13, had moderately impaired cognition and was diagnosed with hemiplegia, hemiparesis, chronic pain, and polyneuropathy. R13 required substantial assistance with bed mobility and was at risk for skin breakdown due to decreased mobility, bowel incontinence, and medication use. Despite these risks, the facility did not implement adequate interventions upon admission, and a deep tissue injury was noted on R13's right heel. Observations revealed that R13 was not repositioned every two hours as required. During a continuous observation period, R13 remained in the same position for extended periods, with staff entering the room for various tasks but not repositioning the resident. Interviews with staff indicated a lack of understanding of what constitutes repositioning, with some staff considering raising the head of the bed as repositioning, which is not sufficient to relieve pressure. The facility's policy required skin risk assessments and appropriate interventions upon admission, but these were not implemented for R13. Interviews with nursing staff and management highlighted a failure to add skin interventions upon admission and a misunderstanding of repositioning practices. The facility's director of nursing confirmed that interventions should be added immediately for residents at risk of skin breakdown, but this was not done for R13, leading to the development of a pressure ulcer.
Failure to Conduct Voiding Trial for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to remove a Foley catheter according to physician orders for a resident (R4) who was admitted with an indwelling catheter. R4's admission records indicated a need for a voiding trial within five days of admission, as per hospital discharge orders. However, the facility's documentation, including the Physician Orders form, medication administration record (MAR), and treatment administration record (TAR), lacked any record of a voiding trial being conducted. Interviews with staff, including a licensed practical nurse (LPN) and a registered nurse (RN), revealed that they were unaware of the voiding trial order, and no documentation was found to indicate that the trial had been completed. R4 was admitted with a diagnosis of urinary retention and had a history of urinary incontinence. The resident's care plan included catheter care every shift and monitoring for signs of urinary tract infection. Despite these interventions, the voiding trial order was missed, and the catheter remained in place longer than necessary. The RN acknowledged the importance of completing a voiding trial to reduce the risk of infection and noted that the order had been overlooked. The Director of Nursing (DON) also confirmed that the voiding trial should have been documented and that staff were expected to clarify and document orders. The facility's policy on catheter care emphasized the removal of indwelling catheters as soon as possible to minimize infection risks. However, the failure to conduct and document the voiding trial for R4 indicated a lapse in following this policy. The oversight was attributed to a lack of communication and verification of orders among the staff, as highlighted by the RN's and DON's statements during interviews.
Failure to Monitor Psychotropic Medication Side Effects and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure proper monitoring and implementation of non-pharmacological interventions for residents prescribed psychotropic medications. Resident R4, who was admitted with intact cognition and depression, was prescribed fluoxetine and trazodone. However, the care plan for R4 lacked interventions for monitoring side effects of these medications. Despite recommendations from the consultant pharmacist to update the care plan with behavior, intervention, and side effect monitoring, these were not implemented. The Director of Nursing acknowledged the absence of non-pharmacological interventions and side effect monitoring in R4's care plan. Similarly, Resident R147, diagnosed with dementia and anxiety, was prescribed quetiapine fumarate for anxiety. The medication administration records for R147 did not include any side effect monitoring for the antipsychotic medication. Interviews with the LPN and RN confirmed that side effect monitoring was expected but not documented. The pharmacist had recommended side effect monitoring and non-pharmacological interventions, but these were not in place at the time of the survey. The facility's policy on psychopharmacological drug use requires monitoring for medication effectiveness and adverse consequences, with documentation in the resident's active record. It also emphasizes the use of behavioral interventions and non-pharmacological approaches. However, the facility did not adhere to these policies, as evidenced by the lack of side effect monitoring and non-pharmacological interventions for residents R4 and R147.
Failure to Implement Enhanced Barrier Precautions for Resident with Foley Catheter
Penalty
Summary
The facility failed to ensure that staff wore appropriate personal protective equipment (PPE) for a resident with a Foley catheter, which was reviewed for infection prevention and control. The resident, who had intact cognition and was dependent on staff for toileting hygiene and transfers, had an indwelling catheter due to urinary retention and other medical conditions. Despite the resident's care plan indicating the need for Enhanced Barrier Precautions (EBP) due to the catheter, there was a lack of signage and instructions for EBP in the resident's room. Observations revealed that nursing assistants were not wearing gowns while handling the resident's catheter, and there was no signage or isolation cart to indicate the need for EBP. Interviews with staff, including nursing assistants, a trained medication aide, and a licensed practical nurse, confirmed the absence of EBP signage and the lack of awareness among staff regarding the resident's need for EBP. The facility's policy on Enhanced Barrier Precautions required the use of gowns and gloves during high-contact resident care activities, but the policy did not specify where staff should look to determine if a resident was on EBP. The director of nursing stated that staff should be alerted to EBP through signage and isolation carts, which were not present in this case.
Failure to Ensure Pneumococcal Vaccination Compliance
Penalty
Summary
The facility failed to ensure that three out of five residents were offered or received pneumococcal vaccinations in accordance with CDC recommendations. The residents involved were identified as having received previous pneumococcal vaccinations, but their electronic health records lacked documentation of shared clinical decision-making regarding the administration of the PCV-20 vaccine. Specifically, the records for these residents did not reflect whether a decision had been made to administer the PCV-20 vaccine, which is recommended five years after the last pneumococcal vaccination under certain conditions. Interviews with facility staff revealed gaps in the vaccination tracking and decision-making process. The infection preventionist, responsible for tracking immunizations, had not included one of the residents on their vaccine spreadsheet and had not consulted with the provider about the need for the PCV-20 vaccine. Additionally, the infection preventionist was uncertain about the vaccination status of another resident and had not documented any refusal or declination of the PCV-20 vaccine. The facility's policy directed staff to follow CDC guidelines and document refusals, but these steps were not consistently followed, leading to the deficiency.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered and/or provided to a resident, identified as R16, to reduce the risk of severe illness. R16, who was admitted to the facility with intact cognition and a history of cancer, hypertension, diabetes mellitus, thyroid disorder, arthritis, and fracture, had received several COVID-19 vaccinations in the past. However, the facility's electronic health record (EHR) lacked documentation of the COVID-19 23-24 immunization and whether a second COVID-19 23-24 immunization was offered and accepted or declined. Interviews with staff revealed a lack of clarity and consistency in the process of checking vaccination records and obtaining consent. RN-C mentioned that the charge nurse or another unspecified person was responsible for checking vaccination records and obtaining consent, but RN-C had not administered COVID-19 vaccines to residents. RN-D stated that the infection preventionist (IP) tracked resident COVID vaccines and received pharmacy reviews, which were forwarded to the IP. The IP or nurses would administer the vaccines, and consents or refusals were documented in the residents' EHR. The infection preventionist (IP) explained that they reviewed residents' vaccine history and recommendations from the pharmacist, following CDC guidelines for vaccine timing. The IP maintained a spreadsheet listing resident names, vaccine information, consent status, and follow-up needs. However, R16 was not listed on the IP's vaccine spreadsheet, indicating a gap in the tracking and administration process. The facility's COVID-19 Preparedness Plan required staff to check residents' vaccination status upon admission and offer the vaccine to those who had not received it, but this was not adequately followed for R16.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to develop comprehensive care plans for monitoring side effects in two residents who were prescribed antipsychotic medications. One resident, identified as R147, had a diagnosis of dementia and was prescribed quetiapine fumarate for anxiety. However, the care plan for R147 did not include any measures for monitoring side effects of the antipsychotic medication. The Director of Nursing acknowledged that residents on antipsychotic medications should be monitored for side effects, and the facility's pharmacist had recommended such monitoring, along with non-pharmacological interventions and monthly orthostatic blood pressure checks, but these were not implemented in the care plan. Another resident, R4, who had intact cognition and was taking fluoxetine for depression, also lacked a care plan for monitoring side effects of psychotropic medications. The resident's Care Area Assessment indicated an increased risk for falling and depression due to antidepressant use, but the care plan did not include interventions for side effect monitoring. The facility's pharmacist had recommended updating the care plan to include behavior monitoring and side effect monitoring for psychotropic medications, but these recommendations were not followed. The Director of Nursing confirmed that the care plan should have included these interventions but did not.
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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 Edina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Of Edina | 0.6 mi | ★★★★★ | 15 | 0 |
| Mount Olivet Careview Home | 2.3 mi | ★★★★★ | 7 | 0 |
| Mount Olivet Home | 2.3 mi | ★★★★★ | 7 | 0 |
| The Villas At Richfield | 3.4 mi | ★★★★★ | 11 | 0 |
| Grand Avenue Rest Home | 3.5 mi | ★★★★★ | 9 | 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.