Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Benedictine Living Community Owatonna during CMS and state inspections, most recent first.
A resident with atrial fibrillation was admitted after surgery with Eliquis on hold until a JP drain was removed, but the facility did not clearly track the hold order, did not clarify compression wraps present on admission, and did not document DVT prevention education or shift-to-shift clot monitoring. After the drain was removed, Eliquis was not restarted promptly and doses were missed; the resident later developed a severe leg clot and PE, required emergent hospital transfer and surgery, and died. A second resident’s healing groin incisions were also not adequately monitored in the chart until the wounds later opened and became infected.
Failure to develop a baseline care plan within 48 hours for a resident admitted with surgical incision sites and urinary incontinence. The resident had PAD, AKI, CKD, HTN, needed help with all ADLs, and was incontinent of urine on admission. The care plan sections for bladder/bowel incontinence and skin/incision care were not started until a week later, and the DON and LPN confirmed the facility did not use a separate baseline care plan template.
Incomplete bladder assessment and toileting program decision A resident with PAD, CKD, AKI, HTN, severe cognitive impairment, and healing groin surgical sites was documented as frequently incontinent of urine and occasionally incontinent of bowel after admission. The bladder evaluation left key sections blank, including further assessment, incontinence profile, and toileting program decision, even though the resident sometimes asked for a urinal and staff noted functional incontinence. The care plan listed vague toileting interventions, but the record lacked evidence of a comprehensive assessment or clear rationale for not implementing a toileting program.
A resident with AFib and recent surgery had Eliquis ordered to restart after a JP drain was removed, but the first doses were not given when scheduled. Staff acknowledged the med was listed as available in the E-kit, yet the MAR showed the doses were missed because the pharmacy delivery had not arrived. The DON and pharmacist both confirmed the drug should have been available to start sooner, and the resident later had a change in condition and was sent out by ambulance.
A resident with a history of intestinal perforation and a colostomy developed nausea, abdominal discomfort, and later epigastric/chest‑area pain, refused supper, and exhibited elevated BP, dry heaving, pallor, diaphoresis, and anxiety. A physician examined the resident, ordered PRN ondansetron (Zofran) for nausea, and later ordered transfer to the ED, expecting prompt implementation. The RN did not administer the Zofran for several hours after the order and delayed calling for ambulance transport despite repeated requests from the resident and reports from NAs that the resident looked unwell and wanted to go to the hospital. Progress notes and interviews show ongoing severe epigastric pain, abnormal VS, low O2 sats requiring increased oxygen, and continued nausea before non‑emergency transport was finally arranged, and leadership later stated that earlier focused assessment, MD notification, and immediate ambulance activation were expected.
A resident receiving hospice care, with multiple serious diagnoses and dependent for transfers, did not have a current hospice care plan, visit schedule, or documentation of hospice visits available in the facility. LPNs and the DON reported that hospice nurses did not communicate with facility staff about care provided or changes in the plan of care, and the hospice RN manager was unaware that required documentation and schedules were not being received. The facility's policies and hospice agreement required collaborative care and communication, but these were not followed, resulting in a failure to coordinate and document hospice services.
Multiple residents consistently received cold, unappetizing, and incorrectly prepared meals, with staff failing to follow standardized recipes and proper food temperature procedures. Ongoing complaints about food quality, temperature, and presentation were documented, and staff interviews revealed confusion about temperature monitoring and documentation, resulting in persistent dissatisfaction among residents.
A resident with hemiplegia and cognitive impairment was left in bed unclothed and exposed after an inexperienced agency NA failed to complete morning care and left the room. Another NA found the resident exposed, covered him, and finished his care. The incident was not promptly reported to nursing leadership, resulting in a failure to maintain the resident's dignity.
The facility did not provide a method for residents to submit grievances anonymously, and residents were unaware of any such process. Additionally, a resident's report of a missing personal item was not documented or investigated according to facility policy, as staff failed to communicate and follow up on the concern.
A resident with a documented diagnosis of PTSD and related care plan interventions was not coded for PTSD on the MDS assessment, despite evidence of the diagnosis in the medical record and care plan. Staff indicated the diagnosis was omitted because it was not in the most current provider note, even though it was present in recent documentation and active interventions were in place.
A resident with type 2 diabetes was administered insulin by an LPN who failed to disinfect the rubber septum of the insulin pen with an alcohol wipe before attaching the needle and giving the injection. The LPN confirmed the expected procedure was not followed, and the DON verified that facility policy requires disinfection of the septum prior to each dose.
A resident who was unable to perform activities of daily living independently did not receive the necessary care and assistance from facility staff.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in care that was not individualized or consistent with regulatory requirements.
A resident with diabetes was administered insulin from a pen that was not labeled with their name or the date it was opened, contrary to facility policy. An LPN confirmed the omission during medication administration, and a second insulin pen for the same resident was also missing the date opened. Nursing staff and the DON acknowledged that both the resident's name and the date opened were required on insulin pen labels.
Staff failed to maintain infection control standards when a resident's Foley catheter drainage bag was repeatedly observed lying on the floor, contrary to care plan instructions, and another resident's soiled washcloths were placed on an overbed table used for meals during peri-care. Staff interviews confirmed these lapses, and the DON acknowledged the practices were unacceptable.
The facility did not ensure that posted nurse staffing information accurately reflected the actual number of CNAs and total hours worked, as required by policy. The posted schedule was not updated to account for staff call-outs or last-minute changes, resulting in discrepancies between posted and actual staffing data. This issue was confirmed by both the DON and the staffing coordinator.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
A resident with chronic kidney disease was mistakenly given 100 units of insulin instead of the prescribed Heparin by an LPN, leading to hypoglycemia and hospitalization. The LPN misread the medication label, resulting in the error.
A facility failed to ensure proper hand hygiene and cleaning protocols during medication administration and wound care. An LPN did not perform hand hygiene before entering rooms or after removing gloves, and a universal glucometer was not disinfected after use. Additionally, Enhanced Barrier Precautions were not implemented during wound dressing changes for residents with chronic wounds, despite facility policies requiring such measures. Staff interviews confirmed these lapses in protocol adherence.
The facility failed to update care plans for two residents with non-pressure related skin injuries. One resident experienced a fall resulting in significant injuries, but their care plan was not revised to address impaired skin integrity. Another resident suffered burns from hot food, yet their care plan lacked necessary interventions. Staff interviews revealed communication gaps and unmet expectations for care plan updates.
A resident with severe cognitive impairment suffered a leg laceration after a fall. The facility failed to adequately monitor and document the wound care, leading to a deficiency. The wound was not properly assessed or communicated among staff, resulting in inadequate treatment and pain for the resident.
A resident with multiple diagnoses, including hemiplegia and epilepsy, required substantial assistance for transfers. Despite the care plan requiring two staff members for transfers, only one nursing assistant assisted the resident during a transfer, resulting in a fall. The resident's foot got caught on the door frame, leading to a fall and subsequent hospitalization for pain management. Interviews confirmed the care plan was not followed, contributing to the incident.
A resident fell from a mechanical lift in an LTC facility, resulting in a fractured sternum and hip hematoma. The incident occurred during a transfer from a commode to a bed when a sling strap detached. Staff failed to check the tension and security of the sling straps, leading to the fall. The equipment was found to be in working order, suggesting operator error.
A resident with intact cognition and dependent on staff for transfers fell from a mechanical lift, resulting in skin tears. The incident was not reported to the Director of Nursing within the required 2-hour timeframe, and the state agency was notified the following day, contrary to the facility's policy for immediate reporting of such incidents.
A resident with severe cognitive impairment and a history of wandering exhibited disrobing behavior in public areas, which was not addressed in their care plan. Despite assessments noting these behaviors, the care plan was not updated with interventions until after an incident occurred. Staff interviews indicated a lack of direction on managing the behavior, highlighting a deficiency in the facility's care planning process.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as staff did not use PPE during care. Interviews revealed a lack of awareness and education about EBP among staff, and the infection preventionist, still in training, acknowledged the absence of EBP implementation. The facility's policy required EBP for such residents, but it was not followed.
Culinary aides at the facility failed to follow proper hand hygiene practices, potentially impacting 30 residents. Observations showed aides handling food without changing gloves or washing hands after touching various items. Interviews revealed a lack of documented training on hand hygiene, and the facility's infection prevention policy highlighted the risk of microorganisms entering through unclean hands.
A resident with a history of hemiplegia and hemiparesis was served a meal inconsistent with her dietary orders, leading to a failure in providing a dignified dining experience. Despite having a diet order for soft and bite-size meals, she was given ground steak bites and asparagus, which she found demeaning. The culinary director acknowledged the error, and the director of nursing noted that dietary staff should have checked with the resident or offered an alternative before altering the food texture.
The facility failed to accurately identify PTSD on the MDS assessment for two residents. Despite having PTSD listed as an active diagnosis on their face sheets, it was not marked on their quarterly MDS assessments. Interviews revealed that the clinical reimbursement manager relied on the most current provider note for MDS marking, while the DON and regional director indicated that active diagnoses should be marked. A policy on MDS was requested but not provided.
Two residents did not receive copies of their baseline care plans upon admission, despite attending care conferences. One resident, with multiple health issues, expressed a desire to be informed about her care plan, while another resident, with conditions like rhabdomyolysis, also did not receive her care plan. Facility staff confirmed that care plans are discussed but not routinely distributed unless requested, contrary to the facility's policy.
A resident with neuropathy and osteoporosis was not consistently walked as per her care plan, which required twice-daily ambulation with assistance. Despite being on the walk list, she reported not being walked for weeks, and documentation confirmed infrequent implementation of the walking program. Staff interviews revealed inconsistencies in following the care plan, and the clinical manager had not verified the program's execution.
The facility failed to assess and manage the vaping practices of two residents, leading to a deficiency in maintaining a smoke-free environment. Despite being informed of the policy, the residents continued to vape indoors, and the staff did not conduct safety assessments or update care plans. The facility's policies on smoking and medical cannabis were not effectively enforced, resulting in ongoing vaping activities within the facility.
A resident with obstructive sleep apnea did not receive proper CPAP care due to the facility's failure to provide distilled water, as required by the manufacturer's guidelines. Staff used tap water for several days, which was confirmed through interviews and observations. The purchasing coordinator was unaware of the shortage until informed, and the director of nursing expected staff to use distilled water and contact the on-call nurse if supplies were depleted. The facility did not provide a policy for CPAP use when requested.
The facility failed to assess and implement trauma-informed care for two residents with PTSD. One resident lacked a care plan addressing PTSD, while another's initial assessment did not capture triggers. Staff were unaware of these needs, and care plans were not updated to reflect trauma-informed approaches, despite facility policy requiring such care.
Failure to Resume Anticoagulant Therapy and Monitor Surgical Incisions
Penalty
Summary
The facility failed to educate a resident on deep vein thrombosis (DVT) prevention, failed to clarify whether compression wraps that were present on admission should continue, and failed to act on the hospital discharge instruction to resume Eliquis after a Jackson Pratt (JP) drain was removed. The resident had a history of atrial fibrillation, heart failure, and recent hospitalization for acute cholecystitis with surgery. The hospital discharge paperwork stated Eliquis was to remain on hold until the JP drain was removed, and the resident arrived at the care center with compression socks/wraps in place, but the record did not show that the anticoagulant hold was entered in a way that alerted staff, that the compression wraps were clarified with the provider, or that the resident was educated on clot prevention measures such as ankle pumps. The resident’s JP drain was removed during a surgical follow-up visit, but the note did not address restarting Eliquis. The medication order to resume Eliquis was not signed and received by the facility until four days later, and the MAR showed missed doses after the order was entered because the medication was unavailable and not administered as scheduled. The record also lacked evidence of shift-to-shift monitoring for signs of a blood clot, and the TAR did not show use of compression wraps or TEDs despite their presence on admission. Staff interviews confirmed there was no reliable process in place to ensure the hold order was tracked, the anticoagulant was restarted promptly, or the compression wraps were clarified. After a nursing assistant reported the resident could not move the left leg and the leg appeared discolored and cool, the resident was sent to the hospital. The emergency department documented decreased sensation, a cool and dusky leg, inability to Doppler pulses, an acute pulmonary embolism, and near complete occlusion of the left iliofemoral and femoropopliteal system. The resident was treated with heparin and taken emergently to surgery for thrombectomy and possible fasciotomies. A family member stated the resident had been expected to return home after rehabilitation but instead developed the clot and died in the hospital. The report also identified a separate deficiency for another resident whose healing surgical groin incisions were not adequately monitored in the record from admission until the wounds later opened and became infected.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who arrived with active surgical incision sites and urinary incontinence. The resident’s progress note on admission documented multiple medical conditions, including PAD, AKI, CKD, and high blood pressure, along with dependence for all ADLs, need for cues and reminders to ask for help, and orientation to self only. The note also stated the resident had been incontinent of urine and was unaware of it, and identified two healing surgical sites in the bilateral groin, bruising to the bilateral upper extremities, and a small scabbed area to the posterior calf of the left lower extremity, with all areas open to air and not draining. The resident’s care plan later included bowel and bladder incontinence interventions and a pressure ulcer/injury section addressing the surgical incisions and skin breakdown risk, but both sections were initiated seven days after admission rather than within 48 hours. Interviews confirmed the facility did not use a separate baseline care plan template and instead began building the comprehensive care plan after admission. The LPN verified the skin and bladder/bowel sections were started a week after admission, and the DON confirmed those plans were not initiated until 4/20/26 and should have been started within 48 hours after admission, although weekend admission could sometimes delay the process.
Incomplete bladder assessment and lack of toileting program determination
Penalty
Summary
The facility failed to comprehensively assess and, if needed, develop a toileting program for a resident who was incontinent of urine and bowel. The resident was admitted after an extended hospitalization, had multiple medical conditions including PAD, AKI, CKD, and hypertension, and required assistance with ADLs. On admission, the resident was documented as frequently incontinent of urine and occasionally incontinent of bowel, with no elimination appliances in use. The admission documentation also noted the resident needed supervision for toileting transfer and partial/moderate assistance with toileting hygiene. The resident’s bladder evaluation, completed several days after admission, documented frequent urinary incontinence, impaired mobility, severe cognitive impairment, and that the resident was currently incontinent with clothes found wet. However, the sections for further assessment, incontinence symptom profile, and summary of program placement decision were left blank or incomplete. Although the evaluation concluded that the resident had functional incontinence and sometimes asked for a urinal, there was no completed documentation of what toileting program was needed or why one was not appropriate. The MDS also recorded that a toileting program had not been attempted since admission. The care plan identified bowel and bladder incontinence and included interventions such as keeping the call light within reach, monitoring for signs of infection, providing the urinal/bedpan/commode as needed, and offering toileting frequently, but it did not define what frequently meant. Family members stated the resident had been continent when discharged from the hospital but was later found incontinent at the facility, and they were unsure whether a toileting plan had ever been attempted. Nursing staff and the DON acknowledged that the bladder evaluation sections were expected to be completed and that the record lacked evidence or rationale for why the assessment and toileting program decision had not been fully done.
Delayed Administration of Eliquis After Order Received
Penalty
Summary
The facility failed to ensure Eliquis, a high-risk anticoagulant, was provided timely after it was ordered for a resident with atrial fibrillation and recent gallbladder surgery. The resident had been hospitalized for acute cholecystitis, underwent surgery, and was discharged with a Jackson Pratt drain in place. The hospital discharge instructions stated Eliquis was to remain on hold until the JP drain was removed, and the resident’s follow-up surgical visit documented that the drain was removed, but no medication changes or orders were listed in that note. On the nursing home H&P, the medical director documented that Eliquis was to be restarted when the JP drain was removed and wrote the order to restart it. The order was signed and received by the facility late in the evening, and the MAR showed the medication was scheduled to begin the next day. However, the MAR also showed both scheduled doses on that day were not administered, with comments indicating the pharmacy would deliver the medication ASAP and that the drug/item was unavailable. The first recorded dose was not given until the following morning. During interviews, nursing staff stated the order had been entered to begin the next day and acknowledged the doses were not given despite Eliquis being listed as available in the onsite emergency kit. The DON stated the medication should have been available from the E-kit to provide at least one dose when the order was received late at night. The dispensing pharmacist later confirmed Eliquis was available in the E-kit and stated the facility had a balance on hand to initiate therapy before the cards were delivered. The resident later developed a change in condition involving the left leg and was sent out by ambulance.
Delay in PRN Anti‑Nausea Medication and ED Transfer After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to timely implement a physician’s order for an anti‑nausea medication and to timely act on an order to transfer a resident to the emergency department (ED) following a change in condition. The resident had diagnoses including a non‑traumatic perforation of the intestine and colostomy status, used a walker and wheelchair, required one‑person assistance with several ADLs, and had an ostomy. On the afternoon in question, a nursing assistant reported that after emptying the resident’s colostomy bag and taking him to dinner, the resident soon stated he did not feel well, had stomach pain, was not hungry, and wanted to lie down. Vital signs taken at 6:43 p.m. showed elevated blood pressure (171/95), oxygen saturation of 94%, pulse 90, temperature 96.7°F, respirations 18, and pain 3/10. A clinician note documented that the resident had developed nausea that afternoon, chose not to eat supper, had mild diffuse abdominal tenderness with bowel sounds present, and nausea over the past couple of hours without abdominal pain at that time. The note indicated Zofran was available and that nursing was to update the physician later that evening. A signed physician order dated that day directed administration of ondansetron (Zofran) 4 mg by mouth every 6 hours as needed for nausea. The physician later clarified that this order was written between 6:00 p.m. and 7:00 p.m. and that she expected the Zofran to be administered at that time because the resident had acute issues requiring immediate attention. However, the medication administration record shows Zofran 4 mg was not given until 9:40 p.m., with a comment time of 9:15 p.m., and was documented as not effective. During interview, the RN on duty acknowledged that she did not administer the Zofran after the order was written and could not clearly articulate why, stating she associated the resident’s symptoms with indigestion and was occupied with other paperwork and documentation. Multiple nursing assistants reported that between approximately 9:00 p.m. and 10:00 p.m. the resident repeatedly requested to go to the ED, appeared gray, sweaty, anxious, and complained of epigastric or chest‑area pain, with abnormal vital signs reported to the RN. Progress notes document that the resident refused supper, complained of stomachache, dry heaved, and later complained of epigastric pain while spitting clear phlegm. Zofran was given at about 9:15 p.m. with no relief. The note was later edited to add that the physician had been at the facility, ordered Zofran every 6 hours as needed, and was called again when the resident did not improve. A subsequent edit at 10:22 p.m. recorded that the physician ordered the resident sent to the ED for increased belly pain. The physician stated her expectation that an ambulance should be called right away after she gave the order to send the resident to the ED. Instead, the record shows ongoing documentation of severe epigastric pain rated 10/10, continued dry heaving, elevated blood pressure, low oxygen saturations requiring an increase in supplemental oxygen, and the resident remaining pale and diaphoretic. The resident continued to state he wanted to go to the ED. Non‑emergency dispatch was called for transport, and the resident ultimately left with paramedics after midnight. The DON later stated that, based on the vital signs and symptoms documented at 6:43 p.m. and again around 9:10 p.m., she would have expected focused assessment, timely physician notification, and that the ambulance should have been called when the order to send the resident to the ED was obtained. The facility also lacked a policy on administering newly ordered medications for a change of condition.
Failure to Ensure Communication and Documentation for Hospice Services
Penalty
Summary
The facility failed to ensure effective communication and coordination between its staff and the hospice provider for a resident receiving hospice services. The resident, who had diagnoses including heart failure, atrial fibrillation, and anxiety disorder, was dependent for all transfers and was cognitively intact. The hospice focus care plan indicated that the facility should coordinate with hospice providers and reference the hospice care plan for the resident’s preferences and needs. However, interviews with LPNs revealed that the hospice binder did not contain a current hospice care plan, visit schedule, or documentation of hospice visits, and that hospice nurses did not communicate with facility staff about care provided or changes in the plan of care. Further interviews with the RN contact for hospice agencies and the DON confirmed that there was inconsistent communication from the hospice agency, and that the hospice plan of care and visit schedules were not present in the hospice binder or the electronic health record. The hospice registered nurse clinical manager stated that the hospice care plan had been sent to the facility but had not verified its receipt, and was unaware that the facility was not receiving visit schedules or documentation. The facility’s own policies and hospice agreement required collaborative care, documentation of hospice assessments and care in the facility chart, and verbal communication with staff after each visit, but these procedures were not being followed. The lack of documentation and communication meant that facility staff were not consistently informed about the care being provided to the resident by hospice, nor about any changes to the plan of care. This failure to maintain a communication process and ensure the availability of essential hospice documentation resulted in the facility not meeting its obligations to coordinate and deliver appropriate end-of-life care as outlined in its policies and agreements.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Multiple residents, both cognitively intact and impaired, consistently reported receiving cold, unappetizing, and sometimes incorrect food items. Observations and interviews revealed that food such as sweet potato fries and grilled ham and cheese sandwiches were served cold or at inconsistent temperatures, with some items being undercooked, overcooked, or not prepared according to the menu or standardized recipes. Residents expressed ongoing dissatisfaction with the quality, temperature, and presentation of meals, noting that their concerns had been raised repeatedly over several months without improvement. Staff interviews and document reviews indicated a lack of clear procedures and consistent practices for monitoring and documenting food temperatures. Dietary aides and culinary staff were observed taking food temperatures at varying stages, such as after removal from the oven or warmer, but not consistently at the point of cooking as required. The Food Temperature Log lacked documentation of cooking temperatures, and staff were uncertain about the formal process for temperature checks. The Culinary Services Director acknowledged that staff could benefit from further education on proper food temperature procedures and confirmed that issues with food timing, appearance, and temperature had persisted despite the formation of a food committee and ongoing audits. Resident council meeting minutes and concern reports documented repeated complaints about cold food, incorrect menu items, and poor food quality, including instances of burnt, tough, or frozen food. The facility's own policies required that food be prepared to retain nutritive value, enhance flavor and appearance, and be served at appropriate temperatures, but these standards were not met. The facility's dietician was unaware of the ongoing food concerns and confirmed that recipes and temperature documentation were not being properly followed. Despite staff acknowledgment of the issues and some attempts at education, there was no evidence of measurable improvement in the quality or temperature of food served to residents.
Resident Left Unclothed and Exposed Due to Incomplete Care by Inexperienced NA
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and moderately impaired cognition was left in bed unclothed, with his genitals exposed, after an agency nursing assistant (NA) failed to complete his morning care. The resident, who required assistance with dressing and personal hygiene due to his medical condition, reported that the NA was unfamiliar, lacked a name tag, and appeared unsure of the care routine. The NA began cleaning the resident but then left the room, instructing the resident to find someone else to finish the care. The resident called out to another NA, who found him exposed and immediately covered him before completing his care. The second NA reported the incident to an LPN, but the LPN did not escalate the issue to nursing leadership. The director of nursing (DON) only became aware of the incident two days later through staff communication. The NA responsible for leaving the resident exposed was a new employee who had recently completed orientation and training on resident dignity and personal care. The facility's policy required prompt notification and protection of resident rights, but the incident was not reported in a timely manner, and the resident's dignity was not maintained during care.
Failure to Provide Anonymous Grievance Submission and Follow Grievance Process for Missing Property
Penalty
Summary
The facility failed to provide residents and their representatives with a method to submit grievances anonymously, as required by facility policy. Multiple residents reported during a council meeting that they were unaware of any anonymous grievance process, and no grievance box or designated area for anonymous submissions was available in resident-accessible locations. Additionally, there was no signage or posted information indicating an option for submitting concerns confidentially or anonymously. The administrator confirmed the absence of a grievance box and acknowledged that the location of concern forms was difficult for residents to access independently. In a separate incident, the facility did not follow its grievance process regarding a missing personal item for a resident with chronic pain, restless leg syndrome, muscle weakness, and type 2 diabetes mellitus. The resident reported a missing windchime after being moved to a new room, and although an activity assistant stated she reported the missing item to her supervisor, there was no evidence that the concern was documented or investigated. The wellness director recalled being told about broken items but did not follow up, and the social services staff was unaware of the missing or damaged items. The administrator acknowledged that the required process for reporting and investigating missing items was not followed.
Failure to Accurately Code PTSD Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified on the Minimum Data Set (MDS) assessment. Specifically, a resident with documented diagnoses of major depressive disorder and post traumatic stress disorder (PTSD) was not coded for PTSD on the quarterly MDS assessment, despite this diagnosis being present on the resident's face sheet and care plan. The care plan included interventions related to trauma responses, such as ensuring clear paths to doors and honoring the resident's preferences regarding door positions, which were observed being implemented during facility activities. Interviews with facility staff revealed that the clinical reimbursement manager did not mark PTSD on the MDS because it was not documented in the most current provider note, even though the diagnosis was active in the last 60-day provider note and the care plan had active interventions for PTSD. The administrator indicated there had been previous efforts to ensure only documented active cases were marked on the MDS, but acknowledged the need to review this process. Facility policy requires that assessments accurately reflect the resident's status and that staff certify the accuracy of their portions of the assessment.
Failure to Disinfect Insulin Pen Septum Prior to Administration
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to disinfect the rubber septum of a resident's insulin pen with an alcohol wipe prior to attaching the needle and administering insulin. The incident was observed during a medication administration for a resident with type 2 diabetes, who was receiving Novolog Flex Pen U-100 Insulin per sliding scale. The LPN removed the pen cap and immediately attached the needle without disinfecting the septum, then proceeded to prime the pen and inject the insulin into the resident's abdomen. The LPN later confirmed that the same pen was used daily and acknowledged that the rubber top was expected to be wiped with alcohol before each use. The facility's policy on safe injection practices, dated September 2023, requires that the rubber stopper of medication vials and the neck of glass ampules be disinfected with sterile 70% alcohol before inserting a needle. The director of nursing (DON) confirmed that the rubber septum of an insulin pen should be disinfected with an alcohol wipe prior to each dose. The failure to follow this protocol was confirmed through observation, staff interview, and review of facility policy and resident records.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
A deficiency was identified in the facility's provision of care and assistance with activities of daily living (ADLs) for residents who are unable to perform these tasks independently. The report notes that care and assistance were not provided as required for at least one resident who was unable to complete ADLs without help. This failure to provide necessary support directly affected the resident's ability to perform essential daily activities.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Properly Label Insulin Pens for a Resident
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes was administered insulin using a NovoLog FlexPen that was not properly labeled with the resident's name or the date it was opened. During medication administration, an LPN retrieved the insulin pen from the emergency kit, attached a needle, primed, and administered the insulin without ensuring the pen was labeled according to facility policy. The pen only had a manufacturer label and an E-Kit sticker, with a blank space for the resident's name and no date of opening. The LPN confirmed that the labeling was incomplete and acknowledged the expectation for both the resident's name and the date opened to be documented on the pen label. Further inspection of the medication cabinet revealed a second insulin pen (Toujeo Solostar) that was labeled with the resident's name but also lacked the date it was opened. Interviews with nursing staff, including an RN case manager and the DON, confirmed that facility policy required insulin pens to be labeled with both the resident's name and the date opened. The facility's Safe Injection Practice policy specifically stated that insulin pens should be dedicated to one resident, not used if unassigned or unlabeled, and that labels should be affixed directly to the pen.
Failure to Maintain Infection Control During Catheter and Peri-Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in two separate instances involving catheter and peri-care. For one resident with a Foley catheter and diagnoses including acute kidney failure and obstructive uropathy, observations on multiple occasions revealed the urinary drainage bag was lying on the floor next to the resident's recliner chair. Staff interviews confirmed that the catheter bag was frequently found on the floor, despite care plan interventions requiring the bag to be kept off the floor and below the level of the bladder. The facility was unable to provide documentation of a catheter care policy when requested. In a separate incident, a resident with dementia and urinary incontinence was observed receiving peri-care during which a nursing assistant placed soiled washcloths on the resident's overbed table, which also held personal items and was used for meals. The nursing assistant initially denied the action but later admitted to placing the soiled washcloths on a strip of plastic on the table, acknowledging that this did not adequately protect the surface from contamination. The DON confirmed that this practice was unacceptable, especially since the table was used for eating.
Inaccurate Posting of Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information accurately reflected the actual number of nursing assistants (NAs) and the total number of hours worked for the posted schedules. On the observed date, the posted information indicated that ten CNAs were scheduled from 6:00 a.m. to 2:00 p.m. with 65 staffing hours, and one CNA from 6:00 a.m. to 12:30 p.m. with 6 hours, totaling 81 hours. However, a review of the actual staffing schedule revealed that only one CNA worked from 7:55 a.m. to 2:00 p.m. (7 hours and 5 minutes), and eight CNAs worked from 6:00 a.m. to 2:00 p.m. (72 hours total), resulting in a total of 79 hours and 5 minutes, not the 81 hours posted. This discrepancy was confirmed by the Director of Nursing, who acknowledged that the posted information did not accurately reflect the actual number of NAs or their hours worked on that day. Further interview with the staffing coordinator revealed that the posted staffing hours were not updated to reflect staff call-outs or last-minute changes, leading to discrepancies between the actual and posted staffing hours. The facility's policy required that the number of licensed and unlicensed nursing staff, as well as their actual hours worked, be posted daily and amended as schedule changes occurred. The failure to update the posted information as required by policy had the potential to affect all residents and visitors who relied on the accuracy of the posted nurse staffing information.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Significant Medication Error Due to Insulin Administration
Penalty
Summary
The facility failed to ensure the correct administration of medication, resulting in a significant medication error for one resident. The error occurred when an LPN administered 100 units of short-acting insulin instead of the prescribed 5,000 mL of Heparin. This mistake led to the resident experiencing iatrogenic hypoglycemia, requiring hospitalization, continuous monitoring, and intravenous fluid recovery to return to baseline. The resident involved had a medical history that included hypertensive chronic kidney disease with stage 5 chronic kidney disease, requiring dialysis, and was not diabetic or insulin-dependent. The error was discovered when the LPN, unable to locate the prescribed Heparin in the medication cart, mistakenly administered insulin from a vial found in the medication room. The LPN misread the label on the vial, believing it contained the correct medication for the resident. Following the administration of insulin, the resident was transferred to the emergency department after the error was realized. The resident's blood glucose levels were monitored, and treatment was provided to stabilize the condition. The incident was reported to the facility's administration, and the error was acknowledged as significant, with potential for serious harm or death, as noted by the nurse practitioner and pharmacist involved in the case.
Removal Plan
- LPN-A suspended pending investigation and then completed re-education and competency education.
- Interviewed residents for any medication error concerns.
- Provided education and competency testing on the rights of medication administration to licensed nursing staff.
- Replaced the vial of Fiasp insulin with insulin pen.
- Removed the vial of heparin from the medication cart and placed in resident's locked medication cupboard.
- Updated procedure for administration of all subcutaneous injections, when signing off in the electronic medication administration record, to include the lot number and expiration date of the medication.
- Implemented an auditing system for administration of subcutaneous injections.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and cleaning protocols during medication administration and wound care, as observed in several instances. An LPN did not perform hand hygiene before entering rooms or after removing gloves while administering medication and performing blood sugar checks for residents with diabetes and other conditions. The LPN also failed to disinfect a universal glucometer after use, which was then placed back into the medication cart for potential use with other residents. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) during wound dressing changes for residents with chronic wounds. Observations revealed that an LPN and other staff members did not use EBP or provide signage and supplies outside the rooms of residents with wounds, such as a burn on the left thigh and a laceration on the right lower leg. This oversight occurred despite the presence of a chronic wound and the facility's policy requiring EBP for such conditions. Interviews with staff, including the DON and the infection preventionist, confirmed the lapses in protocol adherence. They acknowledged that the glucometer should have been cleaned after use and that hand hygiene should be performed before and after resident contact and glove use. The facility's policies on hand hygiene, resident care equipment, and EBP were not followed, contributing to the deficiencies observed during the survey.
Failure to Revise Care Plans for Residents with Skin Injuries
Penalty
Summary
The facility failed to revise the care plans for two residents who had non-pressure related skin injuries. The first resident, identified with multiple diagnoses including contusion to the head and laceration to the right lower leg, experienced a fall on 10/10/24, resulting in significant injuries. Despite these injuries, the resident's care plan, dated 9/16/23, was not updated to reflect the impaired skin integrity or to include goals and individualized interventions following the fall. Interviews with staff revealed a lack of communication regarding the resident's wound, which was not included in the care plan, and the Infection Preventionist/Wound Nurse was not informed of the wound, preventing it from being added to her list for monitoring. The second resident, who had a history of surgical aftercare and burn risk due to decreased sensory perception, suffered burns from hot food items. The care plan, dated 10/1/24, did not include the burns or the necessary interventions to prevent further incidents. Despite a physician's evaluation and prescribed treatment for the burn, the care plan was not revised to include these details. Interviews with the Director of Nursing and a nurse practitioner indicated an expectation for such incidents to be documented in the care plan, but this was not done, leading to a deficiency in care planning for the resident's condition.
Failure to Monitor and Document Wound Care
Penalty
Summary
The facility failed to comprehensively assess, monitor, and notify the physician of new wounds for two residents who had non-pressure related skin injuries. One resident, identified as R1, had a history of severe cognitive impairment and was involved in an incident where her wheelchair rolled off a curb, resulting in multiple injuries including a complex laceration on her right lower leg. Despite a physician's order to monitor the laceration site daily for signs of infection, the facility did not conduct a comprehensive assessment or document continuous monitoring of the wound's condition. Observations and interviews revealed that the wound care was inadequate. A Licensed Practical Nurse (LPN) noted that the dressing on R1's leg was not dated and adhered to the wound, causing pain during removal. The wound was described as open with some erythema, and the dressing applied was too small to cover the entire wound. The Nurse Practitioner (NP) was unaware of the wound and had not been following its care, indicating a lack of communication and documentation among the staff. Further investigation showed that the facility's Director of Nursing (DON) and Infection Prevention and Wound Nurse (IPWN) were not adequately informed about the wound's status. The DON expected the Clinical Manager to follow up on wounds not monitored by the wound nurse, but there was no clear process for notifying the IPWN of new or worsening wounds. The facility's policy required weekly measurements and documentation of wounds, but this was not adhered to, leading to a deficiency in the care provided to the resident.
Failure to Follow Transfer Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan for a resident who required assistance during transfers, resulting in a fall. The resident, who had diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, muscle weakness, and epilepsy, required substantial assistance for transfers. Initially, the care plan required assistance from one staff member with a non-mechanical sit-to-stand aid, which was later updated to require two staff members. However, this intervention was discontinued shortly before the incident. On the day of the incident, the resident was left in the bathroom by two staff members but was later assisted by only one nursing assistant during a transfer from the toilet. The resident's foot got caught on the door frame, leading to a fall. The nursing assistant attempted to manage the situation alone, despite the care plan's requirement for two staff members to assist with transfers. The resident reported that the sit-to-stand machine was moved too quickly, contributing to the fall. Interviews with staff revealed that the nursing assistant did not follow the care plan, which required two people for transfers. The director of nursing confirmed that the transfer process should have involved two staff members, as per the care plan. The incident resulted in the resident being hospitalized for pain management, although no fractures were found. The facility's failure to follow the care plan for transfers directly led to the resident's fall and subsequent hospitalization.
Failure to Safely Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to safely use a mechanical lift according to the manufacturer's recommendations, resulting in a resident falling from the lift and sustaining serious injuries. The incident occurred when two nursing assistants were transferring the resident from a commode to a bed using a full-body mechanical lift. During the transfer, the upper right sling strap detached from the lift, causing the resident to fall approximately three feet to the floor. The resident, who was on anticoagulants, suffered a fractured sternum and a large left hip hematoma, requiring hospital admission and a blood transfusion. The resident's care plan specified the use of a medium-sized sling and two staff members for transfers with the mechanical lift. However, the nursing assistants involved in the incident did not adequately check the tension and security of the sling straps after lifting the resident. Although they confirmed using the same color sling straps, they failed to ensure the straps were properly secured before moving the resident. This oversight led to the sling strap detaching and the subsequent fall. Interviews with staff revealed a lack of adherence to proper procedures for using the mechanical lift. The nursing assistants involved were unable to articulate how the sling strap became detached and admitted to not checking the tension of the straps. The facility's director of nursing confirmed that the equipment was inspected and found to be in working order, indicating that the fall was likely due to operator error. The incident highlighted the need for staff to follow the manufacturer's instructions and ensure the safety of residents during transfers.
Failure to Timely Report Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to report an allegation of neglect within the required timeframe after a resident fell from a mechanical lift. The incident occurred when the resident, who had intact cognition and was dependent on staff for transfers, fell during a transfer from a chair to a bed, resulting in skin tears to her right index and middle fingers and left bicep area. The resident's progress note documented the fall at 9:40 p.m. on 7/21/24, but the Director of Nursing (DON) was not informed until 8:03 a.m. on 7/22/24, which was beyond the 2-hour reporting requirement. The facility's policy mandates immediate notification of the Charge of Building and subsequent reporting to the Executive Director or designee for any suspected abuse, neglect, or misappropriation of resident property. In cases involving serious bodily injury, the report must be made no later than 2 hours after forming the suspicion. However, the facility did not adhere to this policy, as the incident was reported to the state agency only on 7/22/24 at 1:34 p.m., indicating a delay in the required notification process.
Failure to Revise Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to revise the care plan for a resident with behavioral issues, specifically disrobing in public, which was not addressed in the care plan. The resident, who had severe cognitive impairment and a history of wandering, was observed to disrobe in public areas, including other residents' rooms and common areas. Despite these behaviors being noted in assessments, the care plan was not updated to include interventions for managing the disrobing behavior until several days after an incident was reported. The resident's medical history included anxiety disorder, dementia, restless leg syndrome, pain, arthritis, abnormalities of gait and mobility, a history of falling, and weakness. The resident was independent with transfers and wheelchair use but exhibited behaviors such as wandering and disrobing, which intruded on the privacy and activities of others. Staff interviews revealed that the resident frequently disrobed in public, and there was a lack of direction or interventions provided to staff on how to manage this behavior. The facility's policy required comprehensive assessments and care plans to be developed, reviewed, and revised based on direct observation and communication with the resident and staff. However, the care plan for the resident was not revised in a timely manner to address the disrobing behavior, and staff were not provided with appropriate interventions to manage the behavior, leading to a deficiency in the care provided to the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as observed in five residents. These residents included those with pressure injuries, catheters, and chronic wounds, yet staff did not use personal protective equipment (PPE) such as gowns and gloves during care. For instance, a nursing assistant provided care to a resident with a pressure injury without using gowns or gloves, and another resident with a suprapubic catheter did not have staff using PPE during care. Interviews with staff, including nursing assistants and licensed practical nurses, revealed a lack of awareness and education regarding the necessity of EBP for residents with wounds or indwelling devices. Staff members indicated that they only used PPE when there was an active infection and were not informed about the requirement to use EBP for residents with catheters or wounds. The infection preventionist, who was still in training, acknowledged the lack of EBP implementation and mentioned that the person training her did not agree with the guidelines. The facility's policy on EBP, dated March 2024, clearly stated that EBP should be used for residents with chronic wounds or indwelling devices, regardless of MDRO colonization status. However, observations and interviews indicated that this policy was not being followed. The regional clinical director confirmed that residents with wounds or indwelling devices should be on EBP and had instructed the infection preventionist to identify residents requiring EBP, but this had not yet been implemented.
Inadequate Hand Hygiene by Culinary Aides
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by culinary aides during food handling, which had the potential to impact all 30 residents on the Kindle and Oak units. Observations revealed that a culinary aide on the Kindle unit did not change gloves, wash hands, or don new gloves after handling various items and before directly handling food. Similarly, on the Oak unit, another culinary aide was observed handling food with the same gloves used for other tasks. Both aides admitted to not following proper hand hygiene protocols, and one aide did not recall receiving specific training on the matter. Interviews with the culinary services director and the infection preventionist confirmed that the aides should have removed contaminated gloves, washed their hands, and donned new gloves before handling food. However, there was no documentation of hand hygiene training during orientation for the aides, and the culinary services competency checklist was blank. The facility's infection prevention and control program policy indicated that microorganisms could enter residents through food handling with unclean hands, but the corporate policy or recommendations for hand hygiene were not provided.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident who required a general soft and bite-size texture diet. The resident, who had a history of hemiplegia and hemiparesis following a stroke, was served a meal that was not consistent with her dietary orders. Despite having a diet order for soft and bite-size meals, the resident was given ground steak bites and asparagus, which she found demeaning and likened to being treated like a baby. The culinary aide and LPN confirmed that the meal did not meet the resident's dietary requirements, as it was ground instead of being soft and cut into bite-size pieces. The culinary director acknowledged the error, explaining that the meat served had gristle, which could be difficult to chew, and they erred on the side of caution by serving a ground consistency. The resident expressed distress over the meal presentation, stating it made her feel like a child and hindered her ability to feed herself. Speech therapy confirmed that the resident had no swallowing issues but required smaller bites due to esophageal mobility issues. The director of nursing indicated that dietary staff should have checked with the resident or offered an alternative before altering the food texture. The facility's meal service policy emphasizes catering to dietary requirements and preferences, which was not adhered to in this instance.
Inaccurate MDS Assessment for PTSD Diagnosis
Penalty
Summary
The facility failed to ensure that the resident status was accurately identified on the Minimum Data Set (MDS) assessment for two residents reviewed for mood and behaviors, specifically post-traumatic stress disorder (PTSD). Resident 62's face sheet indicated an admission date and diagnoses including PTSD, but the quarterly MDS did not list PTSD as an active diagnosis. Similarly, Resident 23's face sheet included an active diagnosis of PTSD, but the quarterly MDS assessment did not reflect this. During interviews, the clinical reimbursement manager confirmed that both residents had an active problem noted in the last 60-day visit from the provider, but it was not marked on the MDS because it was not on the most current provider note. The director of nursing and the regional director of clinical services indicated that if PTSD is listed as an active diagnosis, it should be marked on the MDS. A policy on MDS was requested but not received.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to newly admitted residents and/or their representatives, as evidenced by the cases of two residents. One resident, who was admitted and readmitted with multiple diagnoses including cerebral infarction and heart failure, reported never receiving a copy of her baseline or current care plan. Despite being cognitively intact and able to communicate, she expressed a desire to be informed about her care plan. Documentation from a care conference involving the resident, social services, and family members did not indicate that a copy of the care plan was shared with those present. Another resident, admitted with conditions such as rhabdomyolysis and peripheral autonomic neuropathy, also did not receive a copy of her care plan upon admission or thereafter. Although she attended a care conference with nursing and therapy staff, there was no documentation that a copy of the baseline care plan was provided. Interviews with facility staff, including a registered nurse and the regional director of clinical services, revealed that while care plans are discussed during conferences, copies are not routinely distributed unless specifically requested by the resident. The facility's policy states that residents have the right to see and sign their care plans, but this was not adhered to in these cases.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as R35, who was assessed to require assistance with ambulation to maintain or improve her range of motion and mobility. R35, who has diagnoses including idiopathic peripheral autonomic neuropathy, osteoporosis, and a history of repeated falls, was supposed to be walked twice daily with the assistance of one staff member using a front-wheeled walker. Despite being on the walk list and having a care plan that specified these interventions, R35 reported not being walked for weeks and expressed a desire to walk to improve her chances of going home. Observations and interviews revealed inconsistencies in the staff's adherence to the care plan, with some staff members claiming to walk R35 while others, including the clinical manager, had not witnessed such activities. Documentation review showed that R35 was walked only twice in April and not at all in May, with some instances marked as deferred due to her condition. In June, she was walked on two occasions, but there were still days when the walking program was not implemented. The facility's Restorative Nursing Program policy requires regular assessments and oversight to ensure restorative interventions are carried out as planned, but the lack of consistent documentation and execution of the walking program indicates a failure to meet these standards. The director of nursing acknowledged the expectation for staff to follow the care plan, highlighting a gap between policy and practice.
Failure to Assess and Manage Resident Vaping Practices
Penalty
Summary
The facility failed to comprehensively assess two residents, R7 and R23, for safe vaping practices, leading to a deficiency in ensuring a smoke-free environment. R7, diagnosed with multiple sclerosis and using medical cannabis, was observed vaping inside the facility despite being educated multiple times about the smoke-free policy. The facility's staff, including RN-B, the DON, and the administrator, were aware of R7's vaping but did not conduct a vaping assessment or update the care plan to address this behavior. R7 refused to cooperate with assessments and continued to vape inside, indicating a lack of effective supervision and enforcement of the facility's policies. R23, with diagnoses including quadriplegia and psychosis, was also involved in vaping activities within the facility. Despite being informed of the smoke-free policy, R23 continued to vape indoors and refused to sign a non-smoking agreement. The facility's staff, including RN-B and SS-B, were aware of R23's non-compliance but did not document any attempts to assess the safety of R23's vaping practices. The care plan addressed smoking but did not include vaping, and there was no evidence of a vaping safety assessment in R23's medical record. The facility's policies on smoking and medical cannabis were not effectively implemented, as evidenced by the lack of assessments and care plan updates for residents who vape. The staff's repeated attempts to educate the residents on the smoke-free policy were met with resistance, and there was a failure to document and address the ongoing vaping activities adequately. This deficiency highlights the facility's inability to maintain a safe environment free from smoke and vape hazards, as required by their policies.
Failure to Follow CPAP Guidelines Due to Distilled Water Shortage
Penalty
Summary
The facility failed to ensure staff followed the manufacturer's guidelines for the use of a CPAP machine for a resident diagnosed with heart failure, spinal stenosis with neurogenic claudication, and obstructive sleep apnea. The resident's care plan did not include a respiratory plan or the use of a CPAP machine, and the physician's orders did not specify CPAP use, only that distilled water should be used. Observations and interviews revealed that the facility had been out of distilled water for several days, leading staff to use tap water in the CPAP machine, contrary to the manufacturer's instructions. The resident reported that staff had been using tap water for four to five days due to the unavailability of distilled water. Staff interviews confirmed the use of tap water and the lack of distilled water in the storeroom. The purchasing coordinator was unaware of the shortage until informed and subsequently procured distilled water from a local store. The director of nursing stated that staff should use distilled water and contact the on-call nurse if supplies were depleted. The facility did not provide a policy for CPAP machine application and use when requested.
Failure to Implement Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to comprehensively assess and reassess past trauma and implement care plan interventions utilizing a trauma-informed approach for two residents diagnosed with PTSD. One resident, identified as R23, had an active diagnosis of PTSD but lacked a care plan that addressed this condition. The care plan did not include individualized trauma-informed approaches or interventions, nor did it identify triggers to avoid potential re-traumatization. A PTSD/trauma assessment was not present in the medical record, and staff interviews revealed a lack of awareness and assessment attempts regarding R23's PTSD. Another resident, R62, also had a diagnosis of PTSD related to experiences in Vietnam. Although a PTSD/trauma assessment was completed, it initially did not capture the resident's triggers. The resident later expressed willingness to discuss his PTSD and identified specific triggers, such as military celebrations and loud noises. However, the facility's staff, including the clinical manager, were not initially aware of these triggers, and the care plan did not reflect this information until after further assessment. The facility's policy on trauma-informed care required that residents who are trauma survivors receive culturally competent, trauma-informed care, including the identification and mitigation of triggers. Despite this policy, the facility did not adequately assess or document the PTSD conditions of the residents, nor did it develop comprehensive care plans that addressed their trauma-related needs. Interviews with staff confirmed the lack of assessments and care plans related to PTSD for both residents.
What surveyors are citing around you — mapped
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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 18 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Owatonna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeshore Rehabilitation Center Llc | 11.5 mi | ★★★★★ | 0 | 0 |
| The Emeralds At Faribault Llc | 12 mi | ★★★★★ | 3 | 0 |
| New Richland Care Center | 18.2 mi | ★★★★★ | 2 | 0 |
| Whispering Creek | 20.6 mi | ★★★★★ | 5 | 0 |
| Prairie Manor Care Center | 20.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.