Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Catholic Eldercare On Main during CMS and state inspections, most recent first.
A facility failed to maintain proper temperatures in an Atrium dining area and a shared resident room. Two residents repeatedly reported being cold in their room and during meals, with one resident with Parkinson's disease stating the cold made her ache. Multiple residents were observed wearing coats, sweaters, blankets, scarves, and even gloves while trying to eat, and several complained that ceiling fans were making the dining area colder. The CDM reported residents had complained but were told nothing could be done, and the maintenance director later found the dining area temperature was about 65 degrees and identified a closed vent limiting heat to the shared room.
A dietary aide assisting with meal cart preparation and transport was observed with hair not fully covered and long facial hair without a beard cover. He used gloved hands to handle shredded cheese directly from a container, then continued tray-line work without changing gloves or performing hand hygiene. In addition, multiple reusable steam table pans were observed stacked and stored while still wet, including one pan with food residue present.
Incomplete informed consent for psychotropic medications: Two residents received quetiapine and sertraline, but the consent forms were missing required details such as side effects, dates, signatures, and approval/denial documentation. Staff interviews confirmed the consents were not in the chart when reviewed, and the DON stated informed consent should include the medication, dose, reason, benefits, side effects, and date.
Failure to assess residents for SAM before bedside medication use. Two residents had medications kept at the bedside without the required SAM assessment, provider order, care plan documentation, or progress note support. One resident with intact cognition had Miconazole powder on the nightstand despite no bedside order, while another resident with pain had Anbesol gel at bedside and stated she had not been given clear directions or supplies. RN staff and the DON confirmed the SAM process had not been completed.
Call lights were not kept within reach for two residents. One resident with impaired cognition, aphasia, dementia, schizophrenia, diabetes, and an indwelling catheter had the call light placed on top of a nightstand while sleeping in bed. Another resident with impaired cognition, Alzheimer's, Parkinson's, psychosis, and hospice status had the call light placed on the bed near the head while lying on the side facing the wall. Staff, including an LPN, RN, NAs, and the DON, stated call lights should be in reach, and the facility policy required the call light to be placed within reach while the resident was in the room.
A resident’s record contained conflicting code status documentation, with the EMR and physician orders showing different directives than the POLST and care plan. The resident stated a preference for full resuscitative measures, and an LPN, RN, and DON confirmed the discrepancy should have been identified when the orders were entered and reviewed. Staff also described multiple sources used to verify code status, including the EMR banner, orders, a nursing station reference binder, and the care plan.
A resident with severe cognitive impairment, Parkinson’s disease, dementia, and hospice services was found with pillows positioned in bed to keep him from rolling toward the edge and attempting to self-transfer. NA and LPN staff stated the pillow was used for safety because he would swing his legs out of bed and try to sit up, while the DON confirmed that if the pillow prevented movement it would be considered a restraint and was not aware of any assessment for it. The resident’s care plan addressed supervision and comfort positioning, but did not identify a restraint or movement-restricting device.
A resident who needed help with bathing, grooming, and shaving did not receive routine hygiene care as planned. Staff observed and interviewed during the survey stated the resident had not been shaved for days, had not received a shower, and had severe dandruff, while documentation showed no record of a shower since admission. NAs reported providing some morning care but not offering shaving help, and the RN, nurse manager, and DON confirmed the resident required assistance and that showers and shaving were expected to be documented.
Failure to Implement Ordered Palm Protector: A resident with impaired LUE ROM, hemiplegia, and hemiparesis had a Posey palm protector recommended by OT, but it was not documented in the care plan, MAR, or TAR and was found left on a recliner instead of being applied. The RN manager received the OT email with the recommendation but did not read it, so the device was not implemented even though the resident stated her left hand clenched into a fist without noticing.
Indwelling Catheter Bag Not Managed Per Order: A resident with impaired cognition, dementia, schizophrenia, diabetes, aphasia, and a suprapubic catheter was observed in bed with a small leg bag attached at bladder level instead of the ordered large drainage bag. Staff, including an LPN, RNs, an NA, the IP, and the DON, stated the large bag should be used whenever the resident is in bed, including naps, and the facility policy required the drainage bag to remain below the bladder.
A resident with severe cognitive impairment, vascular dementia, and anxiety had missing teeth, poor oral status, and difficulty with swallowing, yet the facility did not coordinate follow-up dental care after a dental exam noted inflamed gingival tissue and recommended recall visits. The care plan called for dental consults, oral hygiene assistance, and monitoring for infection, but the record lacked evidence of subsequent dental visits or missed appointment documentation. Staff confirmed the HUC handled dental scheduling and that the resident should have been seen for follow-up, but no notes showed the dental provider was unable to see her.
Failure to provide adaptive eating equipment and assistance for a resident who needed help with meals. The resident had MDS-documented need for touching assistance with eating and diagnoses including hemiplegia and hemiparesis, but the care plan, resident profile, and EMR lacked documentation for Dycem or a lipped plate. During meal observation, the resident struggled to scoop oatmeal with a shaking arm, pushed the bowl around the table, and said staff were too busy to help. OT had emailed the RN about the adaptive equipment, but the RN did not open the email or implement the recommendation.
A facility failed to reassess and implement necessary interventions for a resident with severe cognitive impairment who experienced two choking episodes while eating unsupervised. The care plan was not updated, and there was no comprehensive reassessment after the second incident. Additionally, the facility did not conduct a comprehensive fall risk assessment for another resident with severe cognitive impairment, resulting in multiple falls and injuries. The facility's inaction led to immediate jeopardy and actual harm.
The facility failed to cover residents' clothing during storage and delivery, potentially affecting all residents. Laundry aides and the director of environmental services confirmed that personal laundry carts were never covered, contrary to the facility's policy. The DON acknowledged that covering the carts is necessary to minimize cross-contamination.
The facility failed to provide a dignified, home-like dining environment, as residents were served meals on hard plastic trays with plates on warmers, and drinks and silverware placed on the trays. Observations across multiple dining rooms showed this setup was consistent, and interviews revealed no rationale for this method. A resident expressed a preference for a more home-like experience, while staff indicated a lack of policy guidance on promoting such an environment.
The facility failed to provide appropriate wheelchair foot supports for a resident, leading to unsupported feet while seated. Another resident did not consistently receive ordered skin protectors, increasing the risk of skin tears or bruising. Additionally, a resident undergoing dialysis missed multiple insulin doses due to an unadjusted administration schedule, resulting in elevated blood glucose levels. Staff failed to communicate these issues to the provider in a timely manner.
A resident with chronic pain and other health issues did not receive consistent pain assessments or non-pharmacological interventions before being given as-needed narcotic medication. The facility failed to document pain levels and locations adequately, and non-pharmacological options were not offered or recorded, leading to insufficient pain management.
A facility failed to monitor target behaviors for a resident prescribed antipsychotic medication, quetiapine, for delusional disorder. The resident's care plan and MAR/TAR initially lacked documentation of target behaviors, which were only added later. Observations showed the resident was calm and engaged in activities, with no signs of agitation or paranoia. Staff confirmed the importance of monitoring target behaviors to assess medication effectiveness, which was not done until after the deficiency was identified.
A resident with Parkinson's disease did not receive timely follow-up dental care as recommended, due to the facility's lack of coordination and tracking of dental appointments. Despite a recommendation for a follow-up visit 3 months after a dental appointment, the resident had not been seen for 5 or 6 months. Interviews with staff revealed a lack of clarity and responsibility in scheduling and tracking dental appointments, and no policy on dental appointments was provided.
Uncomfortable Temperatures in Dining Area and Shared Resident Room
Penalty
Summary
The facility failed to maintain a comfortable temperature between 71 and 81 degrees Fahrenheit in the Atrium dining area and in a shared resident room used by two residents. During observation, one resident was seated in her room wearing a knitted scarf and quilted coat and stated it was cold in her room and had been cold for the past couple of days. She reported that she had told staff and asked for her room to be warmer, but nothing had been done. A second resident in the same room was observed wearing a heavy knit sweater and covered with a blanket, and she also reported cold air coming from the ceiling vent and said staff had told her the room was the coldest on the unit. The same residents reported that the Atrium room used for dining was so cold that it was hard to eat meals there. During supper, multiple residents were observed wrapped in blankets or wearing heavy sweaters or coats, and several complained that the ceiling fans were making the room colder. One resident was observed wearing gloves while trying to eat. A visiting family member reported that it had been very cold for all the residents and that she had wrapped blankets around residents to help them stay warm. The certified dietary manager reported that residents had complained about the temperature in the Atrium, but she was told nothing could be done, and that residents had asked for the ceiling fans to be turned off but administration said they had to remain on to regulate the heat. The maintenance director later reported that he was contacted because residents were complaining the Atrium was uncomfortably cold and estimated the temperature at about 65 degrees Fahrenheit, below the designated range. He also reported that a vent had been closed in the shared room, limiting heat to the room. One resident with Parkinson's disease stated the cold made her ache and that she felt better only when in bed with all her blankets on. Both residents later stated the room and dining area were more comfortable, but they did not understand why the temperature problem had not been corrected sooner.
Infection Control Lapses During Meal Service and Pan Storage
Penalty
Summary
The facility failed to ensure appropriate infection control technique was followed during meal service when a dietary aide assisted with preparing and transporting meal carts to the nursing units. During observation, the aide had a hair net on the top of his head, but hair extended about 1 inch on the front and sides of his head, and he had long facial hair with no beard covering in place. He also used his gloved hands to remove a large container of shredded cheese from the refrigerator, removed the cover, reached into the container with the same gloved hand to take a handful of cheese, placed it into a dish for the tray line, recovered the container, and returned it to the refrigerator without changing gloves or performing hand hygiene before continuing to load resident meal trays. The facility also failed to ensure reusable steam table pans were clean and dry before storage. During the kitchen tour, multiple pans were observed stacked on a metal cart while still wet, including five 1/4 steam table pans, two 1/8 steam table pans, a deep steam table pan with food substance left on the surface and wetness inside, two full sheet pans, and twelve 2-inch steam table pans. The certified dietary manager and registered dietitian both stated the pans should not have been stacked while wet and should have been cleaned and dried before being placed on the storage rack for reuse.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain and document informed consent, including explanation of risks and benefits, for psychotropic medications for 2 residents reviewed for unnecessary medications. For one resident, the record showed quetiapine 12.5 mg three times daily and sertraline 50 mg daily were being administered, but the informed consent documents were incomplete: the quetiapine form lacked side effect information, did not indicate whether consent was approved or denied, and had no nurse date or signature, and the sertraline form lacked the completion date and side effect information. The resident’s MDS indicated short- and long-term memory impairment, with no hallucinations, delusions, behaviors, wandering, or rejection of care. For the second resident, the record showed quetiapine 75 mg at bedtime and sertraline 50 mg daily were being administered. The informed consent form for quetiapine was signed by the responsible party, but the sertraline consent lacked side effect information. The sertraline form also did not indicate whether consent was approved or denied. The resident’s MDS indicated severely impaired cognition with no hallucinations, delusions, behaviors, wandering, or rejection of care, and the resident was observed seated in a wheelchair, alternating between scooting around the dining room and eating supper. Staff interviews confirmed the consents were not present in the electronic record when reviewed. The HUC stated there were no uploaded medication consents for either resident, and the LPN and RN manager both stated they could not find signed consents for the quetiapine or sertraline orders in the chart. The DON stated informed consent for psychotropic medications was expected and should include the medication, dose, reason, benefits, side effects, and date, and the facility policy required obtaining informed consent from the resident and/or responsible party.
Failure to assess residents for self-administration of bedside medications
Penalty
Summary
The facility failed to assess two residents for safety and ability to self-administer medications before allowing medications to remain at the bedside. One resident had a comprehensive MDS showing intact cognition and required substantial assistance with toileting, showers, and dressing; diagnoses included diabetes, morbid obesity, and an infection of the bone. That resident had a physician order for Miconazole powder twice a day as needed, but the order did not indicate leaving it at bedside, and the care plan did not address self-administration of the medication. During observation, the Miconazole Nitrate 2% antifungal powder was found on the resident’s rolling nightstand on multiple occasions. The resident stated he had been using it as needed since admission, that the facility knew about it, and that he had not been asked about self-administration, frequency of use, or refills when he admitted. RN-B observed the medication at bedside and stated it should not have been there without a self-administration order and care plan entry; RN-A confirmed the order did not say it was to be left at bedside. RN-C stated nurses were expected to assess residents on admission for self-administration and obtain a physician order, and the DON stated the assessment and care plan update were not done for this resident. A second resident was admitted with diagnoses including acute embolism and thrombosis of the left femoral vein, UTI, essential hypertension, and unspecified diarrhea. Her resident profile showed she needed maximal assistance with dressing, minimal assistance with transfers, contact guard assistance with ambulation, and moderate assistance with toileting hygiene, and she had pain treated with medication orders. Her EMR lacked an assessment for self-administration of medications, and there was no progress note documentation about the Anbesol gel. During observation, the resident stated she had tooth pain and staff gave her gel, which she believed was Anbesol; a tube of Anbesol maximum strength 20% gel was found in a basket at her bedside. She stated she had been told to apply it with her finger, did not know how often she could use it, and said she had not been given cotton applicators or directions. RN-E, RN-F, and the DON stated a SAM assessment and physician order were needed, and the DON stated medications should not be left at bedside and residents needed education and EMR documentation.
Call lights not kept within residents' reach
Penalty
Summary
The facility failed to accommodate resident needs by not ensuring call lights were accessible for two residents reviewed for call light use. One resident had impaired cognition and diagnoses including diabetes, aphasia, dementia, schizophrenia, and an indwelling catheter, and the care plan directed staff to answer call lights per protocol. During observation, the resident was lying in bed sleeping while the call light was resting on top of the nightstand, out of sight and out of reach. An LPN stated the call light should be in reach at all times for safety, and an RN stated the resident was capable of using a call light and had used it in the past. The second resident had impaired cognition and was dependent on staff for bathing, toileting, dressing, personal hygiene, and rolling in bed, with diagnoses including Alzheimer's, Parkinson's, psychosis, and hospice status. During observation, the resident was lying on the left side facing the wall, with both arms bent toward the torso and the call light placed on the bed next to the head, out of reach and sight. An LPN observed that the call light was out of reach. Nursing assistants stated call lights should be in reach so residents can call for help, and the DON stated all nursing staff were expected to ensure call lights were in reach of all residents while in their rooms. The facility policy stated the call light must be placed within reach of the resident while in their room.
Conflicting Code Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of 1 resident’s medical record when conflicting end-of-life code status documentation was present. The resident’s current undated EMR identified the resident as full code, while the resident’s POLST indicated Attempt Resuscitation/CPR and Full Treatment, with documentation that the resident had capacity and had signed the form along with a CNP. At the same time, the resident’s current electronically signed physician orders identified the code status as DNR/DNI. During interview, the resident stated a preference for full resuscitative measures if found not breathing or without a pulse. Staff interviews confirmed that code status was expected to be verified by checking the EMR face sheet banner, physician orders, a reference book at the nursing station, and the care plan posted in the room closet door. An LPN and an RN both reviewed the record and confirmed the physician orders conflicted with the POLST and care plan and should have been identified and corrected when entered and reviewed. The DON stated staff were expected to confirm the POLST, EMR banner, physician orders, and care plan to ensure the correct code status was documented, and agreed the resident could have potentially not received resuscitative measures in an emergent situation.
Unassessed Pillow Used to Restrict Bed Mobility
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints when a pillow was used to prevent him from attempting to self-transfer from bed. The resident had severe cognitive impairment related to dementia, Parkinson’s disease, Alzheimer’s disease, major depressive disorder with psychotic symptoms, impaired mobility, and dependence on staff for ADLs, and he was receiving hospice services for Parkinson’s disease with dementia. His recent history included a fall from his chair in the common area, and his care plan identified supervision, positioning near the nursing station, and use of a soft pillow on the left side of his Broda chair for comfort, but it did not identify any restraint or device to restrict movement. During observation, the resident was found in bed with multiple pillows positioned around him. A body-type pillow was placed on his left side, and a square pillow was folded and placed against his right side to prevent him from rolling back toward the room side of the bed. Nursing assistant staff stated the pillow on the right side was used because the resident would throw his legs off the bed and attempt to sit up to self-transfer, and that the pillow was used for safety to keep him from getting up and falling. A licensed practical nurse also stated the resident would swing his feet out of bed, attempt to sit up, and call out for his wife, and she did not think the pillow was a restraint. The DON observed the pillow positioned behind the resident on the room side of the bed and confirmed that if the pillow prevented the resident from putting his legs out of bed or turning, it would be considered a restraint if it had not been assessed. He reported he was not aware that such an assessment had been completed. Hospice staff reported the resident had restless behaviors, anxiety, agitation, and falls, and that he was kept near the nursing station so staff could observe him. The facility policy reviewed stated that when falls or threatening behavior persist, the least restrictive intervention or restraint should be considered and that reassessment for physical restraints should occur at quarterly care conferences or with a significant change, but the report did not identify a restraint assessment for the pillow used in bed.
Failure to Provide Scheduled Hygiene Assistance
Penalty
Summary
The facility failed to ensure routine personal hygiene care, including showering and shaving, was provided for one resident who required assistance with activities of daily living. The resident was admitted with jaw osteonecrosis due to drugs, prostate cancer, depression, sleep apnea, and polyneuropathy. His resident profile and care plan indicated he needed assistance with bathing, dressing, toileting, and grooming, and he was also at risk for skin integrity loss with daily monitoring and wound treatment. During observation, the resident stated he wanted to shave that morning, but the nursing assistant did not offer to help him shave and instead left and returned with a disposable razor, asking where he wanted it. The resident stated he had not shaved for 8 days, liked to be clean shaven, and had overgrown facial hair. He also stated he had not taken a shower while in the hospital or at the facility and reported severe dandruff from scalp dermatitis. Interviews with staff showed that morning care included helping residents with toileting, dressing, face washing, and teeth brushing, and that shaving assistance was expected when needed. One NA stated she helped the resident dress and comb his hair but did not offer shaving assistance. Another NA stated he helped the resident wash his face, brush his teeth, and dress, but did not notice whether he needed to shave. Family provided a picture showing several unshaved areas. The nurse manager and RN stated the resident needed help with grooming, bathing, and shaving, and that showers should be documented when given. The DON stated residents were expected to follow their care plans, showers were communicated on care sheets, and staff were expected to provide shaving assistance and document refusals or bed baths. The resident was scheduled for a shower, but there was no documentation that it was provided, and staff confirmed there was no documentation of a shower since admission.
Failure to Implement Ordered Palm Protector
Penalty
Summary
The facility failed to implement a Posey palm protector for one resident who had impaired left upper extremity ROM and a history of hemiplegia and hemiparesis following a cerebral infarction. The resident’s MDS indicated she was cognitively intact, had no behaviors or rejected personal care, needed assistance with eating, toileting hygiene, dressing, bed mobility, and transfers, and was at risk for skin breakdown. Her OT evaluation documented that the right upper extremity ROM was within normal limits, while the left upper extremity ROM was impaired. The resident stated her left hand became a clenched fist without her noticing and that therapy had previously used a brace on her left hand, but nursing staff did not put it on after therapy ended. The resident’s care plan and resident profile lacked documentation about the Posey palm protector, and the MARs and TARs from the reviewed period also lacked documentation about it. During observation, the palm protector was found on a recliner next to the bed while the resident’s left hand was clenched, and later the resident was observed sitting in her wheelchair without the palm protector on. The director of rehabilitation provided an email from OT to the nurse manager stating that an edema glove and Posey palm protector had been provided for the resident’s left hand and that the palm protector could be worn during the day. The nurse manager verified receiving the email but stated she did not read it and therefore did not implement the therapist’s recommendation. The DON stated the palm protector needed to be implemented as ordered and added to the care plan to prevent contractures and protect the resident’s skin.
Indwelling Catheter Bag Not Managed Per Order
Penalty
Summary
The facility failed to ensure appropriate management of an indwelling catheter for one resident who had impaired cognition and diagnoses including diabetes, aphasia, dementia, and schizophrenia. The resident’s annual MDS identified substantial assistance needs for personal hygiene, dressing, and rolling in bed, and the resident had a suprapubic catheter. A physician order dated 5/19/25 directed that a large drainage bag be used when the resident was in bed, including during daytime naps. During observations on 12/15/25 and 12/16/25, the resident was found lying in bed sleeping with a small leg bag attached to the left leg, positioned horizontally at the level of the bladder, and no large night drainage bag was observed in the room. Staff interviews stated the resident should have the large drainage bag on whenever in bed and the leg bag when up in a chair. The DON, RNs, LPN, NA, and IP all described the expectation that the drainage bag be changed so urine would drain below the bladder, and the facility policy stated the urinary drainage bag should be below the level of the bladder at all times.
Failure to Coordinate Follow-Up Dental Care
Penalty
Summary
The facility failed to ensure dental needs were coordinated with a dental provider for further care for one resident with severe cognitive impairment, vascular dementia with anxiety, osteoarthritis, anxiety disorder, and chronic knee pain. The resident’s MDS indicated oral/dental status could not be examined and that she had complaints of difficulty or pain with swallowing. During observation, she was seen in a wheelchair, missing numerous teeth, and answering questions nonsensically. She did not wear dentures and required assistance with oral care. The resident’s care plan identified oral/dental concerns, including inability to perform an oral examination due to elevated anxiety, the need to notify the NP before dental appointments for PRN antianxiety medication, observation for signs and symptoms of infection, and obtaining a dental consult. The care plan also directed staff to assist with oral hygiene every morning and evening and noted decreased chewing ability related to poor condition of her own teeth. Progress notes documented anxiety/restlessness during dental appointments and that she had several missing teeth, but the record lacked any dental visits, missed appointments, or refusals to attend dental appointments. A chart progress note showed the resident completed a dental exam with inflamed gingival tissue and a recommendation for a 6-month recall, with prophylaxis every 3 months and oral hygiene instructions. However, no additional dental progress notes were found, and the resident was not seen again as expected. Staff interviews confirmed the HUC coordinated dental appointments, that the resident should have been seen for follow-up, and that no notes could be found showing the dental provider attempted but was unable to see her. Facility staff also stated dental recommendations were expected to be followed if family agreed, and the facility policy stated residents would have access to dental examinations, cleanings, and necessary dental treatments.
Failure to Provide Adaptive Eating Equipment and Assistance
Penalty
Summary
The facility failed to provide special eating equipment and utensils, and appropriate assistance, for a resident who needed adaptive support while eating. The resident’s quarterly MDS indicated cognitive intactness, need for touching assistance with eating, and dependence for toileting hygiene, dressing, bed mobility, and transfers. The resident’s face sheet listed diagnoses including benign neoplasm of meninges, COPD, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side. The resident’s profile directed staff to cut meals into small pieces, but it did not document adaptive eating equipment, and the care plan also lacked documentation about adaptive equipment. The EMR likewise lacked documentation about Dycem and/or a lipped plate. During breakfast observation, the resident was eating in bed with two bowls of oatmeal on the bedside table and was loosely holding a spoon in the right hand while the right arm visibly shook. While trying to scoop the oatmeal, the resident pushed the bowl around the table, and at one point the bowl fell sideways between the bed table and the resident’s lap. The resident used the spoon in the right hand and the left forearm to push the bowl back onto the bedside table and stated, "this is how I eat" and that staff were "too busy to help." A NA stated the resident did not like to be helped and had never been seen using adaptive eating equipment. The DR stated OT had evaluated the resident and sent an email to the RN indicating Dycem had been provided to help stabilize lipped plates, but the RN stated she did not open the email and did not implement the therapist’s recommendations. The DON stated the therapist’s recommendations for adaptive equipment needed to be implemented to maintain the resident’s quality of life and that communication between nursing and therapy needed improvement.
Deficiencies in Resident Safety and Risk Management
Penalty
Summary
The facility failed to adequately reassess and implement necessary interventions for a resident (R67) who experienced two choking episodes while eating unsupervised. Despite having severe cognitive impairment and a history of choking, the resident continued to eat unsupervised in their room. The facility did not update the care plan or conduct a comprehensive reassessment after the second choking incident, which required staff intervention. The care plan lacked specific instructions on supervision frequency, and there was no documented discussion of the risks and benefits of the resident's diet with the resident or their responsible party. Additionally, the facility did not conduct a comprehensive fall risk assessment for another resident (R107) upon admission or after multiple falls. The resident, who had severe cognitive impairment and a history of falls, sustained a head laceration and a fractured hip from falls. The facility's documentation lacked evidence of a root-cause analysis or consideration of proactive interventions to prevent further falls. The care plan was not updated with effective interventions despite the resident's repeated falls and injuries. The facility's inaction in both cases resulted in immediate jeopardy for R67 and actual harm for R107. The lack of timely reassessment and intervention updates in response to these incidents highlights deficiencies in the facility's approach to managing accident hazards and ensuring resident safety.
Uncovered Laundry Carts Lead to Potential Contamination
Penalty
Summary
The facility failed to ensure that residents' clothing was covered during storage and delivery, which had the potential to affect all residents. During observations and interviews, it was noted that laundry aides were pushing large, uncovered laundry carts containing cleaned resident clothing items down the hallways on both the first and second floors. The laundry aides confirmed that they had never covered the personal laundry carts. The director of environmental services-housekeeping and laundry also stated that the carts used to deliver personal clothing had never been covered, as it was the facility's process to only cover carts used for bed linen and towels. The director of nursing acknowledged that personal clothing carts should be covered to minimize possible cross-contamination. The facility's policy on laundering linen and resident clothing, revised in 2016, indicated that all linen and resident clothing should be cleaned and handled in a manner that prevents contamination and decreases the risk of spreading infection. The policy also specified that clean linen and clothing should be sorted and folded in the laundry and placed on covered shelves or racks for transport to nursing stations.
Failure to Provide a Home-like Dining Environment
Penalty
Summary
The facility failed to promote a dignified, home-like environment during dining services in four out of six dining rooms reviewed. Observations revealed that residents were served meals on hard plastic trays with their plates sitting on plate warmers. Drinks and silverware were also placed on these trays, and hard plastic dome-shaped lids, which were used to cover the food plates, were left in the middle of the tables. This setup was consistent across multiple dining rooms and observed on several occasions. Interviews with residents and staff highlighted a lack of rationale for serving meals in this manner. One resident expressed a desire for a more home-like dining experience and noted that the current method might be easier for staff but was not her preference. A registered nurse and the facility administrator both indicated that there was no specific reason for using the plastic trays, and the director of nursing deferred the question to dietary staff, declining to comment further. The facility's policy on serving meals and feeding residents, last revised in 2016, did not provide guidance on promoting a dignified home-like environment during dining services. This lack of policy direction contributed to the deficiency, as the facility did not have a structured approach to ensure that dining services were conducted in a manner that respected residents' rights to a comfortable and homelike environment.
Deficiencies in Wheelchair Support, Skin Protection, and Insulin Management
Penalty
Summary
The facility failed to ensure appropriate wheelchair foot supports for a resident with severe cognitive impairment, leading to the resident's feet dangling unsupported while seated in a wheelchair. Despite the resident's care plan indicating the use of a Broda wheelchair and the need for total assistance, there was no rationale or instruction regarding the lack of wheelchair pedals or platform. Observations over two days showed the resident without foot supports, and staff interviews revealed a lack of awareness and communication about the necessity of foot pedals, with no recent therapy consultation for wheelchair positioning. Another deficiency involved the facility's failure to consistently implement proactive skin interventions for a resident at risk of skin tears or bruising. The resident, who had severe cognitive impairment, was observed multiple times without the ordered skin protectors, despite a physician's order for bilateral protectors to be worn at all times. Interviews with staff and family indicated inconsistency in the use of protectors, and the resident's care plan lacked guidance on this intervention. The Treatment Administration Record showed the order was signed off as completed, despite observations to the contrary. The facility also failed to assess and revise an insulin administration schedule for a resident undergoing dialysis, resulting in missed doses of insulin. The resident, who had end-stage renal disease and type 2 diabetes, missed her noon insulin dose on multiple occasions due to dialysis appointments. Despite the resident's concerns about her blood glucose management, staff did not notify the provider of the missed doses or adjust the insulin schedule until after the surveyor's inquiry. The resident's blood glucose levels were frequently above 200, and the facility's failure to address the missed doses was not communicated to the provider in a timely manner.
Inadequate Pain Management and Documentation for a Resident
Penalty
Summary
The facility failed to consistently assess a resident's pain level before administering as-needed narcotic pain medication and did not implement non-pharmacological pain interventions for a resident identified as R106. R106, who had intact cognition and various diagnoses including polyneuropathy, muscle weakness, and chronic pain, reported frequent pain that occasionally affected sleep. Despite having a care plan that included both pharmacological and non-pharmacological interventions, the facility did not adequately document or offer these interventions. R106's Medication Administration Record (MAR) showed that oxycodone was administered multiple times without proper documentation of pain assessment, including pain scale and location. Out of 26 administrations of oxycodone, only 5 had a pain scale documented, and only 2 had the location of pain noted. Additionally, there was no documentation of the use or refusal of other prescribed medications like acetaminophen, tizanidine, or non-pharmacological interventions such as aromatherapy and Healing Touch. Interviews with facility staff, including registered nurses and the director of nursing, confirmed that the expected procedures for pain assessment and documentation were not followed. The facility's policy required non-pharmacological interventions to be offered and documented before administering PRN pain medication, which was not done for R106. The lack of proper documentation and assessment led to inadequate pain management for the resident.
Failure to Monitor Target Behaviors for Antipsychotic Medication
Penalty
Summary
The facility failed to monitor resident-specific target behaviors related to the use of antipsychotic medications for one resident, identified as R105, who was reviewed for unnecessary medications. R105's quarterly Minimum Data Set indicated moderately impaired cognition without hallucinations, delusions, or behavioral symptoms, yet the resident received antipsychotic medication, quetiapine, for delusional disorder. The Physician Order Report lacked documentation of target behaviors or directions for monitoring them. Additionally, R105's care plan and Medication Administration Record (MAR/TAR) did not initially include target behavior monitoring, which was only added on a later date. Observations of R105 over several days showed the resident was calm, pleasant, and engaged in activities like sewing, with no signs of agitation, aggression, or paranoia. Interviews with facility staff, including a nurse practitioner, pharmacist consultant, registered nurse, and director of nursing, confirmed the importance of monitoring target behaviors to assess the effectiveness and necessity of antipsychotic medications. The facility's policy on psychotropic medication required the addition of target behaviors to the care plan and the initiation of a monitoring graph, which was not followed in R105's case until after the deficiency was identified.
Failure to Coordinate Dental Care for Resident
Penalty
Summary
The facility failed to ensure that dental needs were coordinated with a dental provider for a resident, identified as R88, who was reviewed for dental care and services. R88, who has Parkinson's disease and requires assistance with oral care, had not been seen by the in-house dental provider for 5 or 6 months despite a recommendation for a follow-up visit in 3 months after her last appointment on 4/19/24. During this appointment, R88 had a cavity filled and was advised to return for a follow-up. However, there was no documentation or coordination for this follow-up appointment, and R88 expressed uncertainty about when her next appointment would be. Interviews with facility staff revealed a lack of clarity and responsibility regarding the scheduling and tracking of dental appointments. The Health Unit Coordinator (HUC) was responsible for setting up initial dental appointments and urgent visits but did not track routine or follow-up appointments for residents seen by the in-house dental provider. The Registered Nurse (RN) and Director of Nursing (DON) confirmed that after-visit summaries were reviewed, but there was no system in place to ensure follow-up appointments were scheduled as recommended. The deficiency was further highlighted by the absence of a policy on dental appointments and the lack of documentation to support the coordination of dental care for R88. Despite the facility's process of reviewing after-visit summaries, there was no effective tracking system to ensure residents received timely follow-up care, leading to R88 being overdue for her dental appointment. The facility's failure to coordinate dental care and maintain adequate documentation resulted in a deficiency in providing necessary dental services to R88.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Andrew Residence | 2 mi | ★★★★★ | 15 | 1 |
| Benedictine Health Center Of Minneapolis | 2 mi | ★★★★★ | 8 | 0 |
| Villas At Bryn Mawr Llc | 2.4 mi | ★★★★★ | 5 | 3 |
| The Estates At Chateau Llc | 2.4 mi | ★★★★★ | 14 | 1 |
| Fairview University Trans Serv | 2.5 mi | ★★★★★ | 0 | 0 |
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