Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Edenbrook Of Edina during CMS and state inspections, most recent first.
A facility failed to fully assess and document safe self-administration and storage of meds for two cognitively intact residents and did not obtain provider orders for all meds kept in the room. One resident with respiratory failure had an albuterol inhaler at bedside despite an assessment that did not address secure storage, and another resident with HTN, PVD, and DM had nicotine gum at bedside without a self-administration assessment or order, even though staff confirmed an order and locked storage were required.
Failure to provide timely SNFABN notice. A resident receiving Medicare Part A skilled services was not given the SNFABN within the required 48 hours before services ended. The MDSC stated the facility had difficulty identifying the correct payer source and later had the resident sign a new SNFABN after the original form could not be located. The administrator stated beneficiary notices were expected to be given 48 hours before the end of services so residents are aware of payment changes and possible financial responsibility.
A resident with severe cognitive impairment and diagnoses including dementia, anxiety, and depression was prescribed Lorazepam 0.5 mg PO every 1 hour PRN with no end date. The record lacked evidence supporting continuation beyond the 14-day limit for PRN psychotropic meds, and the DON confirmed the facility missed the requirement.
A resident with severe cognitive impairment and diagnoses including diabetes, hyponatremia, hypertension, and heart failure had an order for daily weights with provider notification required for weight gains outside set parameters. The record showed multiple weight changes outside those limits, but no documentation that the provider was updated. Staff interviews confirmed nurses and nurse leadership were responsible for monitoring weights and notifying the provider, and the PA stated she would have wanted to be informed of any out-of-parameter weight changes.
The facility failed to implement and maintain an effective fall management program for multiple high-risk residents, including those with hemiplegia, Parkinson’s disease, stroke, dizziness, and cognitive impairment. One resident with chronic dizziness and severe cognitive deficits had multiple unwitnessed falls and self-transfers despite documented high fall risk, incomplete orthostatic BP monitoring, and inconsistent environmental interventions such as missing no-skid tape near the bed. Another resident with Parkinson’s disease and dizziness was identified as a moderate fall risk at admission but had no fall-prevention care plan initiated before experiencing an unwitnessed fall while walking to the bathroom unassisted, resulting in a spinal fracture and hospitalization. A third resident with stroke-related deficits and visual impairment had repeated unwitnessed falls linked to self-transfers, call light access, and shoe use, while incident reports and IDT reviews lacked comprehensive causal analysis and timely care plan revisions. Staff interviews showed that NAs and LPNs were often unaware of residents’ transfer status and specific fall interventions, and baseline or updated care plans were delayed or incomplete, contributing to repeated falls and serious injuries.
The facility failed to operate its QAPI committee in accordance with its written plan by not identifying falls as a high-risk, problem-prone area, not initiating Performance Improvement Projects, and not conducting root cause analyses despite repeated elevations in fall rates and internal metric triggers for falls with major injury. Over multiple months, fall rates per 1,000 resident days exceeded the facility’s goal, with many unwitnessed falls occurring primarily in resident rooms and bathrooms, yet Quality Review minutes showed only data tracking without analysis of causal factors or development of system-wide corrective actions. Several residents experienced multiple unwitnessed falls, including two who sustained major injuries (a left tibial fracture and a spinal fracture) requiring hospitalization, and one major injury event was not accurately reflected in quality meeting minutes. Interviews with the DON, regional clinical leader, and medical director confirmed that concerns about increased falls were not brought forward to the QAPI committee and that the medical director was not informed of the rise in falls.
Two residents with significant neurological and mobility-related diagnoses experienced unwitnessed falls that resulted in serious injuries, including a T12 compression fracture and a comminuted tibial plateau fracture. In both cases, staff documentation identified the falls as explainable events, incident reports lacked comprehensive fall investigations and analysis of causal factors, and one resident’s baseline care plan and toileting plan were not in place before the falls. An LPN could not describe required transfer methods or fall-prevention interventions for one resident, and prior episodes of dizziness for the other resident were not followed by thorough assessment or individualized fall-prevention strategies. Despite hospital findings of major injuries and MDS coding of a fall with major injury, the administrator did not report either serious-injury fall to the State Agency, stating they were not viewed as allegations of abuse, contrary to facility policy requiring reporting of events resulting in serious bodily injury.
The facility failed to timely revise care plans for two residents after changes in fall risk interventions and transfer status. One resident with multiple comorbidities and high fall risk had a care plan intervention for brightly colored tape on wheelchair brakes added after a self-reported fall, but later the wheelchair had anti-roll bars instead of tape and the care plan was never updated to reflect this change. Another resident with hemiplegia, epilepsy, Charcot’s foot, severe cognitive impairment, and prior falls, including a fall with fracture, continued to have a care plan requiring a total mechanical lift for transfers even though therapy had changed the resident’s transfer status to independent and the resident was self-transferring. Nursing leadership and therapy staff confirmed that the care plans were not revised in a timely manner to match current interventions and transfer recommendations.
Two residents experienced deficiencies in their living conditions at the facility. One resident, with moderate cognitive impairment, reported that staff did not respond promptly to her call light, resulting in her urinating in her brief and soiling her bed, which was not promptly addressed. Another resident, who is totally dependent on staff, had a cluttered room with supplies and personal items scattered, making it difficult for family visits. The facility lacked a policy for maintaining a homelike environment, and staff were unaware of the cleanliness status of items in the room.
A resident with a leg prosthetic did not have a comprehensive care plan addressing the prosthetic's placement and use, leading to inadequate care. The care plan lacked specific instructions, and the Kardex did not document the prosthetic, leaving staff without guidance. Interviews revealed that staff were not specifically trained on the resident's prosthetic, resulting in discomfort and improper placement. The director of physical therapy noted the need for the prosthetic during transfers, but this was not included in the care plan.
A resident with a below-the-knee prosthesis was unable to use his preferred toileting method due to staff delays in applying the prosthesis, leading to the use of incontinent briefs. Despite being aware of his bowel movements, the resident often soiled himself before staff could assist. The facility did not document attempts to provide alternative toileting measures, and staff were unaware of the resident's preferences.
The facility failed to ensure proper procedures for self-administration of medications (SAM) for three residents. One resident self-administered insulin without a SAM assessment or physician's order, another was left with medications unattended in the dining room without proper documentation, and a third had an over-the-counter pain relief roll-on in their room without a SAM assessment or order. The facility's policy required assessments and orders for SAM, which were not followed in these cases.
A resident with a feeding tube was found to have an unclean tube feeding pole in their room, with smudged areas and a tannish substance on the pole and floor. Staff interviews revealed inconsistencies in cleaning routines, with no documentation or clear protocol, leading to concerns about infection control and resident dignity.
The facility failed to provide proper wound care for a resident with a skin tear, as documented care was not administered. Additionally, false documentation of wound care was noted for two residents whose wounds had healed. Observations and interviews confirmed discrepancies in care and documentation, with staff lacking clarity on discontinuing wound care orders. The medical director expressed concern over these deficiencies, indicating a systemic issue in wound care management.
The facility failed to implement enhanced barrier precautions and proper hand hygiene during care for two residents. A resident with a history of MRSA did not receive care with the required personal protective equipment, as an LPN did not don a gown despite EBP signage. Another LPN performed wound care with improper hand hygiene, using double gloves and not sanitizing hands between glove changes, contrary to facility policy.
A resident with cognitive impairments reported rough handling by staff, leading to an abuse investigation. Despite implementing a 'Cares in Pairs' intervention requiring two staff members during care, this was not consistently followed. The facility's investigation was ongoing, and there was uncertainty about when the intervention was implemented. The facility's policy emphasized resident safety during investigations, which was not adequately followed.
A resident with post-surgical needs called 911 for assistance after being neglected by staff who were found sleeping during their shift. The resident required pain management and toileting assistance, which were not provided, leading to the involvement of police. Facility policy mandates a safe environment free from neglect, which was not upheld in this instance.
The facility did not assign a designated charge nurse for each shift, as required. An LPN reported that on a specific night, no charge nurse was assigned, and all nurses were considered in charge. The administrator confirmed that the nurses were in charge, with the DON on call for clinical concerns. The DON acknowledged the lack of a designated charge nurse, and the facility could not provide a policy on this matter.
A facility failed to report an alleged abuse incident involving a resident to the State Agency within the required timeframe. Law enforcement visited the facility to investigate claims of staff being physically rough with the resident, who has a history of PTSD and other conditions. Despite the visit, the facility did not document or report the allegations, relying on the resident's verbal assurance of having no concerns. The facility's policy requires immediate reporting and investigation, which was not followed.
A resident with a history of PTSD and renal dialysis dependence reported being mishandled by staff, prompting a police visit. Despite the facility's policy requiring investigation of abuse allegations, the DON did not initiate an investigation, citing frequent false reports by the resident's family. Interviews revealed that neither the DON, ADON, nor the administrator conducted a formal investigation or documented the incident, failing to adhere to the facility's abuse prevention policy.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The facility failed to comprehensively assess residents for safe self-administration and storage of medications and failed to obtain a physician order for two residents reviewed for self-administration. One resident was cognitively intact, had respiratory failure and chronic obstructive respiratory failure, and had an order for an albuterol sulfate inhaler to use as needed. The resident’s self-administration assessment indicated the resident could self-administer medications after set up by a licensed nurse, but the assessment also marked the question about storing medications securely in the room as not applicable. During observation, the resident’s inhaler was sitting on the bedside table, and the resident stated it was the rescue inhaler and was always kept with him. Staff interviews showed awareness of the inhaler being at bedside, but the ADON stated the resident had an order to self-administer after nurse set-up and could not keep the inhaler in the room. The second resident was cognitively intact and had diagnoses including hypertension, peripheral vascular disease, and diabetes. A provider note documented a discussion about nicotine gum and its effects on blood sugars, and the provider told the resident she could continue chewing nicotine gum, but no order for the gum was entered. The resident’s record lacked a self-administration assessment, lacked a care plan indication for self-administration, and lacked any order allowing nicotine gum in the room. During observation, nicotine gum was on the resident’s bedside tray table and later on the bed, and the resident stated she always used nicotine gum brought by her nephew. Staff interviews confirmed that a self-administration assessment, provider order, and locked storage were required before keeping medications in the room, and the DON and PA both acknowledged that an order was needed for over-the-counter medications.
Failure to Provide Timely SNFABN Notice
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN-10055) was provided to one resident, R59, within the required 48 hours before Medicare Part A services ended. Record review showed R59’s MDS indicated a Medicare Part A discharge date of 8/13/25, but the SNFABN stated services would end on 8/14/25 and was not given until 9/22/25. During interview, the MDS Coordinator stated the facility had difficulty identifying the correct payer source for the resident and, after locating the original form, had R59 sign a new SNFABN because the prior one could not be found. The MDS Coordinator confirmed the notice was provided outside the required 48-hour timeframe. The administrator stated the expectation was that beneficiary notices be provided 48 hours before services end so residents are aware of payment changes and possible responsibility for payment.
PRN Psychotropic Medication Exceeded 14-Day Limit
Penalty
Summary
The facility failed to ensure an ordered PRN psychotropic medication was limited to a 14-day time period for one resident, R34. R34’s admission MDS indicated severe cognitive impairment and diagnoses including hypertension, renal insufficiency, hyperlipidemia, dementia, anxiety, and depression. The resident’s order summary showed Lorazepam 0.5 mg orally every 1 hour PRN with a start date of 12/17/25 and no end date. The medical record lacked evidence of a rationale to continue the PRN psychotropic medication beyond the required 14-day timeframe. During interview, the DON confirmed awareness of the 14-day time frame for psychotropic medications and stated the facility missed it with R34.
Failure to Report Weight Changes Outside Ordered Parameters
Penalty
Summary
The facility failed to follow physician orders for daily weights for a resident with severe cognitive impairment and diagnoses of diabetes, hyponatremia, and hypertension. The resident had an order for daily weights due to heart failure, with instructions to update the provider for a weight gain of 3 pounds or greater in 24 hours or 5 pounds in one week unless otherwise directed. The resident’s recorded weights showed multiple changes outside those parameters, including increases and decreases across the review period, such as 218.0 lbs to 228.4 lbs, 212.2 lbs to 221.1 lbs, 204.9 lbs to 213.8 lbs, 201.0 lbs to 208.6 lbs, 206.0 lbs to 214.1 lbs, 200.2 lbs to 245.6 lbs, and 187.5 lbs to 203.0 lbs. Review of the medical record did not show updates to the provider for the weight changes as instructed in the order. During interviews, an LPN stated she would typically call a provider when weights were outside parameters and document a progress note after updating the provider. The ADON stated floor nurses were responsible for monitoring daily weights and updating the provider when a resident was outside ordered parameters, and confirmed no progress notes or provider notes were found for the resident’s weight changes. The DON stated nurse managers or the ADON were responsible for monitoring weights and updating the provider as needed, while the floor nurse entered the weight and notified the nurse manager or ADON of concerns. The PA stated she would have wanted to be updated on any weight changes outside ordered parameters and that early adjustment to medications was important to prevent hospitalization. Facility policy for weight monitoring was requested but not provided.
Failure to Implement Effective Fall Management and Care Planning for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective fall management program, including accurate assessment, care planning, and follow-through on fall-related interventions for multiple residents at high risk for falls. For one resident with hemiplegia, epilepsy, Charcot foot, dizziness, severe cognitive impairment, and dependence in most ADLs, the record showed repeated unwitnessed falls associated with dizziness and self-transfers. Although the care plan labeled the resident as high risk for falls and listed various interventions such as low bed, therapy screens, anti-skid tape, and medication review, the facility did not complete ordered orthostatic blood pressures after falls, did not revise the care plan to address ongoing dizziness and self-transfers, and did not conduct a comprehensive assessment of the cause of the dizziness. Post-fall reviews repeatedly identified dizziness and self-transfers as root causes, but there was no evidence of a thorough root cause analysis or effective modification of interventions, and the resident’s environment lacked consistent no-skid surfaces near the bed despite independent transfers. Another resident with Parkinson’s disease, CHF, atrial flutter, diabetes, dizziness, and dyskinetic movements was identified as a moderate fall risk on a Morse Fall Scale at admission and had a PT evaluation noting unsteadiness and fear of falling. However, no fall prevention care plan was initiated after admission despite the identified risk. The resident experienced an unwitnessed fall while attempting to walk to the bathroom unassisted, after which she was found on the floor with pain in multiple areas and later diagnosed in the ED with an acute T12 compression fracture requiring hospitalization. The facility’s records showed that the baseline care plan, including fall interventions, was not initiated until after the resident had already been transferred to the hospital and did not return. Interviews with staff and the ADON confirmed that the baseline care plan had not been completed over the weekend, that there was no investigation into the fall because the resident did not return, and that the absence of a care plan increased the resident’s risk of falls. A third resident with stroke, diabetes, visual impairment, epilepsy, hemiplegia, and foot drop was assessed as high risk for falls and required substantial assistance with transfers and ADLs. The fall care plan initially identified the resident as a moderate fall risk and included general interventions such as medication review, pain evaluation, snacks, therapy, and clutter-free environment, but did not address specific, evolving fall patterns. Over a series of unwitnessed falls, the resident repeatedly attempted self-transfers, tried to retrieve a fallen call light, ambulated without assistance, and fell while trying to put on shoes. Incident reports frequently left predisposing environmental and physiological factors blank, and post-fall reviews documented root causes such as new admission, self-transfers, and balance issues but lacked comprehensive causal analysis. Care plan revisions were delayed or incomplete, with some interventions (e.g., wheelchair placement by bed, gripper socks, removal of shoes as visual cues) added days to weeks after falls, and staff interviews revealed unawareness of key fall-prevention interventions such as wheelchair placement and specific monitoring expectations. Across these residents, the facility did not consistently ensure that staff knew residents’ transfer status or fall interventions, as multiple NAs and LPNs reported needing to check the EHR or being unable to articulate current fall-prevention measures. One nurse aide caring for the resident with hemiplegia and dizziness was unaware of the resident’s transfer status and falls until checking the Kardex, which showed a total mechanical lift order that was not being followed, while the resident was observed independently transferring without no-skid tape at the bedside. Another LPN caring for the same resident acknowledged daily reports of dizziness but could not identify any fall-prevention interventions in place. For the resident with Parkinson’s disease, the LPN who found her on the floor could not describe how the resident was supposed to transfer or what fall interventions should have been used. These documented inactions and gaps in assessment, care planning, and staff awareness contributed to multiple unwitnessed falls, including two residents who sustained major injuries (a tibial plateau fracture and a spinal fracture) requiring hospitalization. The facility’s fall incident documentation and IDT post-fall reviews repeatedly lacked complete information on environmental, physiological, and situational predisposing factors, and often recorded generic immediate actions such as encouragement to call for help, without detailed analysis of why residents continued to self-transfer or how dizziness, balance, cognition, and environmental setup contributed to the falls. Orders and recommendations for orthostatic blood pressure monitoring for the dizzy resident were not carried out or documented, and there was no evidence that the results were evaluated or used to adjust care. Residents reported not being involved in care plan development or being asked about symptoms such as dizziness, and one resident’s family member reported that a requested fall mat was never provided. Collectively, these actions and omissions demonstrate that the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision and individualized fall-prevention interventions for residents at known risk for falls.
Failure of QAPI Committee to Analyze and Address Increased Falls and Falls With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement its Quality Assurance and Performance Improvement (QAPI) program in accordance with its written plan, specifically related to identifying, analyzing, and responding to increased resident falls and falls with major injury. The facility’s QAPI Plan requires the QAA committee to review data monthly, identify high-risk and problem-prone areas, initiate Performance Improvement Projects (PIPs), conduct root cause analyses, and develop system-level corrective actions. Facility records, Quality Review minutes, QAPI documentation, and incident reports showed that falls, including falls with major injury, triggered internal quality measures in multiple quarters, but the QAPI documentation did not show initiation of sustained PIPs, completion of comprehensive root cause analyses, or implementation and monitoring of system-wide corrective actions related to falls. Quality Review documentation over several months showed that the facility tracked fall rates per 1,000 resident days with a stated goal of 5, and repeatedly recorded fall rates above this goal. For example, fall rates and counts included: March (4.2; 9 falls), April (15.1; 31 falls), May (5.9; 12 falls), June (9.0; 17 falls), July (3.1; 6 falls), August (8.5; 17 falls), September (8.3; 16 falls), October (6.1; 13 falls), and November (5.7; 12 falls month-to-date in mid-November, with 23 total falls for the month). The documentation consistently included data tables and graphs showing cumulative fall totals, with a high proportion of unwitnessed falls and a concentration of falls in resident rooms and bathrooms. Despite increases in cumulative falls between reporting periods and repeated exceedance of the facility’s fall rate goal, the Quality Review minutes did not reflect discussion of underlying or contributing factors, completion of comprehensive root cause analyses, initiation of PIPs, or development and monitoring of system-wide corrective actions related to fall prevention. The deficiency is further supported by specific fall events and harm identified in a related fall management citation (F689), which documented that the facility failed to implement a fall management program including care plans, comprehensive fall analysis, and appropriate interventions for five residents at risk for falls. These residents experienced multiple unwitnessed falls, including one resident with four unwitnessed falls and a left tibial fracture requiring hospitalization, and another resident with an unwitnessed fall resulting in a spinal fracture and hospitalization. Quality Review documentation identified at least two residents with falls resulting in major injury, but one major injury was not reflected in the November Quality Review minutes because the facility became aware of it after the report was generated, and it was still not accounted for in the subsequent quality meeting minutes. Interviews with the DON, regional director of clinical services, and medical director confirmed that, despite recognition of high fall rates and metric triggers, concerns about increased falls were not brought to the QAPI committee, and the medical director was not informed of any concern with an increase in falls.
Failure to Report Serious-Injury Falls and Inadequate Fall Investigation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to timely report to the State Agency falls with serious injury for two residents and to conduct adequate fall investigations and care planning. One resident with Parkinson’s disease, congestive heart failure, atrial flutter, and diabetes was assessed as a moderate fall risk and required substantial assistance with transfers, toileting, and some ADLs, but the admission assessment lacked a cognitive assessment and a baseline care plan was not initiated until after the resident had already been transferred to the hospital. The resident experienced an unwitnessed fall in the early morning, was found on the floor with her head on a pillow, and was documented as having no injury, with neuro checks and vital signs completed. The incident report did not include a comprehensive fall investigation or analysis of causal factors, including the absence of care plan interventions to direct staff on the level of assistance needed for ADLs. Hospital emergency department records later showed that this resident sustained an acute superior endplate compression fracture of T12 with burst-type morphology and slight bony retropulsion, requiring pain management, a spinal brace, and physical therapy. The resident’s family member reported that the resident stated she had been on the floor for several hours before being found, and that the family member called 911 to transfer the resident to the hospital, where the spinal fracture was discovered. The LPN who found the resident on the floor was unable to state when the resident was last checked and could not articulate how the resident was supposed to transfer or what fall-prevention interventions were to be used. The administrator later stated that this fall was not reported to the State Agency because it was considered explainable and not an allegation of abuse, and the administrator was unaware that the resident’s MDS had been coded as a fall with major injury based on hospital information. The second resident had diagnoses including hemiplegia and hemiparesis following stroke, epilepsy, Charcot joint of the left ankle and foot, and dizziness, and had severe cognitive impairment and dependence in most ADLs. This resident had multiple prior falls where dizziness was repeatedly identified as a causal factor, but records lacked monitoring of dizziness and comprehensive assessments to identify individualized fall-prevention strategies. The resident then had an unwitnessed, self-reported fall in the bathroom during a self-transfer after toileting, resulting in left knee swelling and significant pain; an x-ray later showed a comminuted fracture of the left tibial plateau, and the resident was hospitalized for worsening leg/knee pain with displaced and impacted intra-articular fractures. The administrator stated that this fall also was not reported to the State Agency after knowledge of the serious injury because it was considered explainable and not an allegation of abuse, despite facility policy directing that events resulting in serious bodily injury must be reported to the State Agency.
Failure to Revise Care Plans After Changes in Fall Risk and Transfer Status
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and accurately maintain comprehensive care plans for residents at risk for falls and accidents. One resident with multiple diagnoses including acute respiratory failure with hypoxia, seizures, bipolar disorder, heart failure, reduced mobility, and a history of pulmonary embolism had a fall-focused care plan identifying high fall risk and interventions such as reviewing medications, managing pain, monitoring for acute changes, using gripper socks, and keeping the environment free of clutter. After the resident self-reported an unwitnessed fall while transferring from bed to wheelchair when a wheelchair brake was not locked, the care plan was updated to include brightly colored tape on the wheelchair brakes as a reminder and discussion of risks versus benefits of self-transfers. Later observation showed the wheelchair did not have the colored tape on the brakes but instead had anti-roll bars on both wheels, and the DON confirmed that the care plan had not been revised to remove the tape intervention or add the anti-roll bars despite this change having occurred “a while back.” Another resident with hemiplegia and hemiparesis following stroke affecting the right side, epilepsy, Charcot’s joint of the left ankle and foot, dizziness, severe cognitive impairment, and dependence in most ADLs had a mobility care plan indicating limited physical mobility and an intervention requiring assist of two with a total mechanical lift for transfers. A significant change MDS indicated this resident had falls in the past six months, including a fall with fracture, but the MDS section stated no falls in the last six months and no falls with fracture. A NA reported that the resident had been self-transferring to the wheelchair multiple times during a shift and, upon reviewing the care plan, saw that it still required a total mechanical lift, prompting the NA to seek clarification. The therapy director and OT stated that the resident’s transfer status had been changed to independent on a specific date, and that therapy recommendations are provided to nursing so the care plan can be updated. The ADON acknowledged that the care plan had not been revised to reflect the change in transfer status after therapy’s recommendation, leaving the written care plan inconsistent with the resident’s current transfer abilities and practice.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two residents, R1 and R3. R1, who has moderate cognitive impairment and is frequently incontinent, reported that staff did not respond promptly to her call light at night, resulting in her urinating in her brief and soiling her bed. On one occasion, R1's bed was made over a urine-soiled bath blanket, which was confirmed by a surveyor and staff. Despite R1's complaints, the bedding was not changed promptly, and the room had a noticeable urine odor. R3, who has no cognitive impairment but is totally dependent on staff for personal care, had a cluttered room with facility supplies covering furniture and clean supplies on the floor. His room was observed to have various items scattered, including wound care supplies, clothing, and personal items, making it difficult for his family to visit comfortably. R3 expressed a desire for his room to be organized, particularly for his wound care supplies to be placed in a bin, but this had not been addressed by the facility. The Director of Nursing acknowledged that beds should not be made if they are soiled and that residents have the right to have their rooms arranged as they wish. However, the facility did not have a policy regarding maintaining a homelike environment, and the Assistant Director of Nursing was unaware of the cleanliness status of items in R3's room. The facility's failure to maintain a clean and homelike environment for these residents was evident in the observations and interviews conducted.
Inadequate Care Plan for Resident with Leg Prosthetic
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a leg prosthetic, leading to inadequate care and services. The resident, who had a significant change MDS indicating no cognitive impairment, was dependent on staff for various activities of daily living and had multiple diagnoses, including the absence of a right leg below the knee. Despite these needs, the resident's care plan lacked specific, person-centered details regarding the placement and use of the prosthetic. The care plan did not specify when the prosthetic should be used, how it should be placed, or if it was required during transfers with the EZ-stand. Additionally, the resident's Kardex did not document the prosthetic, leaving staff without guidance on its use. Interviews with the resident and staff revealed further deficiencies. The resident expressed discomfort and irritation from the prosthetic due to improper placement by floor staff, who lacked specific training. The assistant director of nursing and nursing assistants were uncertain about the training and care plan details for the prosthetic. The director of physical therapy acknowledged the need for the prosthetic during transfers due to the resident's balancing concerns but noted that this was not reflected in the care plan. The director of nursing confirmed the omission of the prosthetic from the Kardex and believed that general prosthetic care training was sufficient, despite the lack of specific instructions for the resident's needs.
Failure to Accommodate Resident's Toileting Preferences
Penalty
Summary
The facility failed to meet a resident's needs and choices for performing activities of daily living, specifically toileting, for a resident with a below-the-knee leg prosthesis. The resident was unable to use his preferred method of toileting due to staff not being able to apply the prosthesis in a timely manner, which was necessary for transferring the resident to the toilet or commode chair as indicated in his care plan. The resident expressed feeling like a baby because he was made to wear an incontinent brief, despite being aware of his need to defecate. However, by the time staff arrived to assist him, he had often already soiled himself. The resident's medical history included chronic congestive heart failure, acute respiratory failure, type II diabetes, morbid obesity, and amputations of the right leg below the knee and left foot. Despite these conditions, the resident had no cognitive impairment and was aware of his bowel movements. The care plan indicated that the resident was to have incontinence care after each episode and was encouraged to sit on the toilet to evacuate bowels if possible. However, the facility did not document any attempts at alternative measures to allow the resident to be free from wearing an incontinent brief. Interviews with staff revealed a lack of awareness and training regarding the resident's preferences and needs. The Assistant Director of Nursing believed the resident wanted to wear briefs, while the Director of Nursing was unaware of the resident's wishes to not wear an incontinence pad. The nursing assistant stated he did not ask the resident if he wanted to use the commode or toilet, assuming it was not the resident's wish. The facility's plan was for the resident to use the toilet or commode, but due to the resident's refusal to wear the prosthetic, he was required to wear an incontinence pad. The facility did not provide a policy regarding activities of daily living when requested.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure proper procedures for self-administration of medications (SAM) were followed for three residents. For one resident, who was admitted with a history of managing their own diabetes and insulin, the facility did not complete a SAM assessment or obtain a physician's order before allowing the resident to self-administer insulin. The resident had been managing their diabetes for many years and brought their own insulin and syringes from home. Despite the resident's ability to communicate and understand staff, the facility did not involve the interdisciplinary team or document the resident's clinical appropriateness for SAM. The resident's blood sugar levels were not recorded on the day of admission, and there was a discrepancy between the resident's self-administered insulin dosage and the physician's orders. Another resident, who was cognitively intact and varied in their need for assistance with activities of daily living, was observed with medications left unattended in the dining room. The resident typically took their medications after breakfast without licensed staff supervision, which was against the facility's policy requiring an order and care plan for SAM. The resident expressed discomfort with staff watching them take medications, and the staff confirmed that the resident had been left with medications routinely. However, there was no documentation of a SAM assessment, physician's order, or care plan for this resident. A third resident, who had intact cognition and physical limitations requiring assistance with self-care, was found with an over-the-counter pain relief roll-on in their room. The resident occasionally requested staff assistance to apply the medication, but there was no SAM assessment or physician's order for self-administration. The facility's policy required a SAM assessment and provider's order for any medication, including over-the-counter products, to be left with a resident. Staff were expected to remove any medications found in a resident's room and bring them to the nurse, but this procedure was not followed in this case.
Unclean Tube Feeding Pole in Resident's Room
Penalty
Summary
The facility failed to provide a homelike environment for a resident who was dependent on staff for all activities of daily living and had a feeding tube through which they received more than 50% of their nutrition. During an observation, the tube feeding pole in the resident's room was found to be unclean, with smudged areas and a tannish colored substance covering parts of the pole and base. The floor also had drops of the same substance. This was confirmed by a registered nurse who acknowledged the need for cleaning and expressed concerns about infection. Interviews with staff revealed inconsistencies in the cleaning routine for tube feeding poles. A registered nurse stated that cleaning was done when dirt was noticed but was not documented. A licensed practical nurse admitted to not knowing the routine and mentioned that different shifts handled different tasks. The director of nursing expected staff to clean the poles, but the lack of a clear protocol led to the deficiency in maintaining a clean and homelike environment for the resident.
Deficiencies in Wound Care Management and Documentation
Penalty
Summary
The facility failed to provide appropriate wound care treatment for a resident, R3, who had a skin tear on the right lower leg. Despite physician orders directing daily wound care, the treatment was not administered as documented. Observations revealed that the dressing had not been changed since 10/10/24, contradicting the treatment administration record (TAR) entries by nursing staff. Interviews with R3 and nursing staff confirmed discrepancies in wound care documentation and actual care provided. The director of nursing verified the dressing date and acknowledged the lapse in care. Additionally, the facility falsely documented wound care for two other residents, R4 and R5, whose wounds had already healed. R4's wound care was documented as ongoing despite the surgical incision being healed, as verified by the director of nursing. Similarly, R5's TAR indicated continued wound care for skin tears that had resolved, as confirmed by both the resident and the director of nursing. The staff appeared to lack clarity on discontinuing wound care orders once wounds were resolved. The medical director expressed concern over the failure to follow wound care orders and the false documentation of care for resolved wounds. The facility's policy on wound care management was not adhered to, resulting in inaccurate records and potential neglect of resident care needs. The report highlights a systemic issue with wound care management and documentation within the facility.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents during personal care and wound care treatments. One resident, who had a history of methicillin-resistant Staphylococcus aureus (MRSA) and required EBP, was observed receiving care without the proper use of personal protective equipment. An LPN entered the resident's room to administer a suppository and reposition the resident without donning a gown, despite a sign indicating the need for EBP. The LPN stated she only wore a gown if a resident had an active infection, indicating a misunderstanding of the EBP requirements. Additionally, another LPN was observed performing wound care for the same resident using improper hand hygiene practices. The LPN used double gloves and failed to perform hand hygiene between glove changes, which was against the facility's policy. The Director of Nursing and the Medical Director confirmed that double gloving was not acceptable and that hand hygiene should be performed before and after wound care, as well as during glove changes. The facility's policies on EBP and wound care management were not followed, contributing to the deficiency.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to protect a resident during an ongoing investigation of an abuse allegation. The resident, who was moderately cognitively impaired and required assistance for daily activities, reported that staff were rough with him, specifically mentioning being lifted by his shirt, which caused pain. The resident's power of attorney corroborated the resident's account, stating that a staff member had yanked the resident by the arm while he was asleep. Despite the resident's inability to identify the alleged perpetrator from staff photos, the facility implemented a 'Cares in Pairs' intervention, which required two staff members to be present during care. However, this intervention was not consistently followed, as observed when a nursing assistant assisted the resident without a second staff member present. The facility's investigation into the abuse allegation was still ongoing at the time of the report. The Director of Nursing and the Administrator were unsure about the exact timing of the implementation of the 'Cares in Pairs' intervention. The Director of Nursing indicated that the intervention was intended to protect staff from false allegations rather than to ensure the resident's safety. The facility's policy on abuse and neglect prevention emphasized the importance of ensuring the safety and well-being of vulnerable adults during investigations, but this was not adequately adhered to in this case.
Resident Neglect Due to Staff Sleeping on Duty
Penalty
Summary
The facility failed to provide adequate supervision and care for a resident during the overnight shift, leading to the resident calling 911 for assistance. The resident, who had undergone surgery for colon cancer and had an ileostomy, required assistance for pain management and toileting due to reduced mobility. The care plan specified that two staff members were needed to assist the resident to the toilet and to provide incontinence care. However, on the night in question, the resident was left unattended, resulting in the resident experiencing pain and needing to use the bathroom without assistance. The incident was discovered when police responded to the resident's 911 call, finding staff members asleep on duty. The police bodycam footage showed officers waking staff members who were sleeping in a dark dining room and an office. The resident expressed distress to the officers, stating that the staff did not take care of her needs. The facility's policy on abuse and neglect prevention emphasizes providing a safe environment free from harm, but the actions of the staff on duty failed to meet these standards, resulting in neglect of the resident's care needs.
Failure to Assign Designated Charge Nurse for Each Shift
Penalty
Summary
The facility failed to have a designated charge nurse for each shift, as required. On the night of June 14, 2024, a Licensed Practical Nurse (LPN) stated that there was no charge nurse assigned, and that every nurse was considered to be in charge. The facility administrator confirmed via email that the nurses in the building were in charge, and that the Director of Nursing (DON) was on call 24/7 for any clinical concerns. The DON also stated that there was not a designated charge nurse for each shift. When requested, the facility did not provide a policy regarding the assignment of a designated charge nurse for each shift.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged violation of abuse involving a resident, identified as R1, to the State Agency within the required timeframe. The incident came to light when law enforcement visited the facility to investigate allegations that nursing staff had been physically rough with R1. Despite the police visit, the facility did not document any progress notes on the day of the incident, nor did they report the allegations to the State Agency as required by their policy. R1, who has a history of post-traumatic stress disorder, dependence on renal dialysis, and major depressive disorder with severe psychotic symptoms, was reportedly grabbed and jerked around by staff. Although R1 was cognitively intact, as indicated by a BIMS score of 14, she expressed fear of reporting the abuse due to potential retaliation. The DON and ADON did not initiate an investigation, citing that R1's family member frequently made allegations and that R1 had no concerns when asked. The facility's policy mandates immediate reporting of abuse allegations to the State Agency, but this was not followed. The DON and administrator both failed to report the incident, relying instead on R1's verbal assurance that she had no concerns, despite the serious nature of the allegations. The facility's policy requires an investigation and reporting within two hours if abuse is alleged, but this protocol was not adhered to in this case.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate a report of abuse involving a resident who was visited by law enforcement due to allegations of being grabbed and jerked around by nursing staff. The resident, who has a history of post-traumatic stress disorder, renal dialysis dependence, and major depressive disorder with severe psychotic symptoms, was reported to be cognitively intact. Despite the police report indicating the need for an investigation, the Director of Nursing (DON) did not initiate one, citing that the resident's family member frequently makes such allegations and that the resident appeared fine according to law enforcement. Interviews with the DON, Assistant Director of Nursing (ADON), and the administrator revealed that none of them conducted a formal investigation or documented the incident in the resident's progress notes. The facility's policy requires immediate reporting and investigation of abuse allegations, but this protocol was not followed. The DON and ADON both stated that the resident expressed no concerns when asked, but they did not specifically inquire about abuse. The administrator also failed to ask directly about abuse, neglect, or mistreatment, despite the facility's policy mandating such actions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,046 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aurora On France | 0.6 mi | ★★★★★ | 13 | 0 |
| Mount Olivet Careview Home | 1.7 mi | ★★★★★ | 7 | 0 |
| Mount Olivet Home | 1.7 mi | ★★★★★ | 7 | 0 |
| Grand Avenue Rest Home | 3 mi | ★★★★★ | 9 | 0 |
| The Villas At Richfield | 3.1 mi | ★★★★★ | 11 | 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.