Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fair Oaks Lodge during CMS and state inspections, most recent first.
An unlocked mini-fridge in a med room contained liquid lorazepam, and the med room door and refrigerators were observed unsecured. An unlocked 5-drawer med cart was also found in the chapel with medications and supplies for multiple residents, including current and discharged residents, plus needles and other items. The DON and ADON confirmed the cart was being used for TMA training, was left unlocked, and should not have contained resident medications or been stored in a public area.
Failure to Assess Self-Administration Before Leaving Medications at Bedside: The facility left medications with two residents without confirming they were assessed and ordered to self-administer. One resident had a SAM that approved only inhalers and certain other items, yet Nystatin powder was observed at the bedside and the DON questioned whether it was even the resident's because the pharmacy label was missing. Another resident had no SAM or order to self-administer, yet a medication cup was repeatedly observed on the bedside table and an RN admitted she did not watch the resident take the meds.
Failure to assess seat belt use in power wheelchairs for two residents. One resident with diabetes, HTN, prior TIA, hemiplegia, and hemiparesis had a care plan and therapy note directing seat belt use, but the EMR lacked a restraint assessment and MD order despite repeated observations with the belt fastened. Another resident with hemiplegia/hemiparesis, CP, epilepsy, spondylosis, and OA also used a seat belt in a power wheelchair, but the EMR lacked a restraint assessment and MD order, and the care plan did not address the belt.
Daily Nurse Staffing Posting Not Updated: The facility failed to keep the required nurse staffing information current. During survey observations, the staffing post displayed an outdated date, and the DON/Administrator confirmed the list was wrong and had not been updated. The facility policy required daily posting of actual hours and total hours worked by licensed and unlicensed nursing staff in a clear and readable format.
A resident with severe cognitive impairment and mobility dependence was transported in a facility van without a seatbelt due to the transport driver's inability to secure it and misunderstanding of safety requirements. During the trip, the resident slid out of the wheelchair and sustained fractures to both tibias and the left femur. The transport driver had not received specific training on safe transport procedures, and facility policy requiring all residents to be safely secured was not followed.
Two residents in a memory care unit with known wandering behaviors managed to leave the facility unnoticed due to inadequate supervision and monitoring. One resident, who required 24-hour supervision, tailgated a staff member through an exit door, while the other resident, dependent on a wheelchair, followed. Both were found outside the facility, highlighting a lapse in monitoring and supervision.
The facility failed to ensure safe patient handling during mechanical lift-assisted transfers for three residents, leading to potential accident hazards. A resident with quadriplegia was transferred using an incorrect sling size, while another resident had to frequently remind staff about proper sling usage. Interviews revealed staff guessed sling sizes due to a lack of resources, and the facility's policy did not specify how to identify the appropriate sling size.
The facility failed to provide sufficient staffing to meet residents' needs, resulting in significant delays in care, particularly for toileting assistance. Residents and family members reported long wait times for call light responses, with some instances exceeding two hours. Staff interviews confirmed frequent short-staffing, especially on weekends, leading to delays in care and unmet resident needs. The facility's staffing policy was not adhered to, compromising resident care.
The facility failed to provide follow-up responses to concerns raised by the resident council, affecting all 49 residents. During a meeting, residents expressed that they did not receive answers after voicing concerns. Records showed that while concerns were marked as resolved, follow-up information was not communicated back. Interviews confirmed the lack of documentation and follow-up, despite facility policy requiring grievances to be addressed and follow-up recorded.
The facility failed to update care plans for several residents, affecting discharge planning and activity engagement. One resident's care plan did not reflect the spouse's wishes for discharge closer to family, while another resident's plan lacked updates for 24/7 assistance needs. Additionally, a resident receiving hospice services had a care plan that did not include the spouse's requests for additional activities. Staff interviews confirmed care plans were not consistently updated, contrary to facility policy.
The facility failed to ensure appropriate discharge planning for four residents, leading to a deficiency in the continuation of care. One resident, severely cognitively impaired, had undecided discharge plans despite a spouse's request to move closer to family. Another resident, with mild cognitive impairment, had plans to return to an assisted living facility, but lacked discharge planning documentation. A third resident, cognitively intact, expressed a desire to move closer to family, but the medical record lacked follow-up documentation. The facility's director of nursing acknowledged the lack of documentation as a concern.
The facility failed to maintain a clean and sanitary environment, with soiled commode buckets and bedpans left out, and ADL supplies improperly stored. Standing lifts were also found dirty, with staff unclear on cleaning responsibilities. The Director of Nursing noted that all staff should ensure equipment is cleaned between uses.
The facility failed to maintain sanitary conditions for mechanical lifts and implement proper hand hygiene practices. Nursing assistants did not sanitize lifts or their hands between resident transfers. A nursing assistant also failed to change gloves or sanitize hands during personal care tasks, risking cross-contamination. Additionally, dietary aides handled drinkware improperly, and a resident on enhanced barrier precautions lacked proper signage and PPE initially.
A resident with severe cognitive impairment and Parkinson's disease did not receive a comprehensive assessment for their ankle-foot orthosis (AFO) brace. The care plan and electronic health record lacked necessary information, and there were no physician orders or treatment plans for the brace. Observations showed improper application of the brace, and interviews revealed staff were not trained on its use. The DON confirmed the absence of a care plan and assessment for the AFO brace.
A resident's MDS was inaccurately coded, with Section C left blank and Section H incorrectly indicating the absence of a catheter. Interviews with staff confirmed these errors, which contradicted the resident's care plan and progress notes. The facility's policy mandates accurate MDS completion, which was not adhered to in this case.
A resident with moderate hearing difficulty and a history of heart failure and depression did not receive necessary assistance from staff to maintain her hearing aids. Despite informing multiple staff members about the need for repair, no action was taken, and the resident's care plan lacked interventions for hearing aid use. The LSW and DON were unaware of the issue until later, highlighting a communication breakdown in addressing the resident's needs.
A resident with intact cognition and multiple diagnoses did not receive Myrbetriq and Psyllium as ordered due to unavailability for several days. The facility failed to notify the provider or follow the usual process of contacting the pharmacy, resulting in seven missed doses. Interviews revealed that staff did not adhere to the policy requiring physician notification after missing three consecutive doses.
A resident with hypertension, neurogenic bladder, and constipation did not receive prescribed medications Myrbetriq and Psyllium due to unavailability. The RN responsible was unaware of the shortage and did not contact the pharmacy or provider. Interviews revealed the facility failed to follow protocol for handling medication shortages, leading to a 6.25% medication error rate.
The facility failed to offer or administer pneumococcal vaccinations to three residents as per CDC guidelines. Despite the facility's policy requiring adherence to CDC recommendations, the residents' medical records lacked evidence of being offered the PCV20 or PCV21 vaccines. Interviews with the infection preventionist and DON confirmed the oversight, and the facility did not have the most current CDC recommendations.
A resident with an indwelling catheter due to urinary retention had their dignity compromised when their catheter bag was repeatedly left uncovered and visible to others, contrary to the care plan and facility policy. Observations confirmed the uncovered bag, and interviews with staff and the resident highlighted the expectation and preference for the bag to be covered.
A resident with severe cognitive impairment and multiple diagnoses was not provided care according to their comprehensive care plan. The plan required the resident to be fed in a wheelchair in the dining room, but observations showed the resident was fed in bed. Staff were unaware of the care plan requirements, and the plan was not updated to reflect the resident's current preferences, resulting in a deficiency.
A resident who required assistance with hygiene did not receive necessary oral care, as staff failed to perform oral care despite the resident's dependency and care plan requirements. The resident reported never being asked to wash her mouth out, and staff interviews confirmed a lack of awareness and adherence to oral care procedures. The facility's policy lacked specific instructions for oral care, contributing to the deficiency.
A facility failed to provide meaningful activities for a resident with severe cognitive impairment and dementia, despite a care plan emphasizing engagement in leisure activities. Observations showed the resident was often left in their room without being offered activities. Staff interviews revealed that activities were seldom conducted due to staffing issues, and there was a lack of documentation on resident participation. The facility's policy on supporting residents' well-being through activities was not effectively implemented.
The facility failed to ensure that all survey results from the past three years were accessible to residents and visitors. The last survey results in the binder were from a survey dated 8/16/24, missing results from surveys completed on 10/21/24 and 1/14/25. The DON confirmed the oversight and acknowledged the need for transparency, but no policy was provided.
A resident, dependent on staff for personal hygiene, was found with unwanted facial hair that she expressed bothered her. Despite her care plan indicating the need for assistance, staff did not offer to remove the facial hair until it was pointed out during an observation. Interviews revealed a lack of awareness and resources among staff regarding the issue, highlighting a failure to maintain the resident's dignity.
A resident with severe cognitive impairment was involved in an incident where a TMA allegedly responded to the resident's actions with a potentially abusive remark. The incident was reported internally but not to the State agency within the required timeframe, violating the facility's policy on abuse reporting.
The facility failed to submit the results of an abuse investigation to the State Agency within the required timeframe. A resident with severe cognitive impairment was involved in an incident where a staff member allegedly responded in a verbally abusive manner. The investigation was documented, but the report was not submitted as per the facility's policy, leading to a deficiency.
A resident with limited mobility and chronic pain was found without access to her call light, which was clipped to the wall out of reach. This led to the resident being unable to call for assistance, causing distress and a delay in care. Staff interviews confirmed that the call light was improperly placed by the night shift, contrary to facility policy requiring call lights to be within easy access.
A resident with a choking risk was left unsupervised while eating, despite care plan requirements for supervision. The resident, on a Level 6 Soft and Bite-Sized diet, was observed eating independently without staff present due to being moved for behavioral reasons. Staff interviews confirmed the need for supervision, but the facility's policy lacked guidance on supervision requirements.
A resident with specific dietary needs was served an incorrect meal, receiving regular corn instead of the prescribed Level 6 Soft and Bite-Sized texture diet. The dietary aide admitted to an oversight, and the LPN did not correct the error despite observing the resident eating the wrong food. Facility policies on diet verification were not followed, resulting in the dietary error.
A resident requiring assistance for toileting due to medical conditions was not provided with proper hand hygiene care by nursing assistants. One assistant failed to change gloves and perform hand hygiene after assisting with toileting, despite facility policies and expectations. The Director of Nursing confirmed the expected procedures for glove use and hand hygiene.
A resident with a history of neurological and bleeding disorders fell from her bed, resulting in head injuries. Despite being discharged from the ED with instructions for monitoring, the LTC facility failed to document consistent neurological checks and bruising assessments for 72 hours post-fall, as required by their policy. Staff interviews confirmed the lack of adherence to monitoring protocols.
A resident with complex medical needs fell from her bed and sustained head injuries after a nursing assistant failed to follow the care plan requiring two-person assistance for bed mobility. Despite staff awareness of the care plan, the resident was left unattended, leading to the accident. The incident highlighted a lack of immediate comprehensive staff education on care plan adherence.
A facility failed to follow enhanced barrier precautions for a resident with ESBL resistance. Despite signage indicating the need for PPE during high-contact care, nursing assistants provided care without gloves or gowns, mistakenly believing precautions were only for residents with wounds, infections, or catheters. The DON confirmed the need for precautions, as outlined in the facility's policy.
The facility failed to properly label and discard food, maintain correct dishwashing temperatures, and ensure staff wore appropriate hair restraints. Observations revealed expired and unlabeled food items, inadequate dishwashing practices, and staff handling drink glasses improperly. The dietary manager confirmed these practices were against facility policies.
The facility failed to provide mandatory training on its QAPI program, as revealed through interviews and document reviews. Staff, including NAs, LPNs, and TMAs, were unaware of QAPI, and the DON was surprised by this lack of training. The facility's training materials lacked documentation on QAPI, and a training policy was not provided.
A facility failed to maintain cleanliness and sanitation of a resident's tube feeding and suctioning supplies after the resident was hospitalized. The supplies were left in the room, contrary to facility policy. Additionally, standing lifts used by residents were found with dried substances, and staff were unclear about cleaning responsibilities. The DON confirmed expectations for cleanliness were not met.
A resident with moderate cognitive impairment and a history of respiratory issues was observed self-administering a nebulizer without a completed SAM assessment or physician's order. The resident's care plan lacked interventions for self-medication, and staff failed to supervise the nebulizer treatment as required by facility policy. Interviews confirmed the absence of a SAM assessment and the expectation for staff to remain with the resident during nebulizer administration.
A resident with moderate cognitive impairment was left unsupervised while smoking, despite a care plan requiring direct supervision and a smoking apron. Observations showed the resident was unsupervised multiple times, with the apron improperly secured, leading to ashes on clothing and the wheelchair. Staff interviews confirmed a lack of supervision and awareness of safety monitoring, and the LPN admitted the smoking assessment was inaccurate. The DON and regional nurse did not update the assessment, failing to ensure resident safety during smoking.
A resident with cancer and diabetes required continuous tube feeding, but the facility failed to administer it according to physician's orders. Nursing staff stopped the feedings during the day without proper documentation or notifying medical personnel, despite the resident's reports of vomiting and inconsistent feeding. The DON was unaware of these actions, and the facility's policy on verifying physician orders was not followed.
A resident with COPD and respiratory failure did not receive continuous oxygen therapy as ordered, resulting in critically low oxygen saturation levels. The resident was observed in the dining room without oxygen, despite having a portable tank available. The RN was delayed in addressing the issue due to other duties, and the resident's oxygen saturation was found to be 79% before oxygen was administered.
The facility failed to prevent contamination risk by improperly handling linens. A nursing assistant carried soiled bed linen with bare hands against her clothing, and a nurse manager carried a clean hoyer sling over her shoulder after providing care. Both actions were against the facility's policy, which requires soiled linen to be bagged and clean linen to be carried away from the body.
The facility did not notify the State agency when the current DON was appointed, as required. During a survey, both the administrator and the DON confirmed the lack of notification, with the administrator believing it was no longer necessary. A review of the DON's job description, signed in October 2023, provided no additional information.
The facility failed to ensure residents received prescribed diets as ordered, affecting three residents. One resident received inappropriate food items and liquids, another received a pureed diet instead of a minced and moist texture, and a third resident received uncut food items. The dietary manager and director of nursing confirmed these discrepancies.
The facility failed to ensure non-pressure related wounds were monitored for signs and symptoms of infection and healing until resolved for three residents. One resident had a surgical wound that was not properly monitored, leading to an infection diagnosed after discharge. Another resident had surgical wounds with staples, but the treatment administration record lacked evidence of a nursing order to monitor for signs of infection or healing. A third resident had a skin tear, open areas on the coccyx, and stitches on the left knee, but the care plan failed to identify the actual skin impairment of the left knee with stitches, and staff were unaware of the stitches.
Unsecured controlled medication, medication room, and unlocked med cart
Penalty
Summary
The facility failed to secure medications in 2 of 3 medication storage rooms and failed to secure a medication cart that was left in a public area for multiple residents. During observation, the mini-fridge in a medication storage room that contained liquid lorazepam was unlocked. RN-A confirmed the fridge should have been locked and stated the reason was so no one could come in and take it. The medication room door was also observed open, with no nurse in the area, and both the full-size and mini refrigerators in the room had no locks observed on them. During the same survey, an unlocked brown five-drawer medication cart was found in the facility chapel. The cart contained medications and supplies for current residents, including medications for R15, R62, R52, R57, R65, R64, R63, R53, R54, R55, R13, R56, R58, R59, R60, R61, and R33, along with needles and other medical items. The cart also contained medications from discharged residents and discontinued medications. The DON confirmed the cart was unlocked, should not have been stored in the chapel, and that medications from current and discharged residents should be destroyed after discontinuation or discharge unless pharmacy identified them as returnable. The DON and ADON stated the cart had been used as training material for a TMA course and had been stored unlocked since 3/4/26. The ADON confirmed they did not have a key to lock it and acknowledged that medications from current and discharged residents should not be used for training purposes because of privacy violations and risks of medication diversion. The consulting pharmacist confirmed that lorazepam should be double locked, that medication carts should be locked when not in use, and that discontinued medication should be destroyed and not used for training purposes. Facility policy stated controlled drugs are to be stored under double-lock and key, and medications should be locked when not in use.
Failure to Assess Self-Administration Before Leaving Medications at Bedside
Penalty
Summary
The facility failed to ensure that residents' ability to self-administer medications was assessed before medications were left with them at the bedside. The facility policy required a licensed nurse to complete a self-administration screen, determine whether the resident could self-administer independently or with supervision/set-up, and have a physician order for residents deemed appropriate to self-administer. Medications approved for self-administration were to be identified in the assessment and secured appropriately. For one resident, the record showed a completed self-administration safety screen that approved only cough drops, Arnuity Ellipta inhalation aerosol powder, Albuterol sulfate nebulization solution, and Flunisolide nasal solution. The resident's diagnoses included morbid obesity, major depression, generalized anxiety, and female stress incontinence, and the resident was cognitively intact on the last quarterly MDS. During observations, a bottle of Nystatin powder was seen on the bedside table, later missing, and then observed again in the room. The resident stated it was used for rashes between skin folds. The DON confirmed the resident had only been assessed for cough drops and inhalers, and the TMA stated the resident was only allowed to self-administer inhalers. The DON also stated the current order did not allow topical medication and questioned whether the bottle was actually the resident's because the pharmacy label was missing. For another resident, the record showed intact cognition, diagnoses including GERD, depression, and anxiety, and need for moderate assistance with ADLs and transferring. The care plan and order summaries lacked information about leaving medications at the bedside or any order for self-administration, and the chart lacked a self-administration medication assessment. Despite this, a medication cup with medications was observed on the bedside table while the resident was in bed. RN-A stated she gave the medications but did not watch the resident take them. Later, the TMA found the resident with the medication cup in hand and then watched the resident take the medications, while also verifying there was no SAM completed or order to self-administer medications. The DON and pharmacist consultant both confirmed that medications were not to be left in a resident's room without an assessment and provider order.
Failure to assess seat belt use in power wheelchairs
Penalty
Summary
The facility failed to assess two residents for the use of seat belts in power wheelchairs to determine whether the belts were restraints. R29’s quarterly MDS indicated cognitive intactness and dependence on staff for ADLs, with diagnoses including diabetes, hypertension, prior TIA, hemiplegia, and hemiparesis following cerebral infarct. R29’s care plan stated the resident could safely use a power wheelchair with verbal cues and reminders and to use a seat belt, and therapy recommended assisting R29 into the power wheelchair with the seat belt fastened and the chair tilted back with legs elevated. However, the EMR did not show a restraint assessment or a physician order for seat belt use, even though R29 was observed multiple times in the power wheelchair with the seat belt fastened and stated the belt was on when in the chair. R47’s quarterly MDS indicated cognitive intactness and dependence on staff for ADLs, with diagnoses including hemiplegia and hemiparesis following cerebral infarct, cerebral palsy, epilepsy, spondylosis, and osteoarthritis. The EMR also lacked a restraint assessment and physician order for seat belt use in the power wheelchair, and the care plan did not address seat belt use. Staff interviews showed R47 used a seat belt in the power wheelchair, could remove it independently, but had difficulty applying it due to limited use of one arm. The DON stated the expectation was to have a physician order and a restraint assessment to confirm the seat belt was not considered a restraint, and acknowledged there was no documentation that either had been completed.
Daily Nurse Staffing Posting Not Updated
Penalty
Summary
The facility failed to ensure that the required nurse staffing information was posted daily. During observation on 3/9/25 at 11:30 upon entry of the survey, the staff posting for Friday March 6th was observed in the facility. During a later observation on 3/9/26 at 1:00 P.M., the same staff posting for Friday March 6th was still observed in the facility. During interview on 03/09/2026 at 3:49 P.M., the Administrator confirmed that the staff list posted in the facility was the wrong date and stated that it should have been updated, but the person who posted it daily had gone out for the day. A facility policy titled Staff Posting, revised 10/19/23, indicated that the facility shall post daily, for each shift, the actual hours and total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care, and that the information must be verified at the beginning of each shift in a clear and readable format.
Failure to Secure Resident During Van Transport Results in Multiple Fractures
Penalty
Summary
A deficiency occurred when a transport driver (TD) failed to ensure the safe transport of a resident with severe cognitive impairment, morbid obesity, and muscle weakness. The resident, who was dependent on staff for all activities of daily living and wheelchair mobility, was transported in a facility van without a seatbelt. The TD was unable to secure the seatbelt due to the resident's size and, based on previous guidance from a former administrator, believed that securing only the wheelchair was sufficient for safety. During the transport, the resident slid out of the wheelchair and ended up on the floor of the van. Following the incident, the resident was initially evaluated at a clinic where only a hip x-ray was performed and no injuries were identified. However, over the next several days, the resident experienced increasing pain in both legs and hips, as well as visible bruising. The resident was eventually sent to the emergency department, where closed fractures of both tibias and the left femur were diagnosed. The resident required pain management and immobilization of both legs as a result of these injuries. Interviews with facility staff revealed that the TD had not received specific training on the transport of residents or the use of restraints in the facility van. The human resources director confirmed that no policies, procedures, or training related to resident transport had been provided. Facility policy required that all residents and wheelchairs be safely secured during transport, but this was not followed in the incident, leading to the resident's injuries.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to implement adequate interventions and supervision for two residents residing in a memory care unit, both identified with wandering and elopement behaviors. Resident 1, who had a history of wandering and was at risk for elopement, left the facility without staff awareness. Despite being identified as needing 24-hour supervision due to cognitive impairments, Resident 1 was able to exit the building by tailgating a staff member who did not ensure the door was securely locked. Resident 1 was later found at a nearby apartment complex, indicating a lapse in monitoring and supervision. Resident 2, also residing in the memory care unit, exhibited purpose-driven wandering and exit-seeking behaviors. Despite being assessed as a low risk for wandering, Resident 2 managed to leave the facility by using the same exit door as Resident 1. The resident, who was dependent on a wheelchair for mobility, was found outside the facility, indicating a failure in monitoring and supervision. Staff were unaware of Resident 2's absence until informed by an activity director who saw the resident outside. The report highlights that the east hallway exit door was not visible from the nurse's station, contributing to the lack of supervision. Staff interviews revealed that residents frequently talked about leaving the facility, and there was an expectation for staff to monitor residents closely, especially those with elopement risks. However, the facility's failure to ensure the door was secure and to maintain adequate supervision allowed both residents to exit the facility unnoticed.
Deficiency in Safe Patient Handling with Mechanical Lifts
Penalty
Summary
The facility failed to ensure safe patient handling during mechanical lift-assisted transfers for three residents, leading to potential accident hazards. Resident 1, who was diagnosed with functional quadriplegia and cognitive impairments, was observed being transferred using a medium sling instead of the prescribed extra-large sling. This discrepancy was noted despite the resident's care plan and Kardex indicating the need for an extra-large sling. Similarly, Resident 2, with diagnoses including polyneuropathy and muscle weakness, was also transferred using a medium sling, which was consistent with her care plan but not with the observed practice of using a large sling. Resident 3, who had polyneuropathy and mobility impairments, experienced issues with the mechanical lift transfer process. During an observed transfer, the resident had to stop the nursing assistants because the leg straps of the sling were not crossed, a mistake that had previously almost led to a fall. The resident reported frequent reminders to staff about proper sling usage and recounted an incident where she was nearly pulled forward in her recliner due to improper handling of the lift straps. Interviews with nursing assistants revealed a lack of consistent knowledge and resources regarding sling sizing. Staff members admitted to guessing sling sizes based on experience, as there was no readily available sizing guide. The Director of Nursing confirmed that residents did not have dedicated slings and that sling sizes were supposed to be listed on the Kardex. However, the facility's policy did not specify how to identify the appropriate sling size, contributing to the observed deficiencies in safe patient handling practices.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly in providing routine and assessed needs for toileting. This deficiency was evident in the cases of two residents, one residing on the main level and another in the memory care unit, who experienced significant delays in receiving assistance. Family members also expressed concerns about the inadequate number of staff to provide necessary care, and several residents and staff members voiced similar concerns about the lack of sufficient staffing. The facility's staffing shortages were reported to occur frequently, with staff often being required to float to different areas due to call-ins or open shifts, leading to delays in resident care and extended wait times for call light responses. During a resident council meeting, multiple residents reported that the wait time for staff to answer call lights could be as long as one and a half hours. Staff interviews revealed that the facility often worked short-staffed, particularly on weekends, and that agency staff were sometimes used to fill gaps. The facility's master schedule showed that staffing levels were consistently below recommended levels, with numerous instances of insufficient staffing on both the memory care and second floors. The call light alarm response report further highlighted the issue, with numerous instances of call lights going unanswered for extended periods, including two instances where call lights were on for over two hours. Specific incidents included a resident who was left on a bedpan for four hours due to unanswered call lights, and another resident who was left in the bathroom without assistance, posing a high fall risk. Staff interviews indicated that the lack of sufficient staffing prevented them from completing all required tasks and providing timely care. The facility's policy on sufficient staffing emphasized the need for qualified nursing staff to meet residents' needs safely, but the reported staffing patterns and call light response times indicated a failure to adhere to this policy, resulting in compromised resident care.
Failure to Provide Follow-Up on Resident Council Concerns
Penalty
Summary
The facility failed to provide follow-up responses to concerns raised by the resident council, affecting all 49 residents. During a resident council meeting, four residents expressed that they did not receive any answers after voicing their concerns. The facility's records from July 2024 to January 2025 showed that while concerns were marked as resolved, partially resolved, or not resolved, follow-up information was not communicated back to the residents. Concerns included issues such as the need for more shower stalls, lack of respect from aides, and delays in service, among others. Interviews with the social worker and the director of nursing confirmed the lack of documentation and follow-up on the concerns raised. The social worker acknowledged that previous concerns were not discussed with residents after action forms were completed. The director of nursing stated that the social worker was responsible for resident council meetings and documentation, and expected that concerns would be reviewed and addressed by the appropriate department, with follow-up information provided to residents. The facility's policy required grievances to be addressed and follow-up recorded, but this was not adhered to.
Failure to Update Care Plans for Discharge and Activities
Penalty
Summary
The facility failed to update the care plans for several residents, leading to deficiencies in discharge planning and activity engagement. For one resident, the care plan was not updated to reflect the resident's spouse's wishes for discharge closer to family, despite the resident's significant cognitive impairment and the spouse's expressed desires during a care conference. The care plan conference summary indicated the spouse's wish for the resident to be moved closer to family, but the care plan lacked documentation of discharge planning. Another resident's care plan was not updated to reflect the resident's need for 24/7 assistance and the plan to return to an assisted living facility. The care plan conference summary indicated the resident required extensive assistance, but the progress notes lacked documentation of discharge planning. Additionally, a resident receiving hospice services had a care plan that was not updated to include the spouse's requests for additional activities, despite the activity director's awareness of these requests. A resident who was cognitively intact and had a goal to discharge to the community did not have an updated care plan to include discharge planning for long-term care placement. The resident expressed a desire to move closer to family, but the care plan was not revised to reflect this. Interviews with facility staff, including the licensed social worker and director of nursing, confirmed that care plans were not consistently updated to include current discharge planning interventions and goals, contrary to the facility's policy.
Deficiency in Discharge Planning for Residents
Penalty
Summary
The facility failed to ensure appropriate discharge planning for four residents, leading to a deficiency in the continuation of care. Resident R41, who was severely cognitively impaired and required minimal assistance with ADLs, had undecided discharge plans. Despite the spouse's request to move R41 closer to family, there was no documentation of discharge planning in the progress notes from December 12, 2024, to February 12, 2025. Similarly, Resident R15, with mild cognitive impairment and extensive assistance needs, had plans to return to an assisted living facility, but the progress notes also lacked discharge planning documentation. Resident R42, who was cognitively intact and dependent on staff for ADLs, expressed a desire to move to a facility closer to family. Although there was some initial communication with the Mahnomen nursing home, the medical record lacked follow-up documentation on R42's wishes. The licensed social worker admitted to not documenting the discharge planning progress consistently. Resident R13, with intact cognition and extensive assistance needs, also wished to move closer to family, but the care plan and conference summary lacked documentation on discharge planning. The facility's director of nursing confirmed the lack of documentation regarding discharge planning and acknowledged it as a concern. The facility's policy on charting and documentation emphasized the importance of maintaining a medical record that details services provided and changes in the resident's condition. However, the facility did not provide a specific policy on discharge planning, highlighting a gap in their procedures.
Failure to Maintain Sanitary Environment and Equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by several observations and interviews. In one instance, a visibly soiled commode bucket was found next to a nightstand in a resident's room, and soiled bedpans were left out in a shared bathroom. The commode bucket had a darkened ring and contained debris, while the bedpans had visible spots and were not stored properly. Housekeeping and nursing staff were unclear about their responsibilities regarding the cleaning and storage of these items, leading to their prolonged presence in the residents' living areas. Additionally, the facility did not store activities of daily living (ADL) supplies in a clean and discreet manner. Observations revealed that wash basins and briefs were left on the floor in residents' rooms, visible from the hallway. Staff interviews confirmed that these items should have been stored in nightstand drawers, but this was not done, contributing to the unsanitary conditions. The facility also failed to maintain standing lifts in a clean and sanitary manner. Observations showed that the lifts had a thick accumulation of substances on their plates, and staff interviews revealed confusion about who was responsible for cleaning them. The Director of Nursing (DON) stated that all staff should ensure lifts are wiped between uses, but this expectation was not met, resulting in the continued presence of dirt and debris on the equipment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain sanitary conditions for mechanical lifts and implement proper hand hygiene practices. During observations, nursing assistants used a mechanical lift to transfer two residents without sanitizing the lift between uses. Additionally, the nursing assistants did not sanitize their hands before or after assisting the residents, despite acknowledging the importance of these practices to prevent infection spread. In another instance, a nursing assistant failed to follow proper hand hygiene and glove-changing protocols while providing personal care to a resident. The assistant did not change gloves or sanitize hands between different care tasks, such as applying lotion and performing perineal care, which could lead to cross-contamination. The assistant admitted to not receiving adequate education on proper hygiene practices and confirmed the oversight during an interview. The facility also failed to ensure safe delivery of beverages during dining service. Dietary aides were observed handling the rims of glasses and cups with bare hands, which could lead to contamination. Furthermore, the facility did not initially provide proper signage or personal protective equipment for a resident on enhanced barrier precautions due to a pressure ulcer, which was later rectified. These deficiencies highlight lapses in infection control practices within the facility.
Failure to Assess and Plan for AFO Brace Use
Penalty
Summary
The facility failed to conduct a complete and comprehensive assessment for a resident's ankle-foot orthosis (AFO) brace. The resident, who had severe cognitive impairment and multiple diagnoses including Parkinson's disease, required extensive assistance with activities of daily living. Despite these needs, the resident's care plan and electronic health record lacked information and a comprehensive assessment regarding the AFO brace. Additionally, there were no physician orders or treatment plans related to the AFO brace, and therapy recommendations to nursing staff did not include information about the brace. Observations revealed inconsistencies in the application of the AFO brace, such as the absence of a sock underneath the brace, which was not addressed in the resident's care plan. Interviews with nursing staff, including a nursing assistant and an LPN, indicated a lack of knowledge and training regarding the use and application of the AFO brace. The physical therapy assistant confirmed that no orders or assessments had been completed for the brace, and there was no communication to nursing staff about its proper use. The director of nursing acknowledged these findings and confirmed that the AFO brace was not care planned, and an assessment should have been conducted.
Inaccurate MDS Coding for Resident Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, identified as R26, during a quarterly assessment. The MDS, which is crucial for care planning, had several inaccuracies. Specifically, Section C, which assesses cognitive patterns, was left blank, and Section H, which pertains to health-related appliances, was incorrectly coded. The care plan and progress notes indicated that R26 had a suprapubic catheter, but the MDS inaccurately noted the absence of a catheter and incorrectly identified the presence of an ostomy. Interviews with the MDS Coordinator, social worker, and Director of Nursing (DON) confirmed these discrepancies. The MDS Coordinator acknowledged the incorrect coding of Section H, while the social worker admitted to omitting Section C, which should have documented R26's cognitive status. The DON verified the inaccuracies and stated that the expectation was for the MDS to be completed and coded correctly. The facility's policy requires accurate completion and certification of MDS assessments, highlighting a failure in adherence to this policy.
Failure to Assist Resident with Hearing Aid Maintenance
Penalty
Summary
The facility failed to assist a resident in maintaining their hearing needs by not ensuring the availability and repair of hearing aids. The resident, who was cognitively intact and had a history of heart failure, peripheral vascular disease, and depression, was dependent on staff for various activities of daily living. Despite having moderate difficulty with hearing and requiring hearing aids, the resident's care plan did not include any interventions related to hearing aid use. The resident reported that her hearing aids needed cleaning and repair, and although she had informed multiple staff members about the issue, no action was taken to address her needs. Interviews with the licensed social worker (LSW) and the director of nursing (DON) revealed a lack of communication and follow-up regarding the resident's hearing aids. The LSW was unaware of the issue until informed by the resident, and the DON acknowledged that staff should have reported the problem to ensure timely repair. The hearing aids were left in a nursing cart for some time before being returned to the resident's room, and no policy was provided to guide staff on handling such situations. This inaction potentially affected the resident's ability to hear and communicate effectively.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident, identified as R14, who did not receive their prescribed medications. R14, who had intact cognition and diagnoses including hypertension, neurogenic bladder, and constipation, was observed on February 11, 2025, not receiving Myrbetriq and Psyllium, which had been unavailable for several days. The resident's Electronic Medication Administration Record (EMAR) indicated that seven doses of both medications were missed. Progress notes from February 4 to February 11, 2025, documented repeated instances of the medications being unavailable, but lacked any notification to R14's provider about the unavailability of these medications. Interviews with staff, including RN-A, the pharmacy consultant, and the Director of Nursing (DON), revealed that the usual process of contacting the pharmacy and notifying the provider when medications were unavailable was not followed. The medical director confirmed that he was not contacted regarding the unavailability of R14's medications and expected the facility to have reached out for assistance with obtaining prior authorization or alternative medication. The facility's policy required physician notification when three consecutive doses were missed, which was not adhered to in this case.
Medication Error Due to Unavailable Medications
Penalty
Summary
The facility was found to have a medication error rate of 6.25% for one of the seven residents observed during medication administration. The resident, identified as R14, had intact cognition and was diagnosed with hypertension, neurogenic bladder, and constipation. R14's medication orders included Myrbetriq for overactive bladder and Psyllium for constipation. However, during an observation, it was noted that these medications were not available for administration, and the resident had not received them since February 5th. The registered nurse (RN-A) responsible for administering the medications was unaware of the shortage and had not contacted the pharmacy or the provider to address the issue. Interviews with the pharmacy consultant, director of nursing (DON), and medical director (MD) revealed that the facility failed to follow the expected protocol for handling medication shortages. The pharmacy consultant stated that the facility should have contacted the pharmacy and the physician to determine whether to hold the medication or administer an alternative. The DON confirmed that seven doses of Myrbetriq and Psyllium were missed, and the provider was not notified. The MD indicated that the facility should have contacted his office to assist with obtaining prior authorization or to decide on alternative medication. The facility's policy on administering medications emphasized the importance of administering medications as per provider orders and ensuring their availability, which was not adhered to in this case.
Failure to Administer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three residents, aged 68, 78, and 73, were offered or received pneumococcal vaccinations in accordance with the CDC recommendations. The CDC guidelines specify that adults aged 65 years or older who have previously received the PCV13 and PPSV23 vaccines should receive a dose of the PCV20 or PCV21 five years after the most recent dose. However, the medical records of these residents lacked evidence that they had been offered the PCV20 or PCV21 vaccines as required. Interviews with the infection preventionist and the director of nursing confirmed that the residents had not been offered or received the pneumococcal vaccines as per CDC recommendations. The facility's policy, revised in September 2024, stated that all residents should receive vaccines to protect them from pneumonia according to CDC guidelines. However, the facility did not have the most current CDC recommendations, leading to the oversight in offering the necessary vaccinations to the residents.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident who utilized an indwelling catheter. The resident, who had diagnoses including Alzheimer's, neurogenic bladder, and benign prostatic hyperplasia, required extensive assistance with toileting and had an indwelling catheter due to urinary retention. The resident's care plan and facility policy specified that the catheter bag should be covered at all times for dignity. However, during observations, the resident's catheter bag was found uncovered and visible to others on multiple occasions, both when the resident was seated in a recliner and lying in bed. This visibility was confirmed by staff and the director of nursing, who acknowledged that the expectation was for the catheter bag to be covered. Interviews with the resident and a family member revealed that the resident would have preferred the catheter bag to be covered, although the family member was unsure if it would have bothered the resident. The facility's policy on Foley catheter management, revised shortly before the observations, also required that catheter bags be covered at all times. Despite these guidelines, the facility did not ensure the resident's catheter bag was covered, leading to a failure in maintaining the resident's dignity.
Failure to Follow Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to follow the comprehensive care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The resident required extensive assistance with activities of daily living and was on hospice care. The care plan, revised on 11/15/24, specified that the resident should have soft cut-up foods and pureed foods when needed, and should be supervised while eating in the dining room, sitting upright in a wheelchair. However, observations revealed that the resident was fed breakfast in bed, contrary to the care plan instructions. The nursing assistant was unaware of the requirement for the resident to be in a wheelchair during meals, and the licensed practical nurse confirmed that the care plan was not being followed. Interviews with staff, including the director of nursing, indicated that the resident's care plan had not been updated to reflect the resident's current preferences, such as not wanting to get out of bed for meals. The facility's policy required that care plans be individualized and updated continuously to ensure residents receive the necessary care. Despite this policy, the care plan for the resident was not revised to accommodate the resident's current wishes, leading to a deficiency in the care provided.
Failure to Provide Required Oral Care for Resident
Penalty
Summary
The facility failed to ensure that oral care was performed for a resident who required assistance with hygiene. The resident, who was cognitively intact and had diagnoses including diabetes mellitus, arthritis, anxiety, and depression, was dependent on staff for oral care, hygiene, dressing, and bathing. Despite the care plan indicating that the resident required assistance with personal hygiene and oral care, the resident reported that staff had never asked her to wash her mouth out and did not provide oral care, including offering oral swabs or mouthwash. The resident's dentures were at home, and she expressed a desire for oral care. Observations and interviews revealed that nursing assistants did not perform oral care for the resident as expected. One nursing assistant admitted to only completing oral care for the resident twice since admission and was unaware of the proper procedures for residents with dentures. The Director of Nursing stated that the expectation was for oral care to be completed every morning and at bedtime, with specific procedures for residents with dentures. However, the facility's policy on oral assessment and management did not include instructions for oral care, contributing to the deficiency.
Failure to Provide Engaging Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide meaningful and engaging activities for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, who was receiving hospice services. The resident required extensive assistance with activities of daily living and had a care plan that included engaging in structured leisure activities. Despite the care plan's emphasis on music and other activities, observations revealed that the resident was often left in their room without being offered activities, as noted on the activity schedule. The resident's spouse had requested additional activities and communication efforts, but these were not consistently provided. Interviews with staff, including nursing assistants and the activity director, indicated that activities were seldom conducted on the memory care unit due to staffing issues. The activity director acknowledged the lack of documentation regarding resident participation in activities and the failure to complete scheduled activities. The director of nursing confirmed these findings and expressed expectations for residents to be invited to activities and for activities to be completed as scheduled. The facility's policy emphasized the importance of providing an ongoing program of activities to support residents' well-being, but this was not effectively implemented for the resident in question.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that all three years of survey results were readily accessible for residents or visitors, which had the potential to affect all 49 residents currently residing in the facility. During an observation, it was noted that the survey results were located in a white binder near the entrance, but the last survey results included were from a standard abbreviated survey dated 8/16/24. The facility lacked the survey results for surveys completed on 10/21/24 and 1/14/25. During an interview, the Director of Nursing (DON) confirmed that the last survey in the binder was from 8/16/24 and acknowledged that other surveys had been completed since then. The DON stated that all surveys should have been included in the binder for transparency, but a policy was requested and not provided.
Failure to Maintain Resident Dignity Due to Unaddressed Facial Hair
Penalty
Summary
The facility failed to maintain the dignity of a resident who was cognitively intact and dependent on staff for personal hygiene, including shaving. The resident, who had a history of hypertension, diabetes mellitus, respiratory failure, and a recent fracture, was observed with unwanted facial hair that she expressed bothered her. Despite the resident's care plan indicating the need for assistance with personal hygiene, staff did not offer to remove the facial hair until it was brought to their attention during an observation and interview. Interviews with staff revealed that the nursing assistant had not attended to the resident for a few days and was unaware of the facial hair issue until it was pointed out. The LPN acknowledged the need for facial hair removal and mentioned that the resident's family was supposed to bring a new razor, but was unsure if the facility had razors available. The Director of Nursing confirmed that the resident was capable of expressing her needs and emphasized the importance of staff assisting residents with personal hygiene to maintain dignity. The facility's policies on ADLs and resident rights highlighted the obligation to provide necessary care and services based on resident preferences and to treat residents with respect and dignity.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse to the State agency within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, anxiety, and depression, who was dependent on staff for daily activities. The resident was reported to have attempted to hit staff during care, and a trained medication aide (TMA) responded by saying, "Do you want me to hit you?" This was reported by a nursing assistant to the human resources director, but the allegation was not reported to the State agency as required. The human resources director vaguely recalled the incident and found a record of the TMA receiving a verbal warning. The director of nursing confirmed that the incident was not reported to the State agency, despite acknowledging that it could be considered abusive. The facility's policy mandates immediate reporting of abuse allegations to the administrator and the State agency, but this protocol was not followed in this case.
Failure to Submit Abuse Investigation Results Timely
Penalty
Summary
The facility failed to submit the results of an investigation into an alleged abuse incident to the State Agency within the required 5 working days. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, anxiety, and depression, who was dependent on staff for daily activities. The resident was reported to have attempted to hit staff during care, and a staff member allegedly responded in a verbally abusive manner. The incident was reported to the human resources director, who vaguely recalled the report but did not ensure the investigation results were submitted to the State Agency. The investigation into the alleged abuse was documented in the employee's file, including a counseling record and a summary of the incident. The facility's policy required immediate notification of the administrator and a thorough investigation, with a report submitted to the department of health within five business days. However, the Director of Nursing confirmed that the investigation report was not submitted as required. The facility's failure to adhere to its policy and regulatory requirements resulted in a deficiency being identified by surveyors.
Resident Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, leading to a deficiency in call light accessibility for one resident. The resident, who was cognitively intact and had a history of anxiety, depression, asthma, chronic pain, and limited mobility, was found lying in bed unable to move and without access to her call light. The call light was clipped to the wall behind the head of the bed, out of the resident's reach. This situation was discovered when the resident called out for help, and a surveyor entered the room to find the resident in distress, unable to breathe properly, and experiencing pain. Staff interviews revealed that the night shift had placed the call light out of reach, and the nursing assistant on duty was unaware of this until it was brought to her attention. The resident reported that this was not an isolated incident, as staff sometimes clipped her call light to the wall, causing her to wait for assistance. The facility's policy required call lights to be within easy access for residents, but this was not adhered to, as confirmed by the director of nursing, who emphasized the importance of call light accessibility for resident safety and dignity.
Failure to Supervise Resident with Choking Risk During Meals
Penalty
Summary
The facility failed to provide adequate supervision for a resident (R2) who required supervision while eating due to a choking risk. R2's care plan indicated the need for a Level 6 Soft and Bite-Sized diet and supervision during meals, yet during an observation, R2 was seen eating independently in a commons area without staff supervision. The staff, including an LPN and a dietary manager, acknowledged that R2 required supervision while eating, but R2 was left unsupervised due to being moved to a different area because of behavioral issues. Interviews with various staff members, including an LPN, a nursing assistant, a registered nurse, and the director of nursing, confirmed that R2 had impaired cognition and required supervision during meals. Despite this, R2 was not within visual sight of the staff during the observed meal. The facility's policy on diet and diet orders did not provide clear guidance on when residents require supervision while eating, contributing to the oversight in R2's care.
Failure to Provide Prescribed Diet to Resident
Penalty
Summary
The facility failed to ensure that a resident received the prescribed diet as ordered, specifically for a mechanically altered diet. The resident, identified as R2, had diagnoses including epilepsy, hemiplegia, and hemiparesis following cerebrovascular disease, and required a Level 6 Soft and Bite-Sized texture diet. Despite this requirement, R2 was observed eating regular corn, which was not consistent with the prescribed diet. The dietary manager confirmed that R2 should have received creamed corn instead of regular corn, indicating a failure in the dietary process. During the observation, R2 was eating independently in a commons area without staff supervision. The LPN present was unsure of R2's specific dietary needs and did not intervene to correct the diet when observing R2 eating the incorrect food. The dietary aide responsible for preparing the meal admitted to an oversight in providing the correct diet, acknowledging that R2's dietary slip was reviewed but the error occurred due to a lapse in attention. The facility's policies on diet orders and meal service were not followed, as evidenced by the incorrect meal being served to R2. The dietary manager and director of nursing both stated that the facility had processes in place to ensure diet accuracy, including tray identification systems and verification by staff. However, these processes were not effectively implemented, leading to the resident receiving an inappropriate diet.
Failure in Hand Hygiene During Toileting Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed during toileting care for a resident. The resident, who had a significant change in their Minimal Data Set (MDS) and required assistance for toileting and personal hygiene due to conditions such as fusion of the spine and reflex neuropathic bladder, was being assisted by two nursing assistants. During the care process, one of the nursing assistants, after assisting with toileting hygiene, failed to change gloves and perform hand hygiene before proceeding to touch various items in the room, including the resident's wheelchair, the mechanical lift, the garbage, and the doorknob. The nursing assistant acknowledged the expectation to change gloves and perform hand hygiene between different care tasks, especially when moving from dirty to clean tasks. The Director of Nursing also confirmed that staff are expected to remove soiled gloves, perform hand hygiene, and apply new gloves as needed. The facility's hand hygiene policy, revised earlier in the year, clearly directed staff to perform hand hygiene before applying gloves, after removing gloves, and after contact with body fluids, as well as before moving from a contaminated body site to a clean body site during resident care.
Failure to Monitor Resident Post-Fall
Penalty
Summary
The facility failed to adequately monitor a resident, referred to as R1, who experienced a fall resulting in a scalp hematoma and traumatic hematoma of the forehead. R1, who had a history of obstructive hydrocephalus, epilepsy, and was on anticoagulant therapy, fell from her bed while being assisted by a nursing assistant (NA-A) who left her unattended to retrieve wipes. This incident occurred despite R1's care plan indicating she was at risk for bleeding and excessive bruising due to her medical conditions and medication. Following the fall, R1 was taken to the emergency department where she was diagnosed with a right frontal forehead hematoma and occipital right scalp hematoma. She was discharged back to the facility with instructions to apply ice to the affected areas. However, the facility's progress notes lacked evidence of consistent monitoring of R1's bruising and neurological status for the required 72 hours post-fall, as per the facility's policy. The nursing staff, including RN-A and RN-B, failed to document the necessary neurological checks and monitoring of bruising, which were expected to be recorded every shift until resolved. Interviews with the nursing staff and the director of nursing (DON) revealed that there was a lack of adherence to the facility's post-fall policy. The DON confirmed that no treatment order was added for monitoring R1's facial bruising, and neurological checks were not documented as required. This oversight in monitoring and documentation represents a deficiency in the facility's care for R1 following her fall.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan for a resident, resulting in an accident. The resident, who had a history of obstructive hydrocephalus, epilepsy, morbid obesity, and was on anticoagulant therapy, required assistance from two staff members for bed mobility and incontinence care. Despite this requirement, a nursing assistant (NA-A) attempted to provide care alone, leading to the resident rolling off the bed and sustaining a scalp hematoma and traumatic hematoma of the forehead. The incident occurred when NA-A, who was contracted through an outside staffing agency, was assisting the resident after transferring her to bed using a mechanical lift with the help of a registered nurse (RN-A). After the transfer, RN-A left the room, and NA-A proceeded with incontinence care without the required second staff member. During the process, NA-A left the resident unattended on her side to retrieve wipes, resulting in the resident falling off the bed and hitting her head. Interviews with staff revealed that multiple staff members, including RN-A and NA-B, were aware of the resident's need for two-person assistance but did not intervene or ensure compliance with the care plan. The director of nursing (DON) confirmed that NA-A did not follow the care plan, leading to the fall. Despite the incident, there was no immediate comprehensive education or training provided to all staff regarding adherence to care plans.
Failure to Follow Enhanced Barrier Precautions for Resident with ESBL
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions for a resident diagnosed with extended spectrum beta lactamase (ESBL) resistance, which requires specific infection control measures. The resident's care plan, revised on March 21, 2022, did not include the need for enhanced barrier precautions despite the diagnosis. On July 9, 2024, nursing assistants were observed providing high-contact care to the resident without wearing the necessary personal protective equipment (PPE), such as gloves and gowns, as indicated by the signage outside the resident's room. The nursing assistants incorrectly believed that enhanced barrier precautions were only necessary for residents with wounds, infections, or catheters, which was not the case for this resident. The director of nursing confirmed that the resident was indeed on enhanced barrier precautions due to the ESBL diagnosis, and staff were expected to follow the PPE guidelines. The facility's policy on Enhanced Barrier Precautions, dated March 26, 2024, outlined that such precautions should be implemented during high-contact care activities for residents at risk of acquiring multidrug-resistant organisms (MDROs), including ESBL. The policy also emphasized the importance of clear signage and staff education regarding these precautions, which were not adequately followed in this instance.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food and beverages stored in refrigerators and freezers. During an inspection, it was observed that several items, including buttermilk, poppyseed dressing, ranch dressing, sour cream, and hazelnut creamer, were either expired or lacked proper labeling of open dates. Additionally, a package of waffles in the freezer was not labeled with an open date. The facility also had a cleanliness issue with a thick black/gray wet substance found on and around the edges of one of the three-compartment sink areas. The facility did not maintain proper dishwashing practices, as the dishwasher temperatures were not reaching the required 120 degrees Fahrenheit. A dietary aide was observed washing dishes at a temperature of 113 degrees Fahrenheit and did not apply sanitizer to the dishes afterward. The facility's dishwasher temperature logs showed inconsistent temperatures ranging from 106 to 130 degrees Fahrenheit over the past month. The dietary aide was unaware of the correct procedure when the dishwasher did not reach the required temperature. Staff members were not wearing appropriate hair restraints during food preparation and service. A dietary aide was observed wearing a baseball cap that did not cover his shoulder-length hair and had a beard without a beard net. Another dietary aide was seen handling drink glasses by the top rim with bare hands, which could lead to contamination. The dietary manager confirmed that staff were trained to avoid such practices and that proper hygiene was expected. The facility's policies required all dietary staff to wear approved hair restraints and handle utensils and drinking cups to avoid touching eating surfaces.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to its staff. The deficiency was identified through interviews and document reviews, which revealed that the facility's New Employee Orientation Guide, Relias Training Essentials, and the Nursing and Rehab Employee Handbook lacked documentation on QAPI training. Several staff members, including nursing assistants, licensed practical nurses, and trained medical aides, were interviewed and confirmed their lack of knowledge about QAPI. They were unaware of what QAPI stood for or how it was implemented in the facility. The Director of Nursing (DON) was also interviewed and expressed surprise that staff were not being trained on QAPI. The DON acknowledged the importance of staff understanding QAPI as it informs them of current quality projects and necessary improvements within the facility. Despite the DON's recognition of the importance of QAPI training, a policy for such training was not provided upon request, indicating a systemic issue in the facility's training program.
Deficiencies in Sanitation of Resident Supplies and Equipment
Penalty
Summary
The facility failed to store tube feeding and suctioning supplies in a clean and sanitary manner for a resident who was hospitalized. The resident, who was mildly cognitively impaired and had multiple diagnoses including depression, COPD, quadriplegia, and epilepsy, was totally dependent on staff for all transfers, ADLs, and personal hygiene. Observations revealed that after the resident was transported to the hospital, tube feeding and suction supplies were left in the resident's room. These included a tube feeding bag with formula, a bag with clear fluid, and a suction machine with a canister containing substances. The registered nurse confirmed that nursing staff should have managed the supplies when the resident was hospitalized, and the DON stated that supplies should be disposed of immediately after a resident leaves for the hospital. Additionally, the facility failed to maintain standing lifts shared by residents in a clean and sanitary manner. Observations showed that three standing lifts in the hallway had dried yellow/brown food-like substances on their lower ends. Both a housekeeper and a nursing assistant confirmed the presence of the substance and were unsure of who was responsible for cleaning the lifts. The DON stated that all staff should ensure lifts are wiped between uses, including the foot plates, and that lifts should be cleaned per policy. The facility's policy required reusable equipment like mechanical lifts to be cleaned and disinfected after use by one resident and before use by another.
Failure to Ensure Safe Nebulizer Administration for Resident
Penalty
Summary
The facility failed to ensure the safe administration of nebulizer medications for a resident who was observed self-administering a nebulizer without being assessed as safe to do so. The resident, identified as having moderate cognitive impairment and a history of acute respiratory failure, COPD, and hypertension, was observed seated in a wheelchair with a nebulizer mask on, without staff supervision. The resident's care plan indicated a dependency on staff for daily living activities due to immobility and weakness, but lacked interventions related to self-medication administration. Additionally, the resident's medical records did not include a self-administration of medication (SAM) assessment or an order to self-administer medication. During interviews, a trained medication aide (TMA) and the nurse manager confirmed that the resident had not undergone a SAM assessment. The TMA admitted to placing the nebulizer on the resident and leaving the room, which was against the facility's policy that required staff to remain with residents during nebulizer treatments if a SAM assessment had not been completed. The director of nursing also confirmed the absence of a SAM assessment and reiterated the expectation for staff to stay with residents during nebulizer administration in such cases. The facility's policy required a licensed nurse to screen residents for safe medication administration and obtain a physician's order for those deemed appropriate to self-administer medications.
Inadequate Supervision and Assessment for Resident Smoking
Penalty
Summary
The facility failed to ensure adequate supervision and accurate assessment for a resident with moderate cognitive impairment who was identified as not safe to smoke unsupervised. The resident's care plan required direct supervision during smoking activities and the use of a smoking apron for safety. However, observations revealed that the resident was left unsupervised while smoking on multiple occasions, with the smoking apron improperly secured, leading to ashes falling on the resident's clothing and wheelchair. Interviews with staff confirmed that the resident was allowed to smoke without supervision, contrary to the care plan's requirements. The nursing assistant and activity aide were unaware of how to monitor the resident's safety while smoking. The Licensed Practical Nurse (LPN) acknowledged that the smoking assessment did not match the care plan and was inaccurate, leading to a lack of proper supervision. The Director of Nursing (DON) and regional nurse were aware of the discrepancies in the smoking assessment but did not update it. The facility's policy required individualized approaches for resident safety during smoking, but these were not effectively communicated or implemented, resulting in the resident being left unsupervised and at risk during smoking activities.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feeding formula according to the physician's orders for a resident identified as R43. R43, who was cognitively intact and had diagnoses including cancer and diabetes, required tube feeding due to swallowing difficulties. The physician's orders specified continuous tube feeding of Peptamen 1.5 at 65 mL per hour for 24 hours. However, observations and interviews revealed that the nursing staff were not adhering to these orders, as they were stopping the tube feedings during the day without proper documentation or notification to the medical provider or dietician. During observations, it was noted that R43 was receiving tube feedings inconsistently, with the pump being turned off during the day and resumed in the evening. R43 reported that this had been occurring for a couple of weeks, and he often vomited before meals. Despite these issues, there was no documentation in the progress notes indicating that R43 was refusing tube feedings or that the staff were stopping them. Interviews with nursing staff confirmed that they were stopping the tube feedings during the day due to R43's refusal, but they failed to document these refusals or notify the appropriate medical personnel. The Director of Nursing (DON) was unaware of the staff's actions and believed that the orders were being followed. The facility's policy required verification of physician orders for tube feeding, but the staff did not comply with this policy. The DON acknowledged the importance of following orders and documenting any refusals or changes in care, but these expectations were not met, leading to the deficiency in care for R43.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy as ordered by the physician for a resident with chronic obstructive pulmonary disease (COPD) and respiratory failure. The resident, who was cognitively intact, was observed in the dining room without receiving the prescribed continuous oxygen therapy via nasal cannula at 2 liters per minute. Despite having a portable oxygen tank on the back of her wheelchair, there was no oxygen tubing connected to the tank. The resident expressed feeling short of breath multiple times while in the dining room. The registered nurse (RN) on duty was unable to immediately address the resident's need for oxygen due to being occupied with discharging another resident. The RN eventually checked the resident's oxygen saturation, which was found to be critically low at 79%, and then connected the oxygen tubing to the concentrator, setting it to the prescribed 2 liters. The Director of Nursing confirmed that the resident was supposed to have continuous oxygen therapy to maintain saturation levels above 90% and acknowledged the failure to adhere to the physician's orders.
Improper Handling of Linens Leads to Contamination Risk
Penalty
Summary
The facility failed to ensure proper handling and transportation of personal laundry, leading to a risk of contamination. During an observation, a nursing assistant was seen carrying soiled bed linen with her bare hands against her clothing, which included a pillowcase that was dropped on the floor and picked up without gloves. The nursing assistant admitted to carrying the soiled linen, which contained urine, without wearing gloves and acknowledged that the linen should have been placed in a bag before being transported through the hallway. Additionally, a nurse manager was observed carrying a clean hoyer sling over her shoulder, allowing it to touch her clothing after providing care to other residents. The nurse manager confirmed that the clean hoyer sling should not have been placed against her clothing to prevent the spread of infections. The director of nursing and infection preventionist stated that the expectation was for staff to wear gloves and bag soiled linen before transport and to carry clean linen away from the body, as per the facility's policy on handling linens and laundry.
Failure to Notify State Agency of DON Appointment
Penalty
Summary
The facility failed to notify the State agency (SA) as required when the current Director of Nursing (DON) was appointed to their position. This deficiency was identified during an extended survey conducted on June 27, 2024, when evidence was requested to demonstrate that the SA had been informed of the DON's hiring. During an interview on the same day, both the administrator and the DON confirmed that the SA was not notified of the DON's appointment. The administrator further indicated a belief that notifying the SA was no longer a requirement. The facility's document titled 'DON Job Description,' prepared on April 17, 2012, and signed by the DON on October 9, 2023, was reviewed, but no further information was provided.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure residents received the prescribed diets as ordered for three residents reviewed for therapeutic diets. Resident 1 (R1) had a hospital discharge order for a pureed diet with moderately thick liquids and thickened Ensure plus supplements. However, R1 did not receive breakfast on the morning of 4/13/24 and was served inappropriate food items such as a regular piece of cake, a pulled pork sandwich, and regular consistency liquids. Family members reported these discrepancies, and the dietary manager confirmed the issues, stating she was not aware of the problems until 4/15/24. Resident 4 (R4) had a physician's order for a mechanically altered therapeutic diet of minced and moist texture with thin liquids. However, R4 was observed with a plate of pureed food, which she found unappetizing and did not eat. The dietary manager and director of nursing verified that R4 received the incorrect diet. The cook admitted that the team had decided to lower R4's diet to pureed without proper documentation or a physician's order, based on nursing communication about swallowing difficulties. Resident 7 (R7) had a dietary order for a regular diet with soft and bite-sized texture and thin liquids. However, R7 was observed with uncut roast beef and other food items not prepared according to the prescribed diet. The dietary manager confirmed that R7 received food that was not cut into bite-sized pieces. The registered dietician emphasized the importance of communicating diet changes to the dietary department and documenting them in progress notes to prevent potential risks such as aspiration or choking.
Failure to Monitor and Document Wound Care
Penalty
Summary
The facility failed to ensure non-pressure related wounds were monitored for signs and symptoms of infection and healing until resolved for three residents. Resident 1 (R1) had a displaced comminuted fracture of the right tibia and a surgical wound. Despite orders to monitor and document the status of the wound every shift, R1's medical record lacked evidence of such documentation. Additionally, there were no physician orders for wound treatment following an orthopedic appointment, and the wound was not properly monitored, leading to an infection diagnosed after discharge from the facility. Resident 2 (R2) had surgical wounds with staples on the spine and iliac crest. The care plan directed staff to administer treatments and monitor the wounds weekly, but the treatment administration record lacked evidence of a nursing order to monitor for signs of infection or healing. Observations revealed redness around the incision, but no signs of infection were noted. However, the facility failed to ensure proper monitoring and documentation of the wound's status. Resident 3 (R3) had a skin tear on the right hand, open areas on the coccyx, and stitches on the left knee. The care plan failed to identify the actual skin impairment of the left knee with stitches. The treatment administration record directed staff to monitor wounds every shift, but it lacked specific directions on which wounds to monitor. Observations revealed that staff were unaware of the stitches on R3's left knee, and there were no treatment orders for the wound. The facility failed to ensure proper monitoring and documentation of R3's wounds, leading to inadequate wound care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakewood Health System | 15.8 mi | ★★★★★ | 3 | 0 |
| Green Pine Acres Nursing Home | 22 mi | ★★★★★ | 6 | 0 |
| St Williams Living Center | 22.2 mi | ★★★★★ | 5 | 0 |
| Perham Living | 24.8 mi | ★★★★★ | 7 | 0 |
| Central Todd County Care Center | 26.3 mi | ★★★★★ | 5 | 0 |
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