Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Good Samaritan Society Inver Grove Heights during CMS and state inspections, most recent first.
A facility failed to keep advance directive and code status information consistent across the EHR banner, POLST, and order summary for three residents. One resident on hospice with severe cognitive impairment had conflicting full code and DNR documentation, and staff disagreed on whether to rely on the POLST binder or the EHR banner. Another resident’s chart contained both DNR and CPR-related documentation after the resident and daughter requested full code, and a third resident had POLST, hospice, and order summary records that did not match the resident’s stated DNR wishes.
Failure to provide required Medicare non-coverage notices: the facility did not issue SNFABNs for two residents who remained in the LTC facility after Medicare Part A ended, and it did not provide one resident with the required 48-hour NOMNC before Medicare A discharge. The DSS confirmed that a SNFABN is always needed when a resident stays in the facility and that the notice process depends on timely communication from therapy when Medicare A coverage is ending.
Psychotropic Medication Monitoring Not Completed: A resident receiving antidepressants had no documented target behavior monitoring in the order record, care plan, or MAR, despite staff stating psychotropic medications require such monitoring. Another resident with dementia and kidney failure was receiving melatonin, mirtazapine, and quetiapine, but the MAR only showed check marks for side effect and sleep monitoring without documenting observed sedation, daytime drowsiness, or hours slept. Staff observations and interviews described the resident as frequently fatigued, sleepy, and snoring during the day.
A resident with severe cognitive impairment and OSA had a CPAP order for bedtime use, but the facility did not document or consistently manage cleaning and maintenance of the CPAP equipment. Staff observed the mask resting on top of the machine, an RN stated he did not wash the mask and was unsure when it was last cleaned, and the DON verified the orders, MAR, and TAR did not include the cleaning and maintenance directions found in the manufacturer’s instructions and facility policy.
A resident with moderate cognitive impairment, anemia, diabetes, kidney failure, and scheduled hemodialysis had incomplete communication between the LTC facility and the dialysis clinic. The record showed that the resident returned from dialysis without paperwork on multiple occasions, but nursing notes did not document follow-up with the dialysis center, and only a few dialysis communication forms were found for the reviewed treatments; some forms were also left incomplete.
A resident with acute pain related to a right hip fracture received multiple PRN doses of acetaminophen and oxycodone, but the MAR and progress notes lacked documentation that non-pharmacological interventions were offered, used, or declined before administration. Staff stated such interventions should be offered and documented, and the resident said she had not been offered alternatives to pain medication and would like to be offered ice for pain.
A resident with impaired cognition, oxygen use, hospice services, and multiple serious diagnoses was observed with a cracked, splintered headboard and footboard and a personal fan covered with visible dust and matter while blowing air across the resident’s head. The resident and SO stated the bed had been broken for months and the fan had not been cleaned, and multiple staff members acknowledged the dirty fan and damaged bed parts, but no maintenance request had been submitted for the repairs.
Two residents who were cognitively intact and dependent on staff for ADLs did not receive regular grooming or personal hygiene care, resulting in long fingernails, unkempt hair and beard, and an uncovered catheter bag visible in public areas. Both residents expressed dissatisfaction with their appearance and care, and staff acknowledged that scheduled grooming and privacy measures were not consistently provided, contrary to facility policy.
Several residents dependent on staff for ADLs did not receive consistent nail care or scheduled bathing assistance. One resident with quadriplegia had very long fingernails and reported infrequent trimming, while another resident requiring staff help for bathing received only two baths in a month, had unkempt hair and beard, and long, jagged nails. A third resident missed multiple scheduled baths, with no refusals documented. Staff interviews and documentation revealed confusion about responsibilities and discrepancies between care schedules and actual care provided.
A resident with hypothyroidism did not receive a TSH blood draw as ordered due to a missing room number on the initial order and lack of follow-up to ensure the lab was performed. Staff interviews revealed confusion about the lab order process, and documentation showed no evidence that the required lab was reordered or completed, despite facility policy requiring tracking of lab orders.
Staff failed to follow infection control protocols for two residents on enhanced barrier precautions, including not performing hand hygiene between glove changes and when entering or exiting rooms, and not securing a catheter leg bag off the floor. Both nursing and direct care staff acknowledged these lapses, which were observed during routine care and confirmed by facility leadership as contrary to policy.
The facility failed to ensure proper food safety practices in the kitchen, as a cook used a thermometer without cleaning it between different food items, using expired wipes and non-food-safe wipes. The Food and Nutrition Service Manager was unaware of the expired wipes and the cook's improper practices, and the facility's policies on food temperature monitoring and sanitization were not followed, posing a risk of cross-contamination for all 36 residents served the meal.
The facility failed to involve four residents in care planning, as required by policy. One resident with severely impaired cognition and another with intact cognition were not invited to care conferences. A resident with moderately impaired cognition had no care conferences documented in 2024, and another resident with quadriplegia had not had a care conference since July 2024. The licensed social worker acknowledged these oversights, which contravened the facility's policy of involving residents and their representatives in care planning.
A resident with intact cognition reported verbal and nonverbal abuse by three staff members, but the facility failed to report the allegations to the state agency within the required timeframe. Despite the resident's history of making accusations, the facility did not investigate or follow up on the new allegations, and the aide continued to care for the resident. The facility's policy required immediate reporting, but the staff did not adhere to this due to the resident's past behavior.
A resident with a history of making accusations reported verbal and nonverbal abuse by staff, but the facility failed to investigate or implement a protection plan. Despite the facility's policy requiring investigation and removal of accused staff, the resident's aide continued to provide care. The care plan did not specify procedures for handling new abuse allegations, and the facility did not report the incident to the state agency.
A facility failed to develop a baseline care plan for a resident who smoked, despite being a non-smoking campus. The resident, diagnosed with nicotine dependence, was not offered nicotine replacement therapy or smoking cessation support upon admission. Inconsistent messages from staff about smoking locations and a delay in updating the care plan contributed to the deficiency.
A resident requiring assistance with ADLs did not receive routine personal care, including bathing and nail care, for at least 10 days. Despite a preference for two baths per week, the resident had not been offered a bath or shower, and their fingernails were long and untrimmed. Staff confirmed that nail care should be provided with showers, but there was no documentation of this care being offered or performed.
A resident with dementia lost her glasses, and the facility failed to address her vision needs. Despite documentation indicating the use of corrective lenses, the care plan and Kardex lacked this information. Staff were unaware of the missing glasses, and the DON was not informed until the survey. The facility's Eye Care policy was not followed, as no appointment was set up to replace the glasses.
A resident with severe cognitive impairment and a history of pressure ulcers was not repositioned as required in an LTC facility. Despite orders to turn the resident every two to three hours, observations revealed the resident remained in the same position for several hours. The RN and NA responsible for repositioning admitted to not following the schedule due to being busy, highlighting a lapse in care for a resident at high risk for pressure injuries.
A facility failed to monitor side effects for a resident on psychotropic medications, including trazadone and Cymbalta, despite the presence of boxed warnings for suicidal thoughts. The care plan and MAR lacked documentation of side effects, non-pharmacological interventions, or target behaviors. Staff interviews confirmed the absence of necessary monitoring practices.
A facility experienced a delay in transcribing a medication order for a resident with pressure ulcers, leading to a delay in antibiotic administration. The order, written by an NP, was not entered into the EHR until 15 days later. Communication and documentation issues were identified, including the misplacement of the written order and incomplete wound care assessments. Staff interviews revealed challenges in EHR entry and follow-up by an LPN, highlighting gaps in the facility's processes for timely and accurate documentation.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that residents’ advance directives were accurately and consistently documented across the EHR banner, POLST, and physician orders for three residents reviewed for code status. Surveyors found conflicting code status information in multiple locations, including full code, DNR, and comfort-focused orders, with some records showing outdated or incomplete POLST forms and others showing different orders in the EHR order summary and banner. For one resident with severely impaired cognition who was receiving hospice care and had diagnoses including stroke, seizure disorder, and respiratory failure, the record contained multiple conflicting POLSTs and progress notes showing changes between full code and DNR/comfort measures only. The resident’s EHR banner showed DNR, while other documents in the chart and hospice reports alternated between full code and DNR. Staff interviews showed the RN relied on the orange POLST binder at the nursing station to determine code status in an emergency, while the DON stated staff should use the EHR banner and order summary because those should match. The DON also stated the binder at the nursing station was not something she realized was there and was unsure when it was last updated. For another resident with intact cognition and diagnoses including stroke, heart attack, end-stage kidney disease on dialysis, diabetes, and heart disease, the chart contained a POLST indicating DNR/allow natural death with selective treatment, but later progress notes documented the resident and daughter requesting full code. The resident later affirmed full code when staff discussed it, and the EHR banner showed CPR with instructions to follow POLST part B if not in arrest. The care plan did not reference code status, and one care conference note did not clearly document whether code status was discussed. For a third resident receiving hospice services with moderate cognitive impairment and diagnoses including heart failure, kidney disease, and respiratory failure, the chart contained POLSTs showing attempt resuscitation/full treatment, while the order summary included a DNR order and progress notes documented the resident wanting DNR with comfort-focused care after returning from the hospital. A care conference note stated an updated POLST was needed, but it was not received. Hospice reports later documented DNR with comfort measures only, while the EHR and binder still contained inconsistent code status information.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to 2 of 3 residents reviewed whose Medicare Part A coverage ended and who remained in the facility. For R14, the admission MDS indicated admission on 12/5/25, and the NOMNC signed on 1/26/26 showed Medicare A coverage ended on 1/29/26 with the resident assuming the cost of care; however, the EMR lacked evidence that R14 and/or the representative received a SNFABN after Medicare A ended and the resident remained in the facility. For R38, the admission MDS indicated admission on 1/12/26, and the EMR lacked evidence that R38 and/or the representative received a SNFABN when Medicare A coverage ended on 2/11/26 and the resident remained in the facility assuming the cost of care. The facility also failed to ensure an appropriate 48-hour notice was given for R51, whose admission MDS indicated admission on 12/12/25. R51's NOMNC signed on 1/22/26 showed Medicare A coverage ended on 1/23/26, but the notice did not provide the required 48-hour advance notice before discharge from Medicare A and the facility. During interviews, the DSS stated that R38 transitioned to hospice within hours of Medicare A ending and did not have time to complete a SNFABN, that R14 transitioned to hospice within days of Medicare A ending and had Medicaid pending, and that R51 was not given an appropriate 48-hour NOMNC notice. The DSS also stated that if a resident remains in the facility, a SNFABN is always needed, and that notices are issued when therapy informs her Medicare A is ending.
Psychotropic Medication Monitoring Not Completed
Penalty
Summary
The facility failed to monitor resident-specific target behaviors related to psychotropic medication use for one resident. The resident had diagnoses including major depressive disorder and was ordered bupropion HCL ER 150 mg each morning and escitalopram oxalate 10 mg daily. The physician order report did not include any direction to monitor target behaviors or identify what behaviors were to be monitored, and the care plan also lacked documentation of target behaviors or monitoring instructions. The February MAR/TAR showed the medications were administered as ordered, but there was no evidence of target behavior monitoring documented there either. During interviews, RN-B stated that any psychotropic medication has target behavior monitoring and that nursing enters the orders with side effect monitoring when a resident is admitted. RN-A stated target behaviors are identified on the care plan and documented under treatments, and verified this resident did not have target behavior monitoring in place. The DON stated target behaviors are documented on the MAR and that the expectation was all psychotropic medications have target behavior monitoring to help ensure the medication is appropriate for residents, and also verified this resident did not have target behavior monitoring in place. The facility also failed to ensure appropriate medication side effect monitoring for another resident with dementia, paranoid personality disorder, depression, and kidney failure who was receiving melatonin, mirtazapine, and quetiapine. The resident’s MAR included orders for antidepressant, antipsychotic, and hypnotic side effect monitoring, including sleep problems, sedation, daytime drowsiness, and hours of sleep each shift, but the entries were only checked as completed and did not document whether symptoms were observed or how many hours the resident slept. Progress notes and observations described the resident as often tired, fatigued, sleepy, and snoring during the day, including while lying in bed with the lights on. Staff interviews confirmed the resident was often sleepy, especially after dialysis, and RN-A stated the sleep-hour tracking was not being completed. The DON later confirmed the sleep monitoring order had been entered incorrectly and that the resident’s hours of sleep were not being monitored.
CPAP Cleaning and Maintenance Not Properly Managed
Penalty
Summary
The facility failed to ensure proper cleaning and maintenance of a resident’s CPAP machine. The resident had severe cognitive impairment, required maximal assistance with bathing and upper body dressing, and moderate assistance with personal hygiene. The resident also had diagnoses of Parkinson’s disease, depression, and obstructive sleep apnea, with an order for CPAP use at bedtime. The resident’s care plan did not include a respiratory care plan related to the CPAP machine, and the electronic medical record lacked documentation about cleaning and maintaining the equipment. During observations, the CPAP mask was seen resting on top of the machine with the cushion down, and later the mask remained on top of the machine while attached to the tube and machine. An RN stated he removed the mask, checked the resident’s oxygen level and skin, but did not wash the mask and was not sure when it had last been cleaned. He also stated the overnight nurse changed the tube and washed the machine using vinegar. The resident’s family member stated she had been cleaning the mask and wiping the machine during visits, washing the tubing weekly, changing the mask as needed, and had taken the CPAP to the sleep clinic once since admission. The DON stated the facility expected staff to clarify CPAP cleaning and maintenance orders and the family member’s role, and verified the resident’s orders, MAR, and TAR did not include directions to clean the mask daily or change the filter, reservoir, or tubing as described in the manufacturer’s instructions and facility policy.
Dialysis Communication and Follow-Up Not Maintained
Penalty
Summary
The facility failed to maintain an appropriate communication and collaboration system with an outside dialysis clinic for a resident who received hemodialysis on Mondays and Fridays. The resident had moderate cognitive impairment and medical conditions including anemia, diabetes, and kidney failure. The resident’s order summary directed staff to send a dialysis communication sheet with the resident and to check it upon return for new orders, and the care plan included dialysis monitoring, dialysis center contact information, transportation information, and instructions related to the dialysis access port. Progress notes from the review period documented that on two occasions the resident returned from dialysis without any paper from dialysis, and the notes did not show that staff followed up with the dialysis center when communication was not received. Of eight dialysis appointments reviewed, only three dialysis communication forms were found, and two of those forms had the section for dialysis completion left blank. One hemodialysis patient communication sheet included vital signs, pre- and post-treatment weight, medications given, and a recommendation of no complications. Interviews with the HIM, RN-A, DON, and the dialysis center charge nurse confirmed that staff expected the facility to call the dialysis center and request the form if it was not returned, but the record did not show that this occurred. A dialysis policy was requested but not received.
Failure to Document Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted and documented before administering PRN pain medication for a resident with acute pain related to a right hip fracture. The resident’s admission MDS identified moderately impaired cognition and no hallucinations, delusions, behaviors, or rejections of care. The resident’s care plan, printed after admission, included interventions for acute pain such as attempting non-pharmacological interventions and encouraging different pain-relieving methods including positioning, relaxation therapy, progressive relaxation, bathing, and heat and cold application. The resident’s MAR showed multiple administrations of PRN acetaminophen and oxycodone, including doses for pain rated 3-7 and 8-10, with effectiveness documented for many doses and some doses marked unknown. However, the MAR and progress notes from the review period lacked documentation that non-pharmacological interventions were offered, administered, or declined before these PRN pain medications were given. Nursing staff stated they would offer nonpharmacological interventions prior to PRN pain medication and document them in progress notes, and the resident stated she had not been offered alternatives to pain medication and would like to be offered ice for pain. The DON stated the expectation was that nonpharmacological interventions would be offered before PRN medications and documented on the MAR/TAR or in a progress note, but no documentation was identified.
Dirty Personal Fan and Broken Bed Components
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for one resident whose headboard and footboard were not in good repair and whose personal fan was visibly dirty. The resident’s significant change in status assessment identified impaired cognition, dependence on two staff for all personal cares and transfers, oxygen use, hospice services, and diagnoses including heart failure, kidney disease, hip fracture, respiratory failure, obesity, and lymphedema. During observation, the resident was lying in bed with cracked, splintered particle board along the top of the headboard and footboard, with edge banding not adhered. The resident’s personal fan had visible matter attached to the front and blades and was operating on high speed, blowing air across the resident’s head while the resident was using oxygen at 2 liters via nasal cannula. The nightstand holding the fan also had visible dust on all surfaces. The resident stated the bed parts had been in disrepair for as long as she had been there and did not look good, and she could not recall whether the fan or nightstand had ever been wiped down when housekeeping came into the room. The resident’s significant other stated he visited daily, that the fan was usually on all the time, that no one had cleaned it, and that the bed had been broken since the prior September with staff aware but doing nothing about it. Staff interviews showed the nursing assistant, RN, DON, housekeeping, infection control preventionist, and maintenance director all observed the dirty fan and damaged bed components, but no one had submitted a maintenance request for the headboard and footboard. The DON stated housekeeping was responsible for cleaning personal fans, while housekeeping stated they had never been told to wipe them down and had not noticed the bed damage before.
Failure to Maintain Resident Dignity Through Personal Care and Privacy
Penalty
Summary
The facility failed to maintain resident dignity for two cognitively intact residents who were dependent on staff for activities of daily living. One resident, diagnosed with quadriplegia, was observed with excessively long fingernails and reported that her nails were trimmed only occasionally, despite her preference for short nails. She expressed feeling neglected by staff. The Director of Nursing confirmed that the resident's nails were too long and should have been cut during routine care, acknowledging that residents do not feel well cared for when such needs are unmet. Another resident, with an indwelling catheter and neurological conditions, was found with uncombed hair, an untrimmed beard, and long, jagged fingernails. The resident stated he had not received a shower in weeks and had only one beard trim and haircut during his seven-month stay. His catheter bag was left uncovered and visible in a public area, which the resident found embarrassing. Staff interviews and family input confirmed that the resident valued personal grooming and would be distressed by his unkempt appearance and exposed catheter. Facility policies required grooming according to resident preferences and covering of catheter bags, but these were not followed.
Failure to Provide Consistent Nail Care and Bathing Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for multiple residents who were unable to perform these tasks independently. Specifically, two residents did not receive appropriate nail care, and two residents did not receive scheduled bathing or shower assistance. One resident with quadriplegia and dependent on staff for all ADLs was observed with very long fingernails and reported that her nails were trimmed only occasionally, with weeks passing since the last trim. Staff interviews revealed uncertainty about who was responsible for nail care, and a family member confirmed the resident's nails were long and needed cutting. Another resident, who was cognitively intact and required staff assistance for bathing, had an inconsistent bath schedule and received only two baths in the past 30 days. Documentation and staff interviews indicated discrepancies between the posted bath schedule and actual care provided, with staff unable to locate recent bath records in the electronic health record. This resident was also observed with uncombed hair, an untrimmed beard, and long, jagged fingernails. The resident stated he had not received regular showers or grooming, and staff acknowledged that nail care was not provided because the resident was diabetic, and the usual staff member responsible was unavailable. A third resident, dependent in all ADLs due to multiple sclerosis, missed several scheduled baths, with no documentation of refusals. Observations noted greasy hair, and staff confirmed that scheduled baths were not provided despite adequate staffing. The facility's policy required assistance with grooming and hygiene for residents unable to perform these tasks, but documentation and interviews confirmed that scheduled nail care and bathing were not consistently provided for these residents.
Failure to Perform Ordered TSH Lab Draw for Resident with Hypothyroidism
Penalty
Summary
A provider order for a TSH (thyroid-stimulating hormone) blood draw was not performed as ordered for a resident with a diagnosis of hypothyroidism. The resident's medical record indicated a history of memory problems and an inability to complete a cognitive assessment. The TSH lab was initially not drawn because the order was missing the resident's room number, and it was documented that the lab would be redrawn on a later date. However, there was no evidence in the medical record that a new order was placed or that the lab was subsequently performed as intended. Interviews with facility staff revealed a lack of awareness and clarity regarding the lab order process. The RN interviewed was new and unfamiliar with the lab order, and the DON stated that nurses were responsible for entering lab orders but was unsure how the TSH order was missed. The nurse practitioner confirmed that the TSH level was necessary to monitor and adjust the resident's levothyroxine dosage, as the previous TSH result was elevated and the medication dose had been adjusted accordingly. Facility policy required staff to enter provider orders and track when labs were due, but this process was not followed in this instance.
Failure to Follow Infection Control Practices for Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for two residents with indwelling catheters and enhanced barrier precautions (EBP) in place. For one resident, staff did not perform hand hygiene between glove changes or when entering and exiting the room, despite posted EBP signage and facility policy requiring such actions. Observations showed a registered nurse changing gloves multiple times without hand hygiene and another nurse entering and exiting the room, as well as changing personal protective equipment, without performing hand hygiene. Both nurses acknowledged during interviews that they did not follow hand hygiene protocols, with one stating she was in a rush and the other admitting to touching multiple items in the room without cleaning hands. For another resident, the facility failed to ensure that a catheter leg bag was properly secured and not resting on the floor. The resident was observed in the dining room with a full catheter bag and its strap on the floor, and the resident expressed concern about the risk of infection due to this practice. A nursing assistant confirmed the bag was on the floor and acknowledged the risk of infection, subsequently securing the bag to the resident's leg. The director of nursing confirmed that catheter bags should not rest on the floor and reiterated the expectation for staff to perform hand hygiene as outlined in facility policy.
Improper Food Safety Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety practices in the main production kitchen, specifically regarding the use of thermometers to check final cooking temperatures. During an observation, a cook used a spike-style thermometer to check the temperature of lasagna without properly cleaning the probe between different food items, such as lasagna and carrots. The cook used expired Ecolab Probe Wipes to clean the thermometer and was unaware of the importance of checking expiration dates on these wipes. Additionally, the cook admitted to occasionally using Purell Hand Sanitizing Wipes, which are not food-safe, to clean the thermometer probe. The Food and Nutrition Service Manager (FNM) was unaware of the expired status of the Ecolab wipes and had not instructed the cook to check for expiration dates. The FNM also did not know that the cook was using non-food-safe wipes for cleaning the thermometer. The facility's policy on food temperature monitoring and thermometer sanitization was not followed, as it required the use of food contact-approved sanitizing solutions and cleaning the thermometer between different food items to prevent cross-contamination. Interviews with the registered dietician and the Ecolab representative revealed a lack of clarity and communication regarding the proper use and expiration of sanitizing wipes. The registered dietician was not regularly onsite and was unsure about the specifics of the wipes used. The Ecolab representative confirmed that the wipes were likely expired and suggested using a food-safe contact cleaning solution instead. The facility's failure to adhere to its own policies and ensure proper food safety practices posed a risk of cross-contamination and foodborne illness for all 36 residents served the meal.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to provide opportunities for four residents to participate in the development and implementation of their person-centered care plans. Resident 22, who had severely impaired cognition, did not have evidence of their representative being invited to or attending a care conference from February to December 2024. The representative confirmed not being invited since October 2023, despite wanting to participate. Similarly, Resident 31, with intact cognition, was not invited to or attended a care conference during the same period, and the resident expressed a desire to participate. Resident 1, with moderately impaired cognition and multiple diagnoses including dementia and diabetes, had no documented care conferences in 2024. The last recorded care conference was in October 2023, and the family member involved expressed concerns about the lack of communication and involvement in care planning. The licensed social worker acknowledged the oversight and the importance of care conferences, noting that Resident 1 was due for one by the end of October 2024. Resident 15, with intact cognition and conditions such as quadriplegia and epilepsy, had not had a care conference since July 2024, after returning from the hospital. The resident expressed a desire for more involvement through care conferences, which had not been scheduled since their return. The licensed social worker confirmed the lapse and acknowledged the need for a care conference following the resident's hospital readmission. The facility's policy requires residents and their representatives to be invited to care conferences, which was not adhered to in these cases.
Failure to Report Abuse Allegations in a Timely Manner
Penalty
Summary
The facility failed to immediately report incidents of potential staff-to-resident abuse to the state agency within the required two-hour timeframe for a resident reviewed for abuse. The resident, who had intact cognition and no delusional behaviors, reported that three staff members were verbally and nonverbally abusive towards her. Despite the resident's history of making accusations against staff, the facility did not investigate or report the allegations to the state agency as required by their policy. The care plan for the resident noted a history of paranoia and accusations against staff but did not specify if these were allegations of abuse. Interviews with facility staff revealed that the allegations were not investigated, and the resident's aide continued to care for her despite the accusations. The administrator and the DON acknowledged the resident's history of making accusations but did not follow up to determine if the new allegations were valid or if a protection plan was needed. The facility's policy required immediate reporting of abuse allegations, but the staff handled the situation differently due to the resident's past behavior, resulting in a failure to report the incident to the state agency.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to respond appropriately to allegations of abuse made by a resident, identified as R29, who had a history of making accusations against staff. R29, who had intact cognition and no delusional behaviors, reported verbal and nonverbal abuse by three staff members, including her current aide. Despite these allegations, the facility did not investigate the claims or implement a protection plan to ensure R29's safety. Interviews revealed that the administrator and the director of nursing (DON) were aware of R29's history of accusations but did not follow up on the new allegations or report them to the state agency. The facility's care plan for R29 acknowledged her history of paranoia and accusations but did not specify whether these included abuse allegations. The care plan also failed to outline procedures for handling new abuse allegations. The facility's policy required that all allegations of abuse be thoroughly investigated and that staff accused of abuse be removed from direct care pending investigation. However, this protocol was not followed for R29, as her aide continued to provide care despite the allegations. The DON admitted that the facility handled R29's allegations differently due to her history, which led to a lack of investigation and reporting.
Failure to Develop Baseline Care Plan for Smoking Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who smoked, despite the facility being a non-smoking campus. Upon admission, the resident was identified as a current tobacco user, but no immediate care plan was developed to address this. The resident was informed by various staff members that smoking was not allowed on facility grounds, yet inconsistent messages were given about where and how the resident could smoke. The resident was not offered any nicotine replacement therapy or smoking cessation support upon admission. The resident, who had a diagnosis of nicotine dependence, continued to smoke outside the facility, as confirmed by multiple staff members. Despite being aware of the resident's smoking habits, the facility did not conduct a comprehensive smoking assessment or update the care plan promptly. The resident's care plan was only updated three days after admission, following the resident's continued smoking on facility grounds. Interviews with staff revealed a lack of clarity and consistency in enforcing the facility's non-smoking policy. Some staff members were unsure of the current policy, while others provided conflicting information to the resident. The facility's policy required a tobacco use assessment upon admission, but this was not adequately completed, leading to a delay in addressing the resident's smoking needs and updating the care plan accordingly.
Failure to Provide Routine Personal Care and Nail Care
Penalty
Summary
The facility failed to provide routine personal care, specifically bathing and nail care, for a resident who required assistance with activities of daily living (ADLs). The resident, who had intact cognition and required maximal staff assistance for bathing and moderate assistance for personal hygiene, had not received a bath or shower for at least 10 days, despite a preference for two baths or showers per week. The resident's care plan and Kardex indicated the need for assistance with bathing and nail care, but there was no documentation of nail care being provided or offered. Observations and interviews revealed that the resident's fingernails were approximately half an inch long with sharp edges and dark debris underneath, and the resident expressed a desire for assistance with trimming them. Nursing assistants and a registered nurse confirmed that nail care should be offered with showers and that there was no specific documentation for nail care in the electronic medical record. The resident, who is diabetic, should have received nail care from nursing staff, but this was not documented or performed as required. The interim director of nursing verified that showers should be offered twice a week and completed at least weekly unless refused, with refusals documented. However, the last documented shower was 10 days prior, and there was no evidence of refusals or additional offers for bathing. The facility's policy on activities of daily living emphasized the importance of maintaining or improving residents' abilities in daily tasks, including personal hygiene and grooming, but this was not adhered to in the case of the resident in question.
Failure to Address Resident's Vision Needs Due to Missing Glasses
Penalty
Summary
The facility failed to ensure that a resident's vision needs were met, as evidenced by the missing corrective lenses for a resident diagnosed with dementia. The resident's quarterly Minimum Data Set (MDS) indicated the use of corrective lenses, and the admission assessment confirmed adequate vision with glasses. However, the care plan did not include the resident's need for corrective lenses, and the Kardex lacked this information as well. The resident reported losing her glasses a couple of months ago and stated that no assistance was offered to replace them. Interviews with staff revealed a lack of awareness regarding the resident's need for glasses, and the Director of Nursing (DON) was not informed about the missing glasses until the survey. The facility's Eye Care policy required assistance in making appointments for vision treatment, but no such appointment was set up for the resident. The DON confirmed that the resident wore glasses and expressed an expectation that nursing staff should have notified her about the missing glasses to facilitate replacement. Despite efforts to locate the glasses, they remained missing, and no documentation was found regarding interventions for the missing glasses. The lack of communication and documentation contributed to the deficiency in addressing the resident's vision needs.
Failure to Reposition Resident with Pressure Ulcer Risk
Penalty
Summary
The facility failed to provide timely assistance with repositioning for a resident with a history of pressure ulcers. The resident, who had severely impaired cognition and was diagnosed with kidney disease, diabetes, and dementia, was dependent on staff for bed mobility and was receiving hospice care. The resident was at risk of developing pressure ulcers, and a provider's progress note indicated the resident had a pressure injury on her right shoulder and was predisposed to pressure injuries due to weakness and inability to reposition herself. The facility's order summary required nursing staff to turn and reposition the resident every two to three hours and document any refusals. On the day of observation, the resident was found in the same left-lying position in bed from 9:46 a.m. until 1:48 p.m., indicating a failure to reposition her as required. The registered nurse on duty was unsure when the resident was last turned and confirmed he had not assisted with repositioning during his shift until the observation at 1:48 p.m. The nursing assistant responsible for repositioning the resident admitted that the last repositioning occurred at 6:30 a.m. and that she had not been able to assist the resident again due to being busy. The director of nursing emphasized the importance of repositioning the resident every two to three hours, especially given her pressure ulcer history, to prevent new injuries or worsening of existing ones.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to provide appropriate side effect monitoring for a resident (R26) who was on multiple psychotropic medications, including trazadone, Cymbalta, bupropion, and aripiprazole. The resident's care plan and medication administration records lacked evidence of monitoring for side effects, non-pharmacological interventions for sleep, or documentation of target behaviors. Interviews with facility staff, including registered nurses and the director of nursing, confirmed the absence of necessary monitoring and documentation practices for residents on psychotropic medications. R26 was cognitively intact and had several medical diagnoses, including depression and anxiety, for which they were receiving psychotropic medication therapy. Despite the presence of boxed warnings for suicidal thoughts and behaviors associated with these medications, the facility did not document any monitoring of the resident's mood, behaviors, or side effects. The facility's policy required such monitoring, but it was not implemented, leading to a deficiency in the care provided to R26.
Medication Order Transcription Delay and Wound Care Documentation Gaps
Penalty
Summary
The facility failed to ensure proper transcription of medication orders for a resident (R1) with a Stage 2 and Stage 4 pressure ulcer. Despite a nurse practitioner (NP-A) ordering an antibiotic and wound care on 3/13/24, the order was not transcribed until 3/28/24. The antibiotic, Bactrim, was not entered into the electronic health record (EHR) on 3/13/24, leading to a delay in administration. The facility was unable to determine how the written order ended up back in NP-A's office, indicating a breakdown in communication and documentation processes. R1's wound care assessments showed a progression of the pressure ulcer on the right heel, with issues such as drainage, necrotic tissue, and foul odor noted in the days leading up to hospitalization for sepsis. Despite the worsening condition of the wound, R1's progress notes lacked detailed information on wound care and assessments prior to 3/28/24. The deficiency was identified during a survey, highlighting gaps in documentation, medication administration, and communication among staff members involved in R1's care. Staff interviews revealed discrepancies in the handling of the medication order, with the licensed practical nurse (LPN-A) encountering difficulties entering the order into the EHR and failing to follow up on its completion. The facility's policy required immediate transcription of orders into the system, emphasizing the importance of timely and accurate documentation to ensure resident safety.
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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 Inver Grove Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southview Acres Healthcare Center | 0.6 mi | ★★★★★ | 12 | 0 |
| Woodlyn Heights Healthcare Center | 1.2 mi | ★★★★★ | 17 | 0 |
| Walker Methodist Westwood Ridge Ii | 1.5 mi | ★★★★★ | 8 | 0 |
| Cerenity Care Center On Humboldt | 3.5 mi | ★★★★★ | 12 | 0 |
| Shirley Chapman Sholom Home East | 3.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.