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 Good Samaritan Society - Waconia And Westview Acre during CMS and state inspections, most recent first.
Inadequate supervision allowed a resident with dementia, psychosis, confusion, and a history of wandering to elope from the facility while wearing a walker and no effective Wander Guard. The resident left through the front door overnight, was later found lying on the ground in a nearby parking lot by a community member, and staff did not realize the resident was missing until law enforcement arrived. Records showed inconsistent elopement risk assessments, a decision to stop using the Wander Guard without a documented reassessment, and missed 2-hour checks.
Incomplete elopement risk assessments failed to capture a resident’s history of wandering, dementia with psychosis, anxiety, depression, confusion, and learning barriers. Staff documented the resident as not at risk on several assessments, even though the resident had a Wander Guard, which was later found in the trash, and the record did not show a new assessment when the device was removed or after the resident returned from the hospital. Interviews confirmed the form used did not prompt review of diagnoses, mood, medications, or family history.
Incomplete Person-Centered Care Plans: The facility failed to develop comprehensive, person-centered care plans for several residents with identified needs. A resident with PTSD and trauma history had no individualized trauma-informed interventions in the care plan, another resident with edema had no edema management interventions, and two residents on EBP had no care plan interventions for gown and glove use, PPE availability, or signage. The DON confirmed some of these needs were known, but they were not reflected in the care plans.
Failure to address distress from a Wander Guard device: A resident with moderate cognitive impairment, dementia, weakness, gait/mobility issues, HTN, arthritis, and insomnia repeatedly stated the wrist device was "stupid," "bugs" him, and kept him from leaving or going home. Staff observed the resident fidgeting with and grabbing the device, but the record lacked evidence that the facility assessed the distress or considered less intrusive placement options such as the ankle. Interviews confirmed the resident frequently asked for the device to be removed and that the DON viewed the situation as a dignity concern.
Failure to Conduct Required Care Conferences: The facility did not conduct the initial and quarterly care conferences for a cognitively intact resident with diagnoses including PVD, BPH, renal insufficiency, hyperlipidemia, and depression. The resident's record had no evidence that a care conference was offered or held since admission, and the administrator, SW designee, and DON confirmed the conferences were missed during a staff changeover despite the facility policy requiring a baseline care plan meeting and documentation of resident and representative participation.
Failure to Provide Resident Trust Account Statements A resident with HF, HTN, renal insufficiency, DM, and schizophrenia was responsible for having the facility manage personal funds, but stated they had no idea what was happening with the account and that the facility received the statements. The BOM said monthly statements were received at the resident’s request and then explained and provided, but there was no documentation confirming the conversations or explanations, and the record lacked evidence that statements were provided or agreed to.
A resident with diabetes, anxiety, chronic pain, weakness, falls, and impaired mobility wanted to return home, while therapy recommended AL for medication management, eating, and cognitive concerns. The resident was told that leaving AMA would prevent the facility from setting up services or sending prescriptions, agreed to stay until therapy ended, and then discharged with belongings, but the EMR lacked documentation that the provider was contacted, that a planned discharge was facilitated, or that the provider was notified of the AMA discharge.
Missing discharge summaries for two residents. One resident was transferred to the hospital and did not return, and another resident left home by taxi after discharge planning discussions. Both EMRs lacked the required discharge summary/recapitulation of stay, and the DON confirmed the documents were missing.
Failure to Complete Baseline Care Plans Within 48 Hours: The facility did not develop and implement baseline care plans within 48 hours of admission for two residents. One resident had multiple chronic conditions including DM, GERD, arthritis, osteoporosis, anxiety, depression, PTSD, and mobility-related diagnoses, while the other had Lewy body neurocognitive disorder, non-Alzheimer’s dementia, depression, and was receiving antipsychotic medication. Interviews with the RN case manager and DON confirmed baseline care plans were expected within 24-48 hours, but the ADL interventions for both residents were documented after the required timeframe.
Failure to Update Care Plan for Mobility Change: A resident with moderate cognitive impairment, dementia, muscle weakness, and gait/mobility abnormalities had a care plan that still listed a front wheeled walker for mobility, while observations showed the resident self-propelling in a wheelchair throughout the facility. The EMR lacked evidence the care plan was revised to reflect the resident’s current wheelchair use, and the RN care manager and DON confirmed the change had not been updated in the care plan.
A resident with severe cognitive impairment, Parkinson’s disease, dementia, and a self-care deficit requiring staff help with bathing, dressing, and personal hygiene was repeatedly observed with long gray facial hair on the chin and upper and lower lip. A family member said they had asked staff to shave the resident and that the resident would be bothered by the facial hair; a NA and TMA acknowledged the resident should have been shaved for comfort and dignity, and the DON stated the expectation was that men and women be shaved when hair or whiskers had grown.
A resident with dementia, weakness, gait impairment, HTN, arthritis, and edema had an order for compression stockings to be applied in the morning and removed at night, but staff did not consistently assist with the stockings and the resident was repeatedly observed wearing regular socks with indentations on the lower extremities. The TAR falsely documented the stockings as applied and removed as ordered, and staff interviews confirmed the documentation was inaccurate and that the resident should have been wearing the stockings for edema management.
Failure to Monitor Pressure Ulcers Consistently: The facility did not ensure weekly measurement and documentation of pressure ulcers for two residents with significant wound histories. One resident had a coccyx/sacral wound that changed from a stage II ulcer to suspected deep tissue injury and then unstageable status, with gaps in documented measurements. Another resident had bilateral heel stage 3 pressure ulcers with repeated gaps in wound documentation despite ongoing changes in wound appearance and size. The DON stated wounds were expected to be measured and documented weekly, and the facility policy required wound RN assessment at least every 7 days when skin integrity was impaired or an open area was present.
A resident who received scheduled dialysis had intact cognition and diagnoses including dependence on renal dialysis, CKD stage 5, and vascular access implants/grafts. The facility did not consistently send required dialysis communication forms and transfer information with the resident, with missing or incomplete details such as vital signs, current meds, recent condition changes, weights, and/or MD orders; the resident stated no paperwork was sent, and the DON confirmed the forms were expected but not consistently provided.
A resident with intact cognition, ADL assistance needs, and diagnoses including PTSD, anxiety, and depression did not have a trauma assessment completed on admission. The EMR lacked evidence of assessment for past trauma, triggers, or individualized needs, and the care plan did not include trauma-informed interventions, trigger reduction approaches, or emotional safety strategies. The DON and SSD confirmed the resident’s PTSD history and that no trauma-informed interventions had been developed or implemented.
The facility failed to act on repeated CP recommendations for an AIMS assessment for a resident receiving quetiapine. The resident had Lewy body neurocognitive disorder, non-Alzheimer's dementia, and depression, and the EMR showed no evidence the AIMS assessment was completed. The DON and RN case manager confirmed the recommendation was not followed up in a timely manner, despite the facility policy requiring pharmacist recommendations to be acted upon and documented within 30 days.
Failure to Implement EBP During Resident Care: The facility did not initiate or follow EBP for residents with a pressure ulcer, an indwelling urinary catheter, and a dialysis access device. Records showed EBP orders or indications for some residents, but staff were observed providing high-contact care without gowns or gloves, and rooms lacked signage and PPE outside the door. The DON and RN confirmed the precautions should have been in place.
A resident with severe cognitive impairment and a documented high risk for elopement and falls was admitted without appropriate safety interventions in place. Despite assessments identifying the risk, staff failed to apply a wanderguard or implement increased supervision due to lack of training, unclear responsibilities, and poor communication. The resident was able to leave the facility unsupervised and was found by police offsite, resulting in an immediate jeopardy deficiency.
A resident was discharged with another resident's medications, including a blood pressure-lowering drug not prescribed to her. Due to incomplete medication reconciliation and lack of verbal education, the resident ingested the incorrect medications, resulting in multiple falls, acute facial trauma, and hospitalization for orthostatic hypotension. The error was discovered during a follow-up clinic visit when the medications were reviewed and identified as belonging to another patient.
A resident with significant cognitive and physical impairments was left on a bedpan for over eleven hours after staff failed to follow care plan instructions for regular repositioning and toileting assistance. The lack of communication between staff and failure to check on the resident led to the development of multiple deep tissue injuries on the buttocks, as confirmed by wound assessments and hospital evaluation.
The facility did not update care plans to reflect current needs for several residents, including those with behavioral issues, toileting assistance, discontinued medications, changes in diet orders, and frequent falls. Staff observations and interviews confirmed that care plans were not revised to address changes in resident status or interventions, contrary to facility policy.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was receiving both routine and PRN quetiapine while on hospice care. The pharmacy consultant recommended a gradual dose reduction and required prescriber evaluation for continued PRN use, but this recommendation was not communicated to the hospice prescriber. Facility staff believed hospice was responsible for GDRs, and the hospice nurse confirmed the recommendation was never received, with no documentation showing it was addressed.
Two residents experienced significant incidents—one developing a deep tissue injury after being left on a bedpan for over eleven hours, and another sent home with and ingesting medications prescribed to someone else, resulting in multiple falls and a hospital visit. In both cases, the facility did not report the incidents to the State agency within the required timeframe, contrary to policy and regulatory requirements.
A resident with multiple health conditions was discharged with medications, some of which were prescribed for another individual. After taking these medications at home and experiencing falls and a hospitalization, the error was reported to facility staff by an external clinic. Despite this, there was no documentation of an investigation or protective measures, contrary to facility policy.
The facility did not accurately code the MDS for two residents, resulting in missing documentation of falls for one resident and an incorrect discharge status for another. Staff confirmed that the MDS assessments did not match the information in the electronic medical records, and no facility policy on MDS completion was provided when requested.
Three newly admitted residents with complex medical needs did not have baseline care plans developed within 48 hours of admission, as required by facility policy and regulations. Instead, their care plans were completed several days after admission, leaving staff without documented guidance for immediate care. This deficiency was confirmed by a nurse manager and supported by review of electronic health records.
A resident with a history of heart failure and edema had a physician order for PRN Torsemide if their weight exceeded a specified threshold. For several consecutive days, the resident's weight was above this limit, but the PRN medication was not administered or documented. Staff interviews revealed a lack of awareness of the PRN order, which was not readily visible in the electronic MAR, and the resident subsequently developed worsening symptoms and was hospitalized for fluid overload.
A nursing assistant did not perform hand hygiene or wear gloves while assisting a resident with moderate cognitive impairment and multiple medical conditions during meal set-up. The assistant used ketchup packets from the table to spread ketchup on the resident's sandwich, contrary to facility policy and infection control expectations.
The facility did not consistently post daily nurse staffing and census information in a location accessible to all, with postings sometimes missing, outdated, or placed too high for individuals in wheelchairs to read. This failure had the potential to affect all residents and visitors seeking staffing information.
A resident with severe cognitive impairment and a Stage 3 pressure ulcer did not receive consistent care as per the care plan and physician orders. The facility failed to apply an off-loading boot as required, and wound assessments were not completed regularly. Staff interviews and observations revealed a lack of adherence to wound care protocols and inadequate communication among staff regarding the resident's care needs.
A resident with multiple sclerosis and bilateral broken legs did not receive routine toenail care, leading to long, painful toenails. The care plan lacked toenail care instructions, and there was no documentation of care or refusal in the EMR. Staff interviews revealed confusion about documentation and responsibility for nail care, and the resident was on a list to see a podiatrist without a set date.
The facility failed to assess and prevent falls for two residents, R2 and R4, by not performing comprehensive assessments or implementing appropriate interventions. R2 was found on the floor without immediate intervention documented, and R4 experienced multiple falls despite existing care plan measures. Staff interviews revealed inconsistencies in completing fall huddle worksheets and risk management forms, hindering root cause analysis and effective intervention implementation.
The facility failed to thoroughly investigate quality of care concerns reported by two residents. The DON was informed of issues involving an LPN and a nursing assistant but did not interview other residents or staff, nor did she make schedule changes or speak directly with the implicated staff. The investigation lacked comprehensive interviews or assessments, and the DON did not follow up with the residents after the initial report.
A resident with Parkinson's disease did not receive their medication, Sinemet, within the required time frame on multiple occasions, leading to a deficiency. The medication was often administered late, particularly during the morning pass, causing the resident to experience increased stiffness and pain. The facility's policy required medications to be given within one hour of the scheduled time, but this was not consistently followed.
The facility failed to maintain cleanliness in the main kitchen, with significant lint buildup on three kitchen fans located in critical areas. The kitchen manager acknowledged the issue, and further investigation revealed no set cleaning schedule for the fans. Although a cleaning schedule existed, it was not adhered to, as confirmed by the director of environmental services and the director of nutritional services.
The facility failed to maintain cleanliness of wheelchairs for two residents and a tube feeding pump and pole for another resident. One resident's wheelchair was soiled with food debris, while another's motorized wheelchair had rust and torn armrests. A third resident's tube feeding equipment was covered in dried substances. Staff were unclear on cleaning responsibilities, and no policies were provided, leading to unsanitary conditions.
A resident with cognitive impairments reported feeling abused during toileting care, but the facility failed to report the allegation within the required two-hour timeframe. Staff interviews revealed a lack of immediate action, with the incident only being acknowledged days later. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to, resulting in a deficiency.
A resident with cognitive impairments and mood issues accused a nursing assistant of abuse during toileting care. Despite facility policies requiring immediate reporting and investigation of abuse allegations, no investigation was conducted, and the incident was not documented in the resident's health record. Interviews with staff revealed a lack of follow-up, highlighting a deficiency in handling abuse allegations.
A facility failed to monitor orthostatic blood pressure for a resident on psychotropic medications, risking increased falls due to dizziness. Additionally, another resident went ten days without a bowel movement, despite being on a constipation protocol, with no as-needed medications administered. The facility's policies on medication monitoring and bowel management were not followed, leading to these deficiencies.
A facility failed to maintain proper infection control practices for a resident with a urinary catheter and did not utilize enhanced barrier precautions (EBP) for another resident with a pressure ulcer. The catheter bag was repeatedly found on the floor, and staff did not wear gowns during high-contact care activities for the resident on EBP. Staff misunderstandings and lack of adherence to protocols contributed to these deficiencies.
Inadequate supervision allowed a cognitively impaired resident to elope from the facility
Penalty
Summary
The facility failed to provide adequate supervision for a resident with dementia and other cognitive and behavioral concerns after the resident was assessed as being at risk for elopement and was using a Wander Guard bracelet. The resident had diagnoses including Lewy body dementia with psychotic disturbance, diabetes with neuropathy, depression, and psychosis, and the record also described confusion, forgetfulness, hallucinations, delusions, anxiety, and a history of wandering. The resident’s admission assessment noted impaired orientation and learning barriers related to cognitive status, and the care plan included interventions for elopement risk, impaired cognition, and behavior problems. The resident’s record showed inconsistent elopement risk determinations and incomplete reassessments. At different times, assessments stated the resident was not at risk for elopement even though the record also documented dementia, psychosis, anxiety, confusion, and prior wandering concerns. The record further showed that when the resident’s Wander Guard was found in the trash, staff decided it was no longer needed without a documented elopement reassessment. Later, after additional diagnoses of Lewy body dementia, major depression, and psychosis were added, the medical record lacked evidence that the resident was reassessed for elopement risk. On the night of the incident, the resident left the facility through the front door at 12:54 a.m. wearing a short-sleeved shirt, shorts, and tennis shoes while using a walker. The resident was later found by a community member lying on the ground in a parking lot near an apartment building a block away from the facility and was taken to the hospital. Staff did not know the resident was missing until law enforcement came to the facility and showed the resident’s photo, at which point staff discovered the resident was not in bed. Interviews indicated the resident was supposed to be checked every two hours, but those checks were not completed that night.
Incomplete Elopement Risk Assessments
Penalty
Summary
The facility failed to complete accurate and complete elopement risk assessments for a resident with a history of wandering and cognitive and behavioral diagnoses. The resident’s records showed dementia, dementia with psychosis, anxiety, depression, increased confusion, forgetfulness, and learning barriers related to cognitive status, along with a history of elopement from home and recent admission to the facility. Multiple elopement assessments documented the resident as not at risk or omitted key risk factors, including the history of elopement, diagnoses, mood-related concerns, and learning barriers. The resident was also assigned a Wander Guard and later had it found in the trash, after which the nurse manager stated the resident no longer needed it. The record did not show that a new elopement risk assessment was completed at that time to determine whether the device was still needed. After the resident returned from the hospital, the Wander Guard was not re-implemented, and staff were instructed to perform more frequent overnight checks. The provider order for the Wander Guard remained active even after the nursing order was discontinued. During interviews, nursing staff and the DON stated that accurate elopement assessments should have included review of behaviors, diagnoses, medications, mood, and family input about wandering history. Staff acknowledged that the new assessment form did not prompt review of several relevant factors and that prior assessments for the resident were incomplete. The DON also stated the resident should have been reassessed when the Wander Guard was found in the garbage, but that reassessment had not occurred.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that included all identified needs and appropriate interventions for 4 residents reviewed for care planning. R10 had intact cognition and required assistance with all ADLs, with diagnoses including anxiety disorder, depression, PTSD, and mild cognitive impairment, but the comprehensive care plan did not include person-centered interventions related to the resident’s trauma history, including approaches to minimize triggers, promote emotional safety, or individualized care preferences. During interview, the DON and SSD confirmed the resident had a known trauma history, but it had not been incorporated into the care plan with personalized, resident-specific information. R25 had moderate cognitive impairment and required assistance with all ADLs, with diagnoses including non-Alzheimer’s dementia, muscle weakness, gait and mobility abnormalities, hypertension, arthritis, and insomnia, but the care plan did not address edema management, including monitoring, limb elevation, or compression stockings. R72 had intact cognition and required assistance with ADLs, with diagnoses including UTI, viral hepatitis, C. difficile enterocolitis, Sjogren syndrome with vasculitis, vasculitis limited to the skin, and urinary retention, and the MDS identified a Stage 1 pressure ulcer; however, the care plan did not include Enhanced Barrier Precautions interventions such as gown and gloves for high-contact care activities, PPE availability, or signage. R88 had intact cognition and required assistance with ADLs, with diagnoses including dependence on renal dialysis, CKD stage 5, and vascular implants and grafts, but the care plan also failed to include Enhanced Barrier Precautions interventions, including gown and gloves for high-contact care activities, PPE availability, or signage. The DON confirmed that R72 and R88 were on EBP, but this was not included in their care plans.
Failure to Address Distress From Wander Guard Device
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when it continued use of a Wander Guard device on the resident’s left wrist in a manner that caused ongoing distress. The resident, R25, had moderate cognitive impairment and required assistance with all ADLs, with diagnoses including non-Alzheimer’s dementia, muscle weakness, gait and mobility abnormalities, hypertension, arthritis, and insomnia. During multiple observations, R25 repeatedly stated the device was "stupid," said it "really bugs" him, and expressed that staff would not let him leave or go home while the device remained on his wrist. The resident was observed fidgeting with, grabbing, and shaking the device while it stayed in place throughout the observations. Review of the medical record and care plan showed no evidence that the facility assessed or addressed the resident’s ongoing distress related to the Wander Guard. There was no documentation that alternative placement options or less intrusive interventions were considered or implemented. Staff interviews confirmed that R25 frequently asked for the device to be removed and did not like wearing it. The RN Case Manager stated Wander Guards could be placed on the wrist or ankle and should be monitored for proper placement and effectiveness, and the DON acknowledged that if the device was causing distress, it could be a dignity concern and alternative placement, such as the ankle, should have been attempted. The facility’s Resident Dignity policy stated it would promote care in a manner that maintained or enhanced each resident’s dignity and respect.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to conduct the initial and quarterly care conferences for one resident who was reviewed for care conferences. The resident's annual MDS indicated the resident was admitted on [DATE], was cognitively intact, and had diagnoses including peripheral vascular disease, benign prostatic hypertrophy, renal insufficiency, hyperlipidemia, and depression. The resident's medical record lacked evidence that a care conference was offered or conducted since admission. On 3/25/26 at 8:03 a.m., the administrator confirmed there was no record of any care conferences being conducted for the resident. On 3/26/26 at 9:55 a.m., the SW designee and DON stated care conferences were organized by the social worker with the MDS coordinator and should have been conducted within 3 days of admission, quarterly, with a significant change, or at family request. They confirmed the resident had not had any care conferences and stated they were missed during a staff change over. The facility's Comprehensive Care plan and Care Conferences Policy, last reviewed 12/29/25, indicated the facility would establish a baseline care plan, provide the resident and/or representative with a written summary of the care plan, and document that the meeting occurred with the resident and representative and any significant discussion that occurred.
Failure to Provide Resident Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly statements to 1 of 1 resident reviewed for personal funds, R36. R36’s MDS dated [DATE] showed the resident was admitted [DATE], cognitively intact, and had diagnoses including heart failure, hypertension, renal insufficiency, diabetes, and schizophrenia. During an interview on 3/23/26, R36 stated the facility was responsible for managing their money, but they had no idea what was going on with the account and the facility received their statements. On 3/26/26, the BOM stated the facility received monthly statements at the resident’s request and then met with the resident to explain and provide the documents, but there was no documentation to confirm those conversations or explanations occurred. R36’s medical record lacked evidence of agreement or that statements were provided or explained to the resident. The facility’s Resident Trust Account Policy stated the facility, as fiduciary of resident funds, must hold, safeguard, manage, and account for the funds in accordance with state and federal regulation.
Failure to Notify Provider and Facilitate Planned Discharge
Penalty
Summary
The facility failed to contact the provider for a resident who expressed a plan to discharge against medical advice. The resident had diagnoses including diabetes, dizziness, anxiety, chronic pain, muscle weakness, falls, abnormal gait and mobility, and need for assistance with personal care, and required help with dressing, transfers, ambulation, bathing, and toileting. The resident’s care plan stated a desire to return home pending therapy outcomes and included interventions for the facility to arrange community resources to support independence after discharge. During the care conference, therapy was scheduled to end and recommended assisted living for medication management, eating, and cognitive concerns, while the resident’s friends expressed concerns about the resident’s living conditions. The resident continued to state a desire to return home with county services, was told that leaving AMA would mean the facility would not set up home services or send prescriptions, and later agreed to stay until therapy ended. The resident was discharged with personal belongings, but the electronic medical record lacked documentation that the provider was contacted about the discharge plan, that the facility attempted to facilitate a planned discharge, or that the provider was notified when the resident discharged AMA.
Missing discharge summaries for transferred and discharged residents
Penalty
Summary
The facility failed to complete a discharge summary (recapitulation of stay) for a resident who was transferred to the hospital and did not return to the facility. The resident’s admission MDS identified intact cognition and a need for some assistance with ADLs, and the resident’s diagnoses included sepsis, HTN, UTI, DM, non-Alzheimer’s dementia, COPD, gross hematuria, BPH with lower urinary tract symptoms, urinary retention, hydronephrosis, hydrocele, right testicular pain, long-term insulin use, and a history of TIA and cerebral infarction without residual deficits. Progress notes showed the resident was transferred to the hospital for fluid retention and was considered discharged when the family released the bed hold, but the EMR contained no discharge summary with a summary of status at discharge or a post-discharge plan of care. The facility also failed to complete a discharge summary for another resident who left the facility home by taxi after stating during care conference that he was going to discharge home. This resident required assistance with dressing, transfers, ambulation, bathing, and toileting, and had diagnoses including diabetes, dizziness, anxiety, chronic pain, muscle weakness, falls, abnormal gait and mobility, and need for assistance with personal care. The resident’s progress notes documented discussions about leaving, including staff telling the resident that leaving AMA would prevent services and prescriptions from being arranged, and the resident agreeing to stay until the planned discharge date; however, the EMR still lacked a discharge summary. The DON reviewed both records and confirmed the discharge summaries were missing.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for 2 of 18 residents reviewed for care planning. For R10, the admission MDS identified intact cognition and a need for assistance with all ADLs, and the resident’s diagnoses included GERD, diabetes mellitus, hyperlipidemia, arthritis, osteoporosis, anxiety disorder, depression, PTSD, a right rotator cuff tear/rupture, hereditary ataxia, demyelinating disease of the CNS, chondromalacia of the right shoulder, bicipital tendinitis, and mild cognitive impairment of unknown etiology. R10 was admitted to the facility, but the EMR showed the baseline care plan was not initiated or completed within 48 hours; the ADL baseline care plan was first documented on 2/17/26, more than 48 hours after admission. For R11, the quarterly MDS identified intact cognition and a need for assistance with ADLs, with diagnoses of neurocognitive disorder with Lewy bodies, non-Alzheimer’s dementia, and depression, and the MDS indicated the resident received antipsychotic medication. R11 was admitted to the facility, but the EMR showed the baseline care plan was not initiated or completed within 48 hours of admission; the ADL baseline care plan was first documented on 12/1/25, more than 48 hours after admission. During interviews, the RN case manager stated baseline care plans should be completed within 24-48 hours and included items such as transfer status, high-risk medication warnings, medications, fall risk, behaviors, pain, pressure ulcer risk, psychotropic medication use, and feeding tube presence. The DON stated care plans were expected to be initiated upon admission and completed within 48 hours, with at minimum fall and ADL interventions in place, and confirmed both residents’ ADL interventions were initiated beyond that timeframe.
Failure to Update Care Plan for Mobility Change
Penalty
Summary
The facility failed to revise R25’s comprehensive, person-centered care plan to reflect a change in mobility status. R25’s admission MDS identified moderate cognitive impairment and the need for assistance with all ADLs. R25’s diagnoses included non-Alzheimer’s dementia, muscle weakness, abnormalities of gait and mobility, hypertension, arthritis, and insomnia. The comprehensive care plan, printed on 3/26/26, indicated R25 required assistance of one staff with a front wheeled walker for mobility. However, multiple observations showed R25 was using a wheelchair instead of a front wheeled walker. On 3/24/26 and 3/25/26, R25 was observed sitting outside the elevator in a wheelchair and self-propelling to and from various locations within the facility, including the second-floor unit. Review of the EMR found no evidence that the care plan had been revised to reflect current wheelchair use. RN-B stated the wheelchair use had not been reflected in the care plan and should have been revised, and the DON confirmed the care plan had not been revised to identify wheelchair use for mobility.
Failure to Provide Shaving Assistance for a Resident Needing ADL Support
Penalty
Summary
The facility failed to ensure shaving was offered or provided for a resident who was unable to perform ADLs independently. The resident’s quarterly MDS indicated severe cognitive impairment and need for staff assistance with ADLs, and diagnoses included diabetes, Parkinson’s disease, dementia, anxiety, and chronic pain. The care plan revised 3/7/26 stated the resident had a self-care deficit related to Parkinson’s disease and required assistance from one staff member for bathing, dressing, and personal hygiene. On 3/23/26, the resident was observed with gray hairs on the chin, above the upper lip, and below the lower lip, about an inch in length. Similar observations were made on multiple follow-up dates through 3/26/26, with the facial hair still present. During interview, a family member stated they had asked the facility to shave the resident and that the resident would be very bothered by the long hairs on her face; the family member also stated the resident had an electric razor in her drawer. A NA stated that if a resident was unable to request shaving, the resident should be shaved when they start to look scruffy. A TMA stated the resident was cooperative with cares, had long hair on her chin, and had not been shaved that morning, and agreed the resident should have been shaved before then for dignity. The DON stated the expectation was that both men and women should be shaved when there was hair or whiskers that had grown for their comfort and dignity.
Inaccurate TAR Documentation and Failure to Apply Ordered Compression Stockings
Penalty
Summary
The facility failed to provide edema management care in accordance with provider orders for a resident with moderate cognitive impairment who required assistance with all ADLs. The resident’s diagnoses included non-Alzheimer’s dementia, muscle weakness, abnormalities of gait and mobility, hypertension, arthritis, and insomnia. A physician order dated 3/4/26 directed staff to apply compression stockings in the morning and remove them in the evening for edema management, but the resident was observed on multiple occasions without the stockings in place and wearing regular socks that caused indentations around the lower extremities. The resident stated staff had not consistently assisted with applying the stockings and that he had been wearing regular socks for the past several weeks. The Treatment Administration Record documented the compression stockings as applied and removed as ordered from 3/1/26 through 3/26/26, but staff interviews confirmed the documentation was not accurate because the stockings were not actually in place. A NA stated she was not aware the resident should have been wearing compression stockings during the day. An RN confirmed the resident had the order, was not refusing the stockings, and was wearing regular socks when observed, while the RN Care Manager stated the resident had non-pitting edema in both lower extremities and should have been wearing the stockings. The DON stated the intervention should have been care planned and that staff were expected to assist with application and removal, and also stated staff should not document care that was not completed.
Failure to Monitor Pressure Ulcers Consistently
Penalty
Summary
The facility failed to ensure ongoing monitoring of pressure ulcers for residents with existing wounds, including R2 and R15. The report states that the lack of weekly measurement and documentation had the potential to delay identification of changes in wound status and affect timely interventions to promote healing. The facility policy cited in the report required wound RN assessment at least every seven days and as needed when skin integrity was impaired or an open area was present. R2 was cognitively intact, dependent on staff for ADLs, and had diagnoses including hemiplegia/hemiparesis following a stroke, pressure ulcers, anemia, muscle weakness, and protein-calorie malnutrition. R2 was admitted with a stage II coccyx pressure ulcer and later had a care plan for impaired skin integrity related to immobility and an unstageable pressure ulcer to the sacral/coccyx/bilateral intergluteal cleft region. The wound record showed measurements on 11/3/25, then no documented measurement until 12/3/25, followed by additional gaps including 36 days between 12/23/25 and 1/28/26. The wound documentation reflected changes in size, tissue type, and condition over time, including progression to suspected deep tissue injury, unstageable status, maceration, undermining, and induration. R15 had severe cognitive impairment and required assistance with ADLs. Diagnoses included cellulitis of the right lower limb, stage 3 pressure ulcers of both heels, diabetes, Parkinson’s disease, dementia, hypertension, anxiety, and chronic pain. R15’s care plan directed staff to apply foam heel protectors in bed and assess, record, and monitor wound healing. The wound record showed measurements on 12/3/25 and 12/12/25, then no documented measurements for 47 days until 1/28/26, followed by another 15-day gap before 3/5/26. The documentation showed ongoing changes in both heel wounds, including slough, granulation, epithelial tissue, scabbing, and later recurrent measurements of the stage 3 heel ulcers.
Failure to Send Required Clinical Information With Resident to Dialysis
Penalty
Summary
The facility failed to ensure effective communication of necessary clinical information to the dialysis center for a resident who required routine dialysis services. The resident had intact cognition and required assistance with ADLs, and her diagnoses included dependence on renal dialysis, CKD stage 5, and presence of other vascular implants and grafts. She received scheduled dialysis treatments at an external dialysis center on Mondays, Wednesdays, and Fridays. Review of facility records from 3/18/26 to 3/25/26 showed the facility did not consistently send required dialysis communication forms and transfer information with the resident. Missing or incomplete information included vital signs, current medication list, recent changes in condition, weights, and/or physician orders. The resident stated the facility did not send any paperwork or communication form with her to dialysis appointments, and the DON confirmed the expectation that communication forms should accompany the resident to each dialysis appointment while acknowledging the facility did not consistently ensure this information was provided.
Failure to Complete Trauma Assessment and Trauma-Informed Care Plan
Penalty
Summary
The facility failed to ensure a trauma-informed care approach was implemented for 1 of 1 resident reviewed for trauma-informed care. R10’s admission MDS identified intact cognition and a need for assistance with ADLs. R10’s diagnoses included PTSD, anxiety disorder, and depression. Review of the EMR showed no evidence that a trauma assessment was completed upon admission to identify past trauma, triggers, or individualized care needs related to trauma history. R10’s comprehensive care plan did not include trauma-informed interventions, approaches to minimize triggers, or strategies to promote emotional safety. During interview, the DON and SSD confirmed R10 had a known history of PTSD, but no trauma assessment had been completed at the time of admission and trauma-informed interventions had not been developed or implemented. The facility’s Trauma-Informed Care policy required a trauma assessment within five days of admission for all new residents and indicated staff should document how trauma was currently affecting the resident.
Failure to Complete AIMS Assessment After Pharmacist Recommendation
Penalty
Summary
The facility failed to act on consultant pharmacist recommendations in a timely manner for a resident who was receiving an antipsychotic medication. The resident had diagnoses of neurocognitive disorder with Lewy bodies, non-Alzheimer's dementia, and depression, and the quarterly MDS indicated intact cognition, assistance with ADLs, and use of antipsychotic medication. The physician order summary included quetiapine 25 mg at bedtime for repeated episodes of anxiety. The consultant pharmacist's monthly medication regimen reviews repeatedly recommended completion of an AIMS assessment to monitor for potential side effects related to antipsychotic use, first identifying the need in December and repeating it in subsequent monthly reviews. Review of the EMR showed no evidence that the AIMS assessment had been completed, and the recommendation remained unaddressed as of the survey date. The DON confirmed the recommendation had not been completed or followed up in a timely manner, and staff described the recommendation as being printed, divided among nurse case managers, and placed in a drawer for follow-up. The facility policy required consultant pharmacist recommendations to be acted upon and documented within 30 calendar days.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and implement an infection prevention and control program by not initiating Enhanced Barrier Precautions (EBP) when indicated and by not ensuring staff followed EBP during resident care for 3 of 6 residents reviewed for infection control. CDC guidance cited in the report identified EBP as targeted gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices, and the facility policy also required EBP for residents with chronic wounds or indwelling medical devices, including urinary catheters, feeding tubes, and dialysis access devices. R11 had intact cognition, required assistance with ADLs, and had a stage 2 pressure ulcer with ongoing wound care orders and an EBP care plan entry. Although the record included an order for EBP precautions and wound treatment, there was no evidence of implementation, including no documentation of gown and glove use for high-contact care and no signage or PPE outside the room. During observations, no appropriate signage or PPE was present outside R11's room, and NA-D stated she would know a resident was on precautions by signage posted outside the room; she confirmed R11 was not on EBP precautions because no signage was posted. RN-B later confirmed R11 should have been on EBP precautions and that the precautions were not in place. R46 had intact cognition, required assistance with all ADLs, and diagnoses including sepsis due to E. coli, renal failure, obstructive uropathy, UTIs, and an indwelling catheter. The care plan identified EBP precautions due to the catheter and included gown and glove use during high-contact care, but during direct care for toileting, peri-care, and transfer, NA-C and an orientee did not don a gown or gloves. NA-C stated she believed the resident was on EBP precautions because of the catheter and confirmed the PPE was not used. R88 had intact cognition, required assistance with ADLs, and diagnoses including dependence on renal dialysis, CKD stage 5, and vascular implants and grafts; the EMR identified a dialysis shunt. The care plan and physician orders did not include EBP precautions for the shunt, and observations showed no signage or PPE outside the room. The DON stated R88 should have been on EBP precautions and confirmed gown and gloves should be worn during care.
Failure to Implement Elopement Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when a newly admitted resident with severe cognitive impairment, Alzheimer's disease, and dementia, who was identified as being at high risk for both falls and elopement, was not provided with adequate supervision or safety interventions. Upon admission, assessments documented the resident's high risk for elopement and falls, citing factors such as recent admission, disorientation, confusion, inability to communicate needs, and a history of wandering. Despite these documented risks, the resident's care plan did not include elopement or fall prevention interventions until after the resident had already eloped from the facility. Staff interviews and documentation revealed that although the need for a wanderguard device was identified, it was not applied because the admitting nurse did not know where the devices were kept or how to activate them, and believed it was the nurse manager's responsibility. The nurse manager was informed of the risk but left the facility, assuming the device would be applied later. Other staff members, including nurses and nursing assistants, were either unaware of the resident's risk status or did not know what the resident looked like, and increased safety checks were not implemented prior to the incident. The lack of communication and training regarding elopement prevention measures contributed to the failure to supervise the resident adequately. As a result of these failures, the resident was able to leave the facility unsupervised, travel through an attached assisted living area, cross a parking lot and a busy street, and was eventually found by police in a parking lot across the street. The facility's policy required individualized interventions for residents at risk of elopement, but these were not implemented in this case, leading to an immediate jeopardy situation.
Medication Error on Discharge Leads to Resident Harm
Penalty
Summary
A medication error occurred when a resident was discharged from the facility and sent home with another resident's medications, including a blood pressure-lowering agent not prescribed to her. The discharge documentation lacked verification of medication reconciliation, and the education provided to the resident was limited to paper handouts without verbal instruction. The resident, who had intact cognition and no memory concerns, assumed the medications were intended for her and ingested approximately 11 doses of the incorrect medications at home. As a result of taking the wrong medications, the resident experienced multiple falls at home, including one that caused acute facial trauma requiring sutures. She was hospitalized for orthostatic hypotension, which was likely exacerbated by the unprescribed blood pressure medication. Clinic records confirmed that the medication error contributed to her low blood pressure and subsequent hospital admission. Interviews with facility staff revealed that the discharge process involved sending all medications in the facility belonging to the resident, but there was no thorough review to ensure the medications matched the resident's current orders. The discharge summary and medication list were incomplete, and the error was only discovered after the resident's follow-up clinic visit, where medications labeled for another resident were identified and destroyed.
Failure to Prevent Pressure Ulcer Due to Prolonged Bedpan Use
Penalty
Summary
A resident with moderate cognitive impairment and multiple complex medical conditions, including depression, anxiety, cancer, muscle weakness, metabolic encephalopathy, diabetes, and acute kidney failure, was dependent on staff for all activities of daily living. The resident's care plan and kardex required staff to reposition the resident every two to three hours and provide assistance with toileting, including anticipating toileting needs and checking/changing as needed. Despite these instructions, a nursing assistant placed the resident on a bedpan and failed to return, neglecting to inform the next shift that the resident remained on the bedpan. During the following shift, another nursing assistant interacted with the resident, providing food, fluids, and repositioning, but did not check or change the resident or notice the bedpan. The resident, who was more fatigued and less communicative than usual, did not alert staff to her situation. The oversight continued for approximately eleven and a half hours until a registered nurse discovered the resident still on the bedpan during a routine check. The resident subsequently developed multiple deep tissue injuries on the buttocks, as confirmed by wound assessments and hospital evaluation, with the injuries corresponding to the outline of the bedpan. Interviews with staff revealed a lack of communication regarding the resident's status and care needs, as well as a failure to follow the care plan's directives for frequent repositioning and toileting assistance. The care plan did not specify the use of a bedpan, and staff assumptions about the resident's ability to communicate her needs contributed to the incident. The prolonged pressure from the bedpan resulted in actual harm, including the development and progression of deep tissue injuries.
Failure to Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs and conditions of several residents, as required by policy and regulation. For one resident with Alzheimer's disease and behavioral disturbances, the care plan did not address the resident's refusal of assistance with personal hygiene, such as nail trimming and shaving, despite staff observations and interviews indicating the resident was not independent and required reminders and cues. Staff reported repeated attempts to assist, which were refused, but this behavior and the need for partial assistance were not documented in the care plan. Another resident with a neurostimulator implant and recent back surgery required extensive assistance with toileting and had ongoing issues with bowel regulation. The resident expressed concerns about bowel management and was noted to refuse toileting and incontinence care, with staff making specific agreements to provide care. However, the care plan lacked any mention of these toileting needs or the interventions being provided. Similarly, a resident receiving hospice care had a discontinued medication (anastrozole) that remained listed in the care plan, even after the medication was stopped and hospice services began. Additional deficiencies included a resident with a feeding tube whose care plan was not updated after a significant change in diet order, allowing oral intake for quality of life, and a resident with a history of falls whose care plan was not revised to reflect frequent falls and new interventions. In each case, staff interviews confirmed that care plans were not updated in a timely manner to reflect changes in resident status, behaviors, or interventions, despite facility policy requiring such updates with each assessment or change in condition.
Failure to Communicate Pharmacy GDR Recommendation to Hospice Prescriber
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's (PharmD) recommendation for a gradual dose reduction (GDR) of an antipsychotic medication was communicated to the hospice prescriber for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, visual hallucinations, psychotic disturbance, mood disturbance, and anxiety. The resident was receiving hospice care for vascular dementia following a stroke and had active orders for quetiapine fumarate, both as a routine and as-needed (PRN) medication for agitation and hallucinations. The PharmD reviewed the resident's medication regimen and recommended either discontinuing the PRN antipsychotic, issuing a new order with a specified duration and rationale, or adjusting the routine order, in accordance with regulations that PRN antipsychotic orders cannot exceed 14 days without direct prescriber evaluation. Despite this recommendation, there was no documentation in the resident's electronic medical record or hospice communication folder indicating that the recommendation had been reviewed or addressed by the hospice prescriber. Interviews with facility staff revealed a belief that GDRs for hospice residents were the responsibility of hospice providers, but the hospice nurse confirmed that the recommendation had not been received. Facility policy required staff to facilitate communication between the resident, family, and hospice employees, but this process was not followed, resulting in the PharmD's recommendation not being communicated or acted upon.
Failure to Timely Report Suspected Abuse, Neglect, or Misappropriation to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of incidents to the State agency for two residents. In the first case, a resident with moderate cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living was left on a bedpan for approximately eleven and a half hours. The nursing assistant who placed the resident on the bedpan did not return to check on her, nor did she inform the next shift that the resident was still on the bedpan. The subsequent nursing assistant also failed to check or change the resident during her shift. The resident was eventually found by a registered nurse with a bedpan still underneath her, resulting in a deep tissue injury. The incident was reported to the State agency about twelve hours after discovery, exceeding the required two-hour reporting window for incidents involving harm. In the second case, another resident with intact cognition and several chronic conditions was discharged from the facility and later attended a clinic appointment, bringing all her medications with her. It was discovered that she had been sent home with medication cards containing drugs prescribed to another resident. The resident reported taking these incorrect medications at home, which led to episodes of dizziness, multiple falls, and a hospital visit for low blood pressure. The clinic notified the facility of the medication error, but the incident was not reported to the State agency as required. Facility staff acknowledged that the incident should have been reported immediately upon becoming aware of it. Interviews with facility staff and review of the facility's abuse and neglect policy confirmed that the expectation was to report incidents of abuse, neglect, or significant bodily harm to the State agency within two hours, and all other reportable incidents within twenty-four hours. However, in both cases, the facility did not adhere to these timelines, resulting in a failure to meet regulatory requirements for timely reporting of suspected abuse, neglect, or misappropriation of resident property.
Failure to Investigate and Protect Resident After Medication Error Allegation
Penalty
Summary
The facility failed to thoroughly investigate and protect a resident following an allegation of neglect related to a medication error. A resident with intact cognition and multiple diagnoses, including hypertension, atrial fibrillation, anemia, and depression, was discharged from the transitional care unit and later attended a clinic appointment. During this appointment, it was discovered that the resident had been given bubble medication cards at discharge, some of which contained medications prescribed for another resident. The resident reported taking these medications at home, which included a blood pressure medication, and had experienced falls and a recent hospitalization for low blood pressure. The incident was reported to the facility by an external clinic, and staff interviews confirmed that the information was relayed to a nurse and then to the nurse manager. However, a review of the resident's electronic health record revealed a lack of documentation regarding any investigation into the reported medication error. Staff acknowledged that the incident should have been reported to the state agency and that an investigation should have been initiated immediately upon learning of the event, but this did not occur. The facility's own Abuse and Neglect policy requires immediate reporting, assessment, and investigation of any allegations of abuse, neglect, or misappropriation of resident property. The policy outlines specific steps for protecting residents and notifying appropriate agencies, but these procedures were not followed in this case. The failure to initiate an investigation and ensure resident protection constituted a deficiency in responding to the reported allegation of neglect.
Inaccurate MDS Coding for Falls and Discharge Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in inaccurate documentation of falls and discharge status. For one resident, the quarterly MDS did not reflect two falls that had occurred since admission, despite these incidents being documented in the electronic medical record. Both the nurse manager and interim DON confirmed that these falls should have been included in the MDS assessment. For another resident, the discharge MDS was incorrectly coded as a transfer to a short-term general hospital, while the electronic medical record and progress notes indicated the resident was actually discharged home with family. Facility staff acknowledged the MDS was coded incorrectly and verified the actual discharge destination. No facility policy on MDS completion was provided when requested. These inaccuracies in MDS coding were identified through interviews and document review, with staff confirming the errors and the discrepancies between the MDS and the residents' medical records.
Failure to Initiate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for three residents who required varying levels of assistance with activities of daily living (ADLs) and had complex medical conditions. For each of these residents, the electronic health record (EHR) did not show evidence that a baseline care plan was initiated within the required timeframe after admission. Instead, the baseline care plans were developed several days after admission, as indicated by the dates in the EHR. The residents involved had diagnoses including end stage renal disease, heart failure, hypertension, cirrhosis, diabetes mellitus, arthritis, depression, dependence on renal dialysis, chronic pain, acute on chronic systolic heart failure, atrial fibrillation, coronary artery disease, localized edema, prosthetic heart valve, coronary angioplasty implant and graft, fracture, and anxiety disorder. During an interview, a registered nurse manager confirmed that baseline care plans should be completed within 24 hours of admission and acknowledged that this was not done for the three residents in question. The facility's own care plan policy required the development of a baseline care plan upon admission, in accordance with federal and state regulations, to provide effective and person-centered care. The lack of timely baseline care plans meant that staff did not have documented guidance on how to care for these residents immediately after admission.
Failure to Administer PRN Medication per Physician Order
Penalty
Summary
A deficiency occurred when the facility failed to administer a prescribed as needed (PRN) medication, Torsemide, according to physician orders for a resident with a history of congestive heart failure, atrial fibrillation, coronary artery disease, hypertension, renal failure, and localized edema. The resident had an order for daily weights and to receive PRN Torsemide if their weight exceeded 116.0 pounds. Over a seven-day period, the resident's weight was consistently above this threshold, but there was no documentation of the PRN medication being administered as ordered. Review of the electronic health record (EHR) and medication administration record (MAR) confirmed the absence of PRN Torsemide administration on the days when the resident's weight exceeded the specified limit. Observations during this period noted the resident had 2+ pitting edema in the lower extremities and later required oxygen for low saturations, eventually being hospitalized for pneumonia and fluid overload. Interviews with nursing staff revealed a lack of awareness of the PRN order, with some staff stating there were no parameters related to daily weights and others discovering the PRN order only upon review. The PRN order was not visible in the usual workflow of the electronic MAR, requiring staff to access a separate tab to view it. The facility's medication administration policy required correct and timely administration of medications and documentation of PRN medication efficacy. However, the process for entering and displaying PRN orders in the electronic system led to the order being overlooked, resulting in the resident not receiving the prescribed PRN Torsemide despite clear indications based on daily weight measurements.
Failure to Perform Hand Hygiene and Use Gloves During Meal Assistance
Penalty
Summary
A nursing assistant (NA) failed to perform proper hand hygiene and did not wear gloves while assisting a resident with meal set-up. The NA handled ketchup packets from the middle of the table, removed the top of the resident's hamburger bun, applied ketchup, and used the packet itself to spread the condiment before replacing the bun. The NA did not sanitize hands before or after assisting the resident, despite being expected to do so according to facility policy. The NA also confirmed during an interview that she did not follow the required hand hygiene or glove use protocols during this interaction. The resident involved had moderate cognitive impairment and required assistance with all activities of daily living, with multiple diagnoses including hypertension, neurogenic bladder, diabetes mellitus, arthritis, cerebral palsy, epilepsy, atrial fibrillation, and depression. Facility staff, including the infection preventionist and a registered nurse, confirmed that the expected practice was to wash hands and wear gloves when assisting residents with meals, and that using ketchup packets as utensils was inappropriate due to potential contamination. The facility's food handling policy also specified that food should not be touched with bare hands and that proper utensils and hand hygiene must be used.
Failure to Consistently and Accessibly Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently and properly post daily nurse staffing information, including the resident census, in a location and manner that was accessible to residents, staff, and visitors. Observations over several days revealed that the staff posting was sometimes missing entirely or not updated with the current date. When the posting was present, it was often clipped to the administration office doorframe at a height of about six feet, making it difficult for individuals in wheelchairs to access and read the information. On multiple occasions, the posting displayed outdated information or was not visible upon arrival at the facility. Interviews confirmed that the administrator was responsible for posting the staffing information, typically around 9:00 a.m. on weekdays and for the entire weekend at once. The administrator acknowledged that the posting's height was not accessible for all individuals, particularly those in wheelchairs. The facility's own policy required that the nurse staffing posting be prominently displayed daily in a clear, readable format where residents, staff, and the public could view it. These failures had the potential to affect all 69 residents and any visitors seeking this information.
Failure to Implement Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to comprehensively assess and manage the pressure ulcer care for a resident, identified as R3, who had a severe cognitive impairment and required substantial assistance with daily activities. R3 had a Stage 3 pressure ulcer on her left lateral ankle and was at risk for developing additional ulcers. The care plan for R3 included the use of a pressure-reducing mattress and cushion, and the application of an off-loading boot to her left foot while in bed, as per physician orders. However, the care plan lacked specific information about the off-loading boot, and the physician's orders were not consistently followed, as R3 was observed without the boot on multiple occasions. Interviews with staff revealed a lack of adherence to the prescribed wound care protocols. RN-B admitted to not applying the boot during the day shift, citing the absence of an order in the treatment administration record. Additionally, the wound data assessment, which should have been completed daily, was not consistently performed, leading to a lack of information on the wound's condition. The nurse manager and director of nursing confirmed that the wound data assessment and RN wound assessment were not completed as required, which hindered the ability to monitor the wound's healing process effectively. Observations and interviews with family members and nursing assistants further highlighted the inconsistency in following the care plan. R3 was seen without the off-loading boot while in bed, and there was confusion among the staff regarding the correct footwear for R3. The nursing assistants were not adequately informed about the need for the off-loading boot, as it was not documented in their shift documentation or R3's Kardex. This lack of communication and documentation contributed to the failure in providing appropriate pressure ulcer care and preventing the development of new ulcers.
Failure to Provide Routine Toenail Care
Penalty
Summary
The facility failed to provide ongoing, routine toenail care for a resident, leading to potential foot-related complications. The resident, who had intact cognition and diagnoses including multiple sclerosis and bilateral broken legs, required assistance for weekly bed baths. However, the care plan did not address toenail care, and the medical record lacked documentation of toenail care or any refusal by the resident. Interviews with staff revealed that nursing assistants were responsible for clipping nails on bath days unless the resident was diabetic or on blood thinners, which was not the case for this resident. Despite this, there was no documentation of toenail care in the electronic medical record, and the resident reported that her toenails were long and painful, with no action taken despite requests for care. Observations confirmed the resident's toenails were long, uneven, and jagged, with the great toe's nail thickened. Staff interviews indicated a lack of clarity on where to document nail care, and the resident was on a list to see a podiatrist, but no date was set. The facility's policy stated that residents unable to carry out activities of daily living should receive necessary services, including nail care, but this was not adhered to in this case. The deficiency was identified through a combination of resident interviews, staff interviews, and direct observation, highlighting a gap in the facility's care processes and documentation practices.
Failure to Assess and Prevent Falls
Penalty
Summary
The facility failed to perform a comprehensive assessment of falls and implement appropriate interventions to reduce the risk of falls for two residents, R2 and R4. R2's care plan indicated he was at risk for falls due to weakness and shortness of breath, with interventions such as using assistive devices and ensuring appropriate footwear. However, after R2 was found on the floor on 2/21/25, there was no immediate intervention documented to prevent future falls, and the fall huddle worksheet was not completed by the end of the shift. R4's care plan included interventions for fall prevention, such as keeping the door open for checks, using a reacher device, and ensuring appropriate footwear. Despite these measures, R4 experienced multiple falls, including one on 2/17/25 while reaching for a brief and another on 2/24/25 while attempting to sit on the toilet. The facility's documentation lacked immediate interventions and a root cause analysis for these incidents, and the fall huddle worksheets were not completed or located. Interviews with facility staff revealed that the fall huddle worksheets and risk management forms were not consistently completed or reviewed, hindering the ability to determine the root cause of the falls and implement effective interventions. The facility's policies required a comprehensive investigation and documentation process following falls, but these procedures were not followed, contributing to the deficiency in fall prevention and management.
Inadequate Investigation of Quality of Care Concerns
Penalty
Summary
The facility failed to conduct a thorough investigation into reported concerns related to the quality of care for two residents. The Director of Nursing (DON) was notified via email about issues involving two staff members, an LPN and a nursing assistant, who allegedly neglected their duties and behaved inappropriately towards residents. Despite being informed of these allegations, the DON did not interview other residents or staff to gather additional information about the reported incidents. The investigation lacked evidence of comprehensive interviews or assessments to substantiate the claims made by the residents. The facility's investigation was inadequate as the DON did not make any changes to the staff schedule or speak directly with the implicated staff members during their shifts. The DON only communicated with the two residents who reported the concerns and did not review any charting or follow up with them after the initial report. The facility administrator expected complaints to be addressed promptly, but the DON did not adhere to this expectation, resulting in an incomplete investigation into the quality of care concerns.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to consistently administer medication within the required time frame for a resident with Parkinson's disease, leading to a deficiency. The resident, who was cognitively intact and able to communicate needs, was prescribed Sinemet to be administered five times a day. However, the medication administration record revealed multiple instances where the medication was not given within the one-hour window before or after the scheduled time, as required by the facility's policy. The report highlights specific dates where the medication was administered late, ranging from 6 minutes to 1 hour and 49 minutes beyond the allowed time frame. The delays were particularly noted during the morning medication pass at 8:00 a.m., which the resident reported caused increased stiffness and pain. The clinical manager acknowledged these concerns and noted that other residents could potentially be affected by similar issues with time-sensitive medications. The consultant pharmacist confirmed that the delayed administration of Sinemet, a medication with a short half-life, could lead to side effects for the resident. The facility's policy on medication administration emphasized the importance of timely administration, yet the observed practices did not align with these guidelines, resulting in the identified deficiency.
Lint Buildup on Kitchen Fans
Penalty
Summary
The facility failed to maintain cleanliness in the main kitchen, specifically regarding the buildup of lint on three out of four kitchen fans. These fans were located in critical areas of the kitchen, including the dish return and cleaning area, the area near a refrigerator and freezer, and the kitchen prep zone. The lint buildup was significant, with strands measuring approximately 1 1/2 to 2 inches, and was observed on both the front and rear portions of the fan guards. This deficiency was confirmed during an observation and interview with the kitchen manager, who acknowledged the issue and indicated it was on their list of tasks to address. Further investigation revealed that there was no set schedule for cleaning the fans, as confirmed by the director of environmental services. The director of nutritional services also admitted that it had been a while since the fans were last cleaned and could not recall the exact timing of the last cleaning. Although a kitchen cleaning schedule was provided, it indicated that the fans were supposed to be cleaned during the third week of each month on Thursdays, suggesting a lapse in adherence to the schedule.
Failure to Maintain Cleanliness of Resident Equipment
Penalty
Summary
The facility failed to maintain wheelchairs in a clean and sanitary manner for two residents, R20 and R15, and did not ensure the cleanliness of a tube feeding (TF) pump and pole for resident R31. R20, who had diagnoses including cerebral hemorrhage and Parkinsonism, was observed with a soiled wheelchair covered in food debris. Despite a checklist for cleaning wheelchairs being presented to staff, R20's wheelchair had not been cleaned as scheduled. R15, diagnosed with ataxia, used a motorized wheelchair that was observed with rust and debris, and torn armrests secured with tape. The motorized wheelchair could not be cleaned in the wheelchair washer, and staff failed to notice or report its condition. For resident R31, who was dependent on staff for most activities of daily living and had a history of stroke and malnutrition, the TF pump and pole were observed with dried substances covering more than 50% of the legs and pump. Despite the resident's complaints, the equipment remained uncleaned. Staff, including a nursing assistant and a licensed practical nurse, were unaware of who was responsible for cleaning the TF equipment, and the director of nursing could not provide clarity on the responsibility. The facility did not provide policies for the maintenance of resident equipment or cleaning of the TF pump and pole when requested. The lack of clear responsibility and adherence to cleaning schedules contributed to the unsanitary conditions observed for the residents' equipment, indicating a failure to provide a safe, clean, and comfortable environment.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R5, within the required two-hour timeframe. R5, who had moderately impaired cognitive skills and required assistance with daily living activities due to conditions such as hemiplegia, dementia, and other mental health disorders, reported feeling abused during toileting care. The incident was noted in a progress note by a nursing assistant, but there was no documentation of an incident report or investigation in the resident's electronic health record or the Aspen Complaint/Incidents Tracking System. Interviews with facility staff revealed a lack of immediate action following the allegation. A registered nurse confirmed the incident and stated that the nurse manager was notified via email, but no follow-up was recalled. The director of nursing acknowledged awareness of the allegation only during a meeting two days later, attributing the resident's behavior to her known patterns. The facility's policy required immediate reporting of abuse allegations to the administrator or designated personnel, but this protocol was not followed. The administrator and social services staff emphasized the importance of adhering to the abuse reporting guidelines, stating that all allegations should be reported immediately to initiate an investigation. Despite this, the facility did not report the incident within the mandated timeframe, resulting in a deficiency in their handling of the abuse allegation.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as R5, who had moderately impaired cognitive skills and required assistance with daily living activities due to conditions such as hemiplegia, dementia, and other mental health disorders. R5's care plan indicated a preference for no male caregivers and noted mood problems, including unrealistic fears and resistance to care. On a specific date, a nursing assistant reported that R5 accused them of abuse during toileting care, but there was no documentation of an incident report or investigation in R5's electronic health record. Interviews with facility staff revealed that the registered nurse familiar with R5's care was aware of the allegation but did not recall any follow-up actions being taken. The nurse manager was notified via email, but no investigation was conducted. The social services staff expressed that it was unacceptable to disregard an abuse allegation based on a resident's behavior history and emphasized the importance of following procedures. The director of nursing acknowledged the lack of investigation and stated that staff were expected to report allegations immediately to initiate the investigation process. The facility's policy on abuse and neglect required prompt reporting and investigation of all alleged or suspected abuse incidents. However, the administrator confirmed that staff were expected to report allegations as soon as possible, regardless of their validity, to allow for a timely investigation. Despite this policy, the facility did not follow through with the necessary steps to investigate R5's allegation, resulting in a deficiency in handling abuse allegations appropriately.
Deficiencies in Monitoring and Care for Residents on Psychotropic Medications and Constipation Protocols
Penalty
Summary
The facility failed to ensure appropriate orthostatic blood pressure monitoring for a resident who was on psychotropic medications. The resident, who had a history of hemiplegia, high blood pressure, dementia, and several mental health disorders, was prescribed quetiapine fumarate, which required monthly orthostatic blood pressure checks. However, the treatment administration records for June and July 2024 showed checkmarks indicating the task was completed, but there was no documentation of the actual blood pressure readings. The director of nursing confirmed the absence of documented readings, acknowledging the risk of increased falls due to dizziness from unmonitored blood pressure. Additionally, the facility did not implement a bowel movement protocol for another resident who was dependent on staff for all activities of daily living and had a history of dementia and gastro-esophageal reflux disease. The resident's medication administration records indicated the use of laxatives and other medications for constipation, with instructions to contact a provider if there were three days without a significant bowel movement. Despite this, the resident went ten consecutive days without a documented bowel movement, and no as-needed medications were administered during this period. The director of nursing and infection preventionist confirmed the oversight, noting that the resident's care plan lacked documentation regarding constipation management. The facility's policies on psychotropic medication monitoring and bowel and bladder management were not adhered to, leading to these deficiencies. The psychotropic medication policy required monitoring for side effects and effectiveness, while the bowel management policy outlined interventions for constipation, including medication administration. The failure to follow these protocols resulted in inadequate monitoring and care for the residents involved.
Infection Control Deficiencies in Catheter and EBP Practices
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident with an indwelling urinary catheter. The resident, who was cognitively intact and dependent on most activities of daily living, was observed with their catheter bag placed on the floor without a barrier on multiple occasions. Despite the care plan indicating the need for catheter care every shift and monitoring for signs of infection, the catheter bag was repeatedly found on the floor, which was confirmed by both a licensed practical nurse and a nursing assistant. The director of nursing and the infection preventionist acknowledged the infection control risk associated with the catheter bag being on the ground, and the infection preventionist was unaware that the resident's behavior of placing the bag on the floor had returned. The facility also failed to utilize enhanced barrier precautions (EBP) for a resident with an unstageable pressure ulcer. The care plan did not address EBP, and during observations, staff did not wear gowns while performing high-contact care activities, such as wound care and perineal care, despite a magnetic sign indicating the resident was on EBP. Interviews with staff revealed a misunderstanding of when EBP should be applied, with some staff believing it was only necessary for wounds with active infections. The director of nursing confirmed that gowns and gloves should be worn during such care for residents on EBP. The infection preventionist noted that implementing EBP has been challenging for the facility, requiring constant reeducation of staff on the use of personal protective equipment. The facility's EBP protocol indicated that gowns and gloves are needed during high-contact care activities, but this was not consistently followed, leading to a deficiency in infection control practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 398 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waconia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Auburn Home In Waconia | 0.3 mi | ★★★★★ | 4 | 0 |
| Lake Minnetonka Shores | 9.8 mi | ★★★★★ | 0 | 0 |
| Auburn Manor | 10.2 mi | ★★★★★ | 8 | 0 |
| Haven Homes Of Maple Plain | 11.7 mi | ★★★★★ | 4 | 0 |
| The Estates At Excelsior Llc | 12.1 mi | ★★★★★ | 18 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Good Samaritan Society - Waconia And Westview Acre.
100% money-back within 48 hours.
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.