Above 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 Harmony Gardens during CMS and state inspections, most recent first.
Food Items Stored Without Required Labels and Dates: The facility failed to ensure food in the refrigerators was labeled, dated, and not expired. A container of beets had mold and had been opened longer than 7 days, a container of potato salad was expired, and several other refrigerated food items, including a prepared salad and fresh fruit, had no label or date. The DFN, RDFN, and administrator all stated food should be labeled and dated when opened and discarded after 7 days.
Pillows Used as a Physical Restraint: A resident with severe cognitive impairment, dependence for transfers, and hospice care had body pillows placed on both sides in bed and tucked under the fitted sheet. Surveyors observed the pillows in this position more than once, and staff gave conflicting statements about whether this was appropriate. A RN, NA, and LPNs acknowledged that pillows tucked under the sheet could restrict movement and act as a restraint, while the DON and RDCS stated pillows were only intended to be used on top of the sheets for positioning or to define the edge of the bed.
A resident’s discharge MDS was not completed or transmitted to CMS in a timely manner. The resident discharged from the facility, but the MDS remained late and the record showed no evidence that the discharge assessment had been started, completed, or sent. The MDS-RN confirmed it should have been completed, and the DON stated MDS assessments were expected to follow the RAI manual and facility policy.
A resident with a suprapubic catheter, intact cognition, and urinary retention was documented as independent with toileting and preferred a leg bag during the day. The record lacked an assessment or education on emptying the drainage bag, measuring urine output, or reporting output to staff, even though the resident was observed emptying the bag himself and handing an LPN a handwritten output note for entry into the computer. Staff stated he did his own catheter cares, and the LPN and DON both acknowledged that an assessment and documentation should have been present.
The facility did not properly assess or document the use of bedrails as physical restraints for four residents, including those with cognitive and physical impairments. Bedrails were present and in use, but care plans and MDS assessments failed to reflect their use or classify them as restraints. Staff interviews revealed inconsistent practices, lack of provider orders, and absence of resident or representative consent, resulting in a failure to follow required assessment protocols.
The facility did not attempt alternative devices, assess for entrapment risk, review risks and benefits, or obtain informed consent before installing bed rails for four residents. Therapy evaluations and care plans did not document bed rail use, and staff were unaware of safety risks. Residents and families were not educated on the risks, and the facility did not follow its own policy requiring assessment and consent for bed rail installation.
A resident with significant cognitive and physical impairments was the subject of a family grievance alleging aggressive care by a nursing assistant, followed by the discovery of unexplained bruising resembling finger marks. Despite these events, staff did not report the allegations or the injury of unknown origin to the State Agency as required, and key staff were unaware of mandatory reporting protocols.
A resident with moderate cognitive impairment and significant physical limitations was found with unexplained bruising resembling finger marks after a family grievance about aggressive care. The facility did not document or investigate the injury as required, failed to notify the NP, and did not follow its own policy for investigating suspected abuse or injuries of unknown source. Key staff were not interviewed, and the incident was not logged or analyzed according to facility procedures.
The facility failed to adhere to transmission-based precautions and hand hygiene protocols, affecting multiple residents. Staff entered rooms without proper PPE, and there was confusion about the required precautions. Additionally, hand hygiene lapses were observed during medication administration, indicating systemic issues in the infection control program.
A resident with mild cognitive impairment and medical conditions experienced a 62-minute delay in receiving assistance for toileting, due to staff miscommunication and shift change challenges. The delay led to the resident's discomfort and missing an activity, highlighting a failure to adhere to the facility's policy on prompt response to resident needs.
A resident, who was cognitively intact and on high-risk medications, was not assessed for safe self-administration of medication. Despite lacking a SAM assessment and provider order, a nurse left Tylenol at the resident's bedside, contrary to facility policy. Interviews confirmed the oversight, highlighting a failure to follow procedures for self-administration of medications.
A resident with conditions such as diabetes and osteoarthritis was not consistently offered participation in their ambulation program, despite being cognitively intact and willing to participate. Documentation showed a decline in ambulation frequency, and staff interviews revealed confusion about program responsibilities after changes in the restorative nursing program.
A resident at risk for pressure injuries did not receive care planned interventions, such as heel elevation, despite complaints of heel pain. Observations showed the resident's heels resting on the bed, and staff failed to address the pain or elevate the heels. An LPN later found the resident's heel to be red and blanchable, indicating a risk for pressure injury.
A resident with mild cognitive impairment and muscle weakness was not provided with a prescribed hand splint to maintain range of motion, as observed in multiple instances. Despite care plan instructions and occupational therapy recommendations, the splint was not used, and staff were unaware of its necessity. The facility's policy for implementing therapy recommendations was not followed, leading to a deficiency in care.
A facility failed to properly assess and implement a toileting program for a resident with a history of stroke and edema, leading to frequent incontinence. Despite being cognitively intact, the resident experienced delays in staff response to call lights, resulting in incontinence episodes. The care plan inaccurately reflected the resident's continence status, and staff were unaware of any specific toileting plan, contrary to facility policy.
A resident with severe cognitive impairment and a history of weight loss was not weighed weekly as required, despite being on high-risk nutrition monitoring. The facility's staff failed to document and communicate missed weights, and the policy on obtaining resident weights was not provided, indicating a lapse in adherence to care protocols.
A facility failed to monitor and document a resident's dialysis fistula site, resulting in unaddressed bruising and swelling. The resident, requiring hemodialysis, experienced pain and swelling at the site, which was not properly assessed or documented by staff. Communication issues with the dialysis center were noted, and the DON confirmed the need for improved monitoring.
A resident with a history of gastric bypass surgery and malabsorption did not consistently receive their requested breakfast items, such as breakfast bars, despite these preferences being documented in their care plan and meal ticket. Interviews and observations revealed that the facility staff, including nursing assistants and the registered dietician, were aware of the resident's preferences but failed to consistently meet them, leading to dissatisfaction and potential nutritional risk.
A resident with a history of vascular dementia and other conditions required assistance for transfers. During a transfer, a nursing assistant failed to use a gait belt as required, resulting in the resident falling and sustaining a subarachnoid hemorrhage. The assistant was aware of the policy but chose not to use the belt, believing the resident could grab onto the chair. The incident led to noticeable changes in the resident's condition, including difficulty processing and following cues.
The facility failed to follow standard practice when CPR was initiated on a resident who displayed signs of rigor mortis. Despite the resident's POLST indicating a desire for full resuscitation, the staff performed CPR even though the resident exhibited clear signs of irreversible death. The incident involved delays and lack of clear documentation, and the nurse practitioner was not informed of the resident's full code status.
Food Items Stored Without Required Labels and Dates
Penalty
Summary
The facility failed to ensure food stored in the refrigerators was labeled, dated, and not expired. During a kitchen tour, the director of food and nutrition observed a container of beets in the walk-in refrigerator with an opened date of 2/23 and multiple white patches on the top surface; the director confirmed the substance was mold and stated the beets had been opened longer than seven days and should have been discarded. In the same refrigerator, a container of potato salad was observed with an opened date of 3/10, and the director confirmed it was expired and should have been discarded. In a standalone refrigerator, an individual-sized prepared salad, a half-full container of fresh strawberries, and a quarter-full container of fresh blueberries were observed with no label or date. The director stated these items should have been labeled to indicate when they were opened and that all food should be labeled and dated when the container was opened. The regional director of food and nutrition stated food should be removed after 7 days in the refrigerator and all food should be labeled with the date it was opened. The administrator also stated all food stored in the refrigerators should be labeled, dated, and discarded appropriately. The facility policy indicated that all food should be stored appropriately to maintain food safety.
Pillows Used as a Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from the use of a physical restraint when body pillows were placed in a manner that the resident could not easily remove. The resident had severe cognitive impairment, required substantial to maximal assistance for bed mobility, was dependent for transfers, and was receiving hospice care. The resident’s care plan identified the use of body pillows to define the edge of the bed, and nursing documentation indicated the resident used a body pillow for positioning and required assistance with repositioning every 2 to 3 hours. During multiple observations, the resident was found in bed with a body pillow on each side, and the pillows were tucked under the fitted sheet. A RN later removed the pillows from under the fitted sheet and placed them alongside the resident, stating the pillows should not have been tucked under the sheet and that doing so could act as a restraint because the resident could not remove them. An NA stated the pillows should be on either side for positioning and should never be tucked under the fitted sheet because that would act as a restraint. One LPN stated the pillows were supposed to be tucked under the fitted sheet to keep them in place, while another LPN stated they should never be tucked under the fitted sheet because that would restrict movement and be considered a restraint. The RDCS and DON stated the facility did not expect pillows to be placed under fitted sheets and that they should be used only on top of the bed sheets for positioning or to define the edge of the bed. The facility policy defined a physical restraint as material or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily and which restricts freedom of movement.
Late Discharge MDS Not Completed or Transmitted
Penalty
Summary
The facility failed to ensure a discharge MDS was completed and transmitted to CMS in a timely manner for one resident. The CMS RAI Manual identified that applicable MDS assessments, including a discharge assessment for return not anticipated, required completion and transmission by the specified deadline. The resident’s census list showed an admission to the facility on 11/4/25, remained in the same room until 12/5/25, and was listed as discharge-return not anticipated on 12/5/25. A progress note documented the resident discharged from the community at 1:23 p.m. on 12/5/25. Review of the resident’s MDS assessment list showed an admission assessment and 5-day assessment had been completed, but the discharge assessment was listed as late, with an ARD due date of 12/5/25 and a completion due date of 12/19/25. The medical record lacked evidence that a discharge MDS had been started, completed, or transmitted to CMS despite the resident having discharged several months earlier. During interview, the MDS-RN stated discharge assessments should be completed per the RAI manual but were usually completed and transmitted within 30 days of discharge, and confirmed the discharge assessment was not completed and should have been. The DON stated the expectation was for MDS assessments to be completed per the RAI manual and facility policy, which assigned the MDS Coordinator/RAI Lead responsibility for ensuring assessments were completed and locked in compliance with regulatory schedule requirements.
Failure to Assess Independent Catheter Care and Output Reporting
Penalty
Summary
The facility failed to assess a resident’s ability to independently empty and report urine output for a resident with a suprapubic catheter. The resident had intact cognition and diagnoses including Parkinson’s disease, urinary retention, and overactive bladder. The physician’s order directed catheter output to be monitored three times a day, and the care plan identified a chronic suprapubic catheter changed monthly by a urologist, with interventions including catheter care, monitoring for UTI, monitoring and reporting concerns, and monitoring urine output every shift. The resident also requested use of a leg bag during the day despite education about increased infection risk. The resident’s record did not contain an assessment or education on how to empty the leg drainage bag, measure output, or report output to nursing staff independently. During observation, the resident emptied the catheter bag into a graduated cylinder and then brought a handwritten output note to an LPN, who entered the amount into the computer. Nursing assistants stated they did not assist with the resident’s catheter cares because he did them himself. The LPN verified that if residents complete their own catheter cares, there should be an assessment and documentation in the care plan or elsewhere in the record, but none could be found. The DON stated that an assessment should be performed when a resident completes their own catheter cares, but documentation of such an assessment was not available.
Failure to Accurately Assess and Document Bedrail Use as Physical Restraints
Penalty
Summary
The facility failed to accurately assess the use of physical restraints, specifically bedrails, for four residents who were observed to have bedrails in use. Despite the presence of bedrails, the residents' care plans and Minimum Data Set (MDS) assessments did not document the use of these devices, nor did they identify them as restraints. In several cases, residents were cognitively impaired and unable to remove the bedrails themselves, which meets the definition of a physical restraint according to the CMS Resident Assessment User Manual. Interviews with staff revealed that there was no consistent process for obtaining provider orders, documenting the intended purpose of the rails, educating residents or representatives on risks and benefits, or obtaining consent for their use. Observations and interviews indicated that residents with significant physical and cognitive impairments were using bedrails without proper assessment or documentation. For example, one resident with hemiplegia and moderate cognitive impairment was unable to remove the rails and relied on them for support during care, yet this was not reflected in her care plan or MDS. Another resident with moderate cognitive impairment and multiple comorbidities had a bedrail installed, but the assessment did not confirm her ability to remove the device or document consent. Similar issues were found with two other residents, including those who were cognitively intact but dependent on staff for mobility and transfers, with no documentation of bedrail use in their care plans or MDS. Staff interviews further revealed a lack of clarity and consistency regarding the classification and assessment of bedrails. The DON and physical therapist considered the rails as assistive devices rather than restraints and did not follow restraint assessment protocols. There was no evidence of a policy guiding the accurate assessment of such devices, and staff were not consistently obtaining provider orders or documenting the necessary information regarding the use of bedrails. This resulted in a systemic failure to accurately assess, document, and monitor the use of physical restraints for residents using bedrails.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to follow required protocols regarding the use of bed rails for four residents. Specifically, the facility did not attempt alternative devices before installing bed rails, did not conduct or document comprehensive assessments for risk of entrapment, and did not review the risks and benefits of bed rail use with the residents or their representatives. Informed consent was not obtained, and there was no evidence that the facility ensured the bed rails were appropriate for the residents’ needs or that bed dimensions were suitable. These failures were identified through observation, interviews, and record reviews, which revealed that bed rails were in use without proper documentation or assessment. For each of the four residents reviewed, therapy evaluations and care plans did not indicate the presence or need for bed rails. Device assessments, when present, were incomplete and did not document attempts at less restrictive alternatives, the resident’s ability to remove the device, or the acquisition of informed consent. In several cases, residents and their families were not educated on the risks and benefits of bed rail use. Some residents were unaware of the purpose of the rails or how to remove them, and staff interviews revealed a lack of understanding regarding the safety risks associated with bed rails. Maintenance and nursing staff described a process for installing rails that did not include physician orders or consent, and the DON and other staff believed the rails were not considered restraints, relying on manufacturer documentation rather than regulatory requirements. Observations confirmed that residents had bed rails in place, sometimes in configurations that were not consistent or clearly documented. Residents reported using the rails for safety or mobility, but there was no evidence that the facility had assessed whether the rails posed a risk of entrapment or were the least restrictive option. The facility’s own policy required device assessments, orders, and consents for side rails, but these steps were not followed in practice. The lack of proper assessment, documentation, and education contributed to the deficiency identified by surveyors.
Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report allegations of abuse and an injury of unknown origin to the State Agency within the required timeframe for a resident who was moderately cognitively impaired and dependent on staff for most activities of daily living. The resident's family filed a grievance indicating that a nursing assistant was aggressive with the resident, and a nurse later discovered bruising on the resident's upper arm that resembled finger marks. Despite these events, neither the allegation of aggression nor the unexplained bruising was reported to the State Agency as required by facility policy and federal regulations. The resident had significant physical and cognitive limitations, including hemiplegia and polyneuropathy, making her particularly vulnerable. Documentation showed that the resident required maximum assistance and was always incontinent, with a history of stroke and related impairments. The care plan did not identify the resident as being at risk for abuse, and the event history did not document the bruising incident. Interviews with family members revealed ongoing concerns about aggressive care and changes in the resident's mental and physical state, including expressions of distress and a desire not to live if care continued to be painful. The family only learned of the bruising after inquiring, and the DON was unable to explain the cause, suggesting possible improper transfer techniques but not reporting the incident. Staff interviews indicated a lack of awareness and understanding regarding mandatory reporting requirements for abuse allegations and injuries of unknown origin. Nursing staff who observed or were informed of the bruising did not escalate the issue to management or report it externally, relying instead on documentation in the medical record. The DON and other staff did not recognize the need to report the incident, believing that internal interventions were sufficient. The facility's policy clearly outlined the obligation to report such events within two hours if abuse or serious injury was involved, but this protocol was not followed in this case.
Failure to Investigate Injury of Unknown Origin and Alleged Aggressive Care
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of injury of unknown origin for one resident. Staff discovered bruising resembling finger marks on the resident's upper arm, and the resident's family had filed a grievance about aggressive care the day before the bruising was found. Despite this, there was no documented grievance or investigation regarding the bruising, and the event was not recorded in the resident's event history. The resident, who was moderately cognitively impaired and dependent on staff for most activities of daily living, reported pain and showed the bruising to staff and family, but the cause was not determined or documented. Interviews revealed that the nurse practitioner was not notified of the bruising, and the direct care staff were not informed or questioned about the incident. The resident described feeling unsafe with a particular nursing assistant, reporting verbal aggression and rough care, but there was no evidence that these concerns were thoroughly investigated. The care plan did not reflect the resident's risk for abuse or require two staff for all care, despite staff awareness that this was needed. The facility's investigation into aggressive treatment did not include interviews with cognitively impaired residents or direct observation of care practices. Documentation and follow-up were lacking, as the facility did not log the incident as required by policy, nor did they conduct or document interviews with all relevant staff or witnesses. The facility's policy mandates prompt and thorough investigation of all suspected abuse or injuries of unknown source, including physical examination, interviews, and documentation, but these steps were not completed. The results of the investigation were not reported to the appropriate parties, and the incident was not analyzed for prevention of future occurrences.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to adhere to transmission-based precautions (TBP) and hand hygiene protocols, as observed in multiple instances involving residents R29, R45, R17, and R14. For instance, R17 was on contact precautions due to vancomycin-resistant enterococci (VRE) in her urine, yet staff members, including a social worker and a physical therapy assistant, entered her room without donning the required personal protective equipment (PPE). The signage indicating contact precautions was not consistently followed, and there was confusion among staff regarding the type of precautions R17 was under, as evidenced by discrepancies between the signage and the electronic medical record (EMR). Similarly, R45, who exhibited flu-like symptoms, was placed on contact and droplet precautions. However, staff members, including activity staff and an occupational therapist, entered R45's room without the necessary PPE. The signage on R45's door was not consistently adhered to, and there was a lack of understanding among staff about the precautions required, as some believed PPE was only necessary for direct patient care. This inconsistency in following precautions was further highlighted by the fact that R45's door signage changed from indicating both contact and droplet precautions to only droplet precautions without clear communication to the staff. Additionally, the facility failed to ensure proper hand hygiene during medication administration for residents R14, R55, and R47. For example, a trained medication assistant (TMA) did not wash hands with soap and water after exiting R14's room, despite signage indicating the need for soap and water due to norovirus. The TMA also failed to perform hand hygiene upon entering R47's room and after completing a blood glucose test. These lapses in hand hygiene and PPE usage demonstrate a systemic issue in the facility's infection prevention and control program, potentially affecting all residents.
Delayed Response to Call Light Compromises Resident Care
Penalty
Summary
The facility failed to provide timely care to a resident, identified as R64, which compromised the resident's quality of life. R64, who had mild cognitive impairment and diagnoses of heart failure and sepsis, required extensive assistance for bed mobility and transfers. The resident's care plan indicated the need for maximum assistance with toileting due to weakness and sepsis. On the day of the incident, R64's call light was activated at 1:52 p.m. and was not addressed until 2:54 p.m., resulting in a 62-minute delay. During this time, the resident expressed discomfort and urgency to use the bedpan, which was not promptly addressed by the staff. The delay was attributed to a busy shift change and miscommunication among staff members. Nursing Assistant (NA)-G initially responded to the call light but did not provide immediate assistance, instead informing TMA-A, who was occupied with a medication pass. TMA-A acknowledged the delay and the challenge of finding additional help during shift changes. The Licensed Practical Nurse (LPN)-A and the Director of Nursing (DON) both acknowledged the delay in responding to the call light and the need for timely assistance. The facility's policy on resident dignity and prompt response to requests was not adhered to, resulting in the resident missing an activity and experiencing distress.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a comprehensive assessment for safe self-administration of medication for a resident who was observed and reviewed for self-administration. The resident, who was cognitively intact and taking high-risk medications, had multiple diagnoses including type 2 diabetes, neuropathy, dysphagia, weakness, respiratory disease, and congestive heart failure. Despite these conditions, there was no evidence of a self-administration of medication (SAM) assessment or provider order in the resident's records. During an observation, the resident had a medicine cup with two caplets on her bedside table, which she identified as Tylenol due at 1:00 p.m. A registered nurse had left the medication at the bedside after the resident indicated she would take them later. The nurse acknowledged that the resident did not have a SAM assessment and should not have left the medication. Interviews with nursing staff and the director of nursing confirmed that the resident had not been assessed for SAM and did not have a provider order, which was against the facility's policy requiring an assessment and provider order for residents to self-administer medications.
Failure to Implement Resident Ambulation Program
Penalty
Summary
The facility failed to ensure that a resident, who was part of an ambulation program, received the necessary assistance to maintain their ability to walk. The resident, who was cognitively intact and had conditions such as type 2 diabetes, major depressive disorder, osteoarthritis, and muscle weakness, was supposed to participate in a restorative ambulation program at least five days per week. However, documentation showed a significant decline in the frequency of ambulation, with the resident walking only a few times over several months and not at all in December. Interviews with the resident revealed that they were not offered the opportunity to walk as expected, despite expressing a desire to maintain their strength and participate in the program. Staff interviews indicated a lack of clarity and communication regarding the responsibility for the ambulation program after the discontinuation of the restorative nursing program. Nursing assistants and nurses were aware of the resident's ambulation program but failed to consistently offer or document the ambulation activities. The director of nursing confirmed that the expectation was for staff to assist residents with ambulation daily and report any refusals to the nurse and physical therapy for re-evaluation. The facility's policy emphasized the importance of providing appropriate programs to help residents achieve their highest level of function, but this was not effectively implemented for the resident in question.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement care planned interventions for a resident (R64) who was at risk for pressure injuries. R64 had mild cognitive impairment and diagnoses of heart failure and sepsis, requiring extensive assistance for bed mobility and transfers. The care plan indicated that R64 was at risk for skin alterations and included interventions such as elevating heels off the bed with pillows. However, the nursing assistant care sheet did not indicate the need for heel elevation, and multiple observations showed R64's heels resting on the bed, contrary to the care plan. On several occasions, staff failed to address R64's complaints of heel pain or elevate the heels as required. A trained medication assistant (TMA-A) administered medication without addressing the heel pain or elevating the heels. Later, a licensed practical nurse (LPN-D) verified that R64's heels were not elevated and found the left heel to be red and blanchable, indicating a risk for pressure injury. Interviews with staff, including the Director of Nursing, revealed expectations for staff to notify nurses of heel pain and ensure interventions were in place, which were not followed in this case.
Failure to Implement Prescribed Splint Use for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, used a prescribed hand splint to maintain or improve range of motion. R30, who has mild cognitive impairment and requires substantial assistance with daily activities, was observed multiple times without the splint or any palm protector, despite having a care plan that specified the use of a yellow splint for 2-3 hours daily. The resident's diagnoses include vascular dementia, muscle weakness, and neuralgia, which necessitate the use of the splint to prevent contractures and protect joint function. Documentation and interviews revealed that the splint was not used as prescribed. The resident's care plan and occupational therapy notes indicated the need for the splint, yet point of care documentation lacked evidence of its use throughout December and early January. Staff interviews revealed a lack of awareness and recall regarding the splint's use, with some staff unable to remember seeing the splint or any palm protector for the resident's contracted hand. Further investigation by the facility's director of nursing confirmed the absence of the splint, although a carrot was found in the resident's room. The facility's policy requires therapy recommendations to be communicated and incorporated into the care plan, but this was not effectively implemented. The occupational therapy team had recommended the splint's use, and the expectation was for staff to offer it daily and report any refusals or issues, which did not occur as required.
Failure to Implement Effective Toileting Program for Resident
Penalty
Summary
The facility failed to comprehensively assess and implement interventions necessary to maintain continence for a resident (R27) who was reviewed for bowel and bladder care. R27 was cognitively intact and had a history of cerebral infarction with left-sided hemiplegia and edema. The resident's Minimum Data Set (MDS) indicated occasional incontinence of bowel and bladder, yet no toileting program was in place. The comprehensive bowel and bladder assessment inaccurately stated R27 was fully continent, lacking a review of cognitive awareness, diuretic use, and toileting patterns. Despite the urinary incontinence care area assessment indicating frequent bladder incontinence and a need for maximum assistance with toileting, the care plan only included the use of incontinent briefs and peri care after episodes. Observations and interviews revealed that R27 often experienced delays in staff response to call lights, leading to incontinence episodes. The resident expressed frustration over not reaching the toilet in time, especially due to the urgency caused by diuretic medication. Nursing assistants and LPNs were unaware of any specific toileting plan, and the care sheets did not reflect an accurate assessment of R27's needs. The Director of Nursing acknowledged the discrepancy in assessments and the lack of a comprehensive review, emphasizing the importance of identifying and acting upon changes during quarterly assessments. The facility's policy required individualized toileting programs, which were not effectively implemented for R27.
Failure to Complete Weekly Weights for High-Risk Resident
Penalty
Summary
The facility failed to ensure weekly weights were completed for a resident (R32) who was at high nutritional risk. R32 had severe cognitive impairment, required substantial assistance with eating, and had a history of weight trending down. The care plan indicated that R32 should be weighed weekly as per the provider's order, but the December 2024 medication administration record showed weights were not administered on two occasions. Interviews with nursing assistants and licensed practical nurses revealed that weights were typically done on bath days, and if a weight was not taken, the nurse should be notified. However, there was a lack of documentation and communication regarding missed weights. The registered dietician confirmed that R32 was on high-risk nutrition monitoring and should have had weekly weights completed. The director of nursing stated that residents should be weighed according to the provider's order, and any refusals should be documented. Despite these expectations, the facility's policy on obtaining resident weights and nutrition high-risk monitoring was not provided, indicating a gap in policy adherence and documentation. This deficiency highlights a failure in the facility's process to ensure consistent monitoring of residents at nutritional risk.
Failure to Monitor Dialysis Fistula Site
Penalty
Summary
The facility failed to properly monitor and document the condition of a resident's dialysis fistula site, leading to unaddressed bruising and swelling. The resident, who was cognitively intact and diagnosed with end-stage kidney disease and hypertension, required hemodialysis three times a week. The care plan included monitoring the fistula site for signs of bleeding or infection and notifying the provider of any concerns. However, the facility's records lacked documentation of monitoring for bruit and thrill post-dialysis, and there were missed opportunities to document and address the resident's complaints of pain and swelling at the fistula site. Observations and interviews revealed that the resident experienced swelling and bruising at the fistula site, which was not documented by the nursing staff. The resident reported that the dialysis nurses had noted the bruising, but the facility staff did not assess or document these changes. The LPNs interviewed acknowledged issues with obtaining dialysis run sheets and the need for staff to assess and document any changes in the resident's condition. The Director of Nursing confirmed that there were communication problems with the dialysis center and that a new order was placed to ensure proper monitoring of the site.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate the dietary preferences of a resident, identified as R17, who was reviewed for food preferences. R17 had a history of gastric bypass surgery and malabsorption, which necessitated smaller meal portions and specific dietary requests. Despite these needs, the facility did not consistently provide the requested breakfast items, such as breakfast bars, which were noted as R17's preference on the meal ticket. This inconsistency was observed during multiple interviews and observations, where R17 expressed dissatisfaction with the meals provided, specifically noting the absence of breakfast bars. R17's care plan and physician's orders indicated a regular diet with specific requests for small portions and certain breakfast items. The resident's nutritional assessment highlighted inadequate oral intake and a risk for malnutrition, with a history of significant weight loss. Despite these documented needs and preferences, the facility's staff, including nursing assistants and the registered dietician, acknowledged that R17's meal preferences were not consistently met. The dietician had updated the meal ticket to reflect R17's preference for a lighter breakfast, yet the facility failed to adhere to these updates. Interviews with staff, including nursing assistants and the director of nursing, revealed a lack of consistent adherence to the meal tickets and resident preferences. The director of nursing acknowledged the importance of honoring resident preferences to encourage meal consumption but noted that nursing staff might not always have time to verify meal preferences. The facility's policy on resident dignity, choices, and preferences emphasized the importance of honoring resident choices, yet the failure to provide R17 with the requested breakfast items demonstrated a deficiency in this area.
Failure to Use Transfer Belt Results in Resident Injury
Penalty
Summary
The facility failed to ensure that care planned interventions were followed during a transfer for a resident, resulting in actual harm. The resident, who had a history of vascular dementia, cerebral infarction with left-sided weakness, anemia, and heart failure, required partial to moderate assistance for transfers. The care plan directed staff to provide contact guard assistance with transfers using a two-wheeled walker and to follow a toileting and repositioning schedule. However, during a transfer to a wheelchair for a shower, a nursing assistant did not use a gait belt as required by the facility's transfer policy. The nursing assistant, who was aware of the policy, chose not to use the gait belt because she believed the resident could grab onto the chair. During the transfer, the resident's legs gave out, and he fell, hitting his head on the floor. This resulted in a subarachnoid hemorrhage, a left front scalp hematoma, and a laceration that required repair. The resident was sent to the hospital for treatment and later readmitted to the facility with noticeable bruising and swelling. Interviews with staff, including the nursing assistant, director of nursing, and therapists, confirmed that the transfer belt was not used during the incident. The nursing assistant admitted to not using the belt, and the director of nursing confirmed that staff were educated to always use a transfer belt unless otherwise indicated by therapy. The occupational and physical therapists noted changes in the resident's condition following the fall, including difficulty processing and following cues, which were not present before the incident.
Inappropriate Initiation of CPR on Resident with Rigor Mortis
Penalty
Summary
The facility failed to follow standard practice when CPR was initiated on a resident who displayed signs of rigor mortis. The resident had a Provider Order for Life Sustaining Treatment (POLST) indicating a desire for full resuscitation if found with no pulse and not breathing. However, upon discovery, the resident exhibited clear signs of rigor mortis, including stiffness in the limbs and cold body temperature, which should have precluded the initiation of CPR according to both facility policy and the American Heart Association guidelines. Despite these signs, CPR was performed by the staff, and emergency medical services were called, but the resident was not revived. The incident began when a registered nurse (RN-A) found the resident unresponsive and cold to the touch, with stiff limbs indicating rigor mortis. RN-A called for assistance, and another nurse (RN-B) confirmed the absence of vital signs and the presence of rigor mortis. Despite recognizing these signs, the staff verified the resident's full code status and proceeded to move the resident to the floor to begin chest compressions. The timeline of events was not clearly documented in the progress notes, and there was a delay in initiating CPR as observed from the facility's camera system. The facility's CPR policy and the State Operations Manual both state that CPR should not be initiated if there are obvious signs of irreversible death, such as rigor mortis. The staff's actions were inconsistent with these guidelines, leading to the inappropriate initiation of CPR. The emergency medical technician (EMT) who arrived on the scene also noted that CPR was being performed despite the resident showing signs of rigor mortis. The nurse practitioner on call was not informed of the resident's full code status and gave an order to release the body after being notified of the resident's condition and the family's wishes.
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Nursing homes near Maplewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maplewood Rehabilitation Center | 1.1 mi | ★★★★★ | 26 | 0 |
| Good Samaritan Society - Maplewood | 2.4 mi | ★★★★★ | 16 | 0 |
| Cerenity Care Center White Bear Lake | 4.3 mi | ★★★★★ | 8 | 1 |
| The Estates At Roseville Llc | 4.9 mi | ★★★★★ | 2 | 0 |
| The Villas At Roseville | 5.1 mi | ★★★★★ | 8 | 0 |
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