Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jones Harrison Residence during CMS and state inspections, most recent first.
A facility failed to document an adequate clinical rationale for not attempting GDRs of psychotropic meds, used an antipsychotic without an appropriate diagnosis, and lacked documentation of behaviors and non-pharmacological interventions supporting PRN psychotropic use. Records for multiple residents showed antipsychotic and antianxiety meds ordered by hospice or providers without sufficient behavior documentation, target symptoms, or risk/benefit rationale, and staff confirmed the missing documentation.
Failure to report an allegation of sexual abuse: A resident with severe cognitive impairment reported being sexually abused at night, but the allegation was not reported to the DON or state agency as required by facility policy. Staff interviews showed the report was discussed with the resident’s daughter and camera footage was reviewed, but the expected immediate supervisory and external reporting did not occur.
Failure to thoroughly investigate an allegation of sexual abuse: A resident with severe cognitive impairment and extensive ADL/toileting needs reported being sexually abused at night, but the concern was not immediately escalated to the DON or fully investigated. Staff interviews confirmed the allegation was handled informally, with the resident’s daughter reviewing a camera and saying nothing wrong happened, while facility policy required immediate reporting and an internal investigation.
Inaccurate MDS Coding for Hospice Status: A resident with severely impaired cognition and diagnoses including dementia, AFib, dysphagia, chronic pain, and hemiplegia was coded as not receiving hospice on the quarterly MDS even though orders, EMR special instructions, care plan, and staff interviews all confirmed hospice enrollment. The MDS director verified the coding error, and the DON stated MDS accuracy is important for staffing and resident care.
Failure to keep a resident's nails clean and trimmed. A cognitively intact resident with hemiplegia/hemiparesis after a CVA required substantial to maximum ADL assistance and had a care plan directing nail care as needed. Observations showed his fingernails were long with dark matter underneath, and staff confirmed residents were expected to receive nail care on bath days and that there were no EMR notes showing the care was completed.
A resident with severe cognitive impairment received lorazepam 0.5 mg every 2 hours scheduled after a hospice order was written in error, even though the family wanted it kept PRN and staff could not explain why it was changed from PRN to scheduled. The chart lacked documentation to justify the frequent dosing, and nursing staff, the hospice RNCM, and the DON all confirmed the order should have been questioned and clarified before administration.
Failure to Offer and Document Non-Pharmacological Pain Interventions: A resident with chronic pain, rheumatoid arthritis, Sjogren’s syndrome, and other diagnoses reported severe pain that affected sleep and daily activities. Although PRN acetaminophen and oxycodone were given repeatedly and effectiveness was documented, the care plan, MAR/TAR, and progress notes lacked evidence that non-pharmacological interventions such as heat, ice, massage, or other comfort measures were offered or documented before PRN pain meds were administered.
A resident with PTSD, bipolar disorder, anxiety, depression, dementia, and a seizure disorder had a psychosocial assessment noting significant life events affecting life, but the care plan did not include PTSD, triggers, measurable goals, or trauma-informed interventions. The care plan only addressed resistive and aggressive behaviors during care with reassurance and consistency measures. Staff interviews confirmed PTSD and triggers should have been on the care plan, and the DSS later verified there had not been a trauma care plan before the interview.
Laundry was not handled according to infection control practices when multiple mop heads, cleaning rags, microfiber cloths, and clothing protectors were washed and left wet in the washer overnight before being moved to the dryer the next day. A laundry aide confirmed this was the usual practice, and the IP stated she was unaware of it. The facility policy did not address whether laundry could be left in the machine overnight.
PBJ staffing data submitted to CMS was inaccurate and incomplete, showing no RN hours and no licensed nursing coverage for 24-hour periods on multiple dates even though staff schedules and time sheets showed appropriate RN and licensed coverage. The administrator said she was responsible for the submission and had technical issues when trying to enter the August data, and the DON stated the facility had an RN in the building at all times and knew the report was not accurate.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables and specific actions, as observed in the resident's records during the survey.
The facility failed to test chemical levels in the sanitizing sink, improperly stored dry goods, and did not consistently monitor food temperatures before serving meals. These deficiencies were confirmed by the culinary coordinator and regional kitchen manager, highlighting lapses in food safety and sanitation practices.
A facility failed to assess and develop a trauma-informed care plan for a resident with a significant trauma history, including PTSD. The resident's care plan initially lacked trauma-informed care details, which were only added after a survey. Staff interviews revealed a lack of specific interventions for the resident's trauma, highlighting a deficiency in the facility's approach.
A resident receiving over 50% of her calories through a feeding tube was found to have a dried substance, likely tube feeding solution, on her furniture and floor. The resident expressed dissatisfaction with the cleanliness, and staff interviews revealed uncertainty about cleaning responsibilities. A cleaning policy was not provided.
A resident with chronic pain conditions did not receive timely and effective pain management interventions. Despite being on a pain medication regimen, the resident frequently reported high pain levels, and follow-up assessments were often delayed or not conducted. The facility staff failed to notify the provider about the ineffectiveness of the pain management plan, and there was no consistent procedure for addressing unmet pain goals.
The facility failed to time-limit PRN psychotropic medication orders to 14 days and did not document the rationale for continuation beyond this period for two residents. One resident had an indefinite order for lorazepam without provider review, while another had a PRN order for Compazine without an end date or rationale. Additionally, a Trazodone order lacked an indication for use, leaving staff uncertain about its purpose. Interviews confirmed the expectation for 14-day limits and clear documentation of medication indications.
Two residents in the facility were not offered or educated about the PCV20 pneumococcal vaccine, despite being eligible according to CDC guidelines. Both residents, who were severely cognitively impaired and had multiple health conditions, had received previous pneumococcal vaccinations but lacked documentation of being offered the PCV20. Interviews with staff confirmed the oversight, and the facility did not provide a vaccination policy when requested.
A facility failed to offer a COVID-19 vaccination to a resident who was eligible and had no documented refusal. The resident, who was cognitively intact and had several medical conditions, had no COVID-19 vaccination record in the system. The infection preventionist and DON confirmed the oversight, and the facility lacked a documented vaccination policy.
A resident admitted to the facility exhibited aggressive behaviors and had a complex medical history, but a comprehensive baseline care plan was not developed within the required 48 hours. This delay led to the resident falling and sustaining a hip fracture. The facility's policy required a baseline assessment within 24 hours, but it was not completed on time, contributing to the incident.
Unnecessary psychotropic medication use and lack of supporting documentation
Penalty
Summary
The facility failed to ensure residents receiving psychotropic medications had an appropriate clinical rationale documented for not attempting a gradual dose reduction (GDR), that antipsychotic medications had an appropriate diagnosis, and that non-pharmacological interventions and resident behaviors were documented to support as-needed psychotropic use. The deficiency involved 3 of 5 residents reviewed for unnecessary medications: R63, R87, and R180. R63’s quarterly MDS indicated mild cognitive impairment and use of an antipsychotic and an antidepressant without a GDR attempt. R63’s medication orders included aripiprazole 10 mg twice daily for bipolar disorder and mirtazapine 7.5 mg at bedtime for insomnia. The consultant pharmacist recommended a GDR for both medications and noted that CMS guidelines call for trial dose reductions at least twice within the first year of use unless contraindicated, with rigorous risk/benefit documentation if a reduction is not attempted. The provider response stated only that R63 had been on aripiprazole since about 2014 and mirtazapine since 2022, and the EMR lacked further documentation supporting why a GDR was not attempted. The DON confirmed there was no documented clinical rationale for not attempting a GDR. R87’s quarterly MDS showed severe cognitive impairment and antipsychotic use. The EMR contained an order for quetiapine 12.5 mg twice daily for anxiety, ordered by hospice, and the consultant pharmacist noted anxiety is not a sufficient diagnosis to justify antipsychotic use. The record lacked behavior notes or target behavior documentation supporting the new antipsychotic order, and the December and January MARs did not show any as-needed quetiapine or lorazepam administration. R108’s record showed severe cognitive impairment and orders for lorazepam every 2 hours for anxiety, including as-needed use for 14 days, with multiple doses administered in December and January. The EMR, including progress notes, MARs, treatment records, and behavior task documentation, lacked documentation supporting the scheduled lorazepam order or showing that non-pharmacological interventions were attempted before as-needed lorazepam was given. Staff interviews confirmed the absence of documented behaviors and non-pharmacological interventions, and the facility policy required psychotropic use to be supported by documented rationale, attempted non-pharmacological approaches, and sound risk/benefit analysis.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to implement its written abuse reporting policy when an allegation of sexual abuse made by a resident with severe cognitive impairment was not reported to the state agency. The resident’s MDS indicated severe cognitive impairment and that she required partial to moderate assistance with most ADLs and substantial assistance with toileting. Her care plan stated that if she reported being sexually assaulted, staff were to ensure she was safe and report the allegation to a supervisor immediately. In a progress note, the resident reported that she had been sexually abused at night, and staff documented that the daughter reviewed the camera and said two nursing assistants changed the resident and nothing wrong happened, describing it as a behavior issue.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to ensure an allegation of sexual abuse was thoroughly investigated for one resident who had severe cognitive impairment and required partial to moderate assistance with most activities of daily living and substantial assistance with toileting. The resident’s care plan directed staff to ensure safety and immediately report any allegation of sexual assault to a supervisor. A progress note documented that the resident reported she had been sexually abused at night, and the note stated the daughter reviewed the camera and reported two nursing assistants changed the resident and that nothing wrong happened, with the daughter describing the concern as a behavior issue. Interviews showed staff were aware the resident had made similar allegations in the past and that such reports were expected to be escalated for timely reporting and investigation. However, the nurse manager, RN-D, the director of social services, and the DON all confirmed the December allegation was not reported to the DON and was not thoroughly investigated as required by facility policy. The facility policy stated that alleged abuse or suspected crime must be immediately reported to the supervisor, the DON or designee, and that an internal investigation must be initiated immediately, including interviews, resident and representative interviews, witness statements, observations, environmental review, and medical record review.
Inaccurate MDS Coding for Hospice Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident who was receiving hospice services. The resident’s quarterly MDS, dated 11/1/25, identified severely impaired cognition and listed diagnoses including dementia, atrial fibrillation, dysphagia, chronic pain, and hemiplegia. However, Section O of the MDS marked hospice care as “no,” indicating the resident did not receive hospice services, despite the resident’s orders including an order for hospice to evaluate, treat, and accept with a start date of 8/1/24 and an order to call hospice in case of an emergency with a start date of 10/29/25. Additional records also identified the resident as being on hospice. The EMR special instructions section listed the resident’s name, allergies, code status, and the hospice name, and the care plan stated the resident was enrolled in hospice with expected physical and cognitive decline. During interviews, an LPN verified the resident was on hospice, and the MDS director verified the last MDS was coded incorrectly and should have indicated hospice. The DON stated the accuracy of MDS assessments is important because it helps ensure staffing levels are appropriate and appropriate cares are provided to residents.
Failure to Keep Resident Nails Clean and Trimmed
Penalty
Summary
The facility failed to ensure that a resident's nails were kept clean and trimmed. The resident's quarterly MDS indicated he was cognitively intact, had upper and lower extremity impairments on one side, and required substantial to maximum assistance with ADLs. His care plan noted limited physical mobility and self-care deficits related to hemiplegia and hemiparesis following a cerebral infarction affecting his right side, that he required assistance of two staff with bathing and showering, and that staff were to provide nail care as needed. During observation and interview, the resident had fingernails about 1/4 inch long with dark matter underneath them and stated that they needed to be trimmed and cleaned. A later observation showed his nails still extended past his fingertips with dark matter underneath all of them. Nursing assistant staff stated residents were expected to receive nail care whenever needed and on bath days, and that staff should assist residents with washing their hands and ensuring their nails were clean each morning. The nurse manager confirmed staff were expected to keep residents' nails clean and provide nail care on bath days, and also confirmed there were no notes in the electronic medical record showing the resident's nail care had been completed.
Inappropriate Scheduled Lorazepam Order Implemented Without Clarification
Penalty
Summary
The facility failed to ensure a medication order written in error and without documented justification was questioned and double-checked before being implemented and administered multiple times for a resident with severe cognitive impairment. The resident’s EMR contained hospice lorazepam orders, including an order for lorazepam 0.5 mg every 2 hours for anxiety and other PRN lorazepam orders, and the MAR showed 6 PRN doses in one month, 1 PRN dose in the next month, and 11 scheduled doses between two dates. The resident’s treatment record directed monitoring for side effects of Seroquel but not lorazepam, and the chart lacked progress notes, MAR/TAR documentation, and behavior documentation to justify scheduled lorazepam every 2 hours. During interviews, the resident’s family member stated the facility had asked whether the lorazepam could be discontinued, but she wanted it available PRN and not scheduled every 2 hours, and she observed the resident seemed more confused and “doped up.” Nursing staff confirmed the resident was receiving lorazepam every 2 hours scheduled but did not know why the order had changed from PRN to scheduled. The hospice RNCM later stated the PRN order had expired, that he intended the medication to remain PRN, and that he actually meant to schedule it every 12 hours, not every 2 hours. The DON stated staff should have questioned the lorazepam order because it lacked justification and PRN use to support the change from PRN to scheduled dosing.
Failure to Offer and Document Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to assess and develop non-pharmacological interventions to promote comfort for a resident with chronic pain. The resident’s admission MDS indicated intact cognition and diagnoses including rheumatoid arthritis, Sjogren’s syndrome, arthrodesis status, muscle weakness, and chronic pain. The assessment also indicated the resident received PRN pain medications and non-medication interventions for pain. The resident reported frequent pain that occasionally affected sleep and day-to-day activities and rated the pain as 10 out of 10. During interview, the resident stated the pain was "over the top" and that the facility did not offer alternatives such as massage, heat, ice, or essential oils, though the resident believed these would be helpful. The care plan addressed pain medication therapy related to rheumatoid arthritis and included monitoring pain medication efficacy, pain intensity, and side effects, but it lacked evidence of non-pharmacological interventions being offered before PRN medications, what interventions had been tried, what was effective or ineffective, and what interventions should be used. The January MAR/TAR showed acetaminophen was administered 12 times and oxycodone 17 times for pain, with pain scale ratings documented and medication effectiveness noted, but there was no evidence that non-pharmacological interventions were offered prior to administration. Progress notes from 1/1/26 through 1/6/26 also lacked documentation of such interventions. Staff interviews indicated nursing assistants reported pain to nurses but did not offer interventions, and nursing staff and management stated non-pharmacological interventions were expected to be offered and documented prior to PRN pain medication administration.
Failure to Care Plan PTSD and Trauma History
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan with goals and interventions using a trauma-informed approach for one resident with PTSD. The resident’s quarterly MDS dated 11/26/25 indicated severely impaired cognition and listed diagnoses including PTSD, bipolar disorder, anxiety disorder, depression, dementia, and a seizure disorder. A psychosocial history assessment dated 11/19/25 documented that the resident reported experiencing significant life events that continued to affect life, but the form did not specify the traumatic events or identify any triggers. The resident also reported that smoking cigarettes once in a while helped get through difficult times and was seen by a mental health provider. The resident’s care plan, printed 1/8/26, identified resistive behavior during care and a history of becoming aggressive with staff during cares and accusing staff of attempting to hurt her. Interventions included psych follow-up, reassurance, and consistency in care, timing, caregivers, and routines, but the care plan did not mention PTSD, possible triggers, interventions to determine triggers, measurable objectives, or timeframes for staff actions related to PTSD. During interviews, NA-B stated that if a resident had PTSD and triggers, it would be on the care plan, while LPN-B verified the resident had a PTSD diagnosis and said it should be listed with triggers. DSS-A stated it was important to gather information from the resident, records, family, and providers to avoid retraumatizing a resident, and later verified there had not been a trauma care plan prior to the interview and that therapist notes identified trauma history related to current behaviors. The DON stated a resident’s trauma history needs to be assessed and care planned so staff are aware of it and do not retraumatize residents.
Laundry Left Wet in Washer Overnight
Penalty
Summary
The facility failed to ensure laundry was laundered according to standard infection control practices. During observation and interview, multiple cloth mop heads were seen in the laundry machine, and the laundry aide stated that mop heads, cleaning rags, microfiber cloths, and clothing protectors were brought to the laundry room throughout the day and then washed by non-laundry staff in the evening. The laundry aide confirmed that the usual practice was for these items to be washed and left wet in the washing machine overnight, with the laundry aide placing them in the dryer the following day. The infection preventionist stated she was unaware that damp laundry was being left in the washing machine overnight after washing, and the facility's Linen Handling to Prevent and Control Infection Transmission policy did not include direction on whether laundry could be left in the machine overnight.
PBJ Staffing Data Submission Was Inaccurate and Incomplete
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to CMS for Fiscal Year Quarter 4 2025 based on payroll and other verifiable and auditable data. The CMS PBJ Staffing Data Report dated 1/2/26 showed no RN hours and no licensed nursing coverage for 24 hours per day on 25 dates in August, even though review of staff schedules and time sheets showed the facility had appropriate licensed 24-hour nursing coverage and RN hours as required. During interview on 1/6/26, the administrator stated she was responsible for submitting the staffing data and was not surprised the report showed missing RN and licensed nursing hours. She stated she attempted to submit the August data and stayed late to complete the submission, but encountered technical issues and it did not go through. During interview on 1/9/26, the DON stated the administrator was in charge of submitting the PBJ report and that she had nothing to do with submitting it. The DON also stated she knew the administrator was having trouble submitting the report for August and that the facility had an RN in the building at all times, so the report was not accurate.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process and was based on a review of the resident's records, which did not contain a comprehensive or individualized care plan as required.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to properly test the levels of chemicals used in the three-compartment sink for sanitizing pots used in meal preparation. During an observation, it was noted that the facility did not have a testing log available for the chemical sanitization process, and the staff had not been testing the chemical levels. The culinary coordinator (CC) and the regional kitchen manager (RKM) confirmed that the pots used for food preparation were washed in the three-compartment sink and not in the dishwasher, indicating a lapse in ensuring proper sanitation. Additionally, the facility did not store dry goods in a manner that reduced the risk of cross-contamination. During a kitchen tour, two white plastic bins labeled for flour and sugar were found on the floor, with a scoop left inside the flour bin, touching the product. This practice was acknowledged by the CC as inappropriate and posed a risk for cross-contamination. The facility also failed to properly monitor food temperatures before serving meals to residents. The daily temperature logs for the steam table were incomplete, with several instances of missing temperature documentation for meals. The CC and RKM verified the incomplete logs and noted that the cooks and dietary aides were relying on each other to check temperatures, leading to inconsistencies. The absence of a single, reliable temperature log contributed to the deficiency in monitoring food safety.
Deficiency in Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to comprehensively assess and develop a person-centered care plan for a resident with a history of trauma, including monitoring for PTSD. The resident, who was cognitively intact, had a history of significant trauma, including an alcoholic father, loss of siblings and children, and an abusive partner. Despite these factors, the resident's care plan initially lacked any information on trauma-informed care or trauma triggers. It was only updated to include such information three days after the survey entrance. Interviews with facility staff revealed a lack of awareness and specific interventions related to the resident's trauma history. A CNA and RN familiar with the resident were unable to identify trauma-informed care interventions specific to the resident. The Director of Nursing acknowledged the importance of addressing trauma in care plans and confirmed that the resident's care plan had been updated post-survey to include trauma-informed care, triggers, and interventions. However, prior to this update, the care plan did not address these critical aspects, indicating a deficiency in the facility's approach to trauma-informed care.
Failure to Maintain Sanitary Environment for Resident with Feeding Tube
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for a resident who relied on a feeding tube for over 50% of her caloric intake. During observations, a dried light brown/yellow substance, suspected to be tube feeding solution, was found on the resident's feeding tube pole, dresser, bed, and floor. The resident expressed dissatisfaction with the cleanliness of her room, noting that the substance had been present for several months and was not cleaned regularly by the staff. Interviews with the nursing staff revealed a lack of clarity regarding the responsibility for cleaning the resident's room. The registered nurse in charge of the resident's care was unaware of how long the substance had been present, and the unit nurse manager stated that nursing staff should have cleaned the spills as they occurred, with housekeeping being called if necessary. Despite these expectations, the policy regarding resident room cleaning was not provided, indicating a possible gap in procedural guidance.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to ensure that care plan interventions were followed and new interventions were implemented in a timely manner when a resident's pain goals were not met. The resident, identified as R44, had a history of lumbar spinal stenosis with radiculopathy, osteoarthritis, osteoporosis, and failed back surgery syndrome, which contributed to her chronic pain. Despite being on a scheduled and as-needed pain medication regimen, R44 reported constant pain that affected her sleep and daily activities. Her pain management plan included various medications such as Tylenol, gabapentin, lidocaine patches, diclofenac gel, hydromorphone, and tramadol, but her pain was often rated at a seven or eight out of ten, far from her goal of zero. The report highlights several instances where the facility's staff did not adequately follow up on R44's pain management. On multiple occasions, tramadol was administered for high pain scores, but follow-up assessments were either delayed or not conducted, and the medication was often documented as ineffective. Despite the resident's reports of inadequate pain relief, there was no evidence that the nursing staff consistently notified the provider or implemented new pain interventions. The nurse practitioner managing R44's pain plan stated she had not received reports from the nursing staff about the ineffectiveness of the current pain management plan. Interviews with the facility's staff revealed a lack of consistent procedures for addressing unmet pain goals. The registered nurse and unit nurse manager both indicated that trained medication aides were responsible for assessing pain levels and following up on the effectiveness of pain interventions. However, there was confusion about the expected timeline for re-evaluating pain levels after administering medication. The facility's failure to provide a policy on resident pain management further underscores the lack of a structured approach to addressing pain management deficiencies.
Failure to Time-Limit PRN Psychotropic Medications and Document Indications
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders were time-limited to 14 days and did not document the rationale and duration for continuation beyond this period for two residents. One resident, who was moderately cognitively impaired and receiving hospice services, had an order for lorazepam without a specified stop date, and there was no evidence of provider review for discontinuation or renewal every 14 days. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless extended with documented rationale, which was not adhered to in this case. Another resident, who was cognitively intact and had multiple diagnoses including bipolar disorder and anxiety, had a PRN order for Compazine without an end date or rationale for continuation beyond 14 days. Additionally, this resident had an order for Trazodone that lacked an indication for use, leaving staff uncertain about the medication's purpose. Interviews with facility staff, including the DON, confirmed the expectation that all PRN psychotropic medications should have a 14-day end date and that indications for use should be clearly documented to ensure proper assessment of medication effectiveness.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that two residents, who were reviewed for immunizations, were offered, educated, and/or provided the pneumococcal vaccine series as recommended by the CDC. The CDC guidelines specify the administration of the Pneumococcal 20-valent Conjugate Vaccine (PCV20) for adults who have previously received the Pneumococcal 13-valent Conjugate Vaccine (PCV13) and the Pneumococcal Polysaccharide Vaccine 23 (PPSV23). However, the medical records for these residents did not indicate that they had been offered or educated about the benefits of receiving the PCV20 vaccination. Resident 25, who was severely cognitively impaired and had multiple diagnoses including peripheral vascular disease and Alzheimer's disease, had received the PPSV23 vaccine but lacked documentation of being offered the PCV20 vaccine. Similarly, Resident 85, also severely cognitively impaired with conditions such as heart failure and diabetes mellitus, had received both PCV13 and PPSV23 but not the PCV20. Interviews with the infection preventionist and the director of nursing confirmed the absence of documentation and the failure to offer the PCV20 vaccine to these residents. The facility did not provide a vaccination policy when requested.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered and/or provided to a resident, identified as R58, who was reviewed for immunizations. According to the report, R58 was cognitively intact and had diagnoses including anemia, hypertension, hyperlipidemia, and anxiety disorder. The resident's immunization records in the Point Click Care system lacked documentation for the COVID-19 vaccination. During an interview, the infection preventionist confirmed that R58 was eligible for the COVID-19 vaccination but had not been offered the vaccine, nor had the resident refused it. The director of nursing confirmed that R58 had not been offered or received the COVID-19 vaccination. The director stated that the expectation was for all residents to be educated on the risks and benefits of vaccinations and to be offered any eligible vaccinations. The facility did not provide a vaccination policy when requested, indicating a lack of documented procedures to ensure compliance with vaccination protocols. This deficiency was identified during a review of the facility's practices and interviews with staff.
Failure to Develop Timely Baseline Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop a comprehensive baseline care plan within 48 hours after the admission of a resident, leading to a deficiency. The resident, who was admitted on a stretcher from the hospital, exhibited behaviors such as hitting staff and attempting to stand up, which required close observation to prevent falls. Despite these behaviors and the resident's medical history, including a brain disorder, breast cancer, and heart disease, a comprehensive care plan was not created until nine days after admission. This delay in care planning coincided with the resident falling and sustaining a hip fracture. The facility's policy required a baseline assessment to be completed within the first 24 hours of admission, which would then inform the baseline care plan. However, the assessment was not completed in a timely manner, and the care plan was not updated with the necessary interventions. Interviews with nursing staff and the director of nursing revealed that the evening shift typically handled admissions, and the resident's confusion and aggressive behavior hampered the assessment process. The failure to complete the assessment and care plan within the required timeframe contributed to the resident's fall and subsequent injury.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villas At The Park | 0.9 mi | ★★★★★ | 11 | 0 |
| Southside Care Center | 1.8 mi | ★★★★★ | 28 | 1 |
| Birchwood Care Home | 1.9 mi | ★★★★★ | 3 | 0 |
| Redeemer Health Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Villas At Bryn Mawr Llc | 2 mi | ★★★★★ | 5 | 3 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.