Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regina Senior Living during CMS and state inspections, most recent first.
Food-contact equipment and storage practices were not maintained in accordance with professional standards. Surveyors observed a paper bowl used as a scoop in a sugar container, a can opener blade and gear covered with dark dry substance and red paste, and food boxes stored on the walk-in freezer floor. The CD and HC confirmed the scoop was not usual practice, the can opener had not been cleaned, and the boxes should not have been on the floor.
A resident with COVID-19 was cared for by staff who did not consistently wear the correct PPE, including a PT and NA who entered the room without the required N95-based precautions, and the wrong isolation sign was posted on the door. In addition, podiatry care for a resident on EBP was performed in a common area without the appropriate PPE, and another resident with a heel pressure injury and wound care orders was not placed on EBP despite the facility policy and the resident’s device- and wound-related needs.
Privacy was not maintained during podiatry care for three residents. One resident with severe cognitive impairment, one resident who was cognitively intact, and one resident with limited cognitive impairment all received foot care in the day room while other residents were waiting, and nursing and cleaning staff walked through during treatment. FM and residents stated they would have preferred private treatment, and the DON, administrator, and RDCS confirmed podiatry and other medical procedures should be done in private, while also confirming the care was provided in the day room with multiple residents present.
Failure to Evaluate Before Renewing PRN Antipsychotic Medication: A resident with severe cognitive impairment, dementia, anxiety, and hospice services received repeated PRN haloperidol doses and multiple renewed orders. The LPN, DON, and hospice RN stated PRN antipsychotics require provider review every 14 days, but the record did not show a face-to-face evaluation before the medication was renewed.
The facility failed to develop person-centered care plans for two residents. One resident had CVA, CHF, edema, and a pressure-related heel injury, but the care plan lacked a skin section and interventions for pressure ulcer/injury prevention, and staff were unsure about the repositioning schedule. Another resident was admitted to hospice with COPD, emphysema, and chronic respiratory failure, but the care plan did not include a hospice care plan or the resident’s end-of-life preferences.
A facility failed to ensure ordered medications were available for administration for two residents. One resident with chronic foot wounds and multiple vascular and metabolic conditions did not receive ordered metronidazole wound treatment on several scheduled occasions because the medication was unavailable or not processed as expected, despite staff and pharmacy discussions about the ADU supply. Another resident with skin issues and a toe amputation did not receive ordered urea lotion because the pharmacy did not carry the ordered strength and the order remained unresolved until a different concentration was prescribed.
Failure to monitor the effectiveness of melatonin prescribed for sleep for a resident. The resident had no cognitive impairment and multiple diagnoses including polyneuropathy, DM2, MDD, anxiety, and OSA. The MAR showed the melatonin was administered, but the record lacked sleep tracking or any monitoring assessment, and the DON confirmed sleep tracking was only done when ordered by the provider.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to non-compliance with care planning requirements.
A resident with a colostomy was not offered a care conference and was unable to participate in developing his person-centered care plan. The care plan lacked individualized instructions for colostomy care, and the resident's preferences for ostomy supplies and timing of bag changes were not initially accommodated. Interviews with staff confirmed the absence of a documented care conference, despite facility policy requiring resident involvement in care planning.
A deficiency was cited when a resident's care plan did not include all necessary needs, measurable timetables, or specific actions, resulting in incomplete planning and documentation.
A resident requiring colostomy, urostomy, or ileostomy care did not receive the appropriate care or services needed for their condition.
The facility failed to properly label, date, and store food items, and did not consistently monitor dishwasher temperatures, affecting all residents and staff. Observations revealed unlabeled food, incomplete dishwashing logs, and unclean equipment. The FSD confirmed the importance of proper labeling, sanitation, and temperature monitoring.
Medication carts containing drugs, including narcotics, were observed left unlocked and unattended in accessible areas, with residents passing by. Nursing staff and the DON confirmed that the carts were not secured as required by facility policy, which mandates that only authorized personnel may access medications and that carts must be locked when unattended.
Three residents experienced prolonged call light response times, with waits exceeding 20 minutes for assistance with personal care needs. The delays led to emotional distress and discomfort, as reported by the residents. Staff interviews indicated high resident assignments contributed to the inability to respond promptly, and the DON acknowledged that such delays were not acceptable.
A resident with multiple chronic conditions and oxygen dependence developed a persistent cough and sore throat, but staff failed to consistently assess, document, or notify the provider of the change in condition. Despite facility policy requiring immediate action and documentation for significant changes, nursing staff did not follow procedures, resulting in delayed provider notification and inadequate monitoring.
A care sheet containing the personal health information of two residents, including names, room numbers, and care details, was left unattended in a public area for nearly an hour. Multiple staff and residents passed by the exposed document, making the information accessible to unauthorized individuals. Both an LPN and the DON acknowledged this as a HIPAA violation, and one resident expressed concern about their privacy being compromised.
A resident with intact cognition and high ADL needs repeatedly reported missing and damaged clothing due to the offsite laundry service. Despite voicing these concerns to staff, no action was taken, and the complaints were not documented or investigated as required by facility policy. Interviews confirmed that other residents had similar issues, but management was unaware, and no evidence of investigation or resolution was found.
Two residents did not have required cognitive and mood assessments completed as part of their quarterly MDS, with entire sections left blank and no evidence of BIMS or PHQ-9 evaluations in the medical record. The responsible RN confirmed these omissions were due to staff turnover in social services, and the facility could not provide a policy on MDS completion.
A resident with multiple comorbidities and chronic respiratory disease developed new onset cough and sore throat, but staff failed to promptly assess, monitor, or document the resident's condition. PRN medications were not administered or recorded in a timely manner, and vital signs were inconsistently documented. Nursing staff did not notify the provider or initiate appropriate precautions, despite the resident's worsening symptoms and requests for medical attention.
The facility did not ensure staff consistently used enhanced barrier precautions, such as gowns and gloves, during high-contact care for a resident with chronic wounds and an indwelling catheter. Additionally, another resident with ongoing respiratory symptoms was not placed on respiratory precautions or tracked in the infection surveillance system, despite repeated use of PRN cough medications and staff awareness of the symptoms.
Food Contact Equipment and Storage Not Kept Clean
Penalty
Summary
Food-contact equipment and food storage practices were not maintained in accordance with professional standards. During an initial kitchen tour, surveyors observed seven boxes stored on the walk-in freezer floor, a brown paper bowl being used as a scoop left inside the sugar container, and the can opener blade and gear covered with a dark dry substance. The culinary director confirmed the paper bowl was not the usual practice and stated it could cause cross contamination. On a follow-up tour, the can opener blade and gear were still covered with the dark dry substance and a red paste was also noted on the blade; the head cook stated it had been used and must have gotten dirty the day before. Five food boxes remained on the walk-in freezer floor, and the head cook stated they were not supposed to be on the floor and had been delivered the prior day. The culinary director later stated the can opener was expected to be cleaned weekly and confirmed the boxes should not be on the floor.
Failure to Follow COVID-19 PPE, Enhanced Barrier Precautions, and Wound-Related Isolation Requirements
Penalty
Summary
The facility failed to correctly establish and ensure staff followed transmission-based precautions for a resident with COVID-19. A resident admitted from the hospital had severe cognitive impairment, dementia, and COVID-19. During observation, a PT entered the resident’s room wearing only a standard mask and without an isolation gown or gloves, placed a gait belt in the room, and exited. The PT later stated he should have worn the appropriate PPE before entering the room and that the correct PPE included an isolation gown, N95 mask, and gloves. The resident’s meal tray was also delivered by a nursing assistant who wore an isolation gown, standard mask, gloves, and eye protection, but not an N95 mask. The nursing assistant stated she knew the resident had COVID-19 and required additional PPE, but wore a standard mask because the isolation sign on the door stated a standard mask could be used. The DON and RDCS confirmed the sign on the door was not the correct sign and that the correct PPE for the resident included an N95 respirator or higher-level respirator, eye protection, and gloves. The facility also failed to ensure appropriate PPE was used for residents on enhanced barrier precautions during podiatry treatment in a common area. One resident had limited cognitive impairment, used a wheelchair, had a urinary catheter, and was on enhanced barrier precautions due to the catheter. During podiatry care in the day room, the podiatry provider removed the resident’s shoes and socks, performed callous shaving and toenail clipping, and the medical assistant later helped replace the shoes and socks without applying the appropriate PPE. The medical assistant stated she was unsure whether special PPE was required and said the podiatry team did not wear PPE unless directed by facility staff. The podiatrist stated he was unaware the resident required additional PPE for podiatry treatment and said he would prefer the day room to be private, but more residents were brought into the room. The facility further failed to initiate enhanced barrier precautions for a resident with a pressure injury. The resident had intact cognition, required substantial assistance with toileting and bed mobility, and had a pressure-induced deep tissue injury of the left heel with a large blister that had popped. The resident had an order for daily wound dressing changes and wound care instructions for the left heel. However, the room and area outside the room lacked enhanced barrier precaution signage and there was no isolation cart. The DON and RDCS stated the resident was not to be on enhanced barrier precautions and said the facility policy applied only to chronic wounds, diabetic wounds, and pressure ulcers. The facility policy reviewed by surveyors defined enhanced barrier precautions for chronic wound care and described chronic wound care as any skin opening requiring a dressing, excluding shorter-lasting wounds such as skin breaks or skin tears covered with adhesive bandage.
Privacy Not Maintained During Podiatry Treatments
Penalty
Summary
The facility failed to maintain privacy during podiatry treatments for 3 of 3 residents reviewed for privacy. During an observation, one resident was receiving foot care in the day room while two other residents were waiting there for their appointments. After the first resident’s treatment was completed and the resident was removed, the podiatry MA returned and moved the second resident for treatment while the third resident remained in the day room. After the second resident’s treatment, the third resident was moved for care. During the third resident’s podiatry treatment, nursing staff and cleaning staff were walking through the day room, and the resident was then taken back to the room after the treatment was completed. The residents involved had varying levels of cognitive and physical needs. One resident had severe cognitive impairment, was dependent on facility staff for all cares, and had diagnoses including neurocognitive disorder with Lewy-bodies dementia, chronic pain syndrome, and cognitive communication deficit. Another resident had no cognitive impairment and was independent with ambulation, toileting, and hygiene, with diagnoses including cellulitis of both lower extremities and amputation of a toe. The third resident had limited cognitive impairment, used a wheelchair for mobility, required set-up assistance for hygiene and oral care, and had diagnoses including prostate cancer, chronic kidney disease, and difficulty walking. Family and residents stated they would have preferred the podiatry treatments to be done in private, and facility leadership confirmed that medical procedures such as podiatry should be done in private, while also confirming the treatments on the day in question were conducted in the day room with multiple residents present.
Failure to Evaluate Before Renewing PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure an evaluation was completed before renewing PRN antipsychotic medication for a resident with severe cognitive impairment, dementia, anxiety, and a history of verbal behaviors who was receiving hospice services. The resident’s MDS showed antipsychotic use, and the medication record showed repeated haloperidol administration, including 21 doses of 1 mg every 4 hours PRN, followed by additional PRN orders at higher frequency. Hospice records showed haloperidol orders with handwritten stop dates, including a 0.5 mg every 4 hours PRN order, then a 1 mg every 4 hours PRN order, and later a 1 mg every hour PRN order. The resident was last seen by the facility provider on 1/8/26 and by the hospice provider on 1/20/26. During interviews, the LPN stated residents receiving PRN antipsychotics are seen by a provider every 14 days, and the DON stated PRN antipsychotic medications are good for 14 days and are automatically given a stop date. The hospice RN stated hospice managed the medication, but the facility was responsible for determining breakthrough issues, and hospice providers do not see residents face to face to re-order PRN antipsychotics. The DON and RDCS reviewed the record and could not provide documentation that the resident received a face-to-face visit by a provider every 14 days. The facility policy stated PRN antipsychotic orders are limited to 14 days and cannot be renewed unless the attending provider evaluates the resident for appropriateness.
Failure to Develop Person-Centered Care Plans for Pressure Injury Risk and Hospice Care
Penalty
Summary
The facility failed to develop person-centered care plans for 2 residents reviewed for care planning. One resident had intact cognition, required substantial assistance with toileting and bed mobility, was occasionally incontinent of bladder, had diagnoses including CVA, CHF, edema, and a pressure-induced deep tissue injury of the left heel, and was identified on admission skin risk assessments as being at risk for pressure ulcers with an intervention to reposition every 2 to 3 hours. Although the care plan addressed assistance with bed mobility, transfers, ambulation, and locomotion due to CVA, the record lacked an implemented care plan for pressure ulcer and injury prevention, and the care sheet lacked interventions to prevent pressure ulcers and injuries. The resident denied being assisted with frequent repositioning in bed or chair, and the DON stated there was no skin category or pressure ulcer risk on the care plan. Another resident had no cognitive impairment, used a walker, was independent with eating, hygiene, and dressing, and had diagnoses including COPD, emphysema, and chronic respiratory failure. After admission to hospice, the resident's comprehensive care plan did not include a patient-centered hospice care plan. Staff stated they were unsure why the resident was placed on hospice and were unsure of the resident's end-of-life preferences, while the DON and RDCS confirmed the hospice care plan should include hospice company information, hospice diagnosis, and known resident choices and preferences, but none was present in the care plan.
Medication Orders Not Available for Two Residents
Penalty
Summary
The facility failed to ensure medications were available for administration per physician order for two residents reviewed for pharmacy services. For one resident with cerebral palsy, peripheral vascular disease, diabetes, respiratory failure, lymphedema, venous insufficiency, and chronic wounds to both feet, the wound clinic ordered metronidazole 500 mg crushed and sprinkled into the right dorsal foot wound every other day. The record showed the order was entered after the provider visit, but the medication was repeatedly not given on scheduled treatment dates. Facility notes documented that metronidazole was unavailable, messages were left for pharmacy, and staff later stated the medication was in the ADU, while the wound NP confirmed it was not available at multiple visits and had to be reordered. Interviews with nursing staff, the wound NP, and pharmacy staff showed inconsistent handling of the order and medication supply. Staff stated new orders were to be entered and verified the same day, but this order was not verified until several days after it was written. The pharmacy tech stated the medication was dispensed from the ADU on certain dates and that no metronidazole was dispensed from the machine for several days after the order was received. The DON and RDCS confirmed the order date, the delayed entry and verification, and that the medication was not available when expected. The facility policy titled Medication Ordering and Receiving From Pharmacy did not reference the ADU machine, and a policy regarding processing provider orders was requested but not received. For the second resident, who had no cognitive impairment and was independent with ambulation, toileting, and hygiene, the provider prescribed 25% urea lotion to both feet twice daily for skin issues related to cellulitis and a right lesser toe amputation. Facility documentation showed the pharmacy stated it would not provide the OTC medication, then later stated it did not carry the specific percentage ordered and requested clarification. The order remained unresolved until a new order for 20% urea cream was written and transcribed. During observation, the resident stated he had not been using any lotion on his feet because the facility had not gotten it yet, and the MD noted the lotion was needed to help reduce dryness of the feet.
Failure to Monitor Effectiveness of Sleep Medication
Penalty
Summary
The facility failed to monitor the effectiveness of melatonin prescribed for sleep for one resident. The resident’s MDS assessment identified no cognitive impairment, lower extremity impairment on one side, maximum assistance with transfer and bed mobility, independent toilet transfer, and bowel and bladder incontinence. The resident’s diagnoses included polyneuropathy, type 2 diabetes, major depressive disorder, anxiety, obstructive sleep apnea, and a laceration to the right great toe. Medication orders showed melatonin 5 mg by mouth at bedtime, and the MAR indicated it was administered from 1/1/26 through 2/25/26. However, the resident’s record did not contain sleep tracking or any monitoring assessment, and progress notes from 12/1/25 through 2/26/26 showed no sleep tracking notes. During interview, the DON confirmed the resident was taking melatonin for sleep and stated sleep tracking was only initiated when ordered by the prescribing provider.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations.
Failure to Involve Resident in Person-Centered Care Planning for Colostomy Care
Penalty
Summary
The facility failed to offer a care conference to a resident with a colostomy, resulting in the resident's inability to participate in the development and implementation of his person-centered care plan. The resident's care plan did not include individualized instructions for colostomy care, such as the specific supplies required or the process for changing the colostomy bag. Documentation showed that the resident was cognitively intact and had diagnoses including Crohn's disease and a colostomy. The medication administration record indicated scheduled changes for the ostomy bag, but the resident reported a preference for morning changes, which was not accommodated. The resident also experienced multiple episodes of colostomy leakage during the initial weeks of his stay and had to repeatedly request the use of specific ostomy supplies he was familiar with, which were only provided after several weeks. Interviews with the resident, an LPN, and the DON confirmed that there was no documentation of a care conference in the resident's chart, and the DON was unaware if one had occurred. Facility policy required resident involvement in comprehensive person-centered care planning, with documentation if participation was not practicable. The lack of a care conference and individualized care planning for the resident's colostomy care constituted a failure to involve the resident in planning and implementing his care as required by facility policy and resident rights.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's 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 and was based on a review of the resident's records, which did not contain a comprehensive or measurable care plan as required.
Failure to Provide Appropriate Ostomy Care
Penalty
Summary
A resident who required colostomy, urostomy, or ileostomy care did not receive appropriate care or services as needed. The report identifies a failure to provide the necessary ostomy care for a resident with such a medical requirement. Specific details regarding the actions or omissions that led to this deficiency are not provided in the report.
Deficiencies in Food Storage, Equipment Sanitation, and Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of food items in the refrigerators and dry storage areas. During observations, it was noted that several food items, including cereals, tomato paste balls, tater tots, assorted melons, grapes, pancakes, and sausage, were not labeled or dated. The Food Service Director (FSD) confirmed that all items should be labeled, covered, and dated as soon as they are removed from their original containers to ensure freshness. Additionally, the facility did not consistently track and monitor the dishwasher temperatures for both the wash and rinse cycles. The dishwashing log was missing numerous entries, with 32 out of 51 entries missing from March 1 to March 17, 2025. The FSD acknowledged that the documentation was incomplete and emphasized the importance of proper sanitation of dishes before use. Furthermore, the facility lacked a sanitation log for the three-compartment sink, and staff were not aware of how to use the sanitation test strips. The facility also failed to maintain cleanliness of food equipment. Observations revealed a dried creamy white substance on the standing food mixer and a thick black substance on the range and grill grates. Raw ground beef was found under the stove grate. The cleaning checklist for the kitchen equipment was incomplete, with several days missing entries. The FSD verified that the cleaning checklist should be completed daily to ensure proper sanitation and hygiene in the kitchen.
Unattended and Unlocked Medication Carts Observed
Penalty
Summary
Surveyors observed that medication carts containing drugs and biologicals were left unlocked and unattended in areas accessible to residents, staff, and guests. On two separate occasions, an unattended and unlocked medication cart was found in common areas with no staff present. During these times, residents in wheelchairs were seen passing by the unsecured carts. Nursing staff confirmed that the carts were unlocked and acknowledged that this allowed anyone to access the medications, including narcotics and other drugs. The Director of Nursing (DON) confirmed that medication carts should not be left unlocked and unattended, in accordance with facility policy. The facility's policy states that only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications, and that medication carts must be locked when not attended by authorized personnel. The failure to secure the medication carts had the potential to affect all residents whose medications were stored in the carts.
Failure to Maintain Resident Dignity Due to Delayed Call Light Response
Penalty
Summary
The facility failed to maintain resident dignity by not responding promptly to call lights for three residents who required assistance. One resident with left-sided paralysis and depression waited nearly 29 minutes after activating the call light for help with changing a soiled brief, expressing frustration and discomfort at having to wait in a dirty brief. Two other residents, one recovering from hip replacement and another with osteomyelitis and diabetes, experienced call light response times of over 20 minutes each. Both residents reported emotional distress and discomfort due to the prolonged wait for assistance, with one stating it made them cry and another expressing distress at remaining in a wet brief. Interviews with nursing assistants and an LPN revealed that staff were assigned more residents than usual, with some reporting assignments of up to 14 residents, making it difficult to respond to call lights promptly. Staff acknowledged that response times over five to twenty minutes were too long and could impact resident safety and satisfaction. The DON confirmed that the expectation was for call lights to be answered as soon as possible and acknowledged that a 28-minute wait was excessive. Facility policy required calls for assistance to be answered as soon as possible based on immediate needs.
Failure to Timely Notify Provider of Resident's Change in Respiratory Condition
Penalty
Summary
The facility failed to notify the medical provider in a timely manner regarding a resident's change in respiratory condition. The resident, who had diagnoses including diabetes, anxiety, morbid obesity, and chronic obstructive pulmonary disease, was dependent on staff for activities of daily living and was utilizing oxygen. Despite having physician orders for as-needed cough medications, the resident began experiencing a persistent cough and sore throat, which was not adequately assessed or documented in the progress notes. Vital signs were inconsistently recorded, and there was no evidence of monitoring or follow-up for the new respiratory symptoms over several days. Multiple staff interviews revealed that the resident had reported worsening cough and throat pain for at least four days, expressing concern about the lack of intervention and requesting to see a doctor. Nursing staff acknowledged that the resident's symptoms were not properly documented or communicated to the provider, and that follow-up actions, such as obtaining vital signs and notifying the provider, were not consistently performed. The nurse practitioner confirmed that the provider team was not notified of the resident's symptoms until several days after onset, despite the resident being at high risk for respiratory compromise. Facility policy required immediate notification of the provider and documentation in the event of a significant change in condition, including new respiratory symptoms. However, the staff did not follow these procedures, resulting in a delay in provider notification and lack of appropriate assessment and documentation for the resident's change in condition.
Failure to Secure Resident PHI on Unattended Care Sheet
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal health information (PHI) by leaving a care sheet unattended in a public area. The care sheet, which contained identifiable information such as names, room numbers, diets, allergies, assistance needs, shower and weight schedules, preferences, transfer assistance, and reminders for bowel and bladder monitoring, was left exposed in an alcove across from the nursing station for fifty-one minutes. During this time, seventeen staff members and four residents passed by the unattended document, making the information accessible to unauthorized individuals. Two residents, both identified as having intact cognition on their most recent Minimum Data Set (MDS) assessments, were specifically affected as their information was listed on the care sheet. Interviews with staff and one of the residents confirmed that the information should not have been left out and that such an action was a violation of HIPAA privacy policies. The facility's own policy, reviewed earlier in the year, clearly states that protected health information must be kept confidential and not accessible to those without authorization.
Failure to Address and Investigate Resident Grievances Regarding Laundry Service
Penalty
Summary
The facility failed to act upon, investigate, or resolve grievances voiced by a resident regarding missing and damaged clothing resulting from the offsite laundry service. The resident, who was cognitively intact and required significant assistance with mobility and activities of daily living, reported multiple instances where her clothing was either returned late, not returned at all, or was damaged with holes. Despite expressing her concerns to staff, she was told that nothing could be done, and her complaints remained unresolved to her satisfaction. Interviews with direct care staff confirmed that the resident had complained about the laundry service, and that similar complaints had been voiced by other residents regarding delayed or missing items. However, these concerns were not documented in the facility's grievance log, nor was there any evidence in the resident's medical record that the issues had been reviewed or addressed. The offsite laundry service account manager also reported being unaware of any recent concerns from the facility, indicating that no communication or investigation had taken place regarding the reported problems. Facility leadership, including the administrator and DON, acknowledged during interviews that they were unaware of the complaints being reported by floor staff and residents. The facility's grievance policy required that all voiced concerns, including verbal complaints, be documented and investigated, but this process was not followed in the case of the resident's laundry issues. No documentation or evidence was provided to show that the concerns were acted upon, investigated, or resolved during the survey period.
Incomplete MDS Assessments for Cognition and Mood
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed thoroughly for two residents, specifically omitting required evaluations in the areas of cognition and depressive symptoms. For both residents, the quarterly MDS forms had entire sections—Section C (Cognitive Patterns) and Section D (Mood)—left blank, with no evidence that the Brief Interview for Mental Status (BIMS) or the Patient Health Questionnaire-9 (PHQ-9) assessments were conducted. Review of the medical records confirmed that these assessments were not completed during the assessment reference dates, and the corresponding MDS sections were not addressed or documented. Interviews with the registered nurse responsible for MDS completion revealed that the omissions were due to staff turnover in the social services department, which was responsible for these assessments. The nurse acknowledged that the assessments had been missed and that this had been a recurring issue during periods of staff transition. The facility was unable to provide a policy regarding MDS completion when requested.
Failure to Assess and Monitor New Onset Respiratory Symptoms
Penalty
Summary
The facility failed to comprehensively assess and monitor a resident with new onset respiratory symptoms, resulting in a deficiency. The resident, who had intact cognition and was dependent on staff for activities of daily living, had significant medical diagnoses including diabetes, anxiety, morbid obesity, and chronic obstructive pulmonary disease, and was utilizing oxygen. Physician orders were in place for PRN medications to address cough and respiratory symptoms, but there was a lack of timely administration and documentation of these medications in the Medication Administration Record (MAR) for several days after the onset of symptoms. Despite the resident experiencing a persistent cough, sore throat, and requesting stronger interventions, there was no evidence in the progress notes or vital sign documentation that staff performed comprehensive assessments or monitored the resident's respiratory status during the initial days of symptoms. Vital signs were not consistently documented on key dates when the resident was symptomatic, and staff interviews revealed uncertainty about whether the resident had been tested for infectious causes or seen by a provider. The resident reported feeling unwell for several days, with symptoms worsening and no provider contact or enhanced precautions initiated during this period. Interviews with nursing staff and the nurse practitioner confirmed that the facility's expectations for assessment, documentation, and provider notification were not met. Staff acknowledged that vital signs, lung sounds, and symptom reviews should have been performed and documented promptly, and that the provider should have been notified earlier. The facility's policy required assessment and provider notification for significant changes in condition, but these steps were not followed, resulting in delayed recognition and response to the resident's respiratory symptoms.
Failure to Maintain Enhanced Barrier and Respiratory Precautions
Penalty
Summary
The facility failed to maintain enhanced barrier precautions (EBP) for a resident with indwelling medical devices and chronic wounds. According to the resident's care plan, staff were required to wear gowns and gloves during high-contact care activities, such as catheter care and personal hygiene. However, during observation, nursing assistants were seen performing catheter care and assisting with dressing and hygiene without wearing gowns, only using gloves. Interviews with the nursing assistants revealed a lack of understanding regarding when gowns were required, with staff believing gowns were only necessary for wound or catheter care performed by nurses, not for other high-contact activities. The infection control preventionist confirmed that gowns and gloves should be worn for all high-contact care activities for residents on EBP. Additionally, the facility was unable to provide a policy regarding EBP when requested. The facility also failed to implement and maintain respiratory precautions and proper infection surveillance for a resident exhibiting active symptoms of a potential respiratory illness. The resident had a productive cough for several days, was receiving PRN cough medications, and expressed concern about not being seen by a doctor. There were no precaution signs or personal protective equipment outside the resident's room. Nursing staff were aware of the resident's symptoms and medication use but did not contact a provider or initiate respiratory precautions. Progress notes indicated that the resident's symptoms had been ongoing for several days before any assessment or provider notification was documented. Furthermore, the resident with respiratory symptoms was not added to the facility's infection surveillance tracking system, despite staff being trained to create infection events for new or worsening symptoms. Interviews with clinical leadership confirmed that the resident should have been placed on respiratory precautions and tracked for infection surveillance, but these steps were not taken. The facility's surveillance policy required routine and systematic infection tracking, which was not followed in this case.
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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 Hastings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Augustana Care Hastings Health And Rehabilitation | 1.4 mi | ★★★★★ | 2 | 1 |
| Prescott Nursing And Rehab Community | 4.5 mi | ★★★★★ | 6 | 0 |
| Norris Square | 7.2 mi | ★★★★★ | 5 | 0 |
| St Therese Of Woodbury Llc | 10.6 mi | ★★★★★ | 10 | 0 |
| Woodbury Health Care Center | 11.8 mi | ★★★★★ | 8 | 1 |
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