Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Southside Care Center during CMS and state inspections, most recent first.
A facility failed to keep advance directive and code status information consistent between the EHR and hard chart. Two residents had conflicting POLST and physician order information, and staff interviews showed one LPN would not start CPR for one resident based on an incorrect DNR order while another resident would have been given CPR despite a DNR/DNI POLST. A third resident was later found during audit to have a similar mismatch between the POLST and EHR orders, and the DON acknowledged there was no process to ensure the records matched.
Activities were not comprehensively assessed, planned, or provided to meet resident needs. Several residents with intact cognition and documented interests reported boredom and said group activities were not being offered, while records showed incomplete activity assessments, missing activity preference documentation, and care plans that were not individualized. The activities director stated he was the only activities staff member, did not document attendance or progress notes, and did not schedule activities with times or locations; staff also confirmed there were no weekend activities and no organized activities had been observed for weeks.
Unqualified Activities Director and Incomplete Activity Program Documentation: The facility did not have a qualified activities professional directing the activity program. The activities director said he was the only activities staff, created the monthly calendar, was also expected to transport residents to appointments, and did not complete progress notes, attendance records, care plan updates, or QAPI participation; he also had no prior training, licensure, or full-time therapeutic activities experience. The DON and administrator confirmed there were no weekend activities, no attendance or progress note documentation, and that the director was not licensed or registered.
RN staffing was not maintained for the required 8 consecutive hours each day. PBJ staffing data and timecards showed multiple shifts with no RN hours, and the building owner stated that on several occasions an RN was scheduled but an LPN covered the shift or an RN called in. The administrator acknowledged the facility had previously struggled to consistently fill RN hours, especially on weekends, despite a policy requiring RN coverage 7 days a week.
Improper Food Storage, Labeling, Cleaning, and Hair Restraint Use: Surveyors observed multiple opened food items in the kitchen refrigerator, freezer, and dry storage areas that were not dated or labeled, along with an unclean freezer containing frozen residue and black matter on the door seal. A cook was also observed preparing food without a hair net, despite posted expectations and staff statements that food items must be dated and labeled and cooks must wear hair restraints.
QAPI Program Lacked a Formal Plan and Failed to Address Repeated Quality Deficiencies: The facility did not have a formal QAPI plan or process for collecting data, tracking performance, setting goals, or identifying and analyzing quality deficiencies. QAPI meeting notes did not address concerns in activities or dietary/kitchen practices, even though the CASPER report showed repeated citations for activities, food sanitation, the QAPI program/plan, QAPI improvement activities, and the QAA committee. The administrator stated the QAPI committee was new and no formal process was in place.
Failure to maintain an effective QAPI program: The facility held monthly QAPI meetings, but the meeting notes did not show data-driven quality metrics over time or any PIPs. The DON/administrator stated there was no formal process for collecting data, no formal QAPI plan, no established goals, and no process for identifying high-risk or problem-prone areas or gathering input from residents or staff.
QA committee meetings did not include the required members. Review of QAPI notes showed only the administrator, DON, medical director, and consultant pharmacist regularly attended, while the infection preventionist did not regularly participate. The administrator stated he knew additional staff were needed, but scheduling conflicts prevented full attendance. The facility policy required the QAA committee to meet at least quarterly and include the administrator, medical director, DON, infection preventionist, and other departments as requested.
Improper Laundry Infection Control Practices: The housekeeper was observed transporting soiled resident laundry in an uncovered basket, carrying clean linen uncovered, and handling soiled and clean linen without a PPE gown. A resident also placed personal laundry on the utility sink near the running washer while clean linen sat uncovered on the dryer. The housekeeper stated laundry baskets were not washed or sanitized between uses unless visibly dirty, and the facility policy required linen to be covered during transport and soiled linen to be bagged or contained.
Failure to Implement Active Antibiotic Stewardship Program: The facility did not have an active antibiotic stewardship program with protocols and a system to monitor appropriate antibiotic use, including prophylactic use. The IC-MDS worked part time and reviewed MARs weekly, but she was not notified when residents started antibiotics before her visits, had no written guide for antibiotic timeouts or reviews, and was not involved in periodic review of prescribing practices or QAPI discussions. Monthly tracking forms were incomplete and lacked required details such as resident name, diagnostic testing, symptoms, standardized criteria, timeouts, and response to antibiotics.
Failure to maintain building and grounds in good repair: A resident’s room had a damaged closet door jamb, gaps around a window AC unit, and a dirty fan, while other areas of the facility showed rotted and peeling window casings, a hanging piece of exterior trim above the smoking patio, and a hole in the patio sidewalk. The DON described the hanging wood as dangerous and the administrator stated there was no system to track or follow up on environmental concerns and no maintenance staff to monitor or audit these issues.
Failure to Complete Required Resident Rights Training: The facility failed to ensure an RN completed mandatory resident rights training. Review of records showed the RN had not completed education including resident rights within the past year, and the HRA confirmed the training had last been completed in 2024. The DON stated staff would be expected to complete training twice a year when asked about resident rights, abuse, QAPI, and infection control training.
The facility failed to ensure an RN completed required abuse/vulnerable adult training. The facility assessment and Abuse Prevention Policy called for annual training, but personnel records showed the RN had not completed abuse/vulnerable adult education in the last year. The DON expected staff to complete training twice a year, and the HRA confirmed the RN’s resident rights, abuse, and infection control training had last been completed in 2024.
Failure to complete required QAPI training was identified for the DON, two RNs, and two LPNs. The facility assessment required annual QAPI training for clinical staff, but personnel records showed these staff had not completed QAPI education in the prior year. The DON stated she expected staff to complete training twice a year, and the HRA said QAPI training had not been automatically added after training requirements changed. The facility policy did not specify that QAPI training would be completed.
Missed Infection Control Training for RN. The facility failed to ensure an RN completed mandatory infection control training. Records showed the RN had not completed education including infection control within the last year, and the HRA confirmed the last completion was in 2024. The DON stated staff were expected to complete infection control training twice a year, and the facility assessment called for annual training for clinical staff.
Unsecured resident records were left in a basement room used by staff for laundry and food storage and in a public dining area where residents were eating. The papers and binders contained PHI such as resident names, addresses, DOBs, med lists, orders, MARs, glucose readings, vital signs, and weight information. The DON and administrator acknowledged the information was private and should not have been left out in the open.
Unsecured Medication Refrigerator: The facility failed to store refrigerated medications in a locked compartment for 5 residents whose meds were kept in a mini fridge that did not have a lock. RN-A showed a small lock box inside the fridge but said it was not being used, and multiple medication boxes, including Copaxone, Ozempic, and Trulicity, were observed inside the refrigerator. The DON stated the meds had been moved from a locked box in the main refrigerator to the mini fridge and had not considered that the medication refrigerator needed a lock.
Failure to document and offer flu and pneumococcal vaccinations: The facility did not ensure recommended influenza and pneumococcal immunizations were offered or provided in a timely manner for 13 reviewed residents. The DON stated there was no process to document vaccination status, residents were sent to Walgreens for vaccines, and the paper charts and EMRs lacked immunization records. The facility also lacked documentation or provider messaging to determine immunization status, despite policies requiring assessment, offering, and documentation of vaccination status, refusals, contraindications, education, and dates.
The facility failed to maintain documentation of COVID-19 vaccination status for all 13 residents and failed to document COVID-19 education and vaccination status for a cook. The DON stated there was no process in place to track resident immunization records, and chart review showed no immunization documentation for any resident. The cook stated he was never asked about his COVID-19 status or given education on the vaccine’s benefits, risks, or side effects, and the DON confirmed there was no documentation that education was offered or declined.
Failure to reasonably accommodate a resident's preference for private, usable space in a shared room. A resident with intact cognition and diagnoses including depression, diabetes, anxiety, and PTSD was observed in a twin bed enclosed by a privacy curtain that wrapped around the bed and a dresser, leaving no floor space inside the curtained area to stand or get dressed. The resident said the space was the smallest in the facility and wanted a bigger area; the administrator, DON, and co-owner all acknowledged the room was too tight and lacked usable square footage.
The facility failed to report suspected resident-to-resident abuse to the SA within the required timeframe for two residents. One resident with intact cognition and a hx of anxiety, depression, and PTSD reported that her roommate called her names, threatened her, and stole her phone, while the roommate’s notes documented verbal aggression, threats, and other disturbing behaviors. The DON stated the incidents were not reported because she believed reporting was only required for physical or sexual abuse, despite the facility abuse policy requiring allegations of abuse to be reported within two hours.
A resident’s annual MDS was incomplete, with Section C for cognition, Section D for mood, Section F for preferences, and most of Section GG for functional abilities left unassessed or dashed. The IC-MDS stated the facility’s transition from paper charts to an EHR was poorly implemented, staff training was poor, and the facility did not have a good process to ensure MDS assessments were completed and documented.
Incomplete Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments thoroughly for two residents. One resident’s MDS had Section C, Section D, and Section GG items not assessed or dashed, and another resident’s MDS had Section C items not assessed. The MDS coordinator stated the facility’s transition from paper charts to EHR had poor implementation and staff training, and the facility lacked a good process to ensure MDS completion and documentation.
MDS coding was inaccurate for two residents. One resident’s MDS omitted an active dementia diagnosis despite provider documentation of vascular dementia, and another resident’s MDS incorrectly coded Trulicity as insulin even though the MAR showed no insulin use. The DON confirmed the dementia diagnosis and cognitive decline, and the IC-MDS stated she misunderstood Trulicity and did not realize the dementia diagnosis should have been included.
The facility failed to complete quarterly care conferences for 3 residents and did not document interdisciplinary review with resident participation in care planning. One resident had intact cognition and a BIMS of 15/15, but the last care conference note in the chart was months old; two other residents with intact cognition and multiple diagnoses also had no care conference documentation matching their MDS cycles. The DON and MDS coordinator confirmed the missing conferences, and residents stated they had not been invited or involved in care meetings.
Failure to Provide Routine Dental Services: The facility failed to document or provide routine dental appointments for two residents. One resident had cognitive intactness, diabetes, and poor oral status with cavities and missing teeth, while the other resident had intact cognition and reported never being offered a routine dental visit despite being in the facility for nearly two years. The DON verified the missing documentation and stated there was no system to monitor dental appointments or refusals.
Incomplete Daily Nurse Staffing Posting: The facility failed to post required nurse staffing information daily and the posting did not include the daily census or the total number of licensed nursing staff working each shift. The DON stated she usually completed the posting at the end of the week because of call-ins and was not aware census and total licensed staff had to be included. The facility policy required the information to be posted at the beginning of each shift.
The facility failed to employ a registered dietician, affecting all 11 residents receiving food. Interviews revealed inconsistencies in menu adherence and a lack of dietician involvement. The facility was between dieticians, with nursing staff completing nutritional assessments in the absence of a registered dietician. The facility policy allowed for dietary orders to be delegated to a qualified dietitian under physician supervision, but this was not being followed.
The facility failed to ensure proper sanitization of dishware and appropriate food storage, affecting all residents. The dish machine's temperatures fluctuated and did not consistently meet required levels, and food items were found undated and improperly stored. Staff did not consistently follow infection control techniques, such as hand hygiene between tasks.
The facility administration failed to provide adequate oversight and staffing, affecting resident care. The RN-A, acting as both DON and administrator, was overwhelmed due to the lack of an ADON replacement. The facility also lacked a registered dietitian and had issues with infection prevention training, MDS assessments, and PASARR processes. The QAPI and QAA processes were informal, with acknowledged room for improvement.
The facility failed to submit accurate staffing data to CMS for Q4 2024, with discrepancies between reported and actual nursing coverage. The DON admitted to reporting lower numbers due to payroll system limitations, despite having 24-hour coverage on the dates in question.
The facility failed to implement an effective QAPI plan, lacking formal processes for identifying and addressing quality deficiencies. The QAA committee meetings were not attended by the medical director, and the DON also served as the administrator, impacting the program's effectiveness. Meeting minutes focused on resident activities but did not address critical issues like falls. Staff interviews revealed reliance on informal feedback without structured evaluation mechanisms. The facility owner acknowledged the need for improvement in the QAPI process.
The facility's QAPI committee failed to effectively implement action plans to correct quality deficiencies, including MDS assessment inaccuracies, unmet resident activity needs, lack of trauma-informed care, and food sanitation issues. Meeting minutes lacked documentation on performance indicators and tracking of adverse events. Staff interviews revealed informal processes for addressing deficiencies, and the facility's owner acknowledged the need for improvement in the QAPI process.
The QA committee at the facility did not have all required members attending quarterly meetings, as the medical director was absent. Additionally, the facility lacked a trained infection preventionist after the previous one retired, and no staff were enrolled in specialized training. The facility's owner recognized the need for improvement in QAPI processes.
The facility failed to maintain proper infection control during laundry services, affecting all 11 residents. The head of housekeeping and laundry services used the same gloves to handle soiled and clean laundry without wearing a gown, contrary to facility policy. The RN expected staff to change gloves and perform hand hygiene before handling clean laundry.
The facility failed to ensure the acting infection preventionist (IP), the DON, had completed specialized training in infection prevention and control. The DON confirmed the lack of training, and no other staff were enrolled in such training. This deficiency had the potential to affect all 11 residents in the facility.
The facility failed to accurately code the MDS for several residents, leading to deficiencies in care assessments. One resident's activity preferences were inaccurately reported, while another's PASARR status was incorrectly coded, resulting in a lack of necessary mental health services. Staff interviews revealed a lack of understanding of the PASARR process and the importance of accurate MDS assessments.
The facility failed to complete Level II PASARRs for four residents with mental illness diagnoses before admission, as required. The director of nursing and staff were unaware of the process, leading to incomplete assessments and unmet mental health care needs.
The facility failed to serve food according to a menu and did not review changes with a dietician, affecting five residents with specific dietary needs. A resident with diabetes was non-compliant with their diet, while another with cardiac issues was not on a therapeutic diet. Staff interviews revealed inconsistencies in dietary practices, with the head cook admitting the menu was not always followed. The facility was between dieticians, leading to a lack of professional oversight in dietary management.
A facility failed to complete a comprehensive assessment for a resident, R7, using the RAI process, omitting her PTSD diagnosis despite documented trauma history. The MDS and care plan lacked documentation of her trauma and PRN antipsychotic use. Staff interviews revealed a lack of adherence to RAI guidelines, impacting R7's trauma-informed care.
A facility failed to incorporate PASARR level II recommendations into a resident's care plan. The resident, with a history of schizophrenia and other conditions, reported hallucinations and delusions, but her care plan lacked documentation of recommended services. Staff interviews revealed a lack of understanding of the PASARR process, and the facility could not provide relevant policies when requested.
A facility failed to review and revise a resident's activities care plan with input from the resident or their representative. The resident, with mild cognitive impairment, had preferences for activities like word find puzzles and music, but these were not documented in the care plan. Staff interviews revealed a lack of understanding and training regarding the activities care plan, and the facility's policy to incorporate resident preferences was not followed.
A resident with a history of depression, alcohol dependence, and cancer was discharged from an LTC facility without a proper discharge plan, leading to uncertainty about whether their medical and mental health needs could be met at the new location. The facility failed to document the discharge process adequately, and the resident was taken to a facility that had closed, with no communication established with the receiving facility.
A resident with mild cognitive impairment and mental health diagnoses was not provided with individualized activities, despite preferences for arts and crafts and group settings. The facility's care plan lacked documentation of specific activity preferences, and staff did not solicit input from the resident. Observations showed a lack of consistent arts and crafts offerings, and interviews revealed gaps in assessing and documenting activity preferences.
A facility failed to properly monitor a resident's blood pressure before administering Midodrine, a medication with specific hold parameters. The resident, with a history of orthostatic hypotension, was given the medication without a prior blood pressure check, contrary to the prescribed order. Interviews revealed inconsistencies in monitoring practices, and the need for clarification on medication orders was acknowledged by the DON.
A facility failed to identify and document triggers for a resident with a history of trauma, leading to a lack of a comprehensive trauma-informed care plan. The resident's care plan focused on behavioral triggers unrelated to her trauma history, despite staff awareness of her past trauma. The facility's policy on trauma-informed care was not followed, resulting in inadequate documentation and integration of the resident's trauma history into her care plan.
A facility failed to ensure a PRN psychotropic medication order for a resident included an end date or documented clinical rationale. The resident, with diagnoses of depression and alcohol dependence, received frequent PRN olanzapine without an end date or rationale for extending beyond 14 days. Interviews with staff highlighted the importance of adhering to the 14-day limit for such medications. The nurse practitioner confirmed the absence of an end date and stated no request for a rationale was received, although they believed the dose was appropriate.
The facility failed to accurately post nurse staffing information, omitting actual hours worked by RNs and LPNs. Discrepancies were found between posted staffing data and actual hours worked, confirmed by the DON. This affected all residents or visitors reviewing the information.
The facility failed to provide individualized non-pharmacological interventions for two residents with mental health disorders, leading to self-harm and hospitalizations. One resident, with a history of anxiety and self-injurious behavior, repeatedly used hot towels to self-soothe, resulting in burns. The care plan lacked specific interventions, and staff did not consistently offer PRN medications or alternative coping strategies. Another resident with schizoaffective disorder also lacked individualized behavior interventions. The facility lacked a policy for mental health management, contributing to these deficiencies.
Inconsistent Advance Directive Documentation and Code Status Mismatches
Penalty
Summary
The facility failed to ensure resident advance directives were accurately and consistently documented between the physician orders in the electronic health record (EHR) and the POLST in the hard chart. Surveyors found that code status information for multiple residents did not match across records, including two residents whose wishes were not documented consistently enough for staff to rely on in the event of a cardiac arrest. The deficiency was identified through observation, interview, and document review and was cited as immediate jeopardy for two residents, with an additional discrepancy found during a facility-wide audit. For one resident, records were inconsistent across the chart and EHR. The resident had intact cognition on a quarterly MDS and stated that full resuscitation was desired if the heart stopped and breathing ceased. The POLST in the hard chart indicated attempt resuscitation/full treatment and was signed by the resident and provider, but the EHR order summary contained a DNR order. Provider notes repeatedly listed the resident as full code, while the care plan, progress notes, and care conference documentation did not clearly and consistently reflect the code status. During interview, an LPN stated he would check the EHR profile and orders and would not start CPR because the order summary showed DNR/DNI. The DON confirmed the mismatch and stated the POLST was correct, but also acknowledged there was no process in place to ensure the POLST code status matched the EHR orders/documentation. For another resident, provider notes identified the resident as DNR and stated a POLST was on file and uploaded, but the EHR profile, face sheet, care plan, and physician orders did not identify code status. The resident stated that DNR/DNI wishes had been communicated to the facility and that he did not want CPR. During interview, the LPN reviewed the EHR and face sheet and stated he would perform CPR because the resident was not identified as DNR/DNI in those locations. The DON later reviewed the paper chart and confirmed the signed POLST identified the resident as DNR/DNI, while the EHR indicated full code. A third resident was later found during audit to have a POLST indicating DNR/allow natural death with selective treatment, while the EHR order summary still showed full code orders and did not include the DNR order. The resident stated a desire to let nature take its course and not have chest compressions performed.
Activities Not Assessed or Provided to Meet Resident Needs
Penalty
Summary
The facility failed to comprehensively assess, develop, and implement meaningful and engaging activities for 4 of 4 residents reviewed who expressed concerns about a lack of activities. Residents with intact cognition and documented activity preferences, including interests in bingo, Pokeno, crafts, television, outings, news, fresh air, and group activities, reported boredom and stated that organized activities were not being offered. One resident stated the facility had not really had activities for months, and another stated she wished the residents could do things as a group but had to find things to do on her own. The records showed that activity assessments and care planning were incomplete or not individualized for several residents. One resident’s care plan identified enjoyment of small group activities such as pizza and ice cream socials, bingo, and Pokeno, but the resident reported no group activities were occurring. Another resident’s therapeutic recreation assessment identified interests in crafts, television, conversing, and outings, yet the resident stated she got bored and could not remember anything being set up other than going downstairs to get a puzzle or cards. For another resident, the CAA identified a problem with adjustment to a new living environment and prior preference for group activities, but the medical record did not show further assessment of activity preferences and needs, and the DON stated the activity assessment had not been completed. A fourth resident’s MDS did not complete the activity preferences section, and the resident stated she had agoraphobia, had never been asked about activity preferences, and was bored. The activities director stated he was the only activities staff member, created the monthly calendar, did not schedule activities with times or locations, did not write progress notes, update care plans with preferences and choices, or keep attendance documentation, and did not attend QAPI meetings. The DON and administrator stated there were no weekend activities, and multiple staff members confirmed there had been no group activities for several weeks. Facility calendars from October 2025 through April 2026 listed weekday activities only, without times or locations, and observations from late March through early April showed no activities performed or offered.
Unqualified Activities Director and Incomplete Activity Program Documentation
Penalty
Summary
The facility failed to have a qualified therapeutic recreation specialist or other qualified activities professional directing the activities program, as required. During interview, the activities director stated he was hired in September 2025, was the only activities staff member, created the monthly activities calendar, and was also supposed to drive residents to appointments. He stated that nothing was scheduled for time or place of activities, he did not write progress notes, update resident care plans with preferences and choices, keep documentation of activity attendance, or attend QAPI meetings, and that he had no previous training, licensure, or full-time experience to be a qualified activities director. The DON stated the facility did not have weekend activities and that activities were mostly cards or puzzles, and verified there were no attendance records or progress notes regarding activity participation. The administrator stated the facility did not have a full-time activities employee and there were no activities scheduled or planned on weekends, and also verified the activities director was not licensed or registered and had no prior full-time therapeutic activities experience. A former activities director stated he had worked in the role since 2012, resigned in October 2025, and had previously documented the MDS assessment portion for resident preferences when assigned by the MDS coordinator, but the current activities director did not complete progress notes, attendance records, or care plans. The facility assessment identified services to include learning residents' preferences and routines and providing opportunities for social activities and life enrichment, and the staffing plan listed Social Services/Activities Director and Health Unit Coordinator for Medical Appointments at approximately 60 hours per pay period.
RN Staffing Gaps
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours each day. Review of the Payroll Based Journal staffing data for the first quarter of 2026 identified no RN hours on 11/5/25, 11/8/25, 11/16/25, 11/20/25, and 12/21/25. Facility timecards from 10/1/25 through 12/31/25 also showed no RN hours on 11/5/25, 11/16/25, 11/20/25, and 12/21/25. In an email, the building owner stated that on several of those dates an RN had been scheduled but an LPN covered the shift, and on one date an RN called in and an LPN covered. During interview, the administrator acknowledged the facility had previously had difficulty consistently filling RN hours, especially on weekends, and had used agency staff, though March 2026 timecard data showed no gaps in RN hours. The facility policy stated an RN would be staffed a minimum of eight consecutive hours a day, seven days a week.
Improper Food Storage, Labeling, Cleaning, and Hair Restraint Use
Penalty
Summary
Food items in the main production kitchen were found improperly stored, dated, and maintained during surveyor observation and interview. In the main refrigerator, an opened 3-pound container of sour cream, orange juice, apple juice, strawberry jam, a gallon of milk, and seven unpasteurized eggs were present, and CK-A verified that the items were not dated or labeled except for their product expiration/use-by dates. CK-A stated he did not know when the items were first opened. In the attached freezer, surveyors observed an undated package of breakfast muffin, an open pitcher of clear fluid, and a half-inch of frozen yellow-tan material covering the bottom of the unit with the pitcher frozen to it. The freezer door seal had dark black matter on the entire seal, and CK-A stated he had never cleaned the freezer unit before, although he had occasionally wiped down the refrigerator. Surveyors also observed multiple dry food items stored above the countertop in the main kitchen that were opened and undated, including large containers of spices, creamy peanut butter spread, breadcrumbs, and fried onions. A bottle of chili garlic sauce had an expiration date of 12/23/25, and a large plastic container with a worn-off product name had an expiration date of 4/22/22. CK-A stated the breadcrumbs and fried onions looked and smelled stale and that he went by the product expiration date. CK-A also stated he did not know what the unidentified container was or how long it had been in the spice cabinet. A kitchen checklist posted near the refrigerator stated that food service employees wear hair restraints and clean clothing, and another form stated that all dry foods must be stored in a container with a tight-fitting lid, labeled and dated. During additional observation, CK-B was seen cooking hamburger in a saucepan on the stovetop without wearing a hair net and stated he should always wear one when cooking. The infection control preventionist stated cooks are supposed to wear hair nets at all times to prevent bacterial contamination. The administrator stated it was the expectation that all food products be dated and labeled with the date opened and that all logs, including cleaning logs, be completed and documented every day by the cooks. The facility Food Storage and Procurement Policy and Procedure required opened bags of food to be labeled with the date opened and directed staff to discard spoiled or contaminated food, and to label food prepared at the facility with the name of the food, date made, and use-by date.
QAPI Program Lacked a Formal Plan and Failed to Address Repeated Quality Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive QAPI plan was identified, implemented, and maintained to support acceptable levels of performance and continual improvement. Based on interview and document review, the facility had a QAPI Program policy dated 2/2020 that described an ongoing, facility-wide, data-driven QAPI program with processes for tracking and measuring performance, setting goals and thresholds, identifying and prioritizing quality deficiencies, analyzing underlying causes, developing corrective actions, and monitoring effectiveness. However, when surveyors requested documentation of a QAPI plan showing how the facility carried out these requirements, none was provided. The facility also failed to identify and prioritize quality deficiencies that it was or should have been aware of, including concerns related to activities and dietary/kitchen practices. QAPI meeting notes from 10/14/25, 11/11/25, 12/9/25, 1/13/26, 2/10/26, and 3/10/26 did not reference activities or dietary department/kitchen practices. The CASPER report showed repeated deficiencies for activities, food storage and sanitation, QAPI program/plan, QAPI improvement activities, and the QAA committee. During interview, the administrator stated the QAPI committee was fairly new, the facility did not currently have a formal process for collecting data to track and measure performance, and there were no established goals or identified quality deficiencies being analyzed for corrective action.
Failure to Maintain an Effective QAPI Program
Penalty
Summary
The facility failed to maintain a QAPI committee that effectively identified and responded to quality deficiencies and failed to develop procedures for feedback, data collection, and monitoring systems. Document review showed QAPI meeting notes dated 10/14/25, 11/11/25, 12/9/25, 1/13/26, 2/10/26, and 3/10/26, but the notes lacked tracking of data-driven quality metrics over time and did not show any PIPs. The deficiency was identified through document review and interview, and it was stated that the facility held monthly QAPI meetings, but the committee was fairly new. During an interview on 4/6/26 at 1:28 p.m., the administrator stated the facility did not currently have a formal process for collecting data to track and measure performance or a formal QAPI plan at the moment. The administrator also confirmed the facility had no established goals, no identified quality deficiencies being analyzed, and no PIP in place. The administrator stated there was no process to collect data for identifying high-risk, high-volume, or problem-prone areas or to collect information from residents or staff. The facility's QAPI Program policy dated 2/2020 stated the facility should develop and maintain an ongoing, facility-wide, data-driven QAPI program, but further documentation such as a QAPI plan was requested and not received.
QA Committee Did Not Include Required Members
Penalty
Summary
The Quality Assurance (QA) committee failed to ensure that the required members attended its meetings. Review of QAPI meeting notes dated 10/14/25, 11/11/25, 12/9/25, 1/13/26, 2/10/26, and 3/10/26 showed that only four members regularly attended: the administrator, the DON, the medical director, and the consultant pharmacist. The notes did not show attendance by the infection preventionist. During interview, the infection preventionist stated she did not regularly attend QAPI meetings. The administrator stated the facility had four staff members who regularly attended QAPI and acknowledged he had tried to include the infection preventionist in the past, but her schedule did not work. He also stated he knew additional staff members were needed at QAPI meetings, but there were scheduling conflicts. The facility policy stated the QAA committee would meet at least quarterly and include the administrator, medical director, DON, infection preventionist, and other departments as requested by the administrator.
Improper Laundry Infection Control Practices
Penalty
Summary
The facility failed to maintain proper infection control practices during laundry services. During observation and interview, the housekeeper stated the facility had one washing machine and one clothes dryer in the basement and that she was responsible for all personal and facility laundry, as well as sweeping, dusting, vacuuming, and washing hard surfaces. She was observed transporting soiled resident laundry in an uncovered plastic laundry basket with holes/openings, and she stated she did not cover laundry when moving it from resident rooms to the basement or when transporting clean linen to resident rooms and facility closets. She also verified that she did not wear a PPE gown when sorting and handling soiled and clean linen. During later observation, the housekeeper was again seen carrying resident personal laundry uncovered to the basement. A resident also walked downstairs with personal laundry and placed it on the utility sink next to the washing machine while the machine was running. Clean linen was observed folded on top of the dryer, uncovered, and the housekeeper moved the clean linen into an uncovered plastic laundry basket while soiled personal laundry remained on the utility sink. The housekeeper then carried the uncovered basket back downstairs, transferred items from the washing machine to the dryer, and placed the soiled linen from the basket into the washing machine. The housekeeper stated she had never washed or sanitized laundry baskets between handling soiled linen and bringing clean linen back to residents and the facility unless the baskets were visibly dirty. The infection control preventionist stated the expectation was to cover linen during transport and clean laundry baskets after each use to prevent contamination. The facility policy stated that gown and gloves are available for workers sorting linens, linen is covered during transport, soiled linen should be bagged or contained, and soiled linen should not be placed on furniture, floor, or other surfaces.
Failure to Implement Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an active antibiotic stewardship program that included development of protocols and a system to monitor the appropriateness of antibiotic use, including prophylactic antibiotic use. During the entrance conference, the administrator stated the infection control preventionist (IC)-MDS was responsible for infection control, surveillance, and the antibiotic stewardship program. The IC-MDS stated she worked part time at the facility, visited once per week, and usually reviewed the MARs for antibiotics and related information. She also stated she was notified by email or when she arrived weekly of signs and symptoms of potential illness, but there was no communication to her regarding residents being started on antibiotics before her weekly visits. The IC-MDS stated she used Monthly Tracking Sheets to monitor resident infections or antibiotic use, but the Infection and Antibiotic use Monthly Tracking forms reviewed for the previous 12 months lacked multiple required elements, including resident name, diagnostic testing and results, whether standardized criteria were used, resident symptoms, timeouts, and response to antibiotics. She also stated there was nothing written down for her to use as a guide for her role in the antibiotic stewardship program, including antibiotic timeouts or reviews, and that she was not involved in periodic review of prescribing practices because the physician and pharmacist could look at that. The facility policy required collection of specific antibiotic use information and stated the Infection Preventionist and Pharmacy Consultant would provide regular feedback on antibiotic use and outcomes to staff, the QAPI committee, and providers, but the IC-MDS stated she did not attend monthly QAPI meetings and could not speak to the facility's reports on antibiotic use, resistance patterns, practices, or facility assessment involvement.
Failure to Maintain Building and Grounds in Good Repair
Penalty
Summary
The facility failed to maintain the building and grounds in good repair. The Facility Assessment dated 7/21/2025 identified that the resident population must be ambulatory and not require a wheelchair, and also noted that outside grounds and the building are maintained and repaired using an online maintenance work-order system. During the survey, the State Agency requested a list of residents who smoked, and the administrator identified 6 of the 13 residents as smokers. Observation of a resident in a shared room found a closet door jamb with about 3 inches of missing wood where the strike plate and latch met, a window air conditioner unit with gaps around it where the outdoors was visible, and a small fan with visibly soiled fins that the resident said had not been wiped down or cleaned despite weekly use. Additional observations showed a large piece of window casing trim hanging from the front of the building above the smoking patio, with two residents sitting below it. In another shared bedroom above the patio, three street-facing windows had cracked, peeling, and missing paint along the inside casing, and one resident stated a window was so rotted it would not stay open. The DON later observed the hanging wood and described it as dangerous, and also observed a 12-inch by 5-inch hole in the concrete patio sidewalk connecting the smoking patio to the side of the facility for wheelchair accessibility. The administrator stated the facility did not have a system to document and follow up on environmental concerns such as water leaks, pest control, electrical issues, room temperature problems, torn carpet, or wall and window issues, and said there was no maintenance staff to monitor and audit environmental issues. Facility policy stated that areas around the buildings, including sidewalks and patios, shall be maintained in a safe and orderly manner at all times.
Failure to Complete Required Resident Rights Training
Penalty
Summary
Staff members were not educated on resident rights and facility responsibilities as required. Based on interview and document review, the facility failed to ensure mandatory resident rights training was completed for 1 of 5 staff members reviewed, RN-B. The facility assessment dated [DATE] indicated that clinical staff were to receive annual training on resident rights, but review of personnel records showed RN-B had not completed education that included resident rights in the last year. During an interview on 4/6/26 at 11:40 a.m., the DON stated she would expect staff to complete training twice a year when asked about abuse training, resident rights training, QAPI training, and infection control training. During an interview on 4/6/26 at 12:35 p.m., the HRA stated the facility did not usually have staff who continued employment past a year as RN-B had, so she had missed re-assigning RN-B's training for resident rights, abuse, and infection control, and confirmed the last time these were completed for RN-B was in 2024. The facility's Sufficient and Competent Nursing Staff policy dated 4/2025 indicated that licensed staff would demonstrate the skills and techniques necessary to care for resident needs, including resident rights.
Missing Mandatory Abuse Training for RN
Penalty
Summary
The facility failed to ensure that mandatory abuse/vulnerable adult training was completed for 1 of 5 staff members reviewed, RN-B. The facility assessment dated [DATE] stated that clinical staff were to receive annual training on vulnerable adults/abuse, and the facility's Abuse Prevention Policy dated 5/30/25 stated that staff would complete abuse training annually and upon hire. Review of personnel records showed that RN-B had not completed education that included abuse/vulnerable adult training in the last year. During interviews, the DON stated she would expect staff to complete training twice a year, and the HRA stated the facility did not usually have staff who remained employed past a year as RN-B had, so RN-B had missed re-assigning training for resident rights, abuse, and infection control; the HRA confirmed the last time these were completed for RN-B was in 2024.
Failure to Complete Required QAPI Training
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not completed for 5 of 5 staff members reviewed, including the DON, RN-A, RN-B, LPN-A, and LPN-B. The facility assessment dated [DATE] indicated that clinical staff were to receive QAPI training annually, but personnel records showed that these staff members had not completed education including QAPI in the year before survey entrance. During interview, the DON stated she would expect staff to complete training twice a year when asked about abuse, resident rights, QAPI, and infection control training. The HRA stated that training requirements had changed at some point and QAPI training had not automatically been added, and that she added QAPI training during the survey after realizing the requirement was not being met. The facility’s Sufficient and Competent Nursing Staff policy dated 4/2025 did not specify that QAPI training would be completed.
Missed Infection Control Training for RN
Penalty
Summary
The facility failed to ensure that mandatory infection control training was completed for 1 of 5 staff members reviewed, RN-B. The facility assessment dated [DATE] indicated that clinical staff were to receive infection control training annually, but review of personnel records showed that RN-B had not completed education including infection control in the last year. During an interview on 4/6/26 at 11:40 a.m., the DON stated she would expect staff to complete abuse training, resident rights training, QAPI training, and infection control training twice a year. During an interview on 4/6/26 at 12:35 p.m., the HRA stated the facility did not usually have staff who remained employed past a year as RN-B had, so RN-B had missed being re-assigned training for resident rights, abuse, and infection control, and confirmed the last time these were completed for RN-B was in 2024. The facility's Sufficient and Competent Nursing Staff policy dated 4/2025 stated that licensed staff would demonstrate the skills and techniques necessary to care for resident needs, including infection control.
Unsecured resident records left in basement and dining room
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential when multiple documents containing resident information were left unsecured in common areas. In a basement room accessed by staff for laundry and food storage, surveyors observed a small cabinet with an approximately two-foot-high pile of papers that included resident order summary sheets and medication administration records for multiple current residents and discharged residents. The documents were dated from 6/2025 to 1/2026 and were stored in an unprotected manner in a room where staff routinely passed through to reach the washer, dryer, cleaning supplies, and food storage areas. Surveyors observed the basement area being used by the cook and housekeeper, who stated they regularly went downstairs for food, deliveries, laundry, and cleaning tasks. Residents also reported using the basement for their own laundry. The administrator later acknowledged that the stack of papers had been there since he started the prior year and stated the documents should not have been stacked unprotected there. He also stated some of the papers should be uploaded to PCC and that he would speak with the DON about them. In the dining room, surveyors observed unsecured three-ring binders on a portable shelving unit in front of windows while residents were eating. The binders contained medication error reports, pharmacy paperwork, resident names, addresses, dates of birth, medication lists, orders, glucose readings, vital signs, and weight information. The RN, DON, and administrator all identified the dining room as a public area and acknowledged that the binders contained private personal and medical information that should not have been left out in the open. Facility policy required resident information to be protected from unauthorized release or disclosure and limited access to authorized personnel.
Unsecured Medication Refrigerator
Penalty
Summary
The facility failed to ensure medications were stored in a manner to reduce the risk of unauthorized access for 5 of 5 residents whose medications were kept in an unsecured facility refrigerator. During an observation and interview on 4/1/26 at 9:21 a.m. in the dining room, a medication cart with a small mini refrigerator beside it was observed, and the mini fridge did not have a lock. RN-A stated that refrigerated medications were stored in the small mini refrigerator and showed a small lock box inside the refrigerator, but said it was not being used. No medications were observed inside the lock box. Inside the medication refrigerator, multiple boxes of medication were observed, including Copaxone, Ozempic, and Trulicity. During an interview on 4/1/26 at 12:46 p.m., the DON stated that about two to three months earlier, medications had been moved from a locked box in the main refrigerator where food was stored to the new mini refrigerator, and she had not thought about the medication refrigerator needing a lock. In email correspondence on 4/6/26 at 2:12 p.m., the administrator identified the residents whose medications were stored in the small medication fridge as R1, R2, R3, R4, and R5. The facility's Medication, Labeling, and Storage policy dated 2/2023 stated that all medications would be stored in a locked compartment and only authorized personnel would have access to the keys.
Failure to Document and Offer Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure recommended influenza and pneumococcal vaccinations were offered and/or provided in a timely manner for all 13 residents reviewed for immunizations. During interview, the DON stated the facility did not have a process in place to document vaccination status for all residents and that residents were being sent to Walgreens to obtain vaccinations and copies of their immunization information. The DON reviewed the paper charts and EMRs for all 13 residents and stated they lacked immunization records, adding that it was hard to tell who needed a vaccine at that time. The DON also stated the facility lacked documentation or messaging to providers to determine or ask about immunization status. Facility policy required residents to be assessed for current immunization status within 5 days of admission, offered pneumococcal vaccine within 30 days when indicated, and have immunization status, contraindications, refusals, education, and vaccination dates documented in the medical record. The influenza policy similarly required residents to be interviewed upon admission and annually to determine influenza season status and to document contraindications, refusals, and vaccination dates.
Failure to Document COVID-19 Vaccination Status and Education
Penalty
Summary
The facility failed to establish and maintain documentation of COVID-19 vaccination status for all 13 residents. During interview, the DON stated the facility did not have a process in place to document vaccination status for all residents and that the residents were mobile and were sent to a pharmacy, with staff asking for a copy of vaccination information. Review of the residents’ paper charts and EMRs for all 13 residents showed no immunization records, and the DON stated it was hard to tell who needed a vaccine at that time. The DON also stated the facility lacked documentation or messaging to providers to determine or ask about immunization status. The facility also failed to document COVID-19 vaccination education and status for staff, including cook (CK)-B. CK-B stated he had worked at the facility for almost one year and had never been asked about his COVID-19 immunization status upon hire, and he stated the facility never provided education on the benefits, risks, or side effects of the vaccine. The DON stated the facility did not have documentation showing that CK-B was offered education on the benefits, risks, or side effects of the COVID-19 vaccine or whether he declined. Facility policy stated all residents and staff members would be provided SARS-CoV-2 education and offered an opportunity to be immunized unless contraindicated or declined, with documentation completed.
Failure to Provide Usable Private Space in Shared Room
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not met for a resident with intact cognition who was independent with most personal cares and had diagnoses of depression, diabetes, anxiety, and post-traumatic stress disorder. During observation, the resident was lying in a twin bed in a two-person room, with the bed positioned inside the doorway, parallel to the north wall, and with the footboard against a closet that extended 20 inches from the wall. A privacy curtain started above the foot of the bed and wrapped around a dresser that measured 18 inches deep by 30 inches long, then continued parallel to and against the bed to the head of the bed and wall. There was no carpet or floor area inside the curtained space for the resident to stand, making it impossible to obtain clothes and get dressed without standing outside the privacy curtain. The resident stated the area was the smallest in the facility and that the curtain went around the bed and that was all, adding that he would like the space to be much bigger but there was not a bigger space. The administrator verified the measurements and agreed the curtain wrapped around the bed with no floor space to stand or move unless the resident was outside the curtained area. The DON also stated there was not enough room to move around privately and there was barely any floor to walk on inside the privacy curtain. The co-owner stated the facility was licensed for 17 beds, the rooms were tight, and the resident's personal space was much tighter than desired, and that usable square footage had not been taken into account.
Failure to Report Suspected Resident-to-Resident Abuse
Penalty
Summary
The facility failed to immediately report suspected resident-to-resident abuse to the state agency within two hours for two residents. One resident had intact cognition on a quarterly MDS and was diagnosed with anxiety and depression. Her progress notes did not show that her allegations of abuse by her roommate were reported to the state agency. She told staff that her roommate had been calling her names, threatening her, asking to fight her, and had taken her phone and thrown it into a neighbor’s yard. She also stated that the roommate’s yelling was triggering because of her PTSD from an abusive ex-partner. The other resident had intact cognition on admission MDS and was diagnosed with schizophrenia, with verbal behavioral symptoms directed toward others. She and the first resident shared a room. Progress notes documented that she took cigarettes from her roommate without permission, became verbally aggressive, used name-calling, and threatened to physically fight her. Additional notes described ongoing paranoid delusions, verbal aggression, death threats, profanity toward staff, and disparaging remarks toward her roommate about her critically ill mother, causing significant emotional distress. The DON stated the verbal altercations were not reported because she believed reporting was only required for physical or sexual abuse, and the facility’s abuse policy required allegations of abuse, serious bodily injury, or suspicion of a crime to be reported to the state agency within two hours.
Incomplete MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure a complete and comprehensive annual MDS was completed for one resident, R7. R7’s annual MDS showed that Section C for cognitive patterns was not assessed, including the Brief Interview for Mental Status and related items on mental status, memory, cognitive skills, and signs of delirium. Section D for mood was also not assessed, including the resident mood interview and staff assessment of mood, and Section F for preferences for customary routine and activities was not assessed, including the interview for daily and activity preferences and staff assessment of preferences. In addition, Section GG for functional abilities was largely not assessed, with the entire section dashed except for one item indicating the resident did not use a wheelchair and/or scooter. During interview, the IC-MDS stated the facility had transitioned from paper charts to an EHR at the beginning of the year and did not have a good process in place to ensure MDS assessments were completed and documented during that time. The IC-MDS stated there was poor implementation and poor staff training during the transition, and that many MDS assessment areas had been missed, including R7’s. The facility’s MDS Completion and Submission Timeframe policy identified the assessment coordinator or designee as responsible for submitting the MDS according to the RAI manual, but did not further describe the process for completing the MDS before submission.
Incomplete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly MDS assessments were completed in a thorough manner for 2 of 5 residents reviewed for assessment accuracy. The CMS RAI 3.0 User’s Manual was cited as requiring the full RAI process, including the MDS, CAA, and utilization guidelines, and describing quarterly assessments as non-comprehensive assessments completed every 92 days to monitor changes in resident status. The report also noted that Section C is used to assess cognitive patterns and Section D is used to address mood distress and social isolation, with specific methods and instructions provided for accurate coding. For one resident, the quarterly MDS indicated that the Brief Interview for Mental Status or Staff Assessment for Mental Status in Section C was not assessed, Section D was not assessed in its entirety, and Section GG functional ability items such as self-care and mobility were not assessed or were dashed. For the second resident, the quarterly MDS indicated that Section C cognitive pattern items were not assessed. During interview, the infection control preventionist/MDS coordinator stated the facility had recently transitioned from paper charts to an EHR, did not have a good process in place to ensure MDS assessments were completed and documented during the transition, and had poor implementation and poor staff training, resulting in many MDS assessment areas being missed. The facility’s MDS Completion and Submission Timeframe policy identified the assessment coordinator or designee as responsible for submitting the MDS according to the RAI manual, but did not further describe the process for completing the MDS before submission.
MDS Coding Errors for Diagnoses and Medications
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 2 of 5 residents reviewed. For one resident, the quarterly MDS did not indicate a diagnosis of non-Alzheimer's dementia in Section I: Active Diagnoses, even though the diagnosis report showed vascular dementia had been added and a provider note documented vascular dementia with some progression. For the other resident, the quarterly MDS incorrectly coded Section N - Medications as having 1 day of insulin injections during the review period, while the MAR showed the resident received a single dose of Trulicity and no insulin during the lookback period. During interview, the DON stated the resident did have dementia and related cognitive decline, but remained alert and oriented for some decisions. The IC-MDS stated she did not have a good understanding of Trulicity and mistakenly coded it as insulin, and she had not realized the other resident had a recent, active diagnosis of dementia that probably should have been added. The facility policy stated the assessment coordinator or designee was responsible for submitting the MDS according to the RAI manual.
Missed Quarterly Care Conferences and Lack of Interdisciplinary Review
Penalty
Summary
The facility failed to ensure timely person-centered care conferences for 3 of 3 residents reviewed, and failed to include periodic review and revision by an interdisciplinary team with the residents in decisions about their care. R2’s quarterly MDS showed intact cognition with a BIMS score of 15/15, and a later quarterly MDS indicated she was admitted to the facility, but the BIMS and staff assessment for mental status were not assessed. Her medical record showed the last care conference note was dated 8/21/25, and the administrator confirmed that was the most recent note available. R2 stated she did not recall being offered or attending a care conference in the last few months, and the DON stated she could not find documentation showing a care conference had been completed since last August. R4’s quarterly MDS identified intact cognition and independence with hygiene and dressing, with diagnoses including PTSD, borderline personality disorder, diabetes, and depression. Her EMR and paper chart contained no care conference notes matching her MDS cycles for 10/31/25, 12/10/25, and 2/2/26 since admission. R4 stated she had not been invited or involved in any care conference since admission. R6’s quarterly MDS identified intact cognition and diagnoses of depression with recurrent psychotic symptoms, diabetes, anxiety, and PTSD, but his EMR and paper chart contained no care conference note since admission. R6 stated he did not recall having an in-person care meeting or care conference to discuss his plan of care and discharge goals, and both the DON and MDS coordinator verified that R6’s quarterly care conference had not been done and that R4’s EMR lacked evidence of a care conference corresponding to the last MDS assessment. Facility policy stated all residents were to have a care conference hosted at minimum quarterly.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for 2 of 2 residents reviewed for dental care. One resident had a face sheet showing admission in 2020, an MDS identifying intact cognition, independence with personal and oral hygiene, and diagnoses including schizoaffective disorder, bipolar disorder, diabetes, anxiety, and epilepsy. The resident’s CAA noted obvious cavities, missing most of the upper teeth, and a dental care plan triggered by medications and unstable diabetes. The care plan identified a need for supervision to assistance with hygiene and included an intervention to coordinate dental care and transportation as needed, but the EMR and paper chart did not show when the resident was offered or provided a routine dental appointment. The second resident’s quarterly MDS identified intact cognition, independence with all hygiene, and diagnoses including diabetes, PTSD, depression, and borderline personality disorder. The resident’s CAA did not assess dental care planning, and the care plan only included general encouragement for good hygiene and oral care. During interview, the resident stated she had been at the facility for nearly two years and had never been offered or provided a routine dental appointment. Review of the EMR and paper chart also failed to show documentation of a routine dental appointment being offered or completed for this resident. The administrator and DON both verified the lack of documentation, and the DON stated there was no system to monitor or follow up on dental appointments and no documentation of refusals or where residents went for appointments.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the required nurse staffing information was posted daily and that it included required details such as the daily census and the total number of licensed nursing staff working. During observation and record review, the nurse staff posting was found in a hallway between the dining room and the kitchen on a bulletin board and contained columns for days of the week, shift, RN hours, LPN hours, and date, but it did not include the daily census or the total number of licensed staff working every shift. The posting showed incomplete information for Monday and Tuesday, and no hours were recorded for Wednesday or Thursday. The DON stated she oversaw the posting and usually waited until the end of the week, on Saturday, to complete it because staff call-ins could make it inaccurate, and she was not aware that census or the number of staff members had to be included. The facility policy dated 8/2022 stated the nurse staffing information would be posted daily at the beginning of each shift and would include resident census and the total number of licensed nurses.
Facility Lacks Registered Dietician, Affecting Nutritional Services
Penalty
Summary
The facility failed to employ a registered dietician or other qualified clinical nutrition professional to carry out the functions of a facility registered dietician, potentially affecting all 11 residents receiving food from the kitchen. Interviews revealed that the head cook, C-B, noted inconsistencies in menu adherence, with eggs not being served daily as planned, and other cooks not following the menu, complicating food ordering and usage. C-B also mentioned a lack of involvement from the registered dietician, who they believed had quit. The facility administrator and director of nursing, RN-A, acknowledged the absence of a dietician, stating that the newly hired dietician was not as involved as the previous one and that they were in the process of contracting a new dietician. Further interviews indicated that the facility was between dieticians, as the previous dietician had retired or resigned, with the last day being 5/31/24. RN-A confirmed that nursing staff completed nutritional assessments in the absence of a registered dietician, and C-B made menu changes as needed. The facility policy allowed for dietary orders to be delegated to a qualified dietitian under physician supervision, but this was not being followed due to the lack of a dietician. The certified physician assistant, CPA-B, stated they were not involved in nutritional assessments or diet orders, highlighting the gap in professional oversight in the facility's food and nutrition services.
Deficiencies in Dishware Sanitization and Food Storage
Penalty
Summary
The facility failed to ensure proper sanitization of dishware and appropriate food storage, affecting all 11 residents. During an initial tour, the head cook was observed not performing hand hygiene after removing gloves and handling dishes. The dish machine's wash and rinse temperatures fluctuated and did not consistently meet the required temperatures for proper sanitization. Additionally, the dish machine had mechanical issues, such as a door that did not close completely and a side panel that was not secured. Food storage practices were also inadequate. Items in the kitchen refrigerator, such as orange juice and milk, were undated, and a cup of juice was uncovered and unlabeled. The kitchen freezer contained opened and unlabeled tater tots and fish. In the dry storage area, cereal bags were not properly secured. The downstairs storage area had unlabeled chicken and cauliflower with white flaky crusts, indicating spoilage. A head of lettuce in the refrigerator was discolored and should not have been used. Staff did not consistently follow infection control techniques. A resident's personal water bottle was placed in the dish machine, which did not reach the required wash temperature. Staff were observed not washing hands between handling dirty and clean dishes. The facility's policies required labeling of opened food items and proper hand hygiene, which were not adhered to, contributing to the deficiencies observed.
Inadequate Oversight and Staffing Issues in Facility Administration
Penalty
Summary
The administration of the facility failed to provide adequate oversight, training, and guidance for appropriate resident care, which affected various aspects of the facility's operations. The facility did not have a replacement for the assistant director of nursing (ADON) after their retirement, leaving the registered nurse (RN)-A, who also served as the director of nursing (DON) and administrator, overwhelmed with responsibilities. This lack of staffing support hindered RN-A's ability to effectively manage both nursing and administrative duties, including the training of new staff and the handling of new admissions. The facility also failed to employ a registered dietitian or qualified clinical nutrition professional, as the hired dietitian believed the role could be performed virtually, which was not feasible due to technology issues. Additionally, RN-A was acting as the infection preventionist without specialized training in infection prevention and control, a fact that the facility's owner was unaware of. The facility's policy required relevant staff to be trained in infection control, but this was not adequately implemented. Furthermore, the facility had issues with the Minimum Data Set (MDS) assessments, as RN-B, who was responsible for these assessments, was new to the role and received insufficient training from RN-A. The facility also had deficiencies in the Pre-Admission Screening and Resident Review (PASARR) process, as some residents were admitted without completed assessments. The Quality Assurance and Performance Improvement (QAPI) and Quality Assurance and Assessment (QAA) processes were not formalized, and the facility's owner acknowledged the need for improvement in communication and time allocation for RN-A's dual roles.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter of 2024. The review of the facility's payroll-based journal (PBJ) staffing data report revealed that the facility did not have licensed nursing coverage 24 hours a day on multiple dates throughout the quarter. However, the facility's schedules indicated that there was indeed licensed nursing coverage for those dates, suggesting discrepancies between the reported data and the actual staffing levels. During an interview, the Director of Nursing (DON), who was also the administrator, acknowledged responsibility for submitting the PBJ data and admitted that the reported data were sometimes lower than actual staffing levels. This was attributed to the inability to report staff who had been discharged from the payroll system. The DON verified that there was licensed nursing coverage for the dates in question and stated that any inaccuracies in the reported data were unintentional. A policy regarding the reporting of PBJ data was requested but not provided.
Deficient QAPI Implementation and Oversight
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, which is essential for maintaining acceptable levels of performance and ensuring continual improvement in care and services. The facility's policy required a Quality Assessment and Assurance (QAA) committee to meet quarterly, consisting of key personnel such as the administrator, medical director, director of nursing (DON), program director, and consulting pharmacist. However, the medical director did not attend any of the QAA meetings, as evidenced by the absence of their signature on the meeting sign-in sheets. Additionally, the director of nursing was also serving as the administrator, which may have impacted the effectiveness of the QAPI program. The facility's QAA meetings lacked formal processes for identifying and addressing quality deficiencies, and there was no evidence of systematic data collection or analysis to identify high-risk or problem-prone areas. The facility's QAA meeting minutes revealed a focus on a quality improvement project aimed at enhancing resident activities and participation, but there was no mention of addressing falls or falls with injury, which are critical issues in long-term care settings. Interviews with staff indicated that the QAA process relied heavily on informal feedback and lacked structured mechanisms for evaluating health outcomes and resident safety. The facility owner acknowledged the need for improvement in the QAPI process and expressed reliance on the DON/administrator for updates on survey results and plans of correction. Overall, the facility's failure to implement a robust QAPI plan and ensure governing body oversight had the potential to affect all residents in the facility.
Ineffective QAPI Committee and Quality Deficiencies
Penalty
Summary
The facility failed to ensure the effectiveness of its Quality Assessment and Assurance (QAA) and Quality Assurance Process Improvement (QAPI) committee in implementing appropriate action plans to correct quality deficiencies identified in previous surveys. These deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, activities not meeting the interests and needs of each resident, lack of trauma-informed care, food sanitation issues, and failure to implement a QAPI plan and maintain a QAPI committee with improvement projects. The report indicates that these deficiencies had the potential to affect all residents residing in the facility. The review of the Certification and Survey Provider Enhanced Reporting (CASPER) system report showed that the facility had several deficiencies with a survey exit date of 11/30/23, including repeat deficiencies from a previous survey dated 10/22. The QAPI meeting minutes from various dates in 2024 and 2025 lacked documentation on how the facility developed, monitored, and evaluated performance indicators for improvement activities. Additionally, the minutes did not document how the facility identified, reported, and tracked adverse events, high-risk, high-volume, and problem-prone concerns. Interviews with facility staff revealed that correcting quality deficiencies was not a formal process and was not always included in the meeting minutes. The facility's RN-A acknowledged that the QAA committee could improve in comparing itself to benchmarks and tracking improvement projects. The facility's owner confirmed the need for improvement in the QAPI process and relied on RN-A for updates about survey results and the facility's plan of correction. The facility's policy indicated that the QAA committee should meet quarterly to develop an ongoing quality assurance program and implement plans of action to correct identified quality deficiencies.
QA Committee Lacks Required Members and Infection Control Training
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to ensure that all required members attended the quarterly meetings, as mandated by the facility's Quality Assessment and Assurance (QAA) program policy. The policy specified that the committee should include the administrator, medical director, director of nursing (DON), program director, and consulting pharmacist. However, the review of the QA meeting sign-in sheets revealed that the medical director did not attend any of the meetings throughout the year. Additionally, the sign-in sheets showed that a registered nurse (RN)-A was identified as both the DON and administrator, indicating a potential overlap in roles. Further interviews and document reviews highlighted additional issues within the facility's QA processes. RN-A reported that the facility's infection preventionist had retired and that no staff member had completed or was enrolled in specialized training for infection prevention and control. Despite attempts to interview the medical director, no response was received. RN-A mentioned that the certified physician assistant (CPA)-B attended the meetings as a continuity person, and information from the meetings was relayed to the medical director's designee. The facility's owner acknowledged the need for improvement in the Quality Assurance and Performance Improvement (QAPI) processes.
Infection Control Deficiency in Laundry Services
Penalty
Summary
The facility failed to maintain proper infection control practices during laundry services, potentially affecting all 11 residents. During an observation, the head of housekeeping and laundry services, identified as HK-D, was seen wearing gloves but no gown while handling laundry detergent, Clorox Bleach, and soiled linens. HK-D placed linens and bed sheets from a bag on the floor into the washing machine and folded clean washcloths using the same gloves. HK-D stated that wearing a gown was unnecessary for loading dirty laundry. However, the facility's policy required gowns to be available and used while sorting linens to prevent cross-transmission and adhere to standard precautions. When interviewed, the RN who was also the administrator and director of nursing, expected staff to wear gloves when handling soiled laundry and to change gloves and perform hand hygiene before touching clean laundry. The RN acknowledged that staff should avoid contact between dirty laundry and their body or arms and suggested that staff could be more careful by wearing gowns when handling dirty laundry.
Inadequate Training for Acting Infection Preventionist
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control, which is a requirement for the role. The Director of Nursing (DON), who was serving as the acting IP, confirmed during an interview that he had not completed any specialized training in infection prevention and control. Additionally, no other staff members were currently enrolled in or scheduled for any specialized infection control education. The facility's policy on infection prevention, revised in July 2024, outlines that relevant staff should be trained in infection control upon hire and periodically thereafter. However, the facility did not adhere to this policy, as evidenced by the lack of specialized training for the acting IP. This deficiency had the potential to affect all 11 residents residing in the facility, as the infection control program was not being overseen by a qualified individual.
Inaccurate MDS Coding and PASARR Process Deficiencies
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for several residents, leading to deficiencies in their care assessments. For one resident, the MDS inaccurately reported her activity preferences, despite her having mild cognitive impairment and being able to communicate her preferences. The registered nurse admitted to not interviewing the resident about her activity preferences and instead relied on staff interviews, which led to a gap in understanding and an incomplete care plan that did not address the resident's activity needs. Another resident's MDS was inaccurately coded regarding her Level II PASARR status. Despite having a history of mental illness and being referred for a Level II PASARR, the MDS indicated she was not considered to have a serious mental illness. The facility lacked documentation of the services recommended under the Level II PASARR evaluation, and the registered nurse admitted to not knowing what services should have been provided, indicating a lack of understanding of the PASARR process. Additional deficiencies were noted for other residents, including inaccurate coding of PASARR status and medication use. One resident's MDS did not reflect her use of antianxiety and anticonvulsant medications, and another resident's MDS failed to document her PRN use of antipsychotic medication. The facility also failed to complete required Level II PASARR assessments before admitting residents, leading to a lack of necessary mental health services. Interviews with facility staff revealed a lack of knowledge and understanding of the PASARR process and the importance of accurate MDS assessments for developing appropriate care plans.
Failure to Complete Level II PASARR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Level II Pre-Admission Screening and Resident Review (PASARR) was completed prior to admission for four out of five residents who required it for mental illness. Resident 7 was admitted without a completed Level II PASARR, despite the Minnesota Senior Linkage Line indicating it was necessary. The Hennepin County supervisor confirmed that the assessment was not completed due to a lack of documentation from the facility. The registered nurse responsible for the Minimum Data Set (MDS) was unaware of the PASARR requirements and relied on the director of nursing, who also lacked understanding of the process. Resident 9 was admitted with a primary diagnosis of bipolar disorder, and the preadmission screening indicated a Level II assessment was required. However, the director of nursing admitted that the PASARR process fell through the cracks after a nurse who previously handled it retired. The medical record for Resident 9 lacked evidence of a completed Level II assessment, indicating a failure to meet the resident's mental health care needs. Resident 10 was admitted with diagnoses of bipolar disorder and post-traumatic stress disorder, and the preadmission screening required a Level II assessment. The director of nursing mistakenly believed the process was completed, but no Level II assessment was found. Resident 11 was admitted with similar mental health diagnoses, and the PASARR process was initiated only after admission. The director of nursing acknowledged the importance of completing PASARRs prior to admission to determine necessary services, but the facility did not have a policy in place to ensure compliance.
Facility Fails to Follow Menu and Review Dietary Changes with Dietician
Penalty
Summary
The facility failed to serve food according to a menu and did not review changes to the menu with a qualified dietician or other qualified nutrition professional. The facility also did not ensure that the menu met the nutritional needs of residents with specific dietary requirements, such as a cardiac diet. This deficiency affected five residents who were reviewed for dietary recommendations. The head cook admitted that the menu was not always followed, and there was confusion about the involvement of a registered dietician, as the previous dietician had left, and a new one had not yet been fully integrated. Resident 1 had mild cognitive impairment and several diagnoses, including diabetes mellitus and hyperlipidemia, and was on a no concentrated sweets diet. However, the resident's behavior sheet indicated non-compliance with the diet. Resident 2, with intact cognition and diagnoses including atrial fibrillation and hypertension, was supposed to be on a cardiac, consistent carbohydrate diet, but the MDS did not indicate a therapeutic diet. Resident 3, with intact cognition and diagnoses including orthostatic hypotension and hyperlipidemia, was on a regular diet with increased sodium. Resident 5, with intact cognition and diagnoses including diabetes mellitus, was also on a no concentrated sweets diet. Resident 10, admitted with intact cognition and at risk for malnutrition, was on a regular diet. Interviews with staff revealed inconsistencies in dietary practices. The head cook stated that other cooks did not follow the menu, making it difficult to manage food ordering and usage. The facility administrator acknowledged the lack of a dietician's involvement and stated that the facility was between dieticians. The registered nurse confirmed that residents were not following their prescribed diets, and the facility was not adhering to the menu. The facility's policy indicated that dietary orders could be delegated to a qualified dietician, but this was not being practiced due to the absence of a dietician.
Deficiency in Comprehensive Assessment and Trauma-Informed Care
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed and implemented using the Resident Assessment Instrument (RAI) process for a resident identified as R7. Upon admission, R7's Minimum Data Set (MDS) did not include a diagnosis of post-traumatic stress disorder (PTSD), despite her history of trauma being documented in other assessments. The Care Area Assessments (CAAs) for R7 identified her use of psychotropic medications and non-pharmacologic interventions but lacked documentation of her PRN use of olanzapine and her history of trauma. Additionally, the CAAs did not indicate if referrals to other disciplines were warranted. R7's care plan, while addressing her depression and behavioral management, did not document her history of trauma or the use of PRN antipsychotic medication. Interviews with facility staff revealed a lack of awareness and adherence to the RAI utilization guidelines, which are crucial for determining a resident's functional status and guiding further assessments. The registered nurse responsible for completing R7's MDS expressed hesitancy in reporting a PTSD diagnosis due to its absence in the primary or secondary diagnosis list, despite being aware of R7's trauma history. The facility's failure to accurately capture and document R7's trauma history and related triggers in her care plan and MDS assessments led to a deficiency in providing trauma-informed care. Interviews with the resident and staff highlighted the absence of discussions regarding R7's triggers and past trauma, which are essential for her psychosocial well-being. The facility's policies on comprehensive care planning and MDS or RAI were requested but not provided, indicating potential gaps in procedural adherence and staff training.
Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program by not incorporating recommendations from the PASARR level II determination into the care plan for one resident. The resident, who had a history of schizophrenia, alcohol dependence in remission, insomnia, history of cocaine abuse, and encephalopathy, was not considered by the state to have a serious mental illness or intellectual disability according to her Minimum Data Set (MDS). However, she reported hallucinations and delusions during the lookback period. The Care Area Assessments (CAAs) triggered several areas of concern, but lacked documentation on whether referrals to other disciplines were warranted. The resident's care plan and behavioral management care plan did not include documentation of services recommended under her level II PASARR evaluation. Interviews with facility staff revealed a lack of understanding and awareness regarding the PASARR process. A registered nurse (RN-B) admitted to inaccurately coding the MDS and being unaware of what a PASARR was. The director of nursing (RN-A) also expressed uncertainty about the services recommended under the level II PASARR and admitted to not having read the PASARR evaluation. The facility was unable to provide a PASARR policy or a policy pertaining to MDS accuracy when requested. This lack of coordination and documentation indicates a deficiency in the facility's compliance with PASARR requirements.
Failure to Review and Revise Activities Care Plan
Penalty
Summary
The facility failed to review and revise the activities care plan with input from a resident and/or their representative. The resident, who was reviewed for activities, had a Brief Interview for Mental Status (BIMS) score indicating mild cognitive impairment and was able to communicate effectively. Despite this, the Minimum Data Set (MDS) reported that the interview for daily and activity preferences was not conducted because the resident was rarely/never understood, and no family or significant other was available. The resident's Care Area Assessment (CAA) indicated a preference for certain activities, such as word find puzzles and listening to music, but these preferences were not documented in the care plan. The care plan, revised on a specific date, identified the resident's risk for not meeting emotional, intellectual, physical, and social needs due to cognitive deficits and other conditions. However, it lacked documentation of the resident's activity preferences. Interviews with staff revealed that the registered nurse responsible for the MDS assessments did not interview the resident about activity preferences and acknowledged a gap in understanding regarding the activities care plan. The facility's director of nursing and administrator confirmed that the training provided to the registered nurse on the MDS process could have been more robust. The facility's policy directed staff to incorporate resident preferences into activities, but a comprehensive care plan policy was not provided.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to adequately plan and evaluate the discharge needs of a resident, leading to a discharge to an unknown location without ensuring the resident's medical, mental health, and medication needs could be met. The resident, who had a history of major depressive disorder, alcohol dependence, and cancer, was discharged to a location where it was unclear if their needs could be accommodated. The facility did not have an active discharge plan in place, and the resident did not want a referral to a local contact agency. The resident's care plan did not include discharge planning and indicated the need for pain management, assistance with scheduling medical appointments, and follow-up with oncology staff. Despite these needs, the resident was discharged with all medications, and staff dropped them off at an address that was later found to be a closed facility. The facility's registered nurse and director of nursing stated that the discharge was self-directed by the resident, who did not provide details about the social worker or the discharge location. Interviews with facility staff revealed that the discharge process was not properly documented, and there was no discharge summary available for the resident. The facility's registered nurse acknowledged that the discharge happened faster than desired and without the usual procedures, such as filling out a discharge summary and ensuring communication with the receiving facility. The resident's psychiatric office and chemical counselor were not informed of the discharge, and the facility did not have a policy related to discharge available for review.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities for a resident with mild cognitive impairment and multiple mental health diagnoses, including anxiety, bipolar disorder, schizophrenia, and mild intellectual disabilities. The resident's Minimum Data Set (MDS) indicated a preference for participating in favorite activities and group settings, yet the Care Area Assessment (CAA) noted a lack of interest in activities other than word find puzzles. The resident's care plan aimed to maintain involvement in cognitive and social activities but lacked documentation of specific activity preferences. Observations and interviews revealed that the resident expressed a desire for more arts and crafts activities, which were not consistently offered according to the activities participation logs and calendars. The resident reported that staff did not solicit input on activity preferences and mentioned a lack of supplies for crafts due to budget constraints. Despite the presence of various games and books in the facility, the resident noted the absence of a craft bucket and expressed interest in both structured group activities and independent options. Interviews with facility staff, including the Health Unit Coordinator (HUC) and Registered Nurse (RN), highlighted gaps in assessing and documenting the resident's activity preferences. The HUC confirmed that the resident enjoyed word puzzles and bingo but had not recently updated the resident's activity preferences. The RN acknowledged a lack of an activities care plan focus and expressed uncertainty about the MDS process. The resident's medical doctor emphasized the importance of activities in managing the resident's mental health, noting that engaging in activities could distract from psychosis and improve mood.
Failure in Blood Pressure Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure appropriate blood pressure monitoring and medication administration for a resident diagnosed with orthostatic hypotension, hyperlipidemia, depression, and schizophrenia. The resident was prescribed Midodrine HCL with specific instructions to hold the medication if blood pressure was 110 mmHg or higher, and to administer it if the resident exhibited symptoms of hypotension. However, during a medication administration observation, the registered nurse (RN) did not check the resident's blood pressure before giving the medication, which was against the prescribed order. The RN admitted to normally checking the blood pressure before and after medication administration to assess effectiveness, but failed to do so on this occasion. Further interviews revealed inconsistencies in the facility's practice regarding blood pressure monitoring. The licensed practical nurse (LPN) and certified physician assistant (CPA) both indicated that blood pressure should be checked before administering medication with hold parameters. The consultant pharmacist had previously recommended clarifying the frequency of blood pressure checks due to the twice-daily administration of Midodrine, but there was no evidence of follow-up on this recommendation. The director of nursing acknowledged the need to clarify the medication order and confirmed that the resident's blood pressure had not reached 110 mmHg or above, indicating a lack of adherence to the prescribed monitoring protocol.
Failure to Implement Trauma-Informed Care Plan
Penalty
Summary
The facility failed to identify and document triggers to avoid potential re-traumatization and did not develop a comprehensive care plan with individualized trauma-informed approaches for a resident with a history of trauma. The resident, who had intact cognition and no hallucinations or delusions, was diagnosed with depression and alcohol dependence but did not have a PTSD diagnosis on her Minimum Data Set (MDS). Her Care Area Assessments (CAAs) for psychosocial well-being and mood state identified the use of psychotropic medications and non-pharmacologic interventions but lacked documentation of triggers or referrals to other disciplines. A comprehensive trauma-informed care assessment identified specific triggers such as loud male voices and yelling, but these were not included in the resident's care plan. Instead, the care plan focused on behavioral triggers related to sleep apnea, insomnia, and stress from medical appointments, without addressing the resident's history of trauma. Interviews with facility staff revealed that while the resident's trauma history was known, it was not adequately documented or integrated into her care plan. The facility's policy on trauma-informed care required assessments upon admission and collaboration with residents and their support systems to develop individualized interventions. However, the policy was not followed, as evidenced by the lack of documentation and integration of the resident's trauma history and triggers into her care plan. Interviews with staff indicated a misunderstanding of the policy requirements and a failure to capture necessary information in the MDS within the required timeframe.
Failure to Document End Date or Rationale for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication order for a resident included an end date or a documented clinical rationale. The resident, who had intact cognition and no hallucinations or delusions, was diagnosed with depression and alcohol dependence. The resident's medication administration record showed frequent administration of PRN olanzapine without an end date or clinical rationale for extending the order beyond the 14-day limit. Interviews with the consultant pharmacist and certified physician assistant highlighted the importance of adhering to the 14-day limit for PRN psychotropic medications to ensure appropriate use and monitoring for adverse effects. The nurse practitioner responsible for the resident's psychotropic medication management confirmed the absence of an end date for the PRN olanzapine order and stated that no request for a clinical rationale to extend the order had been received. The nurse practitioner expressed a belief that the resident was on an appropriate dose of olanzapine and would have provided a clinical rationale if requested. The facility's failure to provide a policy on psychotropic drug use further contributed to the deficiency.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information accurately displayed the actual hours worked by licensed staff for each shift on a daily basis. This deficiency was identified through interviews and document reviews, which revealed discrepancies between the posted staffing information and the actual hours worked by registered nurses (RNs) and licensed practical nurses (LPNs). The weekly staffing posts for the periods from 1/1/25 to 1/28/25 included the facility's name, date, census, and total hours for RNs, LPNs, and trained medication assistants (TMAs), but lacked the actual worked hours for RNs and LPNs. Further investigation showed that the facility schedules for the periods from 1/1/25 to 1/31/25 indicated actual hours worked per shift that contradicted the total hours posted on the weekly staffing posts. During interviews, the director of nursing (DON), who was also the administrator, confirmed responsibility for the weekly staffing posts and acknowledged the discrepancies. Despite a request for a policy pertaining to staffing posts, no such policy was provided. This failure had the potential to affect all 11 residents or visitors who wished to review the staffing information.
Failure to Implement Individualized Behavioral Interventions
Penalty
Summary
The facility failed to develop and implement individualized non-pharmacological interventions to manage behaviors for two residents with mental health disorders. One resident, who had a history of anxiety and self-injurious behavior, was admitted with multiple mental health diagnoses, including borderline personality disorder and generalized anxiety disorder. Despite being cognitively intact and independent in mobility and activities of daily living, the resident experienced episodes of anxiety that led to self-harm using hot towels. The care plan lacked specific interventions to prevent such behaviors, and the facility did not consistently offer PRN medications or alternative coping strategies. The resident's care plan was not updated with individualized interventions to prevent self-harm, and there was no comprehensive assessment to determine triggers or behavior patterns. The facility's documentation revealed multiple instances where the resident attempted to use hot towels to self-soothe, resulting in burns and hospitalizations. Interviews with staff indicated a lack of awareness of non-pharmacological options and an over-reliance on PRN medications, which were not always offered proactively. The facility's administrator acknowledged the shortcomings in offering PRN medications and the lack of individualized care plans. Another resident with schizoaffective disorder also lacked individualized behavior interventions in their care plan. The facility did not have a policy or procedure related to mental health or behavioral management, which contributed to the deficiencies in care. Interviews with staff and family members highlighted the need for better management of anxiety and sleep disturbances, as well as the importance of offering PRN medications based on observed behaviors rather than waiting for resident requests.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,029 citations issued within 25 miles in the last 12 months — including the 31 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Care Home | 0.6 mi | ★★★★★ | 3 | 0 |
| Redeemer Health Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| The Estates At Chateau Llc | 0.9 mi | ★★★★★ | 14 | 1 |
| Benedictine Health Center Of Minneapolis | 1.3 mi | ★★★★★ | 8 | 0 |
| Lakehouse Healthcare & Rehabilitation Center | 1.4 mi | ★★★★★ | 37 | 1 |
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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.