Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Crispin Living Community during CMS and state inspections, most recent first.
A resident receiving Risperdal had no documented orthostatic BP monitoring in the orders, care plan, vital signs record, or progress notes. The resident’s psychotropic care plan lacked orthostatic BP guidelines, and an LPN, RN, and RCS confirmed the monitoring task and order were not completed despite the facility’s protocol for antipsychotic side effect monitoring.
A facility failed to provide needed ADL assistance for two residents. One resident with severe cognitive impairment, hospice care, and a pressure injury did not receive timely incontinence care or consistent feeding assistance during lunch, despite being dependent on staff and having care plan directions for frequent checks, repositioning, and meal support. Another resident who depended on staff for hygiene and grooming was observed with long facial hair on the upper lip and chin, and staff confirmed grooming and shaving were expected on bath days but had not been completed.
Improperly Labeled Food in Resident Refrigerators: The facility failed to ensure proper food storage in 2 resident refrigerators when surveyors found undated and unlabeled food items, including yogurt containers with pasta salad and soup and a container of fresh pineapple with only a room number. Staff gave conflicting accounts of who was responsible for cleaning and checking resident refrigerators, and the facility policy required stored food to be dated, labeled with resident name and room number, and kept in approved containers.
Inaccurate Weight Documentation: A resident with dementia, dysphagia, ischemic heart disease, and generalized weakness had highly inconsistent weight records while being monitored with a provider order for daily weights and RD review. The RDS and RD confirmed the weights were likely incorrect and should have been deleted, and one ordered follow-up weight was not documented in the TAR or a progress note. The inaccurate documentation made it difficult for the RD to manage dietary supplement recommendations.
A resident with no cognitive impairment and diagnoses including HF, DM with CKD, and BPH was treated for UTIs with antibiotics that were not supported by the available lab data. The resident received Macrobid even though the urine culture grew Proteus mirabilis with sensitivities to other agents, and later received ciprofloxacin without a urine analysis being ordered or completed. The 72-hour antibiotic time-out reviews were inaccurate, and the IP acknowledged the follow-up on identified issues was lacking.
A resident with chronic pain, an amputation, and PTSD was ordered morphine IR 15 mg QID with PRN 7.5 mg doses, but staff failed to secure a timely refill when the supply ran low, resulting in multiple missed scheduled doses and only a single partial PRN dose over roughly a day. A day‑shift RN recognized the impending shortage but did not obtain a new prescription, and an on‑call NP later signed an electronic order without confirming pharmacy receipt, declined to resend it that night, and did not order alternative pain control or monitoring for opioid withdrawal. The resident reported 10/10 pain, remained in bed, had decreased appetite, and increased anxiety, while his spouse observed sweating, confusion, and functional decline, and documentation showed no comprehensive assessment for withdrawal. Review of narcotic records revealed incomplete controlled substance sheets lacking RX numbers, prescriber names, and directions, and discrepancies between documented quantities received and pharmacy packing slips for morphine, compromising accurate tracking and availability of the opioid.
A resident with chronic pain syndrome had scheduled morphine IR 15 mg ordered four times daily, but multiple doses were missed when the medication ran out and was not available. Nursing staff contacted the on-call NP and pharmacy several times, but the NP did not resend the prescription that evening, did not order alternative pain management, and did not direct monitoring for withdrawal or increased pain. The resident reported severe pain, decreased mobility, poor appetite, and increased anxiety during the period without scheduled morphine. The pharmacy later confirmed it had not received the NP’s prescription that night and stated that an emergency verbal order process existed and that the lack of medication constituted an omission medication error, while facility policy required timely practitioner orders and 24-hour physician services for immediate care needs.
A resident with chronic pain had scheduled Morphine IR doses ordered four times daily, along with a PRN Morphine order, but multiple scheduled doses were not administered because the medication was not available, and one dose was given late. Progress notes showed staff repeatedly contacted the on-call provider, triage RN, and pharmacy about the missing prescription, and the NP declined to fax the order until a later time. The DON later acknowledged that the missed doses constituted an allegation of neglect but was unaware of the situation at the time, and the event was not reported to the State Agency as required by the facility’s Abuse Prevention Plan policy.
A resident with chronic pain syndrome, amputation, shrapnel‑related osteoarthritis, and PTSD was on scheduled morphine IR with a PRN order. Staff failed to timely re‑order and ensure availability of the scheduled morphine, resulting in four missed doses and a prolonged gap in full opioid coverage. During this period, the resident reported pain escalating from a baseline 5/10 to 10/10, remained in bed, had decreased appetite, increased anxiety, sweating, and confusion, while his spouse observed him quiet, diaphoretic, and unable to operate the TV remote. Nursing documentation between the missed doses lacked comprehensive pain assessments with pain characteristics, non‑pharmacologic interventions, increased monitoring for escalating pain or opioid withdrawal, or consideration of emergency transfer. One RN recognized in advance that the morphine supply would be insufficient but did not contact the provider due to time constraints, subsequent nurses confirmed the missed doses and significant pain, and the DON was not notified and did not become aware until later. The NP did not verify that the prescription reached the pharmacy, did not provide alternate pain management orders, and did not direct staff to monitor for withdrawal. The facility’s pain management policy required ongoing assessment and reassessment but did not specify when to complete comprehensive assessments, how to document baseline pain, or what steps to take when scheduled pain medications are missed or unavailable, contributing to the deficient pain management.
The facility failed to maintain kitchen equipment, specifically a hotbox used to keep food warm, leading to food being served at unsafe temperatures. The hotbox's top compartment lacked a working thermometer and displayed an error code, which the culinary director could not explain. The environmental services manager found no maintenance records, and the administrator was unaware of the issue, highlighting a lack of oversight and documentation.
The facility failed to properly manage contaminated linen in the 300-unit laundry room, where a yellow-stained bed sheet was left unbagged on the floor beneath clean resident laundry. The room was dirty, with lint scraps and a mildew smell. Staff interviews revealed that NAs were responsible for maintaining cleanliness, but the room remained unclean. The DON and RRN confirmed the issues, and the IP acknowledged that soiled linens sometimes get mixed with residents' clothing, contrary to facility policy.
A resident admitted with multiple fractures and a surgical wound in the left groin area was not properly assessed or treated according to physician orders. The facility failed to transcribe the discharge instructions into the resident's records, leading to a lack of monitoring and documentation of the surgical wound. This oversight resulted in the wound dehiscing and becoming infected, necessitating a five-day hospital stay for surgical intervention and antibiotic therapy.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to complete medication side effect monitoring for one resident who was receiving an antipsychotic medication. The resident’s quarterly MDS showed moderate cognitive impairment with no behaviors and dependence on staff for several activities of daily living, including lower body dressing, transfers, and toileting. The resident’s care plan for psychotropic drug use stated the resident would not experience adverse reactions, but it did not include guidelines for orthostatic blood pressure monitoring, which was identified as a potential side effect of psychotropic medications. The resident’s MAR showed Risperdal 0.5 mg was administered once each evening, but the orders did not include orthostatic blood pressure monitoring. The vital signs record did not contain orthostatic blood pressure readings, and the progress notes did not document that orthostatic blood pressures were attempted or refused. During interviews, an LPN stated the resident did not have a provider order or care-planned task for orthostatic blood pressure monitoring, and the RCS and RN confirmed that the monitoring orders and care-planned tasks were not completed for the resident. The RCS stated orthostatic blood pressure monitoring is part of the facility’s protocol when a resident is started on an antipsychotic medication.
Failure to Provide Timely ADL Assistance and Grooming
Penalty
Summary
The facility failed to provide activities of daily living assistance for 2 residents who were dependent on staff for care. One resident had severe cognitive impairment, was dependent on staff for all ADLs except substantial assistance with eating, received hospice care, and had a stage 3 pressure injury to the left heel. The resident’s care plan called for incontinence checks and changes every 2 to 3 hours, repositioning every 2 to 3 hours, and assistance with eating. During observation, the resident was taken to church and then to lunch, where staff gave part of a sandwich but did not remain to assist or encourage intake while the resident made no attempt to eat the rest of the meal. The resident remained at the table with untouched food until later, and when returned to the room was found incontinent of urine with reddened indentations on the thighs from the wheelchair cushion. Interviews confirmed the resident required full assistance with eating and that dependent residents were expected to receive incontinence care and repositioning every 2 to 3 hours. Staff stated the resident could not feed herself and normally ate 100% when assisted, but on the observed day no staff stayed to provide feeding assistance. The dietitian stated the resident was under hospice care and that nutrients were needed for wound healing. The regional director of clinical services stated dependent residents were expected to be repositioned and provided incontinence care every 2 to 3 hours and that staff were expected to assist dependent residents with eating to promote wound healing. A second resident was cognitively intact but dependent on staff for personal hygiene, toileting hygiene, lower body dressing, and required substantial assistance with oral hygiene, bathing, and upper body dressing. The resident’s care plan and bath orders included grooming and shaving on bath days. During observation, the resident had multiple long hairs on the upper lip and chin. The resident stated she had told staff she wanted the hairs removed and wondered why it was not done on bath days. Staff confirmed facial hair removal and grooming typically occurred on bath days, acknowledged the resident had visible facial hair, and stated there were no documented refusals of grooming or hygiene care.
Improperly Labeled Food in Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper food storage for 2 of 2 resident refrigerators that contained food items without required dates and labels. During observation, the 2nd floor refrigerator near the dining room contained an undated and unlabeled yogurt container 3/4 full with pasta salad and a second undated and unlabeled yogurt container 3/4 full with soup. The refrigerator had a posted sign stating stored items must include the date placed in the fridge, use-by date, resident name, and room number, and that items missing this information would be discarded immediately. On the 1st floor, the refrigerator near the dining room contained a clear plastic container of fresh pineapple with a room number but no date. Interviews showed inconsistent staff responsibility for checking and cleaning the resident refrigerators. A dietary aide stated dietary staff checked refrigerator temperatures while housekeeping was responsible for cleaning the inside and verifying food was labeled and dated. A housekeeper stated they cleaned dining rooms and common areas and did not clean resident-use refrigerators. The dietary manager stated dietary staff checked temperatures, while housekeeping cleaned and checked food dates twice a week, and also stated staff had a habit of putting personal food items in the refrigerator. The environmental services director and the Regional Director of Clinical Services both stated housekeeping staff were responsible for cleaning the resident refrigerators and ensuring food items were dated and labeled appropriately, and the environmental services director confirmed the items observed were not dated or labeled appropriately. A policy dated 2019 required food stored in refrigerator/freezer units to be in covered, seamless containers or otherwise suitably protected, with the date, use-by date, resident name, and room number, and stated single-use containers could not be reused for direct food storage.
Inaccurate Weight Documentation
Penalty
Summary
The facility failed to maintain an accurately documented medical record for one resident who was being monitored for weight changes. The resident had moderate cognitive impairment, no behaviors, and required substantial to maximal assistance with personal hygiene, bathing, and upper body dressing, while being dependent on staff for lower body dressing, transfers, and toileting. The resident’s diagnoses included ischemic heart disease, generalized muscle weakness, dementia, and dysphagia. A provider order was in place to obtain daily weights for RD review, and the resident’s dietary supplements were changed multiple times over the course of the record, including Glucerna and later Ensure. The resident’s documented weights were inconsistent and included several marked fluctuations, such as 118, 130, 142, 100, 213, and 141 pounds over the reviewed period. During interview, the RDS reviewed the weight documentation and confirmed it was inconsistent and likely incorrect, stating inaccurate weights should have been deleted. The RD stated she had difficulty making dietary supplement recommendations because the documented weights were inaccurate and had requested a weight verification order for two weights per week for one week. Although one weight was documented, there was no documentation in the TAR or a progress note showing why the second ordered weight was not completed. The RDS again confirmed the inaccurate weights should have been deleted and that accurate weights and documentation were important for appropriate dietary management.
Antibiotic Stewardship and Time-Out Review Failure
Penalty
Summary
The facility failed to ensure proper antibiotic time-out follow-up and failed to ensure that appropriate antibiotics were utilized for a resident reviewed for multiple urinary tract infections. The resident had a quarterly MDS assessment showing no cognitive impairment and substantial assistance with activities of daily living, with diagnoses including hypertensive heart failure, diabetes mellitus with diabetic chronic kidney disease, and benign prostatic hyperplasia with lower urinary tract symptoms. In January 2026, the resident was administered Macrobid 100 mg twice daily for a UTI after a urine analysis was completed and reported positive. The urine culture later identified Proteus mirabilis, with sensitivities listed for multiple antibiotics, but the resident had been treated with an antibiotic that was not sensitive to the organism identified based on the culture result. The resident’s 72-hour antibiotic time-out review completed on 1/16/26 indicated McGeer’s Criteria to treat was met, although the record review showed McGeer’s Criteria and culture were not met. In March 2026, the resident was again administered ciprofloxacin 250 mg twice daily for a UTI, but no urine analysis was ordered or completed before or after the antibiotic was started. The 72-hour antibiotic time-out review completed on 3/10/26 indicated McGeer’s Criteria to treat was not met and that culture or imaging did not confirm infection. During interview, the infection preventionist acknowledged that the 72-hour antibiotic time-out reviews completed on 1/16/26 and 3/10/26 lacked accuracy and follow-up on issues identified. The facility policy stated that, based on review of the clinical situation and pertinent lab and diagnostic tests, the provider and nursing associate would identify whether antibiotics were warranted or whether those already started should continue or change.
Failure to Maintain Opioid Availability and Controlled Substance Accountability
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective pharmacy services and continuous availability of prescribed opioid pain medication for a resident with chronic pain and long-term morphine therapy. The resident had diagnoses including chronic pain syndrome, an above-the-knee amputation, post‑traumatic osteoarthritis with contracture, and PTSD, and was cognitively intact but dependent on staff for transfers and toileting. He had MD orders for morphine IR 15 mg four times daily on a scheduled regimen and morphine IR 7.5 mg twice daily PRN. On one day, the day‑shift RN recognized that the resident’s supply of scheduled morphine IR 15 mg tablets would be insufficient but did not contact the provider for a new prescription before the end of the shift, citing time constraints, and only verbally informed the oncoming nurse without verifying that a prescription was obtained. Later that day, the scheduled afternoon and evening 15 mg morphine doses were not administered because the drug was not available, and only a single 7.5 mg PRN dose was given in place of a full scheduled dose. The evening RN attempted multiple times to reach the on‑call NP through a triage nurse and was told by the NP later that she had signed the order in the electronic system but did not verify that the prescription reached the pharmacy and refused to resend it that night, stating she would address it in the morning. The NP did not provide alternative pain management orders, did not order monitoring for opioid withdrawal symptoms, and did not inquire whether doses had already been missed. Pharmacy records confirmed that no morphine prescription from the NP was received that day, and the pharmacy indicated that no calls from the facility were logged during the reported time frame, despite staff documentation that the pharmacy had been contacted multiple times. The following morning, the resident’s early scheduled morphine dose was again not administered due to lack of medication, and the day‑shift RN was not informed by night staff that multiple doses had been missed. She did not contact the on‑call provider until after mid‑morning, when she discovered the resident was out of morphine, at which time the triage RN and a PA became involved to send a new prescription and authorize use of the e‑kit. The resident reported that during the period without his scheduled morphine he experienced pain at 10/10, could not get out of bed, had decreased appetite, and his anxiety worsened; his spouse observed him sweating, unusually quiet, confused, and unable to operate the TV remote as usual. Documentation showed that the resident went approximately 24 hours without a full scheduled 15 mg dose and about 20.5 hours with only a partial 7.5 mg PRN dose instead of his ordered regimen, with no comprehensive assessment for opioid withdrawal symptoms and no enhanced monitoring for increased pain. In addition to the failure to maintain medication availability, the facility failed to ensure proper reconciliation, transcription, and accountability of controlled substances for the same resident’s morphine. Review of the controlled substance book and medication cart revealed incomplete documentation and discrepancies between the narcotic record, bubble packs, and pharmacy packing slips. One controlled substance sheet documented receipt of 24 tablets of morphine 15 mg without listing the RX number, prescriber name, or directions, and the corresponding bubble pack was no longer present for verification. Another sheet documented receipt of 12 tablets for PRN morphine, while the pharmacy packing slip for the same RX and label indicated delivery of only 6 tablets, and the controlled substance sheet again lacked RX number, prescriber, and directions. These inconsistencies and omissions compromised the facility’s ability to accurately track, verify, and ensure availability of the resident’s ordered controlled substances. The DON stated she was unaware that the resident had missed multiple scheduled morphine doses and acknowledged that this represented a significant medication error that could place the resident at risk for acute withdrawal and significant pain. She confirmed that the provider had not been notified about the missed doses at the time, that no medication error report had been completed, and that there were no orders in place during the gap to control the resident’s pain or to monitor for withdrawal symptoms. The consultant pharmacist and medical director both confirmed, based on record review and interviews, that the resident went without morphine for an extended period, that there were no comprehensive assessments or monitoring for pain or acute opioid withdrawal during that time, and that missing scheduled doses of IR morphine would be expected to result in increased pain and potential withdrawal signs such as sweating and nausea. The surveyors determined that these failures in ordering, communication, monitoring, and controlled substance documentation resulted in severe unmanaged pain and possible early opioid withdrawal symptoms for the resident and constituted immediate jeopardy beginning when the facility first failed to ensure the resident’s prescribed morphine was available for administration.
Failure to Obtain Timely Practitioner Orders and Morphine Refill for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely practitioner orders and provision of prescribed narcotic pain medication when a resident’s scheduled morphine was not available. The resident had an order dated 11/28/23 for morphine IR 15 mg to be administered four times daily for chronic pain syndrome at 6:30 a.m., 11:30 a.m., 4:00 p.m., and 8:00 p.m. The February 2026 MAR showed that on 2/2/26 the 4:00 p.m. and 8:00 p.m. scheduled doses were not administered because the medication was not available, and only a single 7.5 mg PRN dose was given at 5:03 p.m. On 2/3/26, the 6:30 a.m. scheduled dose was not administered and the 11:30 a.m. dose was given late at 1:36 p.m., again due to unavailability of the ordered morphine. Progress notes and interviews documented repeated but unsuccessful efforts by nursing staff to obtain a new prescription and supply of morphine. On the evening of 2/2/26, staff contacted the on-call provider and pharmacy multiple times and documented that the medication was not available. The nurse practitioner reported she had sent the morphine prescription to the pharmacy at 7:00 p.m., but the pharmacy could not locate it, and she declined to fax or resend the prescription that night, stating she might do so the following morning. She did not provide alternative pain management orders, did not give instructions to monitor for opioid withdrawal symptoms, and did not direct staff on how to address increased pain. The charge RN confirmed she attempted to reach the NP multiple times between mid-afternoon and late evening, could not use the MAR reorder function because a new prescription was required, and identified the failure to obtain a timely prescription as the root cause of the missed doses. The resident reported that after running out of morphine in the afternoon, he did not receive his scheduled doses for almost a full day, during which he experienced pain rated 10/10, inability to get out of bed, decreased appetite, and worsened anxiety with difficulty swallowing. The pharmacist stated the pharmacy did not receive a morphine prescription from the NP on 2/2/26 and only received a new prescription from a certified physician assistant the following day, which included authorization to obtain a dose from the e-kit. The pharmacist explained that after-hours procedures allowed for emergency verbal prescriptions for controlled substances and characterized the lack of medication in this situation as an omission medication error. The facility’s Physician Services policy required that a physician, NP, or PA provide orders for residents’ immediate care needs, ensure 24-hour availability of physician services in case of emergency, and maintain residents under physician care with timely communication and documentation of orders, which was not met in this case when timely orders and medication were not secured for the resident’s pain management.
Failure to Timely Report Alleged Neglect Related to Missed Pain Medication Doses
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency within the required timeframe after a resident missed multiple scheduled doses of prescribed pain medication. The resident had physician orders for Morphine IR 15 mg four times daily for chronic pain syndrome and an additional PRN order for Morphine IR 7.5 mg twice daily for pain. The February 2026 MAR showed that the 4:00 p.m. and 8:00 p.m. scheduled doses on 2/2/26 and the 6:30 a.m. scheduled dose on 2/3/26 were not administered because the medication was not available in the facility, and the 11:30 a.m. dose on 2/3/26 was administered late at 1:36 p.m. Progress notes documented that staff contacted the on-call provider and pharmacy multiple times regarding the morphine prescription, that the pharmacy had not received or located the prescription, and that the NP declined to fax the prescription that evening, indicating it might be sent the following morning. Further progress notes indicated continued unavailability of the scheduled morphine dose the following morning and additional contacts with the triage RN on-call, who reported sending a renewed order to the pharmacy and contacting an on-call certified physician assistant. During an interview, the DON stated she was not aware that the resident had missed multiple scheduled doses of morphine due to the medication not being available and confirmed that this constituted an allegation of neglect that had not been reported to the State Agency. The facility’s Abuse Prevention Plan policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required immediate reporting of suspected abuse or neglect to the Executive Director or designee and to the Minnesota Department of Health via the online reporting system in accordance with legal timeframes. Despite these policy requirements, the allegation of neglect related to the missed morphine doses was not reported as required.
Failure to Maintain Scheduled Opioid Therapy and Comprehensive Pain Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s scheduled opioid pain medication was re-ordered, available, and administered as ordered, and to provide comprehensive pain assessment and monitoring when doses were missed. The resident had chronic pain syndrome, an above-the-knee amputation of the left leg, post‑traumatic osteoarthritis with contracture of the left hand from shrapnel injury, and PTSD. His MDS showed intact cognition, dependence on staff for transfers and toileting, use of a motorized scooter, and a scheduled pain regimen without PRN or non‑pharmacological pain interventions. The CAA documented frequent moderate pain over five days and directed staff to assess pain each shift, notify the provider of unrelieved pain, and use pharmacologic and non‑pharmacologic interventions. However, the care plan problem statement for pain was left blank, lacked a documented baseline pain level, and did not provide clear guidance for managing chronic pain, scheduled opioid administration, or monitoring when medications were unavailable, despite an intervention requiring a pain scale each shift. The resident had physician orders for morphine IR 15 mg four times daily for chronic pain and morphine IR 7.5 mg twice daily PRN. The MAR showed that on one day the 4:00 p.m. and 8:00 p.m. scheduled 15 mg doses were not administered because the medication was not available, and a 7.5 mg PRN dose was given at 5:03 p.m. as a substitute. The following morning, the 6:30 a.m. scheduled dose was not administered, and the 11:30 a.m. dose was given late at 1:36 p.m., resulting in four missed scheduled doses and a prolonged gap in full opioid coverage. Progress notes documented repeated contacts with the on‑call provider and pharmacy about the morphine prescription and that the medication was not available. The NP reported having sent a prescription to the pharmacy but did not fax it to the facility that evening and did not provide alternate pain management orders or instructions to monitor for increased pain or withdrawal. A triage RN later reported sending a renewed order to the pharmacy and contacting an on‑call PA. The vitals and intake records for the two days of missed doses showed no documented food intake, with improved intake afterward, and resident and family interviews described decreased appetite during the medication gap. During this period, the record lacked comprehensive pain assessments that included pain characteristics, documentation of non‑pharmacological interventions attempted or offered, increased monitoring for escalating pain or opioid withdrawal symptoms, or any offer or suggestion of emergency transfer for pain management. The resident reported that when he receives all scheduled morphine doses his baseline pain is 5/10, but during the gap he experienced pain at 10/10, could not get out of bed, had decreased appetite, and increased anxiety with difficulty swallowing. He stated he tends to shut down and not ask for medication when in severe pain and that staff only asked for a numerical pain rating without exploring specifics. His spouse described him as stoic, noted that he was sweating, quiet, confused, and unable to operate the TV remote, and confirmed that he did not call her as he usually did. Multiple nurses described him as stoic and requiring prodding to report pain; one nurse identified in advance that the morphine supply would be insufficient but did not contact the provider due to time constraints, and subsequent nurses confirmed the missed doses and significant pain. The DON acknowledged unawareness of the missed doses, agreed this represented a significant medication error with no provider notification, no monitoring for withdrawal, and no alternative pain management, and confirmed that the facility’s pain management policy did not specify when to complete comprehensive pain assessments, how to document baseline pain, or what steps to follow when scheduled pain medications are missed or unavailable. The pharmacist and medical director characterized the situation as emergent, explained the pharmacology of IR morphine, and stated that even one missed dose should trigger assessment and monitoring for escalating pain and acute opioid withdrawal, underscoring that the clinical team was responsible for ensuring communication, medication availability, and monitoring when a scheduled opioid dose was missed. The facility’s written pain management policy required evaluation, documentation, and reassessment of pain at regular intervals, with each new report of pain, and after interventions, using an interdisciplinary approach and involving the resident and responsible party. However, the policy did not specify when or where a comprehensive pain assessment must be completed, did not provide guidance for documenting baseline pain, and did not outline steps to follow when scheduled pain medications are missed or unavailable. This lack of detailed procedural guidance, combined with staff failures to timely re‑order morphine, ensure its availability, notify providers of missed doses, and conduct comprehensive assessments and monitoring during the medication gap, led to the resident experiencing unmanaged severe pain, decreased appetite, sweating, confusion, and anxiety during the period when his scheduled opioid therapy was interrupted.
Failure to Maintain Kitchen Equipment for Safe Food Temperatures
Penalty
Summary
The facility failed to maintain kitchen equipment used to keep food warm prior to serving, as observed during a survey. The culinary director (CD) was found using a hotbox with a malfunctioning top compartment that lacked an internal thermometer and displayed an error code 'E00' on the external display. The CD was unable to clarify the meaning of the error code and was uncertain about the last service date of the hotbox. During a meal service, egg rolls stored in the hotbox were found to have an internal temperature of 120 degrees, which was below the safe serving temperature. The CD acknowledged that improper food temperatures could increase the risk of foodborne illness and stated that staff should monitor and log food temperatures, and report malfunctioning equipment to supervisors or maintenance. Further investigation revealed that the environmental services manager (ESM) could not find any service slips or maintenance requests for the hotbox since January. The ESM mentioned that parts from a second hotbox had been used to fix the current one, but could not verify when this occurred. The facility administrator was unaware of the equipment issue and stated that malfunctioning equipment should be taken out of service until repaired. Maintenance logs and equipment information were requested but not provided, indicating a lack of documentation and oversight in maintaining essential kitchen equipment.
Improper Management of Contaminated Linen in Laundry Room
Penalty
Summary
The facility failed to properly manage and contain contaminated linen in the 300-unit laundry room, which had the potential to affect all 15 residents on the unit. During a tour, it was observed that a yellow-stained contaminated bed sheet was left unbagged on the floor, with clean resident laundry placed in a basket on wheels above it. The laundry room was found to be dirty, with used lint scraps, a used paper towel, and a mildew smell present. The detergent compartment on the washer was also dirty with lint scraps and old soap. Interviews with staff revealed that nursing assistants (NAs) were responsible for keeping the laundry room tidy, but the room remained unclean and the contaminated sheet was not properly bagged and removed. The director of nursing (DON) and regional registered nurse (RRN) confirmed the presence of the unbagged contaminated linen and the mildew smell during their observation. The infection preventionist (IP) stated that soiled linens should be bagged at the point of care and taken to the soiled utility room, but acknowledged that sometimes soiled facility linens get mixed up with residents' personal clothing. The facility's policy dated 5/15/24 also stated that dirty linens should be bagged at the point of use and kept separate from clean laundry, which was not adhered to in this instance.
Failure to Monitor and Treat Surgical Wound Leads to Hospitalization
Penalty
Summary
The facility failed to assess, monitor, and treat a surgical wound according to physician orders for a resident who was admitted with multiple fractures and a surgical wound in the left groin area. Upon admission, the facility did not comprehensively assess the surgical wound or transcribe the physician's orders for its monitoring and treatment into the resident's electronic health record. This oversight resulted in the wound dehiscing and becoming infected, leading to a five-day hospital admission for surgical intervention, antibiotic therapy, and wound vacuum-assisted closure. The resident's hospital discharge summary included specific instructions for the care of the left groin incision, which were not transcribed into the facility's records. The facility's staff failed to document the presence, absence, or removal of the Mepilex Ag dressing that was ordered to be in place over the incision. Progress notes and skin assessments did not identify or monitor the left groin incision, and the baseline care plan was incomplete, lacking specific interventions for the resident's surgical wound. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's surgical incision. Staff members, including licensed practical nurses and registered nurses, did not recall seeing or assessing the incision, and there was no evidence of a comprehensive skin assessment being conducted. The facility's director of nursing and medical director acknowledged the discrepancies in documentation and the failure to follow physician orders, which contributed to the resident's wound dehiscence and subsequent hospitalization.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Red Wing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mayo Clinic Health System - Lake City | 12.8 mi | ★★★★★ | 5 | 1 |
| Ellsworth Health Services | 14.2 mi | ★★★★★ | 6 | 0 |
| Plum City Care Ctr | 17.4 mi | ★★★★★ | 0 | 0 |
| Zumbrota Care Center | 18.2 mi | ★★★★★ | 3 | 0 |
| Prescott Nursing And Rehab Community | 20.3 mi | ★★★★★ | 6 | 0 |
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