Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around May 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 The Terrace At Crystal Llc during CMS and state inspections, most recent first.
The facility failed to disinfect a shared glucometer between resident uses, with an LPN using the same meter for two residents without proper cleaning and disinfection. It also failed to use enteric precautions for a resident with suspected and later confirmed C. difficile while stool testing was pending, and staff did not consistently perform hand hygiene, glove changes, or gown use during personal care and transfers for residents on EBP, including a resident with a catheter and another receiving a bed bath.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A facility failed to ensure its activity program was directed by a qualified professional after the Activities Director position became vacant. No monthly activities calendar was maintained or posted, activities were mainly held on the second floor, and no organized activities were observed on the third floor. A cognitively intact resident said residents had tried to organize activities themselves because formal activities were not occurring, and staff confirmed the Activities Assistant had no formal training and had not been trained on the duties of the role.
Improper Hair and Beard Restraints During Food Service: A dietary aide was observed serving lunch, plating resident meals, and preparing room trays without a hairnet or beard net while having longer hair and a partial beard/goatee. The DA stated the hairnet had been removed during break and not replaced, while the CDM, DON, and administrator stated hair and beard restraints were expected during food service and plating.
Mandatory QAPI training was not completed for an NA reviewed by surveyors. Personnel record review showed no evidence that the NA had completed QAPI education within the last year, and the DON confirmed the records were not found. The facility policy identified QAPI as a mandatory in-service training class, but did not state how often it must be completed.
Missing Mandatory Compliance and Ethics Training: The facility failed to ensure an NA completed required compliance and ethics training. Personnel record review showed the training was not completed in the last year, and the DON confirmed the records were not found and expected the training to be completed annually. The facility policy identified ethics training as mandatory, but did not state how often it must be completed.
A resident with dementia and elopement risk was able to follow staff out of a locked memory care unit and later wandered unsupervised in common areas while staff failed to complete ordered safety checks. The facility also did not verify sling size before Hoyer transfers for two residents and initially used incompatible lift and sling brands for another resident. In addition, a resident kept his bed in a high position despite a care plan for a low bed, and a resident who smoked while using supplemental O2 was not consistently supervised under the ordered smoking safety precautions.
A resident room was observed in disrepair with unpainted wall areas, black marks, discoloration, ceiling staining, and scuffed, missing paint on the door frame, and the same conditions remained on follow-up. The memory care dining room floor also had food crumbs and debris under multiple tables; an LPN said it appeared not to have been cleaned after the prior night's meal, and the administrator confirmed the food was still present.
A resident with impaired cognition, incontinence, and a catheter for neurogenic bladder had his catheter drainage bag visible in the commons area and later from the hallway, with clear yellow urine showing. Staff, including therapy, the IP, and an RN, did not arrange privacy, and the bag was also hung facing out toward the room entrance. The DON stated staff were expected to keep the blue side of the bag facing the public to cover it and maintain dignity.
A resident with seizures, aphasia, dementia, and a recent fall with injury did not have his call light within reach while in bed. The care plan directed staff to keep the call light in reach, but surveyors observed it wrapped around a wall-mounted switch box above the head of the bed and out of reach. The resident and an NA confirmed it could not be reached, and the record showed a prior fall after the resident tried to transfer without using the call light.
Failure to assess and document antipsychotic side effects for a resident receiving quetiapine for Parkinson’s disease and behavioral disturbance with agitation. The resident had moderately impaired cognition, needed staff help with ADLs, and was observed with a flat affect and mild finger tremor. Although an AIMS order was in place, the record showed incomplete sign-offs and no documented assessment results, and staff stated AIMS was used to monitor for side effects and should be documented in the medical record.
Failure to maintain discharge planning for a resident’s requested move closer to family. The resident had impaired memory and severely impaired decision-making skills, and the guardian repeatedly stated a desire for the resident to move closer to family. The care plan listed the goal, but records lacked referral details, follow-up, or documented communication about the request, and a later care conference documented no discharge planning because the resident was on LTC hospice.
The facility failed to give two residents written transfer notices and written bed-hold notices when they were sent to the hospital. Records showed one resident had moderate cognitive impairment and the other had intact cognition, but neither record showed a written notice with ombudsman info, appeal rights, or the required bed-hold details such as state policy duration, reserve bed payment policy, or facility bed-hold policy. Staff interviews indicated uncertainty about whether the notices were provided, and the nurse manager stated the facility did not have a process for written transfer notices.
Missed Care Conference Participation: A resident with intact cognition was not given the opportunity to attend and participate in a care conference. Staff confirmed care conferences were expected after MDS assessments and significant changes, but the resident’s record showed no conference documented for several months, and the family member reported the last conference had been months earlier.
A resident with highly impaired hearing and who spoke Hmong did not have effective communication supports consistently used despite care plan directions to use an interpreter service and communication binder. Staff were unsure of the resident’s language, and during observation the resident was seen wandering, pulling at his pants, urinating in common areas, and squatting behind equipment while staff were not observed using the interpreter line or communication binder to assess his needs.
Failure to provide routine grooming: a resident who was dependent on staff for ADLs and preferred no facial hair was observed with visible facial hair on multiple occasions, and records for baths/showers did not show shaving was offered, completed, or refused. The resident stated staff did not ask about shaving, and RN and DON interviews confirmed shaving should be offered as part of grooming and documented if refused.
A facility failed to provide an ongoing activity program that met residents’ interests and failed to inform residents of available activities. Two cognitively intact residents said group activities and favorite activities were important, but one resident had no documented activity participation during the review period and both residents reported no posted activity calendar, limited or no staff notification, and activities occurring mainly on another floor. Staff confirmed there was no Activities Director, activities were not routinely occurring on the third floor, and the calendar was not posted for resident viewing.
Failure to arrange ordered retinal specialist follow-up: A resident with DM and cognitive intactness reported fuzzy, burning eyes and said she had been told she needed specialist follow-up for possible edema behind her eyes. Although the physician ordered a routine referral to a retinal specialist, the EMR had no evidence the appointment was scheduled or completed, and staff could not find documentation of follow-up or a consultation report. Interviews showed the HUC was responsible for scheduling outside appointments, but no one could confirm the referral had been carried out.
A resident with a catheter for neurogenic bladder, impaired cognition, and total bowel/bladder incontinence had a catheter drainage bag repeatedly observed hooked on a wheelchair arm rest above bladder level. The tubing contained urine that had not drained down, the resident tried to move the tubing to drain it, and staff interviews confirmed the bag should have been positioned below the bladder; one RN also stated the resident was on antibiotics for a bladder infection.
A resident with cancer, kidney disease, malnutrition, and a seizure disorder did not have documentation of the required initial face-to-face physician visit within the first 30 days after admission. The DON stated the physician should have seen the resident during the first month, but no progress note or other record of the visit was found, despite the facility policy requiring monthly physician visits for the first 90 days.
A resident receiving quetiapine for Parkinson’s disease and behavioral disturbance had ordered AIMS monitoring that was not documented in the medical record, despite the consultant pharmacist’s recommendation for baseline and ongoing monitoring. The TAR showed sign-offs without assessment results, a blank entry, and later no sign-off at all, while staff stated AIMS was used to monitor side effects and should be documented in the chart.
A resident who required a mechanical lift for transfers experienced repeated Hoyer lift battery failures during transfers, including one observed transfer where the lift stopped working while he was being lowered. Staff reported that lift batteries were often not charged, that overnight staff were responsible for charging them, and that they sometimes used the emergency release to lower the resident when the battery died. The DON and other staff confirmed the batteries were not consistently checked or maintained, and the maintenance supervisor said batteries were only replaced occasionally.
Missing Fitted Sheets on Bariatric Beds: Two residents with bariatric beds were observed lying on blankets with large areas of bare mattress exposed because fitted sheets were not on their beds. Staff stated the facility did not have enough bariatric sheets, and one resident said the sheets never fit properly. The DON stated all residents should have sheets on their beds, and the facility policy listed sheets as required bedding supplies.
Inaccurate daily nurse staffing postings were identified when the facility’s daily postings did not match the actual staffing levels shown on the schedules. The DON and administrator stated the postings were completed by the receptionist and were not updated for call-ins, no-shows, or staff picking up shifts. The receptionist and staffing coordinator confirmed the postings were not being adjusted to reflect changes, and review of the schedules and postings showed they did not match.
A resident with intact cognition, multiple mental health diagnoses, and a history of substance abuse and aggression was involved in a physical altercation with another resident, during which staff used a physical "bear hug" restraint to prevent further aggression. The resident’s care plan included interventions such as 1:1 supervision and separation from certain residents but did not address restraint use. After the incident, staff did not obtain a provider order for the restraint, did not document the restraint episode or a post-restraint assessment, and did not notify the provider specifically about the restraint, despite facility policy requiring an order, immediate provider notification, and detailed documentation for any emergency restraint use.
A resident with mental health and alcohol dependence diagnoses, previously independent in ADLs and cognitively intact, was involved in an altercation that led to physical restraint by staff and transfer to jail, without documentation of a provider order for the restraint, provider notification, or post-restraint assessment. While the resident was in jail, the facility prepared a discharge summary and provider order citing non-compliance with policy and safety concerns, but failed to specify which needs could not be met, what efforts were made to meet those needs, the resident’s post-discharge residence, or follow-up appointments, and did not include clear medication discharge orders. When the resident returned from jail, the administrator and DON did not perform or document a reassessment of the resident’s needs or the facility’s ability to meet those needs, instead providing discharge paperwork, medication instructions, transportation, and limited funds, contrary to the facility’s own discharge policy requiring a comprehensive summary of status and needs at discharge.
A resident with schizophrenia, intact cognition, and independence in ADLs was involuntarily discharged for alleged non-compliance with facility policy and the facility’s inability to meet needs, but the discharge summary did not specify the policy involved, the unmet needs, the resident’s self-care limitations, the discharge destination, or any post-discharge appointments. The medical record lacked a recapitulation of stay and medication reconciliation, despite facility policy requiring detailed clinical and functional discharge information. Staff interviews indicated that administrative staff issued a discharge notice when the resident returned from jail, that typical practice is to arrange a safe discharge with community supports, and that the social services designee had not completed the discharge summary. The DON confirmed the discharge was involuntary, and the administrator acknowledged the resident did not receive all information required under federal regulations.
The facility failed to administer long-acting insulin at consistent times as directed by the manufacturer for two residents with type 2 DM receiving Lantus. One resident’s order for twice-daily long-acting insulin was transcribed on the MAR with broad time windows, and actual administration times for the evening dose varied widely from night to night. Another resident’s once-daily Lantus order was also entered with a wide morning window, and documented administration times fluctuated significantly from early morning to midday. Staff, including an LPN, an RN, the nurse manager, and the DON, reported that long-acting insulin is often scheduled using time windows when specific times are not written by the provider, despite acknowledging it should be given at the same time each day. A pharmacist stated that long-acting insulin should be given within a very small time window and that variable timing could lead to hyperglycemia, hypoglycemia, or ketoacidosis.
A resident with dementia, a history of stroke, repeated falls, and documented moderate cognitive impairment was allowed to leave independently on multiple occasions without a comprehensive assessment of community safety needs or individualized interventions. Hospital orders indicated the resident required ongoing supervision, and therapy staff later stated the resident would need supervision in the community, yet no formal community safety assessment was completed. Elopement risk tools repeatedly labeled the resident as low risk, the resident was not listed as needing an escort, and facility policies lacked clear criteria for independent community access. The resident twice signed out and left, once during the night and once in the evening, leading to missing person reports by police before the resident returned, while the family expressed concern about the resident’s impaired decision-making and lack of phone service.
A resident with a history of stroke, HTN, repeated falls, and cognitive communication deficit had an order for clonidine TID with specific BP and HR hold parameters. On an evening when the resident left the facility and did not return until the next day, the MAR and medication audit showed a scheduled clonidine dose documented as administered, including a BP and pulse reading, even though the resident was not present. An LPN reported giving all evening medications at once because the resident preferred this and later entered the clonidine administration to appear as if it was given at the ordered time, and could not explain conflicting vital sign entries. The DON verified that documentation showed the resident was out of the building when the dose and vitals were charted, contrary to facility policies requiring immediate, objective, complete, and accurate documentation.
Two residents with chronic pain conditions, including one with severely impaired cognition and another with a stage 3 pressure ulcer and COPD, received multiple PRN doses of acetaminophen and oxycodone without documented evidence that non-pharmacological pain interventions were offered or attempted beforehand, despite care plans and facility policy specifying such measures (e.g., ice, heat, massage, repositioning, music, relaxation). Both residents reported ongoing pain and some relief with repositioning, while interviews with LPNs, the NP, and the DON confirmed that non-pharmacological options were expected to be offered and documented prior to PRN pain medication administration, which was not reflected in the January MARs and progress notes.
The facility failed to document required weekly baths and head-to-toe skin assessments for two residents who were at high risk for skin breakdown and required extensive assistance with hygiene and ADLs. One resident with multiple medical conditions, severe cognitive impairment, high skin breakdown risk, and existing abrasions had only one weekly skin assessment documented during a three-week stay, despite dressing orders and scheduled weekly baths. Another resident with morbid obesity, a surgical wound, Foley catheter, bowel incontinence, anxiety, PTSD, and Fournier disease had only two documented weekly skin assessments over more than two months, even though multiple baths were scheduled. Staff interviews confirmed that policy required a weekly bath/shower with a documented skin assessment, but the TAR functioned only as a reminder and did not show whether the bath or assessment was completed, resulting in missing documentation for these residents.
Inaccurate POLST and code status documentation: A resident with intact cognition and documented advance directives for DNR/DNI comfort-focused care had conflicting code status entries across the EMR, care plan, orders, and hospice records. Staff interviews showed the EMR banner was unclear and that some nurses and the DON would have initiated CPR based on the charted information, while hospice documentation repeatedly reflected DNR/DNI wishes. The facility failed to keep the resident’s POLST and medical record aligned with the resident’s stated code status.
Resident mail was not delivered on weekends for two residents who reported concerns about delayed mail. One resident said she was lucky to get mail monthly and that time-sensitive items were delayed, while another said he received mail on weekdays but not weekends. Staff confirmed mail sorting and delivery were handled Monday through Friday, and the administrator stated there was no weekend mail delivery process despite the facility policy requiring delivery within 24 hours, including Saturdays.
A resident did not receive appropriate care for pressure ulcers, and necessary measures to prevent new ulcers were not consistently implemented, resulting in a deficiency related to pressure ulcer management.
Surveyors found that staff failed to properly date and discard opened milk, inadequately monitored refrigerator temperatures and food quality, and did not consistently use required hair or beard coverings during food preparation and service. Additional issues included improper storage of dry and frozen foods, undated and improperly sealed food items, and stacking wet pans, all of which contributed to unsanitary conditions.
Surveyors observed orangish blackish substances on top of the dish machine, identified as rust sediment falling from the hood above. Dietary and maintenance staff were aware of the issue, but cleaning routines and maintenance had not resolved the accumulation. The facility's warewashing policy lacked specific guidance on cleaning frequency for the dish machine.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A resident with severe cognitive impairment and dependent on staff for eating was referred to as a "feeder" by a nursing assistant during meal service, resulting in the dietary aide withholding the resident's meal. Staff interviews confirmed that using the term "feeder" is inappropriate and could be hurtful to residents.
A resident with dysphagia and cognitive impairment was not served the ordered pureed diet, instead receiving a full piece of pork loin that she could not chew. Staff later replaced the meal with minced meat, and interviews revealed inconsistencies in providing the correct diet texture due to lack of pureed food availability and lapses in following established procedures.
Multiple residents complained that their meals were frequently served cold and unappetizing, with staff failing to consistently check and record food temperatures as required by facility policy. Observations and interviews confirmed that food was not always temped before serving, and temperature logs were incomplete, leading to dissatisfaction among residents and concerns about meal quality.
Two residents with severe cognitive impairment and complex medical histories were administered psychotropic medications without documented informed consent or explanation of risks and benefits. Family members and staff confirmed that required consent forms were missing from the medical records, and the facility's policy did not address the informed consent process for these medications.
A resident who did not have a personal phone was only offered the use of a corded phone at the nursing station, a public area with staff present, despite requesting a more private setting for personal calls. Staff confirmed there was no cordless phone or private area available, and the facility's policy requiring private phone access for residents was not followed.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
A resident with diabetes and other chronic conditions repeatedly voiced concerns about not receiving appropriate diabetic diet options, resulting in significant weight gain. Despite staff awareness of these complaints, there was no documentation or follow-up in the resident's medical record or the facility's grievance log, and the grievance officer confirmed no formal grievances were filed.
A resident prescribed Olanzapine and other psychotropic medications, with a high fall risk and an order for monthly orthostatic blood pressure monitoring, did not have these checks completed or documented for two months. Staff interviews confirmed the monitoring was not performed, despite facility policy requiring side effect monitoring for antipsychotic use.
A resident with multiple medical conditions was admitted from a hospital, but the facility failed to complete the required MDS assessment section on preferences for daily routine and activities. The resident's family was not consulted, and documentation of an assessment was missing, with the responsible RN confirming the section was left incomplete.
Two residents with significant medical conditions did not have their quarterly MDS assessments fully completed, specifically in the areas of cognition and mood. Required evaluations, such as the BIMS and PHQ-9, were either not conducted or not documented, leaving key sections of the MDS blank or marked as 'Not Assessed.' A nurse confirmed these omissions and noted that staff had been made aware of the issue.
A resident's MDS was incorrectly coded to indicate discharge to a hospital, while documentation and staff interviews confirmed the resident was actually discharged home with medications and instructions. Staff acknowledged the error, and facility policy requires assessments to accurately reflect resident status.
A resident who was cognitively intact had only one care conference since admission, despite facility policy and staff expectations for quarterly interdisciplinary care plan reviews. Staff interviews confirmed that the care team did not meet quarterly to review and update the care plan, even though the resident had concerns about her care.
Infection Control Failures With Shared Glucometer Use, C. difficile Precautions, and Personal Care Practices
Penalty
Summary
The facility failed to clean and disinfect shared blood glucose monitoring equipment between resident uses. During observation, an LPN checked blood glucose for a resident with DM II and HIV, placed the contaminated glucometer into a red tote without disinfecting it, and then brought the same tote into another resident’s room to perform another blood glucose check without cleaning or disinfecting the meter first. The LPN initially stated she would use an alcohol wipe from the tote, then acknowledged that this had not been done between residents and that alcohol wipes were not effective against blood borne pathogens. The meter was later cleaned with a disinfecting wipe that was effective against hepatitis B, hepatitis C, and HIV. The facility’s infection preventionist, DON, and MD all stated shared glucometers were expected to be disinfected between uses, and the meter’s user manual required cleaning and disinfection between each patient. The facility also failed to implement transmission-based precautions for a resident with ongoing diarrhea and abdominal pain who was later confirmed to have C. difficile. The resident had stool testing ordered, but the record lacked documented results for a specimen reportedly collected earlier and lacked evidence that a second specimen had been collected as ordered. While testing was pending, there was no enteric precautions sign on the door and no PPE outside the room. The resident reported multiple episodes of diarrhea and feeling unwell, and staff later confirmed the resident tested positive for C. difficile and had been placed on contact precautions after the positive result. The TBP sign on the door indicated contact precautions rather than enteric precautions. The facility further failed to maintain hand hygiene and glove hygiene during personal care and failed to use appropriate barrier precautions during care for residents on enhanced barrier precautions. During a bed bath, nursing assistants changed gloves without performing hand hygiene, moved from dirty to clean tasks without changing gloves, and handled clean washcloths and towels with contaminated gloves. During transfers, staff did not wear gowns for residents who were on EBP. For another resident with a catheter and EBP, nursing assistants transferred the resident without gowns and handled the catheter bag during the transfer. The report also states the facility failed to properly disinfect a blood glucose monitor after use with one resident before placing it on a shelf at the nursing station for shared use.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Activity Program Lacked Qualified Direction and Oversight
Penalty
Summary
The facility failed to provide direction and oversight of the activity program by ensuring a qualified professional directed the development, implementation, and coordination of resident activities. The Activities Director position became vacant, and the facility did not maintain leadership of the department. Staff assigned activity responsibilities were not trained or competent to perform the duties of the position, and basic components of the program were not maintained, including the development and distribution of a monthly activities calendar for May 2026. Record review showed residents on the third floor had limited opportunities to participate in organized activities and minimal documented activity attendance. Observation during the survey found no activities calendar posted in common areas or in the elevator, and no organized activities occurring on the third floor. R3, who was cognitively intact with a BIMS score of 15, stated she and another resident had tried to organize activities themselves because no formal activities were occurring, that she never saw the Activities Assistant on the third floor, did not receive an activities calendar, and was not informed about activities elsewhere in the facility. Staff interviews confirmed activities were mainly occurring on the second floor, that the facility had not had an Activities Director since April 2026, that the Activities Assistant had no formal activities training and had not received training on the responsibilities of the position, and that the monthly calendar had not been printed or distributed.
Improper Hair and Beard Restraints During Food Service
Penalty
Summary
The facility failed to serve food in a sanitary manner by not ensuring dietary staff properly contained hair while serving food and preparing room trays on the 2nd floor. During a continual observation, a dietary aide was seen serving lunch from a warming table, using resident menu tickets, preparing resident plates, and placing plates for delivery to the dining room and room trays for resident rooms. The dietary aide was wearing gloves but was not wearing a hairnet, had longer hair that was not pulled back or contained, and had a partial beard and goatee that was approximately 1/2 inch to 1 1/2 inch long without a beard net. During interview, the dietary aide stated they had finished serving all the food for the floor and had prepared all room trays and served all residents in the dining room. The dietary aide verified they did not have a hairnet on and stated they had taken it off during break and forgot to put it back on. The dietary aide also stated they did not have to wear a beard net. The culinary district manager stated dietary staff were expected to wear hair nets and beard nets when needed anytime they were in the kitchen or serving and plating food on the floors. The DON and administrator both stated staff serving food would be expected to wear appropriate hair and beard nets. The facility policy stated all individuals entering food preparation, food storage, warewashing, or plating areas must wear an approved hair restraint that completely covers head hair and, where applicable, facial hair, and that facial hair exceeding 1/4 inch must wear an approved beard restraint.
Failure to Complete Mandatory QAPI Training
Penalty
Summary
Mandatory QAPI training was not completed for 1 of 10 staff members reviewed, nursing assistant (NA)-J. Review of personnel records showed NA-J had not completed education that included QAPI in the last year. During an interview, the DON was informed that QAPI training records for NA-J were not found in the records provided, and the DON stated that QAPI training was expected to be completed annually. No additional records were received showing that NA-J had completed QAPI training within the last year. The facility's undated Staff Development Program policy stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes, and identified QAPI training as a mandatory in-service training class, but it did not specify how often the training should be completed.
Missing Mandatory Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that staff completed mandatory compliance and ethics training for 1 of 10 staff members reviewed, nursing assistant (NA)-J. Review of personnel records showed that NA-J had not completed education that included compliance and ethics in the last year. During an interview, the DON was informed that compliance and ethics training records for NA-J were not found in the records provided, and the DON stated that she expected the training to be completed annually. The DON stated she would provide any additional records if found, but no additional records showing NA-J had completed compliance and ethics training in the last year were received. The facility's undated Staff Development Program policy stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes, and that ethics training was a mandatory in-service training class, although it did not specify how often it must be completed.
Failure to Supervise Wandering, Lift Transfers, Bed Height, and Smoking Safety
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with wandering and elopement risk. The resident had dementia, was ambulatory, had a history of wandering or attempting to leave the building, and was assessed as at risk for elopement. His care plan called for close supervision in common areas, anticipation of toileting needs, distraction from wandering, and identification of wandering patterns, and his orders included 15-minute safety checks and placement on a locked memory care unit. During observation, the resident followed staff out of the locked memory care doors when a staff member exited without looking back, and later wandered in the unlocked second-floor common area and dining room while staff were nearby but did not intervene effectively. He was observed pulling at his pants, urinating in the common area and on a wall, and later having a bowel movement behind a steam table while staff were unaware. Staff later stated the resident was supposed to receive 15-minute checks, but those checks were not completed because staff got busy. The facility also failed to verify sling size before mechanical lift transfers for two residents and failed to ensure compatible lift and sling equipment for another resident. One resident required a Hoyer lift for transfers, but the care plan and care guide did not document the sling size until after the survey began. Staff transferred the resident using the sling already in the room without checking the size, and the sling tag was worn and difficult to read. A second resident with multiple sclerosis, spastic hemiplegia, and lower-extremity impairment was also transferred with a Hoyer lift and medium sling, but staff again did not verify the sling size before transfer. Staff stated they relied on the sling kept in the resident’s room, even when the tag was worn or unreadable. For another resident, the facility failed to ensure the lift and sling were compatible. Staff attempted to use an Invacare lift with a Joerns sling, and the sling label was worn so the brand and size could not be clearly identified. Staff initially believed the sling was probably large or extra-large and were unsure whether the equipment matched. Later, staff recognized that the Joerns sling required a Joerns lift and switched equipment. The report also identified a bed-height safety issue for a resident whose care plan directed the bed to remain in the lowest position. The resident kept his bed at about 4.25 feet high, and staff observed the bed in that position on multiple occasions but did not lower it or document a change in the care plan. In addition, the facility failed to consistently manage smoking safety for a resident who used supplemental oxygen and was ordered to have cigarettes and a lighter secured and issued one at a time. The resident stated she smoked outside with her oxygen tank and nasal cannula, turning the oxygen off while smoking, and the report indicates the facility did not consistently supervise and monitor compliance with the smoking safety requirements.
Dirty resident room and unclean memory care dining room
Penalty
Summary
The facility failed to maintain a resident room in a clean, sanitary, and orderly condition for one resident, R5. During observations, R5 was lying in bed while the room showed multiple areas of disrepair: a section of wall below the mounted TV was not painted the same color as the rest of the wall, the wall across from the bed had multiple black marks and light brown discoloration, the ceiling above the window had a yellowish discolored area about the size of a basketball extending along the ceiling/wall, and the door frame had multiple scuff marks and missing paint. These same conditions were still present on follow-up observation, and R5's family member stated they had concerns about the environment, describing the facility as not clean, smelling bad, and reporting concerns about the room's smell, missing paint, and ceiling to staff. The facility also failed to keep the memory care dining room floor in a clean and sanitary condition. During observation, the floor under multiple dining tables had light-colored crumbs, brown crumbs, pieces of a white meat-like substance, and spaghetti noodles. An LPN stated it looked like the floors had not been cleaned after the prior night's meal and said housekeeping was supposed to clean the floors after meals were served. The administrator confirmed the food under the tables and stated any staff member who observed it should help clean it up, not just housekeeping. The maintenance policy stated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Visible Catheter Drainage Bag Not Kept Private
Penalty
Summary
The facility failed to ensure dignity was maintained for one resident who had moderately impaired cognition, was dependent on staff for dressing, bed mobility, and toileting, was always incontinent of bowel and bladder, and had intermittent catheterization for neurogenic bladder. The resident’s care plan identified a catheter and included an intervention to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. During an observation, the resident’s urinary catheter drainage bag was visible while he was seated in his wheelchair in the commons area, with clear yellow urine showing and the bag hung under the wheelchair. After the resident was brought to his room, staff emptied the catheter drainage bag and hung it on the side of the bed facing out to the room entrance. On a later observation, the catheter drainage bag was uncovered in the commons area, with the clear side facing toward the hallway and elevator space so that clear yellow urine was visible from the hallway. Therapy staff, the infection preventionist, and the resident’s RN were present in the area and did not arrange privacy for the catheter drainage bag. Staff later stated the bag should be covered for privacy, and the DON stated staff were expected to keep the blue side facing the public to cover the bag and maintain dignity. The facility’s dignity policy stated catheter drainage bags and colostomy pouches should be covered with commercial covers or tucked out of plain sight.
Call Light Not Within Reach for Resident at Risk for Falls and Seizures
Penalty
Summary
The facility failed to ensure a call light was within reach for a resident with a history of epileptic seizures, aphasia, non-Alzheimer's dementia, and a recent fall with injury. The resident's MDS identified moderately impaired cognition, and the care plan directed staff to make sure the call light was in reach when the resident was in the room. The resident also had a history of needing partial/moderate assistance with standing and transfers, and the CAA identified fall risk related to body weakness and decreased muscle strength. During observation, the resident was in bed with the call light wrapped around the wall-mounted switch box above the head of the bed and off to the left, out of reach. On follow-up observation, the call light remained in the same position. The resident stated he would like his call light, and an NA confirmed he would not have been able to reach it and that it should have been within reach. The record also included a prior fall from bed after the resident attempted to transfer to his wheelchair without using the call light, and a later seizure episode in which the resident used the call light to alert staff. Staff interviews stated that all residents should have call lights within reach, and the facility policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Failure to Assess and Document Antipsychotic Side Effects
Penalty
Summary
The facility failed to assess for potential side effects of an antipsychotic medication for one resident who was reviewed for unnecessary medications. The resident’s quarterly MDS identified moderately impaired cognition, rejection of care one to three days, and dependence on staff for dressing, bed mobility, and toileting. The care plan stated the antipsychotic medication was being used for Parkinson’s disease and directed nursing staff to monitor for adverse effects and document findings. The physician order included quetiapine fumarate 25 mg by mouth daily for Parkinson’s disease and behavioral disturbance with agitation, along with 50 mg by mouth daily for the same indications. The resident also had a nursing order to complete an AIMS assessment every three months, but the record showed inconsistent completion and documentation. The TAR indicated the AIMS assessment was signed off as completed on three consecutive days in April, yet no assessment results were documented in the resident’s record. In May, the AIMS sign-off was blank and no assessment results were documented. In early June, no AIMS assessment had been signed off or documented. During observation, the resident was seated in a wheelchair with a flat affect and a mild tremor in the fingers. Staff interviews confirmed that AIMS assessments were intended to monitor side effects and were to be documented in the medical record.
Failure to Maintain Discharge Planning for Resident’s Requested Move Closer to Family
Penalty
Summary
The facility failed to maintain an adequate discharge planning process for a resident whose legal guardian repeatedly expressed a desire for the resident to move closer to family. The resident’s quarterly MDS, dated 5/13/26, identified short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and Section Q indicated there was no active discharge planning occurring for return to the community. The resident’s care plan, printed 6/2/26, documented a discharge goal to move to a facility closer to family, with social services to coordinate discharge services, but the care plan did not include information about referrals sent, updates, or outcomes of referrals. The resident’s progress notes from 12/1/25 through 6/2/26 did not document referrals, follow-up, or communication with the guardian about the request to move closer to family. A social service care conference on 12/31/25 documented that family wanted the resident moved to a facility closer to them in Shoreview, MN, and noted the resident had been denied at many SNFs. A later care conference on 5/29/26 documented no discharge planning needed because the resident was LTC hospice. During interviews, RN staff and the RN manager stated social services led discharge planning, while social services stated the resident’s guardian still wanted the resident moved closer to family and that discharge had not been discussed during the most recent care conference.
Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written transfer notice and a written bed-hold notice for 2 residents who were transferred to the hospital. For one resident, the quarterly MDS indicated moderate cognitive impairment, and the census showed the resident was on hospital unpaid leave after transfer to the hospital; the progress note documented that the resident was transferred and the POA was contacted. For the second resident, the admission MDS indicated intact cognition, and the census and progress note showed the resident was sent to the emergency department and the significant other was notified. For both residents, the medical records did not show that a written transfer notice was given at the time of transfer, including information such as ombudsman information and appeal rights. The records also did not show that a written bed-hold notice was provided to the resident or resident representative with information such as the duration of the state bed-hold policy, the reserve bed payment policy, or the facility's bed-hold policy. During interviews, nursing staff stated they were unsure whether the written transfer and bed-hold notices were given, and the nurse manager stated the facility did not believe it had a process to give residents a written transfer notice and that emails to resident representatives about bed hold did not include the required policy information.
Missed Care Conference Participation
Penalty
Summary
The facility failed to provide R10 the opportunity to attend and participate in a care conference. R10’s quarterly MDS assessment dated 5/25/26 identified intact cognition and no hallucinations, delusions, rejection of care, or behaviors. During an interview on 6/1/26, R10 stated she had not had a care conference recently and said the last one was more than 3 months ago. Review of the record showed R10’s last documented Social Service Conference was on 1/16/26, and progress notes from 1/30/26 through 6/3/26 did not show any care conference held or scheduled. Staff interviews confirmed care conferences were expected to occur quarterly, after significant changes, and following MDS assessments, but R10’s quarterly and significant change MDS assessments were not followed by a documented conference. R10’s family member stated they typically attended care conferences, and the social services staff later verified that R10’s care conference had been missed and was only scheduled after the surveyor’s inquiry.
Failure to Use Communication Supports for a Hearing-Impaired, Non-English-Speaking Resident
Penalty
Summary
The facility failed to implement interventions for a resident who required alternate means of communication due to hearing loss and being non-English speaking. The resident’s MDS indicated highly impaired hearing with no hearing aid or other hearing appliance, and the care plan and banner directed staff to use an interpreting service and a communication binder, but neither identified the resident’s language. The care plan also directed staff to anticipate and meet toileting needs, and the resident had orders for 15-minute safety checks, admission to the locked memory care unit, and close monitoring for safety. During interviews, nursing staff stated they were unsure what language the resident spoke or what the expected process was for communicating with him. The nurse manager stated the resident spoke Hmong and staff were supposed to use the translator during care, but staff were not observed doing so consistently. The nurse manager also stated that if the resident did not understand the interpreter, staff should attempt to use the communication binder to assess his needs. During continuous observation, the resident was seen wandering in the non-locked common area, pulling at his pants, talking to himself in a non-English language, urinating in the common area and later on a wall, and squatting behind equipment where stool was found afterward. Staff were observed at times nearby, but they were not observed using an interpreting service or the communication binder to attempt communication or assess the resident’s needs. The facility’s communication and language access policy indicated the resident’s primary language should be placed prominently in the electronic health record.
Failure to Provide and Document Routine Shaving for a Dependent Resident
Penalty
Summary
The facility failed to ensure routine personal hygiene, specifically shaving, was completed for a resident who was dependent on staff for ADLs. The resident’s quarterly MDS dated 5/11/26 indicated intact cognition, no hallucinations, delusions, behaviors, or rejection of care, and dependence on staff for personal hygiene, toileting, showering, dressing, and mobility. The care plan identified a preference for no facial hair and directed staff to provide grooming on shower days and as needed, with the resident totally dependent on staff for personal hygiene and oral care. Review of progress notes from 5/1/26 through 6/3/26 showed no documentation of refusals or completion of shaving. Weekly skin/bath assessments on 5/22/26 and 5/29/26 documented bed baths, and the weekly bath audit on 5/27/26 documented a shower, but none of these records showed that facial shaving was offered or completed. During observation and interview, the resident was seen with approximately 1/4 inch facial hair and stated staff did not ask if she wanted to be shaved and that she found it embarrassing to have to ask. On a later observation, the resident still had facial hair and stated no staff had asked if she wanted it removed. RN-A and RN-D stated shaving should be offered when staff notice facial hair and that shaving is part of daily grooming, while the DON stated shaving should be offered with showers and as needed and documented if refused.
Lack of Posted Activity Schedule and Resident Notification
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet residents’ interests and well-being and failed to ensure residents were informed of available activities for two residents who identified group activities and favorite activities as important. R3 was cognitively intact with a BIMS score of 15 and, on the activity preference assessment, identified doing things with groups of people and participating in favorite activities as somewhat important. R37 was cognitively intact and dependent on a mechanical device and assist of 2 for transfers; he indicated it was very important to attend activities. R3’s care plan directed staff to provide an activities calendar and notify her of changes, but record review showed no documented activity participation for R3 between 5/1/26 and 5/16/26, and no sign-in sheets were available for 5/17/26 through 5/31/26. Observation showed no activities calendar posted in any public area on the third floor or in the elevator. R3 stated she and another resident had tried to organize activities themselves because no formal activities were occurring, that she never saw the activities aide on the third floor, and that activities, if held, occurred on the second floor without notifying third-floor residents. She stated, “We are all bored up here on third floor.” R37’s care plan directed staff to encourage participation in activities that promote exercise and improved mobility. He stated there were no activities available, that he would have liked to participate if offered, and that he had informed staff of a desire to attend an auction activity but no staff assisted him to attend. He also stated staff did not invite him to activities and there was no communication about what activities were available or when they occurred. Staff interviews confirmed the facility had no Activities Director, activities were mainly occurring on the second floor, there was no activities calendar posted on the third floor, and activities had not been routinely occurring, especially on the third floor.
Failure to Arrange Ordered Retinal Specialist Follow-Up
Penalty
Summary
The facility failed to ensure physician-ordered vision services were arranged and provided for one resident who was reviewed for vision services. The resident’s annual MDS dated 4/1/26 showed she was cognitively intact with a BIMS score of 15 and had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD. Her physician orders included a routine referral to a retinal specialist dated 1/19/26, but the EMR had no evidence that the appointment was scheduled or completed and no documentation of follow-up regarding the referral or any consultation report from a retinal specialist. During interviews, the resident stated she needed to see the eye doctor because her eyes were fuzzy and burned, and she reported being told she had edema behind her eyes and needed specialist follow-up. She stated the facility was supposed to make the referral but she had never heard anything further and that her last eye appointment had been over a year ago. Staff interviews showed the LPN stated the HUC was responsible for scheduling outside follow-up appointments, while the HUC assistant said physician orders needing follow-up were highlighted and given to the HUC for scheduling. The HUC assistant, the nurse manager, and the DON were unable to find documentation that the retinal specialist appointment had been scheduled or that the resident had been seen.
Catheter Drainage Bag Positioned Above Bladder Level
Penalty
Summary
The facility failed to ensure a catheter drainage bag remained below the level of the bladder for a resident with a catheter for neurogenic bladder. The resident’s quarterly MDS identified moderately impaired cognition, rejection of care one to 3 days, dependence on staff for dressing, bed mobility, and toileting, and that the resident was always incontinent of bowel and bladder with intermittent catheterization. The care plan directed staff to position the catheter bag and tubing below the level of the bladder, and the facility’s urinary catheter care policy stated the drainage bag should be held or positioned lower than the bladder to prevent backflow. During observation, the resident’s catheter drainage bag was repeatedly found hooked on the wheelchair arm rest above the level of the bladder while the resident was in the commons area and later in the dining room. The catheter tubing contained urine that had not drained down, and the resident stated he was moving the tubing to try to get urine to drain into the bag. Staff interviews confirmed the bag should have been below the bladder for drainage, and one RN stated the resident was on antibiotics for a bladder infection. Multiple staff observed the incorrect placement, and nursing staff did not intervene while the resident was at an activity for about 1 and 1/2 hours.
Physician Did Not Complete Required Initial Visit
Penalty
Summary
The facility failed to ensure that a resident's physician completed the initial comprehensive 30-day face-to-face visit for one of three newly admitted residents reviewed. R50's admission MDS indicated diagnoses of cancer, kidney disease, malnutrition, and a seizure disorder, and the census report showed R50 remained an active resident with Medicare A as the primary payer and had been admitted to the facility. Review of the medical record did not find a progress note showing that a physician visit had been completed during the resident's stay. During interview, the DON stated the physician should see the resident within the first 30 days and said she would look for documentation that the physician had seen R50, but records showing a physician visit were not received. The facility's Physician Visits policy stated the attending physician must visit residents in a timely fashion and once every thirty days for the first 90 days.
Failure to Document and Complete Ordered AIMS Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed a monthly drug regimen review that included the medical chart and followed irregularity reporting procedures in its policies and procedures. For 1 of 5 residents reviewed for unnecessary medications, R6, the consultant pharmacist identified concerns related to quetiapine use and recommended adding AIMS monitoring at baseline and at least every 6 months unless already ordered, and reporting significant changes to the prescriber as soon as possible. A later pharmacist review noted that an AIMS order had been placed, but documentation showing the assessment was completed was not found in the record. R6’s record showed a quarterly MDS identifying moderately impaired cognition, rejection of care one to 3 days, and dependence on staff for dressing, bed mobility, and toileting. R6 was receiving quetiapine fumarate 25 mg by mouth daily for Parkinson’s disease and behavioral disturbance with agitation, along with 50 mg by mouth daily for the same conditions. Although a nursing order was entered to complete AIMS assessments, the TAR showed the order was signed off as completed on some dates without any assessment results documented, was blank on another date, and had no sign-off or documentation on later dates. During observation, R6 was seated in a wheelchair with a flat affect and mild finger tremor. Staff interviews stated AIMS was important for monitoring side effects and that completed assessments should be documented in the medical record.
Hoyer Lift Batteries Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to keep patient care equipment in safe operating condition for one resident who used a Hoyer lift for transfers. The resident had intact cognition, chronic respiratory failure with hypoxia, morbid obesity, muscle weakness, bilateral lower extremity impairment, and was dependent on staff for transfers. His care guide and care plan directed that he be transferred with a mechanical lift and multiple staff members. During interview, the resident stated that almost every time he was transferred with the Hoyer lift, the battery would run out in the middle of the transfer, sometimes leaving him hanging in the sling while staff went to get another battery, and that the facility had been recharging the same batteries instead of replacing them. He also stated that the prior night two different batteries were needed to get him into bed. Surveyors observed three nursing assistants transferring the resident from bed to his power mobility device using the Joerns Hoyer lift, and the lift stopped working while the resident was being lowered due to a low battery. Staff then used the manual release button to lower him into the device. Multiple staff members stated that batteries for the lifts were not always charged, that overnight staff were responsible for charging them, and that staff sometimes checked whether the lift would work before entering the room because they expected the battery might be dead. The DON stated staff should check that the battery was charged before transfers and use the emergency release if the lift stopped working. The maintenance supervisor stated batteries were replaced only occasionally and only one lift battery had ever been replaced; no invoices for battery purchases were produced. The manufacturer instructions required batteries to be kept fully charged, charged whenever not in use, and never run completely flat, and the facility policy required staff to verify lift batteries were charged at the start of each shift.
Missing Fitted Sheets on Bariatric Beds
Penalty
Summary
The facility failed to ensure that two residents with bariatric beds had fitted sheets on their beds. R15’s quarterly MDS indicated intact cognition, chronic respiratory failure with hypoxia, morbid obesity, chronic pain, bilateral impairment of the lower extremities, and dependence on staff for toileting and transfers. During observation, R15 was lying in a bariatric bed on top of a blanket with large areas of the bare mattress exposed, and R15 stated the facility never put a fitted sheet on the bed because they did not have any sheets that fit. Staff later confirmed there was no fitted sheet on the bed and stated the facility did not have enough bariatric sheets, with one NA reporting the issue had been ongoing for months and another stating it had been a problem since January. R53’s quarterly MDS indicated intact cognition, anxiety, morbid obesity, sleep deprivation, substantial assistance with toileting, and partial assistance with transfers. During multiple observations, R53 was lying in bed on top of a blanket with parts of the bare mattress exposed, and there was no fitted sheet on the bed. R53 stated the facility did not have sheets that fit her bed and that she preferred a fitted sheet that fit properly and did not fall off. A NA verified there was no sheet on the bed and said there should have been one. The DON stated she would expect all residents to have sheets on their beds. The facility policy for making an unoccupied bed listed sheets as required supplies.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that required nurse staffing information was posted each day with an accurate total number and actual hours worked per shift for licensed and registered staff on each shift. Review of the daily staff postings and staff schedules for the past month showed the postings did not accurately reflect actual staffing levels during each day. The DON and administrator stated the postings were completed by the receptionist and did not reflect changes such as call-ins, no-shows, or staff picking up shifts. The receptionist stated she filled out the posting form from the schedule sent by the staffing coordinator and that no one updated the posting for staffing changes. The staffing coordinator stated she was responsible for the schedule and forwarding daily information to the receptionist and DON, but not the staff posting, and she was not aware of anyone updating the postings to reflect call-ins, no-shows, or picked up shifts. Review of May and June 2026 schedules and postings confirmed they did not match, and the facility policy on daily staff postings was not provided.
Failure to Obtain Order and Document Emergency Physical Restraint Use
Penalty
Summary
The deficiency involves the facility’s failure to obtain a provider order and perform required assessment and documentation following the use of a physical restraint on a resident. The resident’s quarterly MDS showed intact cognition, no behaviors, and independence in ADLs and ambulation, with diagnoses including schizophrenia and multiple mental health and substance use disorders. The care plan included substance abuse monitoring, psychosocial support, potential for physical aggression with poor impulse control, room changes, separation from certain residents, and 1:1 supervision after a prior altercation, as well as independent community access. The care plan did not include any indication of restraint use for behavioral intervention. On the date of the incident, progress notes documented that the resident had an altercation with another resident, overpowered staff, and struck the other resident in the face, after which staff on the second floor physically restrained the resident and police were called, resulting in the resident being taken to jail. The notes did not show that the provider was notified of the restraint, that an order for the restraint was obtained, or that an assessment was completed after the restraint. Interviews with a NA and two LPNs confirmed that one LPN held the resident in a “bear hug” or “hug hold” to prevent further aggression, that no order was obtained for this restraint, and that the provider was not informed about the hold itself. The SSD stated there was no evidence in the record of restraint documentation, an order, or provider notification, despite policy requiring such actions. The DON acknowledged that a bear hug is considered a restraint requiring an order, provider notification, and debriefing, and was unsure if these steps or staff training had occurred, in contrast to the facility’s written Use of Restraints policy that specifies emergency restraint procedures and documentation requirements.
Failure to Appropriately Assess and Plan an Unplanned Discharge After Return From Jail
Penalty
Summary
The deficiency involves the facility’s failure to conduct an appropriate reassessment and discharge process for a resident with significant mental health and substance use diagnoses following the resident’s return from jail. The resident’s MDS and care plan documented intact cognition, independence in ADLs, and diagnoses including schizophrenia, schizotypal disorder, alcohol dependence, anxiety, depression, and bipolar disorder, with care plan interventions for substance abuse monitoring, potential physical aggression, room changes, separation from certain residents, and 1:1 supervision after a prior altercation. On one occasion, the resident had an altercation with another resident, overpowered staff, struck the other resident, and was restrained by staff before being taken to jail by police. The medical record for this event lacked documentation of a provider order for the physical restraint, notification of the provider about the restraint, or an assessment of the resident after the restraint. Following the resident’s incarceration, the facility completed a discharge summary stating the resident was discharged due to non-compliance with facility policy and that the facility was unable to meet the resident’s needs, but the summary did not identify which policy was violated, which specific needs could not be met, or the resident’s limitations in self-care. The discharge summary also did not document where the resident would reside after discharge or any post-discharge medical or non-medical appointments. A subsequent provider order authorized discharge to the community due to safety concerns for other residents but did not specify which needs the facility could not meet, what efforts had been made to meet those needs, or any orders for discharge medications. When the resident returned from jail, staff provided a discharge notice, verbal and written instructions on medication administration, and arranged transportation and some personal items, but the progress notes did not document an assessment of the resident’s needs upon return or any reassessment of the facility’s ability to meet those needs. Interviews with the administrator and DON confirmed that no new assessments were performed when the resident returned from jail because the facility considered the resident already discharged while incarcerated. The administrator acknowledged uncertainty about what information should be included in unplanned discharge orders and confirmed that the orders did not include the needs the facility could not meet or the facility’s efforts to meet those needs. The DON stated that, in general, residents being discharged were supposed to have a place to go, be deemed safe to leave, have a care conference to discuss the discharge plan, and have a discharge order, but also acknowledged that no assessment was done upon the resident’s return from jail and that no updated information was obtained from the jail regarding the resident’s care needs. The facility’s written Discharge Summary and Plan policy required a comprehensive final summary of the resident’s status at discharge, including diagnoses, course of illness and treatment, functional status, ADL ability, impairments, nutritional status, special treatments, mental and psychosocial status, discharge potential, and other elements, which were not fully reflected in the documentation for this resident’s discharge.
Incomplete Documentation and Notifications for Involuntary Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and appropriate discharge documentation and required notifications for a resident who was discharged involuntarily. The resident had intact cognition, no behaviors, and was independent with ADLs, with a diagnosis of schizophrenia. The discharge summary documented that the resident was discharged due to non-compliance with facility policy and the facility’s inability to meet the resident’s needs, but it did not specify which policy was violated or which needs could not be met. The summary also omitted information on the resident’s limitations in self-care at the time of discharge, the destination of the discharge, and whether any post-discharge medical or non-medical appointments were arranged. Record review showed that the medical record lacked a recapitulation of the resident’s stay and a reconciliation of all pre-discharge and post-discharge medications, including prescribed and over-the-counter drugs, despite facility policy requiring a comprehensive discharge summary with detailed clinical and functional information. Staff interviews revealed that typical discharges involve arranging a safe place with community supports, but in this case, an LPN reported hearing that administrative staff met the resident at the door with a discharge notice upon return from jail and expressed concern that a motel would not provide adequate supports. The social services designee acknowledged not completing the discharge summary and was unsure if it met criteria, and the DON confirmed the discharge was involuntary. The administrator stated uncertainty about documentation requirements for an unplanned discharge and acknowledged the resident did not receive the information required by federal regulations.
Inconsistent Timing of Long-Acting Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to administer long-acting insulin at consistent times in accordance with manufacturer instructions for two residents prescribed Lantus (a long-acting insulin). One resident had type 2 diabetes with diabetic polyneuropathy and long-term insulin use, with a care plan directing diabetes medications to be administered as ordered. The physician ordered Basaglar 62 units twice daily, which was transcribed on the March 2026 medication administration record (MAR) as Lantus 62 units twice daily with administration windows of 7:00 a.m.–11:00 a.m. and 7:00 p.m. (HS). The manufacturer’s package insert for Lantus states it may be taken at any time of day but must be taken at the same time every day. MAR review showed the evening doses were given at varying times, including examples such as 9:41 a.m. and 10:32 p.m., 9:17 a.m. and 9:43 p.m., 8:29 a.m. and 10:42 p.m., and 9:04 a.m. and 8:27 p.m., rather than at a consistent time. Another resident with type 2 diabetes, on a therapeutic diet and receiving insulin injections seven days per week, had a physician order for Lantus 20 units daily. The March 2026 MAR listed Lantus 20 units in the morning with an administration window of 7:00 a.m.–11:00 a.m., but actual administration times varied, including 8:27 a.m., 10:00 a.m., 8:52 a.m., 12:09 p.m., and 7:58 a.m. Staff interviews confirmed that long-acting insulin should be given at the same time every day for effectiveness, and that nurses transcribed orders using time windows when specific times were not provided. The RN nurse manager acknowledged that Lantus might be one medication where a specific time is preferred, and the DON stated that long-acting insulin orders are not always written with specific times unless the provider specifies one. The consulting pharmacist stated that long-acting insulin should be given with a very small window and that giving doses at different times daily could result in hyperglycemia or hypoglycemia and potentially ketoacidosis. The facility’s insulin administration policy described long-acting insulin characteristics but did not prevent the inconsistent timing documented on the MARs.
Failure to Assess Community Safety and Supervise Cognitively Impaired Resident Leaving Independently
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively evaluate and implement individualized safety interventions for a cognitively impaired resident who was allowed to leave the facility independently on multiple occasions. The resident had diagnoses including stroke, hypertension, repeated falls, and a cognitive communication deficit. Hospital discharge orders specified that the resident needed ongoing supervision due to continued need for help with moving, thinking, safety, and eating. A SLUMS score of 15/30 indicated dementia, and multiple BIMS assessments showed moderate cognitive impairment. The admission MDS documented moderately impaired cognition, a need for maximum assistance with transfers, dependence on staff for wheelchair mobility, and that ambulation was not attempted due to medical or safety concerns. Despite these documented cognitive and functional limitations, the resident’s elopement risk assessments on admission and later dates consistently indicated a low risk for elopement. The care plan addressed impaired cognitive function and fall risk, with interventions such as cueing, reorientation, supervision as needed, and assistance with ADLs and mobility, but it did not include a comprehensive assessment of the resident’s ability to be safely unsupervised in the community. The record from admission through early February and again from early February through early March did not contain any detailed assessment of the resident’s level of supervision needed in the community, nor did it identify vulnerabilities or risks while the resident was in the community independently. Therapy staff were not asked to perform a community safety assessment, even though the OTA and speech therapist later stated that, based on the SLUMS score, the resident would need supervision in the community. The lack of assessment and individualized interventions contributed to two separate episodes in which the resident left the facility independently. In the first incident, around 3:30 a.m., the resident informed an LPN she was leaving; after attempts to convince her to stay, the resident signed out and left, and the family later contacted police and filed a missing person report before the resident was confirmed to be at a family member’s home. In the second incident, the resident told the receptionist she was leaving, signed out, and did not return by early morning the next day, prompting staff to search the facility, attempt to call her, and then contact police to file another missing person report before the resident returned. Interviews with the resident and family confirmed that the resident’s phone did not have active cellular service, that the facility had not provided safety instructions for being in the community, and that the family was upset and concerned about the resident’s decision-making. Staff interviews revealed inconsistent understandings of criteria for independent community access, reliance on BIMS and elopement lists, and acknowledgment by the nurse manager and DON that no formal process or assessment for community safety existed. Facility policies did not address protocols or criteria for residents to leave independently, and the elopement policy only addressed preventing unsupervised departure and responding to missing residents.
Inaccurate Documentation of Clonidine Administration for Absent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident with a history of stroke, hypertension, repeated falls, and cognitive communication deficit. The resident had a provider order for clonidine 0.3 mg by mouth three times a day for hypertensive urgency, with instructions to hold the dose if the heart rate was less than 60 beats per minute or if systolic blood pressure was less than 100 mmHg. Nursing notes documented that the resident told the receptionist she was leaving the facility in the evening and did not return overnight, prompting staff to search the facility, call her cell phone, and eventually contact the police and file a missing person report. The resident did not return until the following day around midday. Despite the resident being out of the building during this time, the February medication administration audit and medication administration record showed that a scheduled dose of clonidine was documented as administered late that evening, with a recorded blood pressure of 121/74 and pulse of 72, and an administration time that did not match the resident’s actual absence from the facility. During interview, the LPN who documented the dose stated he had given all of the resident’s evening medications at the same time because she preferred to take all pills together and would often refuse a second approach, and he admitted entering the clonidine administration later so it would appear as though it was given as ordered. He could not explain conflicting blood pressure readings, having stated he only approached the resident once for medications and vitals. The DON confirmed that, according to the documentation, the resident was out of the building at the time the clonidine dose and blood pressure check were recorded as given, and facility policies required that medication administration be documented immediately after, never before, and that all charting be objective, complete, and accurate.
Failure to Offer and Document Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess pain and to offer or attempt non-pharmacological pain interventions prior to administering PRN pain medications for two residents. One resident had severely impaired cognition, cellulitis of the right leg, type 2 diabetes, and chronic pain syndrome, with an admission MDS indicating frequent pain that interfered with day-to-day activities and use of both scheduled and PRN pain medications. This resident’s care plan included multiple non-pharmacological pain interventions such as ice, heated blankets, massage, repositioning, music, essential oils, food/drink, and relaxation breathing. Despite this, the MAR and corresponding progress notes for multiple PRN administrations of acetaminophen and oxycodone in January did not document any non-pharmacological interventions being attempted or offered prior to medication administration. The second resident had intact cognition, a stage 3 pressure ulcer, COPD, and chronic pain, with a quarterly MDS indicating almost constant pain and use of scheduled and PRN pain medications. This resident’s care plan identified a focus on pain risk related to generalized chronic pain and lower back pain, with interventions that included offering non-pharmacological pain relief prior to pain medication administration, listing the same types of non-pharmacological options as for the first resident. However, the MAR for January showed several PRN oxycodone administrations, and the associated progress notes documented that the medication was given and effective but did not include any record of non-pharmacological interventions being offered or attempted beforehand. Interviews with both residents confirmed that they experienced ongoing pain and used PRN pain medications, and each reported that repositioning sometimes helped relieve their pain. Interviews with LPN staff, the NP, and the DON established that facility practice and expectations were that non-pharmacological interventions should be offered prior to PRN pain medication administration and that such offers and any refusals should be documented in the PRN medication administration note or progress note. The DON confirmed that the medical records for the two residents did not contain documentation of non-pharmacological interventions being offered or refused prior to every PRN pain medication administration. The facility’s Pain Assessment and Management policy stated that pain management is based on appropriate assessment and treatment, including the use of non-pharmacological interventions alone or with medications, and provided examples of environmental, physical, exercise, and cognitive/behavioral interventions, which were not consistently reflected in the documentation for these residents.
Failure to Document Weekly Baths and Skin Assessments for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately document weekly baths and complete current head-to-toe skin assessments for two residents, despite facility policy requiring a weekly bath or shower with a full skin assessment documented on a weekly skin assessment form. For one resident (R1), records showed admission in mid-December with a care plan identifying high risk for skin breakdown and interventions such as keeping fingernails short, using pressure-relieving devices, and preventing him from hitting his extremities. R1 required extensive assistance with hygiene and had a scheduled weekly bath. His TAR showed a dressing order for abrasions on multiple body areas to be treated three times weekly, yet only one weekly skin assessment form was found for his three-week stay, and that assessment documented a shower with no skin issues observed. The TAR for the following month showed weekly skin assessments acknowledged on two dates, but there was no associated documentation indicating the type of bath or any skin integrity findings. For another resident (R3), who required assistance from two staff for bathing, dressing, and toileting, and who had a Foley catheter, bowel incontinence, morbid obesity, a surgical wound, anxiety, PTSD, and Fournier disease affecting the vaginal and vulvar areas, documentation showed only two completed weekly skin assessments over a period of more than two months. Her TAR indicated scheduled baths on multiple dates, but there was no corresponding documentation of weekly skin assessments for each scheduled bath. Staff interviews confirmed that all residents were to receive a weekly bath or shower with a concurrent skin assessment documented on the weekly skin assessment form, and that the TAR only served as a reminder that a bath was due and did not capture whether the bath or skin assessment was actually completed. A nurse reported being able to locate only one weekly skin assessment for R1 during his entire stay, confirming the lack of required documentation for both residents.
Inaccurate POLST and code status documentation
Penalty
Summary
The facility failed to ensure a resident’s POLST and other code status documentation were accurately entered, transcribed, and reflected in the medical record so that current resuscitation measures would match the resident’s stated wishes. The resident had intact cognition, a history of heart failure, hypertension, renal insufficiency/failure, and respiratory failure, and had signed a health care directive stating a preference to allow natural death, avoid artificial life-prolonging treatment, and refuse resuscitation or intubation except for short-term organ donation purposes. The resident’s hospital discharge summaries also documented DNAR/DNI status determined by the patient and advance directive/POLST. The resident’s POLST signed by the resident indicated DNR with comfort-focused treatment, and the care plan and order summary contained conflicting code status entries, including DNI with comfort measures, full code, and DNR. Progress notes showed the resident returned from the hospital with code status updated to DNI, but later documentation also stated full code. A note documented staff calling the POA about a new POLST to be full code, while the POA stated the resident was supposed to be DNR. The resident’s hospice binder repeatedly documented DNR/DNI status and comfort-focused care, but the facility record did not consistently match those documents. Interviews showed staff relied on the EMR banner and other chart locations to determine code status, but the banner listed DNI with comfort measures and was described as unclear. One LPN stated the banner should have clarified whether the resident was full code or DNR, and an RN stated that after reviewing the POLST on file, CPR would be initiated according to that document. The DON also reviewed the record and stated the POLST indicated to attempt resuscitation. Other interviews showed the resident later stated different wishes regarding CPR and intubation, and hospice staff confirmed the resident had been listed as DNR in hospice records and that a new POLST reflecting DNR comfort-focused treatment was completed after clarification. The report states the facility failed to ensure the written POLST was accurately entered, transcribed, and reflected in the medical record, creating an immediate jeopardy situation for the resident.
Resident Mail Not Delivered on Weekends
Penalty
Summary
The facility failed to ensure resident mail was delivered on Saturdays for 2 of 2 residents who voiced concerns about mail delivery. One resident with no cognitive impairment was observed on 12/1/25 receiving a large stack of mail, with only five to ten letters handed to her, and she stated she was lucky if she got her mail every month and that she did not receive mail on weekends. She also stated that some mail was time sensitive and that she wanted to receive it the day it arrived at the facility. Another resident with no cognitive impairment stated on 12/3/25 that he received his mail most weekdays but not on weekends. An activities assistant stated she delivered resident mail every day she worked except Sunday and did not believe mail was delivered on weekends. She explained that when the business office manager was on vacation or on weekends, the mail was not delivered because the business office manager oversaw sorting the mail. The business office manager confirmed she worked Monday through Friday and did not believe mail was delivered on weekends, and the administrator confirmed the facility did not have a process in place to deliver mail on the weekends. The facility policy stated mail and packages would be delivered to residents within 24 hours of delivery including on Saturdays.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor findings that indicated lapses in the care provided to residents at risk for or experiencing pressure ulcers. The report notes that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented, as required by care standards.
Deficient Food Handling, Storage, and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper handling, storage, and monitoring of food and dairy products, leading to multiple deficiencies. Opened milk was observed being served to residents well beyond the recommended seven-day usage period after opening, with one instance of milk being used ten days after opening and another instance where the milk was past its commercial 'best by' date. Staff members were unclear about the correct procedures for dating and discarding milk, and the contracted dietary manager confirmed that milk should be used or discarded within seven days of opening. Additionally, the facility's labeling and dating policy required all time/temperature control for safety foods to be labeled and dated, but this was not consistently followed. The unit refrigerator was inadequately monitored for temperature and food quality. The temperature log had not been updated for over two weeks, and the refrigerator contained expired, undated, and moldy food items, including gravy, stew, rice, and biscuits. Staff interviews revealed a lack of clarity regarding responsibility for monitoring the refrigerator, with both dietary and nursing staff expressing uncertainty. The refrigerator was used for resident food items, some of which were brought in by family members, but there was no consistent process for checking dates or discarding expired items, as required by facility policy. During kitchen observations, staff were found not wearing required hairnets or beard nets while preparing and serving food. There were also issues with food storage, such as scoops being left in flour bins, personal water bottles stored in freezers with resident food, and opened cheese packages not being dated or properly sealed. Additionally, metal pans were stacked while still wet, with condensation observed between them, contrary to the facility's warewashing policy. These actions and inactions directly contributed to the deficiencies identified during the survey.
Unclean Dish Machine and Rust Sediment from Hood in Kitchen
Penalty
Summary
During an initial tour of the kitchen, surveyors observed several orangish blackish substances on top of the dish machine. Dietary staff reported that dishes coming through the machine were clean, and that the outside of the dish machine was washed every one to two days. However, the culinary director stated that staff wiped the dish machine daily and was unsure about the origin of the substances. The culinary district manager identified the sediment as coming from the hood above the dish machine, noting that staff attempted to keep the area clean but faced challenges because Ecolab did not service the hood or custom pieces. The facility was in the process of seeking a company to address the hood issue. The administrator confirmed that maintenance was contacting vendors to install or replace the hood vent, as Ecolab did not work on the hood and available parts did not fit. The maintenance director explained that hot steam from the dish machine caused the metal in the hood to rust and fall, and acknowledged awareness of the issue for several months, but had prioritized other facility needs. The maintenance director was not aware of the severity of the rust falling from the hood. The facility's warewashing policy did not specify when to clean the dish machine, though task descriptions for cooks and aides did indicate scheduled cleaning assignments.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment.
Failure to Provide Dignified Dining Experience Due to Inappropriate Language
Penalty
Summary
During a meal service, a nursing assistant referred to a resident who required assistance with eating as a "feeder" out loud in the presence of other residents and staff. The dietary aide, upon hearing this, withheld the resident's meal by placing the plate on top of the steam table instead of serving it directly. The resident in question had severely impaired cognitive skills and was dependent on staff for eating, as documented in their care plan and Minimum Data Set. Interviews with staff, including the dietary aide, a registered nurse, and the director of nursing, confirmed that referring to residents as "feeders" is inappropriate, not humane, and could be hurtful or belittling. Another resident also reported that staff commonly used the term, which likely made residents feel bad.
Failure to Provide Ordered Pureed Diet Texture
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, dysphagia, and multiple diagnoses including Alzheimer's disease and gastro-esophageal reflux was not provided with the ordered pureed diet texture. The resident's care plan and physician orders specified a regular diet with pureed texture and thin liquids, and a recent speech language pathology evaluation confirmed the need to maintain this diet due to safety concerns. During a meal observation, the resident was served a full piece of pork loin, which she was unable to chew, instead of the required pureed texture. Staff replaced the pork loin with minced meat after noticing the issue, and the resident was then able to eat independently. Interviews with dietary and nursing staff revealed reliance on meal tickets to determine diet orders, but also indicated inconsistencies in the availability and serving of pureed foods. The dietary aide confirmed that pureed pork was not available that day and that only mechanically cut-up pork was served, including to the resident in question. Staff interviews further indicated that while there were systems in place, such as spreadsheets and meal tickets, to communicate diet orders, there were lapses in ensuring the correct texture was always provided. Facility policies required meals to be assembled according to individualized diet orders and for nursing staff to verify meal accuracy, but these procedures were not followed in this instance.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were served in a warm, palatable manner, as evidenced by complaints from three residents who reported that their food was often cold and unappetizing. Interviews with these residents revealed dissatisfaction with the temperature and quality of the food, with one resident describing the meals as 'garbage' and 'nasty,' and another stating that food was 'always freezing cold when it should be hot.' One resident also expressed concern about the lack of appropriate food options for their diabetes. Observations during meal service showed that food temperatures were not consistently checked before serving, and staff were unclear about procedures for recording and monitoring food temperatures. Staff interviews indicated confusion regarding the requirement to temp food after placing it in steam tables, and review of temperature logs confirmed that not all items were recorded as temped. The facility's own policies required food to be served at safe and appetizing temperatures and for staff to record final cooking temperatures and check food temperatures when placed in hot holding units. Despite these policies, there was a lack of adherence to proper temperature monitoring and documentation, resulting in meals being served at suboptimal temperatures and multiple resident complaints.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including an explanation of risks and benefits, prior to administering psychotropic medications to two residents. One resident, who had severe cognitive impairment and multiple medical conditions including heart failure, dementia, and a history of stroke, was admitted from an acute care hospital and was prescribed duloxetine, haloperidol, and mirtazapine. The resident's family member, who was actively involved in care decisions, reported not being informed about the antidepressant medications or their side effects. Review of the medical record confirmed the absence of signed or verbal consent forms for these medications, and staff interviews verified that the required documentation was missing. A second resident, also with severely impaired cognitive skills and multiple diagnoses such as aphasia, traumatic brain injury, epilepsy, anxiety disorder, and depression, was prescribed risperidone for severe, recurrent major depressive disorder with psychotic symptoms. The medical record for this resident similarly lacked evidence of informed consent for the antipsychotic medication. Staff interviews indicated that the admitting nurse was responsible for obtaining consents, but the required documentation was not found in the resident's record at the time of review. The facility's policy on antipsychotic medication use directed staff to gather and document information regarding the resident's condition and symptoms but did not specifically address the process for obtaining informed consent or educating residents or their representatives about the risks and benefits of psychotropic medications. Multiple staff members, including the DON, acknowledged that obtaining and documenting informed consent for these medications was expected but had not been completed for the residents in question.
Lack of Private Phone Access for Resident
Penalty
Summary
The facility failed to provide reasonable access to private phone use for a resident who did not have a personal phone. The resident, who resided on the third floor and used a wheelchair, was observed making a phone call at the nursing station desk, surrounded by multiple staff members and in a public area between two hallways and in front of an elevator. The resident reported that he had requested a more private location for his phone call, specifically asking staff to bring the phone to his room, but was told this was not possible. As a result, he had to conduct his personal conversation in a public setting, which he stated did not provide sufficient privacy, especially when speaking with his wife. Interviews with staff, including a TMA, LPN, and the third-floor nurse manager, confirmed that the only phone available for residents without personal phones was the corded phone at the nursing station, and that there was no cordless phone or private area available for resident use. The administrator stated that a phone could be installed in a resident's room only if the resident could pay for it; otherwise, residents were limited to using the nursing station phone. The facility's own policy indicated that telephones should be available in areas that offer privacy and accommodate wheelchair-bound residents, which was not followed in this instance.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred.
Failure to Address Repeated Grievances Regarding Diabetic Diet
Penalty
Summary
The facility failed to appropriately address and follow up on repeated grievances voiced by a resident regarding the adequacy of food provided for a diabetic diet. The resident, who was cognitively intact and had diagnoses including diabetes, hypertension, peripheral vascular disease, hyperlipidemia, and asthma, experienced a significant weight gain of 35.8% since admission. Despite having an order for a diabetic, regular textured diet, the resident's electronic medical record lacked any progress notes from dietary or nutritional services and did not document the resident's ongoing food concerns. The facility's grievance log for the past six months also did not include any mention of the resident's complaints about the food provided. Multiple staff interviews confirmed that the resident had repeatedly voiced concerns about not receiving appropriate diabetic diet options, such as sugar-free items, and often chose not to eat the food served. Staff members, including LPNs and the certified dietary manager, acknowledged awareness of the resident's complaints, but there was no evidence of formal documentation or follow-up by dietary or grievance personnel. The grievance officer confirmed that no formal grievances had been filed for the resident, despite the facility's policy requiring staff to guide residents in filing written complaints when concerns are voiced.
Failure to Monitor Orthostatic Blood Pressure in Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure appropriate monitoring for side effects of antipsychotic medication, specifically orthostatic hypotension, for one resident who was prescribed Olanzapine and other psychotropic medications. The resident was cognitively intact, had a high risk for falls, and had a physician's order for monthly orthostatic blood pressure checks due to the use of psychotropic medications. However, a review of the resident's electronic medical record, including medication and treatment administration records, vital signs, and progress notes, showed no evidence that these orthostatic blood pressure readings had been obtained or documented for the past two months. Interviews with facility staff, including medication aides, LPNs, and the nurse manager, confirmed that the order for monthly orthostatic blood pressure monitoring was present but had not been carried out or recorded. Staff indicated that such orders should appear in the medication administration record, but none were found for any residents, including the one in question. The facility's policy required monitoring for side effects and adverse consequences of antipsychotic medications, including cardiovascular effects like orthostatic hypotension, but this was not followed in this case.
Incomplete MDS Assessment for Resident Preferences
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident upon admission, as required by federal guidelines. Specifically, the section of the MDS related to Preferences for Customary Routine and Activities (Section F) was either left blank or marked as 'Not Assessed.' There was no evidence in the resident's medical record that an evaluation of their daily routine or activity preferences was conducted during the assessment reference date (ARD) period. The resident in question had multiple medical conditions, including heart failure, dementia, and a history of stroke/transient ischemic attack, and was admitted from an acute care hospital. Interviews with the resident's family member revealed that they had not been consulted regarding the resident's activity preferences, and the resident had not participated in activities or left her bed. The registered nurse responsible for MDS completion confirmed that sections of the MDS were left incomplete and acknowledged that staff should have performed the necessary assessments within the ARD period to ensure accurate coding. Facility policy requires timely and complete assessments in accordance with federal and state requirements, but this was not followed in this instance.
Incomplete MDS Assessments for Cognition and Mood
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed thoroughly for two residents, specifically in the areas of cognition and mood. For both residents, the relevant sections of the MDS—Section C (Cognitive Patterns) and Section D (Mood)—were either marked as 'Not Assessed' or left blank, with no evidence in the medical records that the required assessments, such as the Brief Interview for Mental Status (BIMS) or the Patient Health Questionnaire-9 (PHQ-9), were conducted during the assessment reference date (ARD). This lack of assessment meant that critical indicators of cognitive status and potential depressive symptoms were not evaluated as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. One resident had multiple medical conditions, including high blood pressure, renal insufficiency or failure, and dementia, while the other had a history of stroke and aphasia. Despite these significant health issues, the facility did not complete the necessary cognitive and mood assessments for either resident. A registered nurse responsible for MDS completion confirmed that these sections were not filled out and acknowledged that staff had been informed this was unacceptable. The facility's policy required timely and complete assessments in accordance with federal and state guidelines, but this was not followed in these cases.
Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the discharge status of a resident who was reviewed for hospitalization. The MDS indicated that the resident was discharged to a short-term general hospital, but nursing progress notes and interviews with staff and the resident confirmed that the discharge was actually to home with medications and instructions provided to family members. Multiple staff, including an LPN, the MDS facility liaison, and the MDS clinician, acknowledged upon review that the MDS was coded incorrectly and did not accurately reflect the resident's actual discharge destination. Facility policy requires that the information captured on the assessment accurately reflects the resident's status during the observation period.
Failure to Hold Routine Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to provide routine care conferences for a resident who was cognitively intact and had been admitted to the facility. Documentation showed that the resident had only one care conference since admission, despite policy and staff statements indicating that care conferences and care plan reviews should occur at least quarterly, in conjunction with the MDS assessment cycle. The resident confirmed participation in only one care conference and expressed concerns about her care. Interviews with facility staff, including a licensed social worker and the director of nursing, revealed that the interdisciplinary team is expected to meet quarterly to review and update care plans, even if the resident declines to participate. The social worker acknowledged that no care conference had been held for the resident due to her lack of agreement, but also stated that the team should still meet to discuss the resident's care. Facility policy also requires quarterly interdisciplinary review and update of care plans. The failure to hold these routine care conferences resulted in a lack of regular interdisciplinary review and update of the resident's care plan.
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What surveyors actually found near you
We read the 981 citations issued within 25 miles in the last 12 months — including the 29 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
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Nursing homes near Crystal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Specialty Care Community | 0.9 mi | ★★★★★ | 26 | 0 |
| The Villas At Robbinsdale | 1.2 mi | ★★★★★ | 5 | 1 |
| Covenant Living Of Golden Valley Care & Rehab Ctr | 1.8 mi | ★★★★★ | 2 | 0 |
| Courage Kenny Rehabilitation Institutes Trp | 1.9 mi | ★★★★★ | 7 | 1 |
| Good Samaritan Ambassador | 1.9 mi | ★★★★★ | 2 | 0 |
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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.