Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villas At Bryn Mawr Llc during CMS and state inspections, most recent first.
The facility failed to timely report suspected resident-to-resident abuse involving two residents, an unexplained fracture for a resident who returned from the hospital, and a missing resident whose whereabouts were unknown. Records showed one resident emailed the administrator about threats from another resident, another resident was on safety checks after a verbal altercation, a third resident returned with a closed fibula fracture and denied injury, and a fourth resident did not return to the facility with no timely missing-person or MAARC reporting documented.
A facility failed to keep resident rooms and hallway areas in good repair and safe condition. A broken window in two residents’ room had an open gap to the outside, and staff confirmed bugs could enter. Two other residents’ rooms had missing drawer fronts, a missing mirror, broken wallboard, peeling paint, and curtains off their hooks. Hallway trim, baseboards, and a resident door corner were also cracked or missing, and staff and the DON stated the conditions were not in good repair.
Loose and Unattached Hallway Handrails: Second-floor hallway handrails were found loosely attached to the wall in multiple locations, and one handrail outside a resident room was unattached at one end and pulling away from the wall. Review of TELS work orders showed no report for the loose handrails, and the RM-D, MO-D, RN, and DON all confirmed the condition and that maintenance issues were expected to be reported through TELS.
Dignified Dining Experience Not Maintained: A facility failed to serve residents seated at the same table at the same time. During lunch and breakfast meal service, one resident waited while tablemates ate, another resident received breakfast after a tablemate had already started eating, and a third resident had to request oatmeal twice before being served. The DON stated meals should be served table by table, while nursing assistants described serving residents by tray readiness or meal ticket order instead.
Late Delivery of NOMNC: The facility failed to ensure a resident with intact cognition received the required NOMNC in a timely manner before Medicare Part A coverage ended. The record showed the resident’s last covered day and provider-initiated termination, but there was no evidence staff attempted to give the notice before the resident signed it, and the DON confirmed the notice was not documented as delivered at least 48 hours before the end of coverage.
A facility failed to protect the property of two residents. One resident with impaired vision, multiple chronic conditions, and hospice status reported missing nightgowns and eyeglasses, and family and hospice staff confirmed the items were missing and not investigated. Another resident with cognitive impairment and multiple medical diagnoses had inconsistent vision documentation, and the resident’s family reported prescription eyeglasses were bent, then later missing, with staff unable to locate them. Grievance logs did not show the missing items, and staff interviews showed confusion about who was responsible for documenting and investigating the losses.
Failure to Monitor Psychotropic Medication Use: A resident receiving duloxetine for depression did not have identified target behaviors or side effect monitoring documented in the care plan, TAR, or medical record. An LPN, the unit nurse manager, the DON, and the regional nurse consultant all confirmed the monitoring was not in place for the resident’s psychotropic medication use.
The facility failed to document or provide written BH information for residents transferred to the hospital. Records for multiple residents showed hospitalizations without evidence that a signed bedhold form was offered, completed, or sent with the resident, and family or resident interviews confirmed they were not informed in some cases. Staff and DON interviews verified that the expected BH process was not being followed and that the EMR lacked the required documentation.
Inaccurate MDS Coding for Vision Status: A resident’s MDS and RN vision assessment documented adequate vision and no corrective lenses, but other records, family interview, and direct observation showed the resident wore eyeglasses. Because the visual function CAA was not triggered, the care plan and kardex also failed to reflect the resident’s eyeglasses, and the DON and facility coordinator verified the MDS was coded incorrectly.
Missed Care Conferences and Incomplete Person-Centered Care Planning: The facility failed to complete timely person-centered care conferences for a resident with intact cognition and multiple chronic diagnoses, including schizoaffective disorder, cancer, heart disease, diabetes, seizures, anxiety, depression, bipolar disorder, and lung disease. The EMR showed MDS assessments on the schedule, but care conference documentation was limited and did not show whether the resident was invited or attended. The SS-D, RN-C, and DON all acknowledged that care conferences were not completed in line with the MDS cycle for several assessments, and the resident stated not remembering a meeting to discuss care.
A resident with dementia, schizophrenia, and a chronic fungal rash had weekly skin checks that lacked detailed descriptions of the skin condition, even though staff observed scabbing, redness, and scratch marks and provider notes documented ongoing rash changes. In addition, a resident on hospice had a missing hospice binder with no visit calendar or aide notes, and staff, the hospice RN, and family stated the facility was not effectively coordinating or communicating hospice visit information.
An unlocked medication cart was left unattended at the nurses' station while the assigned RN stepped away. During observation, residents and staff passed by the cart, and the cart was intermittently out of sight. The RN acknowledged leaving it unlocked, and the DON stated staff were expected to lock the cart whenever they walked away. Facility policy required controlled substances to remain double locked at all times.
A resident with severe cognitive impairment, multiple chronic conditions, and a care plan requiring staff to clean or replace his urinal had two dirty plastic urinals left on his bedside table. The urinals had black matter and spots, were partially filled, and had flies and insects around them. The resident said staff emptied the urinals but never rinsed, washed, or replaced them, and an LPN and the DON identified the situation as an infection control issue.
Bathroom Emergency Call Cord Not Reachable From Floor: The facility failed to keep the emergency call system accessible and functional in a shared bathroom used by 4 residents. Observation showed the pull cord was broken off and left only about one inch hanging from the wall, too short to be reached from the floor. The DON confirmed the cord should be long enough for a resident who fell to activate the call system, and the facility policy required pull cords to extend to within six inches above the floor.
A resident with severe cognitive impairment, NPO status, and G-tube dependence was known by the IDT, NP, RD, and SLP to have food-seeking behaviors and a history of silent aspiration. Despite documentation of wandering, attempts to obtain food from other residents’ trays, and being found eating candy, the record showed no new or enhanced interventions beyond general monitoring and re-education, and key episodes were not communicated to the NP. The resident continued to report eating and drinking despite strict NPO orders, and staff observed ongoing wandering into rooms and the dining area. The resident was later found unresponsive with respiratory distress and a high fever, was sent to the ED, where large food particles were suctioned from the oropharynx, and was diagnosed with acute hypoxic and hypercarbic respiratory failure with aspiration pneumonia, requiring intubation and CPR. Surveyors cited the facility for failing to adequately assess, care plan, implement interventions, and supervise this high-risk NPO resident.
A resident with malnutrition, severe cognitive impairment, and NPO status experienced significant weight loss over a short period while dependent on tube feeding for 100% of nutrition and hydration. The care plan and a risk–benefit form noted that the resident disconnected the tube feeding before completion, yet staff were uncertain how long this behavior had been occurring. The RD identified substantial weight loss and staff reports of frequent disconnection, found an incorrect weight entry, and confirmed a lower weight but did not re-educate staff on weight documentation or address the erroneous weight with nursing. Despite a facility policy requiring accurate weights and close monitoring for high-risk residents, documentation and interviews showed gaps in accurate weight tracking and timely adjustment of care in response to the resident’s ongoing disconnection of tube feedings.
A resident with dementia, diabetes, kidney disease, incontinence, and recent functional decline after a wrist fracture developed new skin breakdown on the buttocks and scrotum that was documented on routine skin checks but not promptly measured, characterized, or consistently treated. Early notes identified moisture-associated skin damage and planned barrier cream, yet the treatment record did not show consistent application, and a comprehensive CAA incorrectly stated there were no pressure ulcers. A wound care PA later recommended Triad paste, frequent repositioning, an APM, and RD review, but only the topical treatment was started promptly; the APM and nutritional evaluation were delayed for weeks while the wounds progressed to unstageable pressure ulcers and additional areas of breakdown developed. The IDT did not complete a comprehensive assessment or root cause analysis of the initial wound or its progression until after the resident was hospitalized and did not return.
A resident with schizophrenia and a self-care deficit persistently refused hygiene and medical assessments, leading to severe neglect. Despite staff awareness of her declining condition, including malodor, suspected wounds, and poor nutrition, no effective interventions or escalation to a higher level of care occurred. The resident was eventually found by EMS in a severely neglected state, with multiple pressure ulcers, malnutrition, and other injuries.
A resident with severe cognitive impairment and a history of elopement, who required 24/7 supervision and resided on a locked unit, was able to leave the facility unsupervised during an outdoor activity. Staff failed to provide adequate supervision when responsibility for the resident was transferred between staff members, and the resident was later found by police on a busy street. The root cause was identified as a lack of adequate supervision, despite documented interventions and policies for elopement risk.
A resident with significant physical and cognitive impairments reported being inappropriately touched by another resident. Although the incident was documented and reported to the state agency, facility staff did not notify law enforcement as required, citing the resident's refusal to involve the police. Interviews and documentation confirmed that law enforcement was not contacted, in violation of facility policy.
A resident with severe cognitive impairment and a history of elopement was not provided with an updated care plan reflecting the need for 1:1 supervision when taken off a locked unit. Despite being identified as high risk and requiring constant supervision, the care plan lacked this intervention, leading to an incident where the resident left the premises unsupervised and was later returned by police.
A resident with a history of PTSD and other mental health conditions was not assessed for trauma or psychosocial needs after an allegation of sexual abuse by another resident. Although the incident was reported and the resident's care plans identified her as at risk for trauma-related behavioral changes, no trauma assessment was completed after the event, and the psychology provider was not notified. This failure to follow trauma-informed care protocols resulted in a deficiency in providing appropriate mental health services.
A resident with nicotine dependence and a traumatic brain injury did not receive physician-ordered nicotine lozenges for nicotine cravings, as the medication was not available or administered despite an active order. Staff, including LPNs, the unit manager, DON, and the administrator, were unaware of the medication's unavailability, and facility policy did not address this type of medication error.
A resident with malnutrition, anemia, pressure ulcers, and a history of poor nutrition was admitted with physician orders for daily weight checks, but the facility failed to document daily weights as required. Only three weights were recorded over two weeks, despite the resident's complex medical needs and ongoing risk factors. Staff did not observe or report significant weight loss, and the lack of daily monitoring was attributed to incorrect entry of orders, resulting in a missed opportunity to identify and address a substantial decline in the resident's weight.
The facility failed to maintain proper food storage and hygiene practices, affecting residents, staff, and visitors. Culinary staff were observed without hair nets or facial hair covers, and personal items were stored next to food. Opened food items were not properly labeled or dated, and the dish machine did not reach the required temperature for sanitization. Staff acknowledged these issues, which violated facility policies and posed a health risk.
The facility failed to assess and care plan for a resident's social well-being, neglected dietary needs and preferences for another resident, and did not document or address a resident's skin condition. Additionally, there was a lack of coordination for a resident undergoing dialysis, leading to missed insulin doses and blood sugar checks.
The facility failed to maintain a clean and sanitary shower room on the first floor, where a brown stain on the ceiling was observed. Residents expressed concerns about potential mold, and staff interviews revealed the stain had been present for a long time without resolution. The regional director of maintenance acknowledged communication issues that may have contributed to the delay in addressing the problem.
A resident with moderately impaired cognition was unable to access a private phone for personal communication, as the facility only provided access to a shared phone at the nursing station. Staff interviews confirmed the lack of alternative private phone options, and the administrator acknowledged the oversight in staff education regarding available private spaces for phone use.
The facility failed to complete the quarterly MDS thoroughly for two residents, leaving sections on cognition and mood blank. One resident with conditions like schizophrenia and depression had no completed cognitive or mood assessments, while another with complex medical issues also lacked these evaluations. The corporate director of reimbursement noted the assessments were not done, possibly due to a new social worker still learning the role.
A facility failed to complete a Level I and, if needed, a Level II PASARR for a resident with mental health diagnoses, including depression, anxiety, and PTSD. The resident's medical record lacked a final PASARR determination from the lead agency, Hennepin County, necessary for admission. Interviews revealed that the facility had not contacted the county for the final determination, despite policy requirements to ensure the resident met the level of care for medical assistance payment before admission.
A resident with moderate cognitive impairment was observed with long fingernails and expressed a desire for them to be clipped. Despite this, the facility's records marked nail care as 'not necessary,' and there was no documentation of offers or refusals of nail care. Staff acknowledged the need for assistance, but the facility's policy on maintaining abilities for activities of daily living was not followed, resulting in a deficiency.
Two residents in the facility were not provided adequate ADL care, including nail care and routine bathing. One resident, dependent on staff due to a stroke, had long, dirty fingernails and was not given nail care before meals. Another resident, cognitively impaired and refusing care, had greasy hair, and no alternative interventions were attempted to address her refusal to bathe. The facility's policy emphasizes person-centered care, but these standards were not met.
The facility failed to coordinate cataract surgery for a resident with impaired vision and did not address the loss of hearing aids for another resident. The resident with vision issues had a guardian who was not consulted before scheduling the surgery, leading to a missed appointment. The resident with hearing aids reported them missing, but the facility did not follow up to locate or replace them. Communication issues and lack of relevant policies contributed to these deficiencies.
A resident with long, hard toenails was not referred to the onsite podiatry service in a timely manner, despite having a care plan indicating the need for such services. The resident expressed a desire to see the foot doctor, and their guardian had requested podiatry visits, but there was a delay in scheduling. The facility's staff were unsure of the resident's podiatry visit status, and the medical record lacked evidence of recent podiatry services being offered or refused.
A resident with severe cognitive impairment and physical limitations did not receive routine range of motion (ROM) exercises as required by their care plan. Despite therapy recommendations and family concerns, there was a lack of documentation and communication among staff regarding the resident's need for ROM exercises. Observations and interviews revealed that the resident's ROM needs were not met, and the facility lacked a policy on ROM.
A resident with severe cognitive impairment and schizophrenia frequently threw dining ware, but the facility failed to consistently assess and implement behavioral interventions. Despite the behavior being documented in the care plan, staff were unsure of the resident's triggers and did not consistently document incidents. The facility lacked a specific policy for behavioral management, contributing to the deficiency.
A facility failed to ensure proper PPE use for a resident on enhanced barrier precautions due to a feeding tube. The resident, with severe cognitive impairment, was assisted by two nursing assistants, one wearing gloves without a gown and the other without gloves or a gown. Staff interviews revealed inconsistent understanding of PPE requirements, with some staff not adhering to the facility's policy, which mandates gowns and gloves during high-contact activities.
A clipboard with sensitive information about 48 residents was left in public view at the nursing station, violating HIPAA standards. An LPN confirmed the breach, stating the information should not be accessible to everyone. The DON emphasized the expectation to keep such information private, but a HIPAA policy was not provided.
A resident with diabetic neuropathy and amputation pain did not receive their prescribed Belbuca due to the facility's failure to reorder the medication timely. The resident experienced withdrawal symptoms and was hospitalized after calling 911. The facility's staff did not follow up with the pharmacy or notify the provider about the medication shortage, and the nurse practitioner was not informed until after the resident's hospitalization.
The facility failed to monitor two residents after unwitnessed falls, leading to a deficiency in care. One resident with severe cognitive impairment had a fall resulting in a forehead bump, but lacked detailed documentation and monitoring. Another resident with diabetes was found on the floor, with no injury or monitoring documented. Staff interviews confirmed the lack of proper documentation and monitoring, contrary to the facility's policy requiring neuro checks and monitoring for 72 hours post-fall.
A resident experienced a delay in emergency medical response due to the facility's failure to train staff on unlocking the main entrance doors after hours. The doors were locked for security reasons, but agency staff were not trained on how to access them, leading to a ten-minute delay for EMS personnel. This deficiency placed all residents at risk for serious harm.
The facility failed to provide privacy curtains for residents sharing rooms, affecting their dignity and comfort. A resident reported discomfort due to the absence of a functional curtain, while another resident was exposed to inappropriate behavior due to the lack of privacy. The facility's administration acknowledged the oversight, and no policy for privacy curtains was provided.
The facility did not ensure that three nursing assistants received annual training on Alzheimer's disease, problem-solving with challenging behaviors, and communication skills. The Facility Assessment indicated that staff should be trained annually on dementia management, but a review of training transcripts showed this was not completed. RN-C and the DON acknowledged the lapse, and a behavioral health training policy was not provided.
The facility did not provide necessary training for staff on communicating with non-English speaking residents, despite having two such residents. Five staff members, including NAs and nurses, lacked this training. Interviews confirmed that additional staff could not recall receiving training, even though they recognized a non-English speaking resident in the facility. The Facility Assessment noted the need for interpreter services but did not ensure annual training. The DON acknowledged this oversight.
The facility failed to provide mandatory training on its QAPI program to staff, including nursing assistants and nurses, as revealed through interviews and document reviews. Staff were unable to recall any training on QAPI, and the facility's Quality Plan and QAPI meeting minutes lacked evidence of such training. The director of nursing acknowledged the oversight, and the administrator was unaware of the deficiency.
The facility failed to ensure proper dishware sanitization, with observed low temperatures and inconclusive chlorine test results. Multiple staff interviews revealed gaps in communication and documentation, posing a risk of cross-contamination and foodborne illness for all 88 residents.
The facility failed to implement transmission-based precautions for a resident with respiratory symptoms and did not provide infection control education to two residents who shared cigarettes, posing a risk of spreading infections.
A facility failed to complete a self-administration of medications (SAM) assessment for a resident with multiple medical conditions who was observed self-administering medications without a current assessment or physician's order. The resident's electronic medical record and clinical physician orders lacked the necessary documentation, and the facility's policy requiring an interdisciplinary team assessment was not followed.
The facility failed to timely address broken window blinds, compromising the privacy and homelike environment for two residents. Despite multiple requests and a work order created two months prior, no temporary measures were taken, and the issue remained unresolved. The administrator cited issues with custom-made parts and limited maintenance staff as reasons for the delay.
A resident with a history of stroke and diabetes was observed with overgrown and dirty fingernails despite repeated requests for assistance. Staff acknowledged the need for nail care but failed to provide it, and the facility's policy did not specify the frequency of nail care.
Failure to Timely Report Abuse, Unexplained Injury, and Missing Resident
Penalty
Summary
The facility failed to immediately report suspected resident-to-resident abuse to the state agency within 2 hours for two residents. One resident had intact cognition, depression, bipolar disorder, and was independent with ADLs. He emailed the administrator that another resident had come to his unit, told other residents he intended to fight him, and that he was increasingly concerned about his safety because of the physical threats. The administrator responded by telling him to stay on his unit and notify staff if he had issues, but the resident’s record did not show that the allegation was reported to the state agency. The other resident involved also had intact cognition, depression, and was independent with transferring and walking. His record showed he was on 15-minute safety checks related to a verbal altercation with another resident, but there was no indication that the allegation involving him was reported to the state agency. The facility also failed to ensure timely reporting of an injury of unknown cause for a resident who returned from the hospital with a fracture. The resident had intact cognition but was dependent on staff for all ADLs, including bed mobility and transfers, and his care plan identified him as vulnerable and at risk related to hemiplegia, hemiparesis, and aphasia. Progress notes showed he called 911 for leg pain, was sent to the hospital, and later returned with documentation of a closed fracture of the proximal left fibula. The notes documented that he denied any recent fall, injury, or abuse, and the administrator was notified, but the record lacked documentation of when he returned from the hospital and who was notified. The administrator later verified the incident should have been reported to the state agency within 2 hours. The facility further failed to timely report self-neglect for a missing resident whose whereabouts were unknown. The resident had intact cognition, impaired function on one side, and diagnoses including stroke, schizophrenia, PTSD, opioid abuse, depression, alcohol dependence, and difficulty swallowing. His care plan showed assistance needs for toileting, ambulation, grooming, bathing, and dressing, and his medication record showed multiple medications marked absent from home during the period he was not present. Progress notes showed staff noted he was not in the facility, called his phone and family, filed a missing person report, and later completed a MAARC report, but the record lacked evidence of a missing person report after 24 hours of no contact and showed the MAARC report was filed almost a month after last contact. The administrator stated the report was late and that the last contact with the resident appeared to have been on the earlier date noted in the record.
Unsafe and Poorly Maintained Resident Rooms and Hallway Areas
Penalty
Summary
The facility failed to maintain resident rooms and common hallway areas in a safe, clean, and comfortable condition. For two cognitively intact residents, R30 and R64, the facility did not repair or seal a broken window in their room, leaving an opening to the outside environment. R64 stated he had moved into the room the previous week, and his roommate, R30, had told him the window had been broken for at least four months. Observation showed an approximately one-inch gap between the window frame and windowsill, and R64 reported seeing flies in the room over the previous several days. The Regional Maintenance Director confirmed the window was broken and acknowledged there was a gap between the window and frame. He stated the facility had identified an additional issue with the window the previous week and agreed there were methods to cover gaps such as this that should have been implemented. The DON also agreed the window should not have been open to the outside environment allowing pests or bugs to enter the facility. The facility also failed to maintain the rooms of R10 and R100 in good repair. R10, who had intact cognition, impaired vision, multiple diagnoses including anemia, viral hepatitis, arthritis, osteoporosis, hip fracture, anxiety, depression, chronic lung disease, respiratory failure, cataracts, and hospice services, was observed with a missing drawer front and no mirror on the wall above the dresser. R10 stated the room had always been that way since admission and that it bothered her. R100’s room had a hole in the wallboard near the head of the bed, peeling paint, missing drawer fronts, and a curtain hanging off its hooks. In addition, second-floor hallway areas had cracked and missing wall corner trim, a missing baseboard section, and a broken corner piece on a resident door, with staff and maintenance leadership stating these items were not in good repair and were not safe for residents walking by.
Loose and Unattached Hallway Handrails
Penalty
Summary
The facility failed to ensure that handrails on the second floor were securely attached to the wall. During observation on 6/14/26 at 9:17 a.m., second floor hallway handrails were found loosely attached to the wall across from the elevator, across from the dining room and nursing desk, and between two resident rooms. One handrail outside a resident room was also unattached at one end and pulling away from the wall. During review of April, May, and June 2026 electronic work orders (TELS), there was no report of loose handrails. On 6/15/26 at 5:26 p.m., the regional maintenance director and maintenance operation director reviewed and verified the loose and unattached handrails. The maintenance operation director stated staff were expected to submit a TELS work order for anything needing repair or replacement, including loose and unattached handrails, but no such report was identified for January through June 2026. Staff interviews on 6/17/26 reflected that loose or unattached handrails were considered a safety concern and that staff were expected to submit TELS reports for maintenance issues, while the director of nursing confirmed that unattached and loose handrails were not safe.
Dignified Dining Experience Not Maintained
Penalty
Summary
The facility failed to provide a dignified dining experience for 3 residents who were seated at dining room tables with other residents but were not served meals at the same time as their tablemates. R11 had intact cognition and required set up or clean-up assistance with eating, R40 had memory that appeared OK and was independent with eating, and R53 had moderately impaired cognition and required set up or clean-up assistance with eating. During lunch service on the 2nd floor main dining room, the meal cart arrived at 12:13 p.m., and R11 was seated at a table with other residents while tablemates were served and ate before he received his meal. R11 stated he was frustrated because this happened all the time and was still waiting while others at his table had already finished eating. R11 was served 18 minutes after tablemates were observed eating, and desserts were delivered to some residents while others had not yet been served lunch. During breakfast service, R82 was served cereal and milk while R40, seated at the same table, did not receive breakfast until 12 minutes later after tablemate had already begun eating. At another table, R53 sat with other residents who had already been served cold cereal, but he had no food in front of him and requested oatmeal twice before it was provided 23 minutes after tablemates had been served. R53 stated he had to wait for breakfast after asking a couple of times for oatmeal, and R40 stated this happened all the time and that she was used to waiting for meals after others at the table were served. Nursing assistants stated residents were served based on tray preparation or meal ticket order rather than by table, while the DON stated meals should be served table by table and the administrator verified residents seated at the same table should be served at the same time.
Late Delivery of NOMNC
Penalty
Summary
The facility failed to ensure the required Notice of Medicare Non-Coverage (NOMNC) was provided timely to one resident, R39, who was reviewed for beneficiary notices. R39’s admission MDS indicated intact cognition. The SNF Beneficiary Protection Notification Review form showed that R39’s last covered day of Medicare Part A service was 5/28/26 and that the termination was provider-initiated when Part A benefit days were not exhausted. The NOMNC form was dated 5/28/26, listed 5/28/26 as the last covered day, and was signed by the resident on 5/27/26. Review of the medical record found no indication that facility staff attempted to give R39 the NOMNC before 5/27/26. During interview, the administrator confirmed she could not find evidence that the NOMNC was given before 5/27/26 and stated she would have expected it to be given at least 48 hours before the service end date. The facility’s NOMNC policy stated the notice must be delivered at least two days before Medicare-covered services end.
Failure to Protect Resident Property and Track Missing Eyeglasses and Clothing
Penalty
Summary
The facility failed to protect resident property for 2 residents who were reviewed for missing items. One resident had intact cognition, moderately impaired vision with corrective lenses, impaired lower-extremity function, and required substantial to maximal assistance with dressing and personal hygiene; diagnoses included anemia, viral hepatitis, arthritis, osteoporosis, hip fracture, anxiety, depression, chronic lung disease, respiratory failure, cataracts, and hospice status. Admission records showed a personal belongings inventory listing glasses, but no clothing items were identified. During observation, the resident stated several nightgowns and a pair of eyeglasses were missing, and the resident and family reported the facility knew about the missing items but had not investigated. Family and hospice staff confirmed the resident was missing multiple labeled nightgowns and replacement eyeglasses, and the hospice nurse stated the resident’s room had missing items and that the facility had not acted after being notified. The facility grievance logs did not identify the missing items, and staff interviews showed confusion about who was responsible for filing grievance forms and initiating investigations. The social services designee stated she was unaware of the missing items and could not locate the personal inventory form in the EMR, while the DON stated staff failed to document and follow up on missing items. The second resident had inability to determine cognition, adequate vision documented on some forms, impaired upper-extremity function, wheelchair use, and required substantial assistance with dressing and personal hygiene; diagnoses included encephalopathy, blood clots, kidney disease, anxiety, depression, and rhabdomyolysis. Admission paperwork listed glasses on the personal belongings inventory, but the vision-related assessments and MDS documentation were inconsistent, with some records stating no corrective lenses and no visual impairment while another transfer form noted the resident used glasses when prompted. The resident’s family reported the eyeglasses were bent and dirty, later missing entirely, and that staff were unable to locate them or contact the family. The MDS coordinator and RN acknowledged incorrect vision documentation, which prevented the vision CAA from being triggered and left the care plan and kardex without reference to the resident’s prescription eyeglasses.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure ongoing, adequate monitoring for side effects related to psychotropic medication use for 1 of 5 residents reviewed, and also failed to ensure the resident’s psychotropic medication had identified target behaviors or symptoms for monitoring. R15’s admission MDS indicated some difficulty making decisions in new situations, no delusional thinking during the review period, and use of an antidepressant medication with diagnoses of depression and anxiety. R15’s care plan identified an alteration in mood and behavior related to anxiety, depression, ADHD, and mild cognitive impairment, and noted enrollment in mental health services, but it did not include target behaviors or side effect monitoring for duloxetine. R15 had an order for duloxetine 60 mg daily for depression, but the medical record and TAR did not show identified target behaviors or monitoring for duloxetine use. Side effect monitoring for duloxetine was also not found in the record. During interviews, an LPN stated target behavior and side effect monitoring are usually added to the TAR but did not see that it had been added and was unsure what target behaviors related to duloxetine. The unit nurse manager confirmed target behaviors were not identified and monitoring was not in place, and the DON and regional nurse consultant stated residents taking psychotropic medications should have target behavior and side effect monitoring documented in the TAR.
Failure to Document and Provide Written Bed Hold Information During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold (BH) for residents who were transferred to the hospital, including R9, R15, and R100. The facility's policy stated that prior to transfer, residents or their representatives were to be informed in writing of the bed-hold and return policy, including the rights and limitations regarding bed holds and the details of the transfer. However, the record review found that the required BH documentation was not completed or scanned into the EMR for the hospitalizations reviewed. R15's records showed multiple hospital transfers after admission to the facility, including a fall with head strike and later another hospitalization. The Hospital Transfer form for the 5/23/26 transfer did not indicate that a signed bedhold form was sent with R15, and the EMR lacked evidence of a BH being offered or signed. R15's family member stated the family was never notified or informed about a bedhold or transfer form for either hospitalization. Staff interviews confirmed that nursing was responsible for completing and scanning a signed bedhold form, and that if the form was not signed, a progress note and social services follow-up were expected; staff acknowledged this was not done for R15. R100's EMR documented several hospitalizations, but each Hospital Transfer assessment failed to identify that a signed bedhold form was offered and signed, and R100 stated he had never been asked to sign a bedhold form before any hospitalization. R9's records also lacked evidence that a BH was discussed with the resident or representative during either of two hospitalizations, and the Hospital Transfer forms and EMR contained no documentation that a written BH form was sent with the resident. Review of Ombudsman notices also failed to identify hospital transfers for some residents, and staff interviews confirmed that bedholds were not being documented in the EMR as expected.
Inaccurate MDS Coding for Vision Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect a resident’s vision status for one resident who was reviewed for MDS accuracy. The resident’s Admission MDS identified adequate vision and no corrective lenses, and the Hearing/Vision Form completed by the RN also documented adequate vision and no corrective lenses. However, other records showed the resident used glasses, including the hospital discharge transfer form, the admission contract personal belongings inventory, and the resident’s observed use of eyeglasses during dining room observation. The resident also had diagnoses including encephalopathy, kidney disease, anxiety, depression, blood clots, and rhabdomyolysis, and required assistance with hygiene and had an ostomy. The Care Area Assessment for Visual Function was not triggered, and the resident’s care plan and kardex did not indicate the resident wore eyeglasses. During interviews, the family member stated the resident wore prescription eyeglasses, the MH technician confirmed the personal belongings inventory was completed from the admissions packet, and the RN acknowledged she knew the resident wore glasses but documented otherwise on the assessment. The facility coordinator and DON also verified the MDS was coded incorrectly and that the visual function CAA did not trigger the care plan or kardex documentation.
Missed Care Conferences and Incomplete Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure timely person-centered care conferences for one resident and failed to include periodic review and revision by an interdisciplinary team with the resident in care planning decisions. The resident had intact cognition and required substantial assistance with dressing and toileting hygiene, with diagnoses including schizoaffective disorder, cancer, heart disease, diabetes, seizures, anxiety, depression, bipolar disorder, and lung disease. The resident’s MDS assessments were completed on 7/15/25, 8/5/25, 10/22/25, and 1/15/26, but the EMR contained care conference forms only for 10/6/25 and 3/26/26. Those care conference forms indicated the resident had a guardian and family involvement, but did not document whether the resident was invited or attended. Review of the EMR found no other care conference forms to match the MDS schedule, including the most recent MDS. During interview, the resident stated not remembering having a meeting to talk about care. The SS-D stated care conferences were originally scheduled every three months regardless of the MDS cycle and acknowledged they were not completed for the 7/15/25, 8/5/25, and 1/15/26 MDS cycles. RN-C and the DON both stated care conferences were expected to occur around the MDS schedule, and the DON verified the facility failed to conduct care conferences for those MDS assessments.
Incomplete skin assessments and poor hospice coordination
Penalty
Summary
The facility failed to consistently and comprehensively assess a non-pressure skin condition for a resident with dementia and schizophrenia who had a history of picking at her skin and a rash on her trunk, buttocks, groin, abdomen, back, and legs. The resident’s annual MDS indicated she had moderately impaired cognition and required varying levels of assistance with bathing and dressing. Her weekly skin inspections documented ongoing fungal rashes and cream application, but the inspections did not include detailed descriptions of the skin alteration, such as whether open areas were present or what color the affected skin was. Provider notes during the review period documented that the resident’s rash was improving at one point, with a small scab on the right buttock and mild redness, and later was stable with a few light scratch marks and no open areas. However, no additional progress notes describing the skin status were found during the period reviewed. During observation, staff saw a small scab on the right buttock, dark pink skin in the gluteal cleft extending to both buttocks, and slight redness down the inner thighs, with no open areas. An LPN stated staff were supposed to document details such as whether the alteration was healing, moist or dry, whether there was odor, the color of the wound, and whether it was open or closed, but the weekly skin checks reviewed did not include those details. The nurse manager and DON also stated they expected documentation of changes in the rash and whether it had opened up. The facility also failed to ensure services were coordinated with the hospice agency for a resident receiving hospice care. The resident’s MDS identified intact cognition, impaired vision, lower-extremity impairment, and substantial to maximal assistance needs for dressing and personal hygiene, along with multiple diagnoses including anemia, viral hepatitis, arthritis, osteoporosis, hip fracture, anxiety, depression, chronic lung disease, respiratory failure, cataracts, and hospice enrollment. Review of the hospice binder at the nursing desk showed no calendar of visits and no home health aide visit notes. Facility staff, including the social services designee, RN, nursing assistant, staffing coordinator, and DON, stated the binder should contain the hospice visit calendar and written visit notes so staff would know who was coming, when, and what happened at each visit. The hospice RN stated the binder had been replaced several times because the facility kept losing it, and stated the facility did not have the information needed to provide care because the visit notes and calendars were missing. The hospice RN and family member also stated communication between the facility and hospice was lacking.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medication storage was not maintained in a secure manner when an unlocked medication cart was left unattended at the nurses' station while the assigned RN was away from it. During continuous observation, four ambulatory residents walked past the cart, staff members came and went from behind the nurses' station, and the nurse manager also walked past the unattended cart while it remained out of sight intermittently. Because the cart was left unlocked, medications stored within it, including controlled substances, were not maintained in a double-locked manner. The RN acknowledged leaving the cart unlocked after being called away, and the DON stated staff were expected to lock the medication cart whenever they walked away from it. A facility policy stated controlled substances were to remain double locked at all times.
Dirty Urinals Left in Resident Room
Penalty
Summary
Provide and implement an infection prevention and control program was not followed when R2's urinals were observed dirty and improperly maintained. R2's quarterly MDS indicated severe cognitive impairment, bladder continence, independence with ADLs and transfers, wheelchair use, and diagnoses including anemia, coronary disease, heart failure, hypertension, and chronic lung disease. His care plan identified a risk for alteration in elimination related to impaired mobility, stated he was continent of bladder, kept a plastic urinal on his wheelchair, and required staff to clean or replace the urinal as needed. During observation, two plastic urinals were found on top of R2's bedside table with black matter around the rims, numerous black spots inside the vessels, and 6-8 flies standing on them; little black insects were also flying throughout the room. R2 stated he used the urinals throughout the day, sometimes staff emptied them in the room bathroom, and he also used the spa room toilet to empty them, but staff never rinsed or washed the urinals and had not replaced them for a long time. TMA-B stated she emptied the urinal once to twice per shift but had never washed or changed them. LPN-A observed the urinals on the bedside table, noted they were dirty, stated they should not be near food, and identified the situation as an infection control issue. The DON later stated she had been informed about the urinals and said it was an infection control issue.
Bathroom Emergency Call Cord Not Reachable From Floor
Penalty
Summary
The facility failed to ensure the emergency call system remained accessible and functional in a shared bathroom used by 4 residents. Observation on 6/14/26 at 9:48 a.m. showed the bathroom emergency call light pull cord was broken off, leaving approximately one inch of cord hanging from the wall connection about halfway up the wall. The remaining cord was not long enough to be reached by a resident from the bathroom floor, so a resident who fell in the bathroom would not have been able to activate the emergency call system to summon assistance. The affected residents were R9, R30, R52, and R64. R9’s quarterly MDS showed cognitive intactness, independence with personal hygiene and toileting, and one fall with minor injury. R52’s quarterly MDS showed severe cognitive impairment with a BIMS score of 4 and independence with ADLs. R30’s quarterly MDS showed cognitive intactness, independence with ADLs, and diagnoses including unsteadiness on feet and unspecified dementia. R64’s quarterly MDS showed cognitive intactness, independence with ADLs, and a history of falling. During interview on 6/16/26 at 12:06 p.m., the DON confirmed the short emergency pull cord in the bathroom and stated the bathroom emergency pull cords should be long enough to be reached if a resident fell to the floor. The facility policy stated a nurse call must be provided for each resident bathroom and that if a pull cord is provided it must extend to within six inches above the floor.
Failure to Manage NPO, Food-Seeking Resident on G-Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, care plan, implement interventions, and provide supervision for a resident who was NPO and dependent on G-tube feedings, despite known food-seeking behaviors and severe cognitive impairment. The resident’s admission MDS documented severe cognitive impairment, dependence on staff for ADLs, incontinence, and G-tube nutrition, with NPO status due to dysphagia and a history of silent aspiration. On 2/19, the care plan and a risk-versus-benefit form identified that the resident self-sought food and fluids while NPO, required reminders and redirection, and was at risk for aspiration, pneumonia, loss of airway, hospitalization, and possible death if consuming oral intake. The RD documented that the resident was self-seeking food and fluids, had impaired cognition, and could not repeat back understanding of the NPO education, and an order was added to the TAR to observe for self-seeking food and provide re-education as needed. Subsequent clinical notes showed ongoing concerns that the resident was eating and drinking despite strict NPO orders. On 2/25, the NP documented that staff reported continued food- and fluid-seeking, and the resident nodded yes when asked if she was eating or drinking; a chest X-ray was ordered, which was normal. On 3/4, the NP again documented silent aspiration, cough, coarse lung sounds, and that the resident continued to report oral intake despite strict NPO, and another chest X-ray was ordered and read as normal. An email exchange on 2/24 showed the IDT was aware of the resident’s low SLUMS score indicating dementia, wandering, and the need for a memory care bed, but no new interventions were established beyond continued monitoring when no memory care bed was available. Staff interviews and documentation revealed multiple unaddressed episodes of food-seeking and wandering into areas where food was present. A staff member reported seeing the resident eating a gummy jolly rancher given by another resident and observing her wandering into other residents’ rooms and attempting to eat food from leftover trays, as well as being in the dining room during and after meals; the record lacked evidence of any action taken in response to these events. Another staff member also reported seeing the resident wandering all over the unit and in the dining room during and after meals. The SLP stated the resident had severe cognitive deficits, wandered around the unit, did not understand what NPO meant, and was at high risk for aspiration if she ate regular food or fluids, based on a prior hospital video swallow study recommending NPO. The NP later stated she was never informed about the resident eating gummy candy and would have expected immediate notification for further assessment and monitoring. Ultimately, the resident was found unresponsive with heavy breathing and a very high temperature, was sent to the ED, and was diagnosed with acute hypoxic and hypercarbic respiratory failure with aspiration pneumonia; large food material was suctioned from the oropharynx, and the resident required intubation and CPR for a brief cardiac arrest. The surveyors concluded that the facility failed to assess, develop, and implement appropriate interventions and supervision for this known NPO, food-seeking resident, resulting in an immediate jeopardy situation.
Removal Plan
- Completed a full house audit of residents with modified diets
- Audited care plans for residents with modified diets
- Provided training to staff on modified diets and changes made to care plans
Failure to Ensure Adequate Tube Feeding and Weight Monitoring for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and plan care to ensure that a resident’s tube feeding needs were met, resulting in significant weight loss in less than 30 days. The resident’s admission MDS documented diagnoses of malnutrition, anxiety disorder, and depression, with severe cognitive impairment and NPO status, and indicated that tube feeding provided nutrition. The care plan noted that the resident self-sought food and fluids while NPO, required reminders and redirection due to poor cognition, and had actual alteration in nutrition with weight loss over 30 days related to inadequate caloric intake, evidenced by disconnecting the feeding prior to the end time. A Risk vs. Benefits form completed by the RD stated that the tube feeding met 100% of the resident’s nutrition and hydration needs and that disconnecting the tube feeding prior to the prescribed time could result in continued weight loss, malnutrition, dehydration, return to hospitalization, or possible death. Dietary documentation showed that the RD identified a weight drop from 168 lbs to 155 lbs in less than 30 days, confirmed by reweight, and staff reported that the resident often disconnected the feeding before completion, leading to inadequate caloric intake. Staff also reported that the resident moved frequently in bed, placing the tube at risk of being tugged or pulled. The RD documented that the resident had poor cognition and was difficult to assess for understanding of the risk vs. benefits discussion. The RD re-estimated the resident’s nutritional and fluid needs and recommended a bolus tube feeding regimen with specified formula volumes and water flushes to meet calculated caloric, protein, and fluid requirements, and noted that the provider was notified of the weight loss related to the resident’s noncompliance with the feeding regimen. Weight records in the facility’s electronic system showed multiple entries over the period in question, including an entry that the RD later struck out as incorrect after obtaining a second weight that confirmed 155 lbs. The RD acknowledged that she discovered the weight loss on the same day she learned from staff that the resident was disconnecting the tube feeding, and that she did not speak with the RN about the incorrect weight or re-educate staff on handling incorrect weights. Interviews indicated uncertainty among staff about how long the resident had been disconnecting the tube feeding, and at least one NA reported never seeing the resident disconnect the feeding. The facility’s weight policy required accurate weights and monitoring to ensure residents’ nutritional parameters were maintained, with more frequent monitoring for high-risk residents at the discretion of the interdisciplinary team and/or physician, but the documentation and interviews showed gaps in accurate weight documentation and timely response to the resident’s behavior of disconnecting the tube feeding in the context of significant weight loss.
Failure to Timely Assess and Implement Interventions for New Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess and treat newly developed skin breakdown and to timely implement ordered interventions for pressure ulcer care for one resident. The resident initially had intact skin documented on a weekly skin inspection at the end of November, and a significant change MDS in early December showed no unhealed pressure ulcers, though it noted a recent fall with wrist fracture and increased need for assistance. A Braden assessment shortly after the fall scored the resident as low risk, despite dementia, diabetes, stage III kidney disease, incontinence, and increased dependence with mobility and transfers. On 12/6, a weekly skin inspection documented an “ongoing open area on left buttock” but did not include measurements, wound characteristics, or any treatment provided. A subsequent CAA signed 12/11 stated the resident did not have any pressure ulcers, even though it identified the resident as at risk for skin breakdown. On 12/11, another weekly skin inspection noted redness and a wound to the scrotum, again without clarifying whether this was the same area as previously documented or whether the earlier area had healed, and without documenting any treatment. On 12/12, skin issues were formally measured and recorded as MASD on the sacrococcygeal area and left gluteus, and another note the same day identified MASD to the scrotum and left buttocks with a plan for barrier cream, but there was no corresponding documentation on the TAR to show that barrier cream was consistently applied. On 12/16, a wound care PA evaluated the resident and documented scattered erosions over the right buttock and sacrum, with MASD to the buttock/sacrum, and recommended meticulous pericare, Triad paste BID and PRN, repositioning per Braden protocol, initiation of an APM, and RD review of nutritional needs. The record shows Triad paste treatments beginning 12/17, but the APM and RD evaluation were not implemented at that time. By 12/23, the sacrococcygeal area had progressed to an unstageable pressure ulcer with necrotic tissue, and the wound care PA again documented that the requested APM was not in place, re-requested it, and again asked for RD evaluation and wound-healing supplements. The care plan was not updated with new skin interventions until 12/24, and the APM was not documented as in place until 12/29, despite being readily available. Throughout December, provider regulatory visits did not address the resident’s skin condition, and Braden scoring continued to rate the resident as low risk. By 12/30, skin assessments documented multiple unstageable pressure ulcers and additional MASD areas, with the sacral wound significantly enlarged and new pressure ulcers on the buttocks, while the IDT did not complete a comprehensive assessment of the initial buttock wound identified on 12/6 or its progression from MASD to pressure ulcer until after the resident was hospitalized in early January. The facility’s own policy on Skin Assessment & Wound Management required that when a new pressure wound is found, staff notify the provider, initiate a skin and wound evaluation, refer to dietary as needed, and review and update the care plan interventions. The record lacked evidence that these steps were carried out when the first open area was documented on 12/6 or as additional areas and worsening wounds were identified. The TAR showed that the first documented treatment for the developed skin breakdown did not begin until 12/17, despite earlier documentation of open areas and MASD. Recommendations from wound care providers for an APM and RD evaluation were not acted upon for weeks, and the IDT did not complete a pressure injury root cause analysis or comprehensive review of the wounds until after the resident had been transferred to the hospital and did not return. Interviews with nursing staff and leadership confirmed that the root cause analysis process was not initiated when the wounds first developed and that the RD was not notified in a timely manner of the need for nutritional evaluation related to the resident’s wounds.
Neglect of Resident with Mental Health Needs and Refusal of Care
Penalty
Summary
A resident with a history of schizophrenia, depression, and back pain was admitted to the facility with significant mental health needs and a self-care deficit. The resident consistently refused assessments, hygiene care, and interventions from staff since admission, including skin checks and bathing. Despite being identified as at risk for skin breakdown, malnutrition, and having altered mobility, the resident's refusals were documented, and staff reported ongoing concerns about her hygiene, malodor, and declining condition. The care plan included interventions such as regular skin assessments, turning and repositioning, and nutritional support, but these were not effectively implemented due to the resident's persistent refusals. Over a period of several weeks, the resident's condition deteriorated. Staff, including nurses and providers, noted malodor, suspected wounds, and poor hygiene, but were unable to perform thorough assessments or provide adequate care due to the resident's lack of cooperation. The resident remained mostly in bed, was unkempt, and had poor oral hygiene. Despite these observations and the resident's ongoing refusal of care, the facility did not escalate her care to a higher level or seek alternative interventions to address her worsening condition. Communication among staff, providers, and the interdisciplinary team acknowledged the refusals, but no decisive action was taken to ensure the resident's safety and well-being. The situation culminated when the resident called EMS due to dizziness, vomiting, and inability to move her lower extremities. Upon EMS arrival, the resident was found adhered to her mattress, covered in urine and feces, and in a severely neglected state. Hospital admission revealed malnutrition, maggots in the groin area, an embedded bra hook causing deep tissue injury, multiple pressure ulcers ranging from stage one to stage four, and significant skin tears. The facility and its staff were aware of the resident's refusals and deteriorating condition but failed to provide necessary care or transfer her to a higher level of care, resulting in a finding of neglect.
Removal Plan
- Completed a full house skin check audit.
- If a resident had refused, a skin check was done.
- Audited all care plans for refusing skin checks.
- Updated target behavior orders to include a section regarding refusal of cares, showers, and skin checks.
- Clinical team attends ACP meetings to discuss concerning behaviors and update care plans.
- Morning meeting agenda includes a section for refusal of care.
- In case of refusal staff updates the individual department team meetings, schedules care conference, does a behavior contract or other individual specific interventions.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with profound cognitive impairment and a history of elopement, who resided on a locked unit and required 24/7 supervision, was able to leave the facility without staff knowledge. The resident had a severe traumatic brain injury, lacked decision-making ability, and was identified as being at high risk for elopement, as documented in their hospital discharge summary, care plan, and elopement risk evaluation. The care plan included interventions such as monitoring a wanderguard, promptly answering door alarms, and keeping the guardian informed. On the day of the incident, the resident participated in an outdoor activity in the facility's parking lot to pet baby goats. During this activity, the activity director left the area to escort another resident back to the locked unit and asked the activity assistant to supervise the remaining residents, including the high-risk resident. The activity assistant, who was responsible for multiple residents, was not able to provide adequate supervision and did not notice when the resident left the area. The resident was later found by police on a busy street approximately a half mile from the facility. Interviews with staff, including the activity director, activity assistant, nursing assistant, LPN, and others, confirmed that the resident required close supervision due to impulsivity, mobility, and a tendency to elope. Staff acknowledged that the root cause of the incident was a lack of adequate supervision, particularly when responsibility for the resident was transferred between staff members. The facility's elopement policy required interventions for residents at risk, but these were not effectively implemented during the outdoor activity, resulting in the resident's unsupervised departure from the facility.
Failure to Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime, specifically an allegation of sexual abuse, to law enforcement as required by regulation and facility policy. A resident with significant vulnerabilities, including hemiplegia, cognitive impairment, and a history of trauma, reported being inappropriately touched by another resident. The incident was documented by the social services director and reported to the state agency, and the resident's provider and guardian were notified. However, there was no documentation or evidence that law enforcement was notified of the allegation. Interviews with facility staff, including the administrator and social services director, confirmed that the incident was not reported to law enforcement. The administrator stated that the decision not to report was based on the resident's refusal to involve the police, despite the facility's policy requiring the reporting of suspected crimes such as sexual abuse. Facility records, including incident reports and progress notes, consistently lacked any indication that law enforcement had been contacted regarding the allegation.
Failure to Update Care Plan for Elopement Risk
Penalty
Summary
The facility failed to revise the care plan to include a critical elopement-safety intervention for a resident with a history of wandering and severe cognitive impairment due to traumatic brain injury. The resident was admitted with orders to reside in a locked unit and was identified as being at high risk for elopement, requiring 24/7 supervision. Despite these known risks and a previous elopement incident at another facility, the care plan did not reflect the need for 1:1 supervision when the resident was taken off the locked unit. On the day of the incident, the resident was taken outside with staff to see animals and subsequently went missing from the front parking lot. Elopement protocols were initiated, and the resident was returned by police without injury. Interviews with staff and leadership confirmed that the root cause of the elopement was inadequate supervision and that the care plan had not been updated to include the newly implemented intervention of 1:1 supervision when off the locked unit, despite this being recognized as necessary after the incident.
Failure to Assess and Provide Trauma-Informed Care After Alleged Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to assess a resident with a history of post-traumatic stress disorder (PTSD), adjustment disorder, and other mental health diagnoses for additional trauma or psychosocial needs following an allegation of sexual abuse. The resident, who had been in the facility since 2004, was reported to have been touched inappropriately by another resident. Although the incident was reported to the state agency, and the resident's provider and guardian were notified, there was no documentation that a trauma assessment was completed after the incident. The resident's care plans identified her as being at risk for behavioral alterations related to trauma and PTSD, and interventions included considering past trauma and collaborating with psychology and social services. Despite these documented risks and the facility's policy on trauma-informed care, the most recent trauma assessment on record was over a year old and predated the incident. Interviews with facility staff confirmed that trauma assessments were expected after such incidents, but none was completed in this case. The social services director acknowledged the importance of trauma assessments post-incident but had only spoken with the resident, who declined to discuss the event further. Additionally, the resident's psychology provider was not notified of the incident, contrary to facility expectations and best practices. The provider stated she would typically be informed of such events to assess for signs of distress or behavioral changes. Facility policy required identification and care planning for trauma history, but the lack of a timely trauma assessment and communication with the psychology provider after the allegation constituted a failure to provide appropriate treatment and services for the resident's mental and psychosocial well-being.
Failure to Provide Ordered Nicotine Lozenges for Resident with Nicotine Dependence
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of nicotine dependence and traumatic brain injury received physician-ordered nicotine lozenges to address nicotine cravings. The resident had an active order for 2 mg nicotine lozenges to be given by mouth every hour as needed, but the medication administration record showed that from the beginning to the end of the month, no doses were administered. During interviews and observations, the resident expressed a desire for cigarettes, and staff confirmed that the nicotine lozenges were not available and had never been administered, despite the order being present in the system. Multiple staff members, including an LPN, the unit manager, the DON, and the administrator, were unaware that the prescribed nicotine lozenges were not available or being given. The facility's policy on medication errors did not specifically address the unavailability of physician-ordered medications as a medication error. The lack of access to the ordered medication was identified through record review, staff interviews, and direct observation of the resident's requests and staff responses.
Failure to Implement Daily Weight Monitoring for Resident with Malnutrition
Penalty
Summary
The facility failed to implement physician's orders for daily weight monitoring for a resident with a diagnosis of malnutrition, anemia, hip fracture, difficulty swallowing, and multiple pressure ulcers. The resident was admitted with a care plan that required daily weights, monitoring for signs of malnutrition, and reporting significant weight loss to the medical doctor. Despite these orders, the medical record showed only three weights documented over a two-week period, with no evidence of daily weight checks as required. The resident's condition was complex, including a history of poor nutrition, substance abuse, past gastric bypass, and ongoing wounds requiring increased protein intake. The resident was on a mechanical soft diet, received nutritional supplements, and had orders for a low sodium diet and diuretic therapy for edema. Staff interviews revealed that the resident typically ate 50-75% of meals, had difficulty swallowing due to missing teeth, and was considered frail by staff. However, staff did not notice any significant weight loss, and the registered dietician's notes did not provide direction for weight monitoring. Hospital records indicated a significant weight loss between the last documented facility weight and the hospital admission weight, with a drop from 101.1 lbs. to 77 lbs. within a short period. The facility's director of nursing acknowledged that staff failed to enter the daily weight orders correctly, resulting in the lack of daily weight monitoring. The facility's weight policy required accurate and regular weight monitoring to prevent avoidable decline in nutritional status, but this was not followed for the resident in question.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to maintain proper food storage and hygiene practices in the kitchen, which had the potential to affect all 98 residents, staff, and visitors consuming food from the main production kitchen. During an initial kitchen tour, it was observed that culinary staff were not wearing hair nets or facial hair covers, and personal staff items such as jackets were stored next to food items. Opened food items were not properly wrapped, labeled, or dated, and some were past their use-by dates. The walk-in cooler had fans with visible fuzzy matter, indicating a lack of cleanliness. The dishwashing process was also found to be inadequate. The dish machine did not reach the required temperature for sanitization, with readings as low as 102 degrees Fahrenheit, below the minimum required 120 degrees Fahrenheit. The sanitizer level was also found to be inadequate at times, and dishes were not allowed to air-dry properly before being stacked, which could lead to bacterial growth. Staff confirmed these observations and acknowledged issues with maintaining proper dishwashing temperatures and sanitizer levels. Interviews with the culinary director and dietary aides revealed a lack of adherence to facility policies regarding food labeling, storage, and hygiene practices. The facility's policies required food items to be labeled and dated, personal items to be stored separately from food, and staff to wear appropriate hair and facial hair restraints. The facility's failure to comply with these policies and maintain sanitary conditions in the kitchen posed a risk to the health and safety of residents, staff, and visitors.
Deficiencies in Resident Care and Coordination
Penalty
Summary
The facility failed to adequately assess and care plan for a resident's social and emotional well-being, specifically for a resident who wished to help in the dining area. Despite the resident's care plan indicating that assisting in the dining room was therapeutic, staff members repeatedly discouraged the resident from helping, leading to the resident feeling like they were in a prison. The care plan lacked detailed instructions on how the resident could assist, and staff were inconsistent in allowing the resident to help, citing concerns about state regulations. Another deficiency involved the facility's failure to assess and accommodate a resident's food preferences and dietary needs. The resident, who had a history of stroke and mild cognitive impairment, frequently refused a modified diet and requested regular-textured foods. Despite an order for a video swallow study to assess the resident's ability to safely consume regular foods, there was no evidence that the study was scheduled or completed. The facility also failed to explore alternative interventions to encourage the resident to adhere to dietary recommendations, leading to frequent disruptions during mealtimes. The facility also neglected to properly assess and document a resident's skin condition, particularly regarding dry, scaly skin on the resident's feet. Despite weekly skin inspections, the condition was not documented, and there was no evidence of interventions to address the issue. Additionally, the facility failed to coordinate care for a resident undergoing dialysis, resulting in missed insulin doses and blood sugar checks during dialysis days. There was a lack of communication with the dialysis center and the resident's provider regarding these missed treatments, which could potentially impact the resident's health.
Shower Room Ceiling Staining Issue
Penalty
Summary
The facility failed to maintain the first-floor shower room in a clean and sanitary condition, as evidenced by the presence of brown staining on the shower ceiling. This issue was observed during a survey and was reported by residents and staff. A resident with moderate cognitive impairment and two residents with intact cognition, all residing on the first floor, expressed concerns about the staining, with one resident fearing it might be black mold. The stain was described as a one-foot by one-and-a-half-foot area of small, various spaced and sized, black/brown stains above and to the right of the shower head. Interviews with staff revealed that the stain had been present for an extended period, with a housekeeping aide noting its presence since he started working at the facility a year ago. Despite attempts to clean the stain, it remained, and maintenance had been notified but did not address the issue. The regional director of maintenance, who was filling in after the previous director left, acknowledged a communication breakdown that may have contributed to the unresolved issue. The facility's maintenance request policy did not specify a timeline for completing such requests, which may have further delayed addressing the problem.
Lack of Private Phone Access for Resident
Penalty
Summary
The facility failed to ensure reasonable access to private phone use for a resident with moderately impaired cognition, who relied on the facility phone for communication. The resident expressed that staff allowed him to use the phone at the nursing station, but only for a few minutes, as it was frequently needed by staff for other calls. The resident also mentioned that sometimes he was not allowed to use the phone at all, which limited his ability to communicate with his family and discuss personal matters, causing him distress. Interviews with facility staff, including a nursing assistant and a licensed practical nurse, revealed that the only phone available for residents without personal phones was the one at the nursing station. This phone was located in a shared, non-private area at the intersection of three hallways, with no enclosed walls, and was often in use by staff. The facility administrator acknowledged that residents could use her office or the director of social services' office for private calls but admitted that staff had not been recently educated on offering these options. A policy regarding resident access to a private phone was requested but not provided.
Incomplete MDS Assessments for Cognition and Mood
Penalty
Summary
The facility failed to ensure the quarterly Minimum Data Set (MDS) was completed thoroughly for two residents, focusing on areas of cognition and depressive symptoms. For one resident, the quarterly MDS identified several medical conditions, including delusional thinking, depression, and schizophrenia. However, the sections for cognitive patterns and mood were left blank and not completed, indicating that the Brief Interview for Mental Status (BIMS) and mood interview were not conducted. The medical record lacked evidence of these evaluations being completed during the quarterly assessment reference date (ARD). Another resident, admitted with complex medical conditions such as seizure disorder, non-Alzheimer's dementia, depression, bipolar disorder, and post-traumatic stress disorder, also had incomplete MDS sections. The cognitive patterns and mood sections were marked as not assessed, and the medical record did not show evidence of these evaluations being completed during the ARD. The corporate director of reimbursement confirmed that the assessments were not completed, attributing the oversight to a newer social worker still learning the role. The facility's policy on MDS completion was requested but not provided.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to ensure that a Level I Pre-Admission Screening (PAS) and, if necessary, a Level II Pre-admission Screening and Resident Review (PASARR) were completed for a resident (R17) to screen for mental health needs. The resident's admission Minimum Data Set (MDS) indicated intact cognition, and the medical diagnoses included depression, anxiety, and post-traumatic stress disorder. However, the medical record lacked evidence of a final PASARR determination from the lead agency, Hennepin County, which was necessary for the resident's admission. Interviews with the senior linkage line representative and facility staff, including the receptionist and social services director, revealed that the PAS notice was not final, and the facility had not yet reached out to the county for the final determination. The facility's Pre-Admission Screening policy required social services to ensure the resident met the level of care for medical assistance payment before admission, and the nursing facility was responsible for maintaining a copy of the preadmission forms in the resident's medical record. The absence of the final PASARR in the medical record indicated a failure to comply with these requirements.
Failure to Provide Nail Care Assistance for Resident
Penalty
Summary
The facility failed to provide necessary assistance and equipment for personal hygiene care, specifically nail care, for a resident with moderate cognitive impairment. The resident, who required set-up assistance for grooming, was observed with long fingernails and expressed a desire to have them clipped. Despite this, the facility's records indicated that nail care was marked as 'not necessary' during weekly skin inspections, and there was no documentation of offers or refusals of nail care in the resident's medical record. The care plan for the resident lacked specific information regarding their preferences for nail length, and staff interviews revealed a lack of clarity and consistency in providing and documenting nail care. Staff members, including a nursing assistant and an LPN, acknowledged the resident's need for assistance with nail care and the availability of clippers, yet there was no evidence in the medical record of any attempts to address the resident's long nails until after the surveyor's observation. The facility's policy on maintaining abilities for activities of daily living, which includes grooming, was not adhered to, as evidenced by the lack of proper documentation and follow-up on the resident's nail care needs. This deficiency highlights a failure in the facility's processes to ensure residents receive appropriate care to maintain their abilities in daily activities.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care, including nail care and routine bathing, to two residents, R19 and R31. R19, who was dependent on staff for most ADLs due to a stroke, was observed with long, dirty fingernails and was not provided nail care before being taken to the dining room for breakfast. Despite the expectation that nail care should be done at least weekly during a resident's shower or bath, and that nails should be kept clean and trimmed in between, R19's nails remained unclean. R31, who was cognitively impaired and had a history of refusing care, was observed with dull, greasy hair. Despite her care plan indicating the need for encouragement and reapproach for bathing, there were no additional interventions in place to address her refusal to bathe. Staff acknowledged the difficulty in providing care for R31 and confirmed that her hair was dirty, yet no alternative methods, such as using dry shampoo caps, were attempted. The facility's policy on ADLs emphasizes the importance of person-centered care and maintaining residents' quality of life through proper grooming and hygiene. However, the observations and interviews revealed that the facility did not adhere to these standards, resulting in the residents' unkempt appearance and lack of personal hygiene care.
Failure to Coordinate Vision and Hearing Services
Penalty
Summary
The facility failed to coordinate cataract surgery for a resident with impaired vision, identified as R3, who had been complaining about poor eyesight. Despite the resident's guardian repeatedly expressing the need for cataract surgery and the resident's history of paranoia requiring accompaniment to appointments, the facility did not effectively communicate or coordinate with the guardian. The health information manager scheduled a cataract surgery consult without consulting the guardian, leading to the resident refusing to attend the appointment. The facility's phone system issues further complicated communication, and no policy on vision appointments was provided. Additionally, the facility did not address the loss of hearing aids for another resident, identified as R28, who had moderate cognitive impairment and had been fitted with hearing aids. The resident reported the hearing aids missing, and the audiology provider instructed the staff to search for them before requesting replacements. However, the facility's records lacked evidence of any follow-up actions to locate or replace the hearing aids. Interviews with staff revealed a lack of awareness and action regarding the missing hearing aids, and no policy on hearing aid replacement was provided. These deficiencies highlight the facility's failure to ensure access to necessary vision and hearing services for residents, as evidenced by the lack of coordination and follow-up on critical health appointments and equipment. The facility's communication issues and absence of relevant policies contributed to these lapses in care.
Failure to Provide Timely Podiatry Care for Resident
Penalty
Summary
The facility failed to ensure timely referral of a resident with long, hard toenails to the onsite contracted podiatry service. The resident, who had delusional thinking and required assistance with personal hygiene, was observed with long toenails and expressed a desire to see the foot doctor. The resident's guardian also noted the long toenails and had requested the care center to arrange a podiatry visit, but there was a delay in scheduling. The resident's care plan identified a potential for skin breakdown due to medical conditions, including hallux valgus, and recommended podiatry visits. However, the last recorded podiatry visit was several months prior, and the resident's medical record lacked evidence of any recent podiatry services being offered or refused. The health information manager, responsible for arranging podiatry visits, was aware of the resident's need but could not confirm why the resident was not on the list for the most recent podiatry visit. Interviews with staff revealed a lack of communication and documentation regarding the resident's need for podiatry care. The nursing assistant and licensed practical nurse manager were unsure of the resident's podiatry visit status, and the interim director of nursing was not informed of the issue. The facility did not provide a policy on podiatry appointments, indicating a systemic issue in managing podiatry services for residents.
Failure to Provide Routine Range of Motion Exercises
Penalty
Summary
The facility failed to provide routine range of motion (ROM) exercises for a resident with severe cognitive impairment and physical limitations due to conditions such as aphasia, stroke, and hemiplegia. The resident was dependent on staff for all activities of daily living (ADLs) and had a care plan intervention that directed staff to provide gentle ROM as tolerated with daily care. Despite this, there was a lack of documentation indicating that nursing staff provided the necessary ROM exercises, and interviews with staff revealed a lack of awareness and communication regarding the resident's need for ROM exercises. The resident's therapy evaluations and discharge summaries indicated goals to improve standing tolerance and transfer status, with recommendations for a functional maintenance program to maintain contractures. However, the resident's family member expressed concerns that the facility did not provide continuous ROM or exercises, leading them to perform stretching exercises during visits. Observations confirmed that the resident's right hand was limp, and they used their left hand to move it, indicating a lack of improvement in ROM. Interviews with nursing assistants and licensed practical nurses revealed a disconnect between therapy and nursing staff regarding the resident's exercise needs. The director of nursing confirmed that the care plan and kardex directed daily ROM, but the medical record lacked documentation of such care. The therapy program manager noted that the resident's care plan for ROM was in place before their current role, and there was no facility policy on ROM, contributing to the deficiency.
Failure to Implement Behavioral Interventions for Resident
Penalty
Summary
The facility failed to comprehensively assess and implement behavioral interventions for a resident with a history of throwing dining ware. The resident, who had severe cognitive impairment, hallucinations, delusions, and schizophrenia, was noted to have behaviors such as throwing plates and food in the dining area. Despite these behaviors being documented in the care plan, there was a lack of consistent monitoring and documentation of the resident's behavior. The care plan included an intervention to offer plastic plates as needed, but there were no clear parameters for when this should be implemented, and staff were unsure of the resident's triggers. Observations and interviews revealed that the resident's behavior of throwing dining ware was a common occurrence, yet it was not consistently documented in progress notes. Staff, including the culinary director and nursing staff, acknowledged the behavior but did not have a clear understanding of the reasons behind it or consistent strategies to address it. The director of nursing was unaware of the behavior until recently and questioned the documentation practices. The facility lacked a specific policy for behavioral management and tracking, contributing to the deficiency in providing necessary behavioral health care and services to the resident.
Failure to Use Appropriate PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was used for a resident who was on enhanced barrier precautions due to the presence of a feeding tube. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed being assisted by two nursing assistants. During the assistance, one nursing assistant wore gloves without a gown, while the other did not wear gloves or a gown. Both nursing assistants' scrubs came into contact with the resident's bed, and they did not wear gowns during the transfer of the resident from the bed to a wheelchair using a hoyer lift. Interviews with staff revealed a lack of consistent understanding and adherence to the enhanced barrier precautions. One nursing assistant acknowledged the requirement to wear gloves and gowns but admitted to not wearing a gown during the assistance. A licensed practical nurse indicated that gowns were only necessary for feeding tube care, not for transfers or personal care, which contradicted the facility's policy. The director of nursing expected staff to wear gowns and gloves during transfers and close care for residents on enhanced barrier precautions. The facility's policy required the use of gowns and gloves during high-contact resident care activities, including transferring, dressing, and device care.
Resident Information Left in Public View
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of resident information, as required by HIPAA standards. During an observation, a clipboard containing a care sheet with sensitive information about 48 residents was left in public view on the top counter of the nursing station. This care sheet included residents' full names and detailed information about their care needs, such as levels of assistance required, participation in special programs, behavioral issues, special precautions, and elopement risks. Residents and family members were observed walking past the clipboard, which was easily accessible and visible to them. Interviews with staff confirmed the breach of confidentiality. An LPN acknowledged that the clipboard was improperly placed in public view and contained private information that should not be accessible to everyone. The LPN suggested that the clipboard should be placed face down to prevent unauthorized viewing. The DON also confirmed that the facility's expectation was to keep any documents containing resident information out of public view to comply with HIPAA regulations. Despite a request, the facility did not provide a policy on HIPAA, indicating a potential gap in their documentation or training regarding privacy practices.
Failure to Timely Reorder Pain Medication Leads to Resident Withdrawal
Penalty
Summary
The facility failed to ensure timely reordering of a pain medication for a resident, leading to the resident experiencing withdrawal symptoms. The resident, who had a history of diabetic neuropathy and pain due to a left toe amputation, was prescribed Belbuca Buccal Film for pain management. However, the medication was not reordered in a timely manner, resulting in the resident not receiving the medication as scheduled from 1/1/25 to 1/2/25. The resident's medical record lacked evidence of follow-up with the pharmacy or notification to the provider about the medication shortage from 12/30/24 to 1/1/25. On 1/1/25, the resident experienced withdrawal symptoms and called 911, leading to hospitalization. The facility's staff, including LPNs and the Director of Nursing, acknowledged the failure to reorder the medication when a 5-7 day supply remained, as per facility policy. The pharmacist confirmed that a new prescription was needed, but it was not received until 1/2/25. The nurse practitioner was not informed of the situation until 1/2/25, and the resident reported that the nursing staff did not act when informed about the low medication supply.
Inadequate Monitoring After Unwitnessed Falls
Penalty
Summary
The facility failed to adequately monitor two residents following unwitnessed falls, leading to a deficiency in care. Resident 1, who had severe cognitive impairment and a history of stroke, experienced a fall on January 4, 2025, resulting in a bump on the forehead. The nursing note for this incident lacked details such as the size and description of the injury, and there was no documentation of treatment or ongoing monitoring, including neuro checks and vital signs, in the electronic medical record. Similarly, Resident 4, who had intact cognition and a diagnosis of type 2 diabetes mellitus, was found on the floor next to his bed on January 6, 2025. The nursing note did not indicate any injury or treatment, and there was no documentation of ongoing monitoring for injury or neuro checks following the fall. Interviews with facility staff, including an LPN, RN, and regional nurse consultant, confirmed the lack of proper documentation and monitoring following the falls. The staff acknowledged that neuro checks should be conducted for all unwitnessed falls and head strikes, and nurse's notes should be written every shift for 72 hours post-fall. The facility's Fall Prevention and Management policy also required neuro checks and monitoring for 72 hours after a fall. The failure to adhere to these protocols resulted in inadequate monitoring and documentation for both residents following their falls.
Failure to Train Staff on Emergency Door Access
Penalty
Summary
The facility failed to have a system in place to train staff on the process for unlocking the main entrance doors for emergency medical services (EMS) personnel after hours. This deficiency was highlighted when a resident, who was cognitively intact and required assistance for transfers, experienced difficulty breathing. Staff called 911, but when EMS arrived, they were unable to gain entrance to the building for approximately ten minutes due to locked doors. The delay was caused by the inability of staff, including agency staff, to locate and use the key to unlock the doors. Interviews revealed that the facility's front doors were locked at night due to security concerns, and only the nurse on the first floor had the key to unlock them. However, agency staff, who frequently covered shifts, were not trained on how to unlock the doors. This lack of training and communication led to confusion and delays in emergency response. Staff members assumed others would report the issue to administration, resulting in a lack of awareness among facility leaders about the problem. The fire department had experienced similar access issues during previous calls, indicating a recurring problem. Despite the facility's policy of locking doors for security reasons, there was no documented procedure or training for staff on how to manage emergency access. The deficiency placed all residents at risk for serious harm due to delayed EMS response, as evidenced by the incident involving the resident with breathing difficulties.
Lack of Privacy Curtains in Shared Rooms
Penalty
Summary
The facility failed to provide adequate privacy for residents sharing rooms, as evidenced by the lack of functional privacy curtains. Three residents, identified as R1, R3, and R6, were affected by this deficiency. R1, who was cognitively intact, reported never having a privacy curtain and expressed discomfort at having to watch his roommate being dressed and undressed by staff. This lack of privacy made R1 feel embarrassed and uncomfortable, especially during meal times. Observations confirmed that R1's room had a torn and unusable privacy curtain that did not shield him from his roommate's view. Additionally, R3 and R6's shared room was observed to lack privacy curtains entirely. R3, who had severe cognitive impairment, was exposed to R6's inappropriate behavior, as R6 was seen masturbating in the room. A nursing assistant acknowledged the lack of privacy and attempted to cover R6, who resisted. The facility's administrator admitted to not ordering privacy curtains, and the director of nursing confirmed that all rooms should have functional privacy curtains. Despite requests, the facility did not provide a policy for privacy curtains.
Failure to Provide Required Behavioral Health Training
Penalty
Summary
The facility failed to ensure that three out of five staff members, specifically nursing assistants NA-G, NA-H, and NA-I, received the required annual training on behaviors associated with Alzheimer's disease or related disorders, problem-solving with challenging behaviors, and communication skills. A review of their training transcripts revealed a lack of documentation indicating completion of this essential training. The Facility Assessment dated 7/3/24 indicated that the facility accepted residents with psychiatric and mood disorders and impaired cognition, and it stated that staff were to be trained annually on dementia management and care for cognitively impaired residents. During an interview on 8/12/24, RN-C and the Director of Nursing acknowledged that the mentioned nursing assistants had not received the necessary annual behavioral health training. Additionally, a behavioral health training policy was requested but not provided.
Lack of Staff Training on Communication with Non-English Speaking Residents
Penalty
Summary
The facility failed to provide adequate training for staff on communicating with non-English speaking residents, despite identifying two such residents in their care. A review of staff training records revealed that five staff members, including nursing assistants and nurses, lacked this specific training. Interviews with additional nursing assistants confirmed that they could not recall receiving any training on this topic, even though they acknowledged the presence of a non-English speaking resident in the facility. The Facility Assessment indicated that the facility accepted residents requiring interpreter services, yet it did not show that staff were trained annually on communication with non-English speaking residents. During an interview, a registered nurse and the director of nursing admitted that this area of training had been overlooked.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement Program (QAPI) to all staff, which included the goals, various elements of the program, and how the facility intended to implement it. The deficiency was identified through interviews and document reviews, revealing that five staff members, including nursing assistants and nurses, had not received any QAPI training. During interviews, several nursing assistants were unable to recall what QAPI was or any training related to it, indicating a lack of awareness and understanding of the program among staff. Further investigation showed that the facility's Quality Plan, dated August 23, 2023, outlined the need for quality improvement and communication of revisions to the governing board, residents, families, and employees. However, the QAPI meeting minutes from July 18, 2024, which detailed nursing responsibilities for various initiatives, did not indicate that mandatory training had been provided to staff. The director of nursing acknowledged the oversight in training, and the administrator was unaware of the lack of mandatory QAPI training.
Dishwasher Sanitization Failure
Penalty
Summary
The facility failed to ensure dishware was cleaned and sanitized properly, posing a risk of cross-contamination and foodborne illness for all 88 residents. During an initial kitchen tour, the dietary manager (DD) demonstrated the use of a low-temperature commercial dishwasher and chlorine testing for sanitization. The observed wash temperature was 118 degrees Fahrenheit, below the required 120 degrees, and the chlorine sanitizing strips provided inconclusive results. The facility's log for dishwasher temperature and chlorine measurements had multiple missing entries over several days, indicating a lack of consistent monitoring and documentation. DD admitted to being unaware of any issues with the dishwasher until the surveyor's observation. Interviews with various staff members, including dietary aides and the maintenance director, revealed that while they were aware of the testing and documentation procedures, there was a lack of communication and follow-through regarding the dishwasher's malfunction. The dietary aides confirmed that they were trained to test the dishwasher's sanitization properties at every meal and document the results, but the log showed significant gaps. The registered dietician and dishwasher representative emphasized the importance of proper sanitization to prevent illness. The facility's policy on dishwasher use did not provide clear instructions on using sanitizing strips, contributing to the oversight.
Failure to Implement TBP and Provide Infection Control Education
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) for a resident with symptoms of a respiratory illness, potentially affecting 23 residents on the unit. The resident, diagnosed with chronic obstructive pulmonary disease (COPD), exhibited increased coughing and other symptoms over several days. Despite these symptoms and negative COVID-19 tests, the resident was not placed on TBP, and staff did not wear personal protective equipment (PPE) when interacting with the resident. The resident was observed coughing in common areas without a mask, and staff did not take measures to limit the resident's movement or enforce respiratory hygiene protocols. Additionally, the facility failed to provide infection control education to two residents who were assessed for smoking. Both residents were observed sharing cigarettes, a practice that poses a risk of spreading infections. The staff member supervising the smoking area was unaware of the infection risks associated with sharing cigarettes and had not received training on this issue. The residents themselves were not informed about the potential infection risks of sharing cigarettes. The facility's policies on TBP and smoking did not adequately address the observed deficiencies. The TBP policy required the use of masks and private rooms for residents with respiratory symptoms, but these measures were not implemented. The smoking policy prohibited residents from giving or borrowing cigarettes but did not address the infection risks of sharing cigarettes. The Director of Nursing (DON) acknowledged the lapses in infection control practices and the lack of resident education on these issues.
Failure to Complete Self-Administration of Medications Assessment
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident who stored medication at their bedside. The resident, who had a history of delusional disorders, epilepsy, major depressive disorder, mild intellectual disabilities, insomnia, somatization disorder, bradycardia, history of falling, and thrombocytopenia, was observed self-administering medications without a current assessment or physician's order. The resident's quarterly Minimum Data Set indicated she was independent in making her own decisions and did not exhibit signs of delirium or hallucinations. However, her electronic medical record lacked an assessment for self-administration of medications, and her clinical physician orders did not include orders for self-administration of medications. During an interview, the resident stated that she took her medications on her own while eating, and a Licensed Practical Nurse (LPN) confirmed that the medications were left at the resident's bedside for her to take at her own pace. The LPN was unaware of any current assessment or order for the resident to self-administer medications. The Director of Nursing (DON) later revealed that the resident had a self-administration assessment done in 2016, which indicated she was unable to safely administer her own medications, and acknowledged that a current assessment and order were lacking. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration of medications was safe and clinically appropriate, which was not followed in this case.
Failure to Timely Address Broken Window Blinds
Penalty
Summary
The facility failed to ensure maintenance services were provided in a timely manner to address broken window blinds, compromising the privacy and homelike environment for two residents. Both residents, who had intact cognition, reported that the window blinds in their room had been broken for several months, exposing their room to public view. Despite multiple requests from the residents, no temporary measures were taken to cover the window, and the issue remained unresolved for an extended period. On two separate occasions, the broken blinds were observed by the surveyor, and both residents confirmed that no temporary solutions had been offered. A registered nurse and the maintenance director also verified the disrepair of the blinds. The maintenance director mentioned that parts had been ordered to fix the blinds but was unsure how long they had been broken. The work order for the blinds was created two months prior, but no actions had been taken to resolve the issue. The administrator acknowledged awareness of the broken blinds and the delay in getting them fixed, citing issues with custom-made parts and limited maintenance staff. The administrator mentioned that the facility had considered moving the affected residents to a different unit but had not yet done so. The administrator emphasized the importance of timely repairs to ensure residents' privacy and comfort but admitted that the issue had not been addressed promptly.
Failure to Provide Necessary Nail Care
Penalty
Summary
The facility failed to provide necessary nail care for a resident (R28) who required assistance with personal hygiene. R28, who had intact cognition and needed extensive assistance with activities of daily living due to a stroke, diabetes, and muscle weakness, was observed with overgrown and dirty fingernails. Despite R28's repeated requests for assistance with nail trimming, staff did not provide the necessary care. The resident expressed frustration over the condition of his nails, which had been long for a while and were bothersome to him. During interviews, staff members, including a nursing assistant and a registered nurse, acknowledged the resident's need for nail care but failed to provide it. The registered nurse noted the overgrown nails during a weekly skin inspection but did not document any refusal from the resident. The director of nursing confirmed that nail care should have been completed on bath days and as necessary, and emphasized the importance of regular nail care to prevent infection. However, the facility's nail care policy did not specify the frequency of nail care, contributing to the oversight.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,012 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Courage Kenny Rehabilitation Institutes Trp | 1.7 mi | ★★★★★ | 10 | 1 |
| Southside Care Center | 1.9 mi | ★★★★★ | 28 | 1 |
| Jones Harrison Residence | 2 mi | ★★★★★ | 19 | 0 |
| The Estates At Chateau Llc | 2.1 mi | ★★★★★ | 2 | 1 |
| Benedictine Health Center Of Minneapolis | 2.2 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.