The Estates At Twin Rivers Llc
For profit - Corporation
50 Beds
MONARCH HEALTHCARE MANAGEMENT
Data: November 2025
Trust Grade
40/100
#326 of 337 in MN
Photo by The Estates at Twin Rivers
Photo by The Estates at Twin Rivers
Photo by The Estates at Twin Rivers
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
The Estates At Twin Rivers in Anoka, Minnesota has a Trust Grade of D, indicating below-average care with several concerns. It ranks #326 out of 337 facilities in the state, placing it in the bottom half, and #6 out of 6 in Anoka County, meaning there is only one better option available locally. The facility's trend is worsening, with issues increasing from 9 in 2024 to 23 in 2025. Staffing is a notable weakness, with a 1-star rating and 49% turnover, which is average but still suggests a lack of stability. While the absence of fines is a positive sign, the RN coverage is concerning as it is lower than 98% of facilities in Minnesota, which means residents may not get adequate oversight from registered nurses. Specific incidents include failure to properly secure urinary leg bags, potentially leading to falls, and inconsistent food safety practices that could impact all residents' health. Overall, while there are some positive aspects, families should weigh the significant issues against the limited strengths when considering this facility.
- Trust Score
- D
- In Minnesota
- #326/337
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Minnesota facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Minnesota. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 4%
No red flags
9 → 23 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 23 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Minnesota average (3.2)
Significant quality concerns identified by CMS
Staff Turnover: 49%
Near Minnesota avg (46%)
Higher turnover may affect care consistency
Chain: MONARCH HEALTHCARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 38 deficiencies on record
May 2025
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to implement interventions to maintain a dignified appea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to implement interventions to maintain a dignified appearance related to the failure to properly secure urinary leg bags for 1 of 1 residents (R28) reviewed for urinary catheter.
Findings include:
R28's admission Minimum Data Set (MDS) dated [DATE], indicated R28 had moderate cognitive impairment and required assistance with activities of daily living (ADLs) including dressing, grooming, bathing, and transfers. R28 was noted to have an indwelling catheter. R28's medical diagnoses included an artificial opening of the urinary tract (nephrostomy tubes-tubes which drain urine from the kidneys), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland which can lead to various urinary problems in men), renal insufficiency (a condition which the kidneys are not functioning at their full capacity), urinary tract infections, diabetes (a group of diseases which affects how the body uses blood sugar), specialized disorders of the bladder, and dementia.
R28's care plan printed 5/21/25, identified R28 was on enhanced barrier precautions related to nephrostomy bag, was a fall risk related to nephrostomy tubes (a tube inserted through the skin directly into the kidney that drains urine when the urine is unable to leave the body normally), had alteration in mobility related to nephrostomy tubes, and had self care deficit related to bilateral nephrostomy tubes. R28's care plan lacked direction as to management of the nephrostomy bags, cares to be provided to the sites, and direction as to securing of nephrostomy bags for resident to maintain dignity and prevent falls.
The Group one (1) CNA (certified nursing assistant) work list, updated 5/21/25, identified R28 was dependent with toileting and had nephrostomy tubes. The list lacked any further direction to staff as to how provide cares for the nephrostomy tubes and bags.
On 5/19/25, at 3:59 p.m., R28 was observed seated in his wheelchair near the Transitional Care Unit (TCU) nurses station. R28 was positioned near the medication (med) cart and the wall. R28 was observed to have a urinary leg bag coming out of his left pant leg laying on the floor, with R28 observed dragging it as he self propelled his wheelchair. NA-A stopped to assist R28, but then stepped away to wash hands as had not been wearing gloves. NA-A requested licensed practical nurse (LPN)-B provide assist to R28. LPN-B proceeded to push the resident NA-A was assisting to her room, leaving R28 near the nurses station with the leg bag on the floor. LPN-B then returned to assist R28 to his room to secure leg bag.
On 5/19/25 at 5:17 p.m., an interview was completed with LPN-B, she had assisted R28 to his room and placed his leg bag back on his leg and tightened the strap. LPN-B stated the concern for leg bag being on the floor was related to bacteria and germs.
On 5/22/25 at 10:36 a.m., R28 was observed as he received personal cares. NA-B proceeded to secure nephrostomy bags to R28's legs. The band NA-B was using was a wider width, approximately two inches, such as a band used to secure a catheter tube to the upper thigh. NA-B identified when using a leg bag, there were usually straps which threaded through the leg bag, however, these straps were not available. NA-B stated the straps provided were too large for the bags to secure well to R28's legs. NA-B stated the straps did not work well to maintain the leg bag in place, and the leg bags slid down, at times out of pant legs. NA-B stated it was a concern when the leg bags slid down as the bag would pull on the tubes (nephrostomy tubes). NA-B stated they needed to make sure the (nephrostomy) dressings remained in place and free from drainage. NA-B stated she had asked about different straps, but this is what they give us.
During interview on 5/22/25 at 11:32 a.m., LPN Clinical Coordinator (CC) stated R28's leg bags should be secured properly on his legs and should not be on the floor due to concerns with dignity, as well as concerns for infection control. CC stated the leg bags should be out of view. CC stated it was her expectation if a leg bag was observed to be laying on the floor, they should be immediately assisted to their room to secure the bag properly. CC stated they have tried a variety straps, they have tried to find the best fit. CC stated she was unaware the current strap was not working effectively.
During interview on 5/22/25, at 11:50 a.m., director of nursing (DON) stated the urinary leg bag should not be on the floor. DON stated the leg bag should be secured. She added, they typically came with a strap for the top and for the bottom, and stated she was unsure why this was not being used. DON identified concerns for infection control as well as for dignity of the resident.
A facility policy, Indwelling Catheter Care Procedure, dated 7/21/23, was provided upon request for care of urinary drainage bag management policy. This policy lacked information as to management of urinary drainage bag, including placement and process to secure, to ensure privacy and dignity. Upon request for a policy for maintaining resident dignity, the facility provided the document Combined Federal and State [NAME] of Rights, revised 6/18/19. Within the document, it identified the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The documented identified the facility must protect and promote the rights of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain proper consent for use of psychotropic medicati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain proper consent for use of psychotropic medications (a drug which affects behavior, mood, thoughts or perception) for 1 of 5 residents (R35) reviewed for unnecessary medications.
Findings include:
R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 had impaired cognition. R35 was noted to receive assist with activities of daily living (ADLs) including dressing, grooming, bathing, and mobility. R35's medical diagnoses included unspecified encephalopathy (brain disease, damage, or malfunction which encompasses a range of conditions that could cause brain dysfunction, which might manifest as confusion, memory loss, personality changes, or severe symptoms like coma), cancer, atrial fibrillation (an abnormal heart rhythm which has been known to lead to complications including stroke, blood clots, and heart failure), hypertension (high blood pressure), arthritis (inflammation of joints), dementia, anxiety, depression, visual hallucinations (seeing something that is not there), adjustment disorder with anxiety, chronic pain syndrome, and fibromyalgia (symptoms of widespread chronic pain, headaches, depression and other symptoms).
R35's care plan printed 5/22/25, indicated R35 had alteration in cognition related to confusion, disorientation to place and time. Poor insight to her deficits or cognitive loss. Poor historian. Sundowning type behaviors of crying and calling out. Has decreased in intensity since admission. The problem statement identified R35 had the diagnosis of major neurocognitive disorder, with behavioral disturbance, encephalopathy due to medical illness (various infections), visual hallucinations, and low vision due to retinal pigmentation disease. The care plan directed staff to follow recommendations from mental health provider. The care plan lacked indication of medications used to aide with mood state and behavior.
R35's Medication Administration Record (MAR), printed 5/20/25, indicated R35 received the following medications:
- lorazepam 0.5 milligrams (mg) by mouth one time a day for agitation. Start date of 4/3/25. (benzodiazepines used for anxiety).
- lorazepam 0.5 mg by mouth every four hours as needed for anxiety or agitation for six months. Start date 4/3/2025.
- risperidone 1 mg by mouth at bedtime for agitation/delirium. Start date of 5/5/25. (antipsychotic- works by changing certain signals in your brain which affect how you feel and act).
- risperidone 0.5 mg by mouth two times a day for delirium/ agitation. Start date 5/5/25.
R35 was noted to receive Lorazepam on 13 occasions in April, with results marked as effective on 10 of the 13 occasions used. This was noted to be used on two occasions in May (5/9/25, 5/13/25) with effective results on each occasion. The May MAR was reviewed for the dates of 5/1/25-5/20/25.
A review of R35's medical record lacked indication informed consent had been received from R35's responsible party upon admission to the facility, as well as with change of medication dosing/frequency.
On 5/20/25 at 3:52 p.m., R35 was observed in her room, resting on her bed, with blanket in place. R35 had a visitor in her room, playing her guitar, and singing to resident. Resident was observed to be awake and was interacting with her visitor.
During interview on 5/22/25 at 1:46 p.m., the director of nursing (DON) stated completion of an informed consent was typically completed within the first week following admission if a resident was admitted on a psychotropic medication. DON stated this was typically completed by the floor nurse, however, if it had not been completed within that time frame, it was followed up on by either the licensed practical nurse, clinical coordinator (CC) or the DON. DON stated consents were to be obtained when new medications were added, as well as updated when changes were made in dosage and frequency of existing meds. A request was made for the documentation of informed consent for both risperidone and lorazepam, which were unable to be located in the medical record. DON stated she also did not find them uploaded on the record. DON stated it was important to receive informed consent for psychotropic medications, as they are medications which have the potential to have more adverse (negative ) side effects than other medications, and it is important to notify the responsible part of the possible side effects.
The facility policy, titled Psychotropic Medication Use Policy, created 4/25, identified the facility would
a. Obtain informed consent from the resident and/or resident representative and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice.
b. Discuss any advance directives that the resident has formulated to provide care consistent with resident choice.
c. The resident and/or responsible party will be notified regarding dose changes.
d. This will be documented in the progress notes.
e. Consents and any psychotropic medications will be reviewed quarterly at resident care conferences.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the failed to facilitate resident preferences for bathing and meals for 1 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the failed to facilitate resident preferences for bathing and meals for 1 of 1 resident (R27) reviewed for choices.
Findings include:
R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact. The assessment identified R27 received assistance with activities of daily living (ADLs) including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). The MDS identified it was very important to R27 to choose between a tub bath, shower, bed bath, or sponge bath, and somewhat important to choose what clothes she wished to wear. R27's medical diagnoses included multiple sclerosis (MS), malnutrition (an imbalance of energy and nutrients consumed), thrombocytosis (increase platelet count), pseudobulbar affect (a condition characterized by uncontrollable and inappropriate episodes of laughing or crying, often disconnected from person's actual emotion state). R27 received routinely schedule pain medication, as well as availability of additional pain medication as needed.
R27's care plan with a print date of 5/21/25, identified R27 had the potential for alteration in nutrition related to MS, severe protein calorie malnutrition and dyspepsia (indigestion). The goal for R27 was for her to meet estimated nutrient needs, and to either maintain weight or gain weight to ideal body weight range. The care plan directed staff to provide diet as ordered by the provider. Staff were also encouraged to monitor food and fluid intake per facility protocol and encourage adequate fluid intake. The care plan directed staff to offer fluids and snacks between meals. R27's care plan also identified R27 had a self care deficit related to post surgical status, weakness and MS. The goal indicated R27 will accept assistance with self cares and will be dressed, groomed, and bathed per preferences. The care plan directed staff to follow through with instructions provided by occupational therapy. Staff were also directed to provide with assist of one with dressing and bathing. R27's care plan also identified R27 had alteration in mobility related to post surgical status, weakness and MS. The care plan directed staff R27 was to receive physical therapy (PT) as per doctors orders, and instructed staff to follow PT instructions. The care plan indicated R27 was to receive assist with movement in and out of bed and was to receive assist of one with transfers, however lacked further instructions. Although R27's care plan indicated R27 was on enhanced barrier precautions (increase precautions implemented to prevent the spread of infection) related to surgical incisions, the care plan lacked indication as to how the surgical sites were to be managed, additionally lacked any restrictions in showering related to incisions.
The Nursing Assistant care sheet dated 5/21/25, indicated R27 was to receive assistance to transfer with an EZ stand (a mechanical lift to aid in transfers) and did not ambulate. The NA care sheet outlined R27 required assist of one with dressing, bathing, toileting, and required set up for grooming and eating. The care sheet provided no additional instructions to staff for provision of care.
On 5/19/25 at 5:48 p.m., R27 was served her evening meal. Family member (FM)-A was present in room and asked R27 what she was having for supper. R27 stated she was unaware of what she was having for supper, as she had not ordered the meal selection. R27 uncovered plate and stated it was a tuna fish sandwich and she did not wish to eat this. R27 observed the coffee came without sugar and cream, which she has requested be with meals, and there were also no straws on the tray for resident use with all beverages. R27 placed her call light on to request missing items on tray. R27 stated she was unaware of what the food choices were as she had no menu in her room. R27 stated there was an alternate menu available, however, the evening meal must be ordered by 3:00 p.m. in order to receive this. R27 stated she was unsure what alternatives were available or how to order them. R27 stated she had no special diet, and had been struggling with weight loss. R27 stated she was to receive two supplements per day to help nutrition, but was unsure she had received them consistently. R27 was noted to have liquid protein supplement drinks in her room, however, R27 they were brought in for her by her friend.
On 5/19/25 at 5:58 p.m. R27 expressed frustration she had not received a bath/shower since she had arrived. FM-A affirmed that R27 had doctor's appointments last week and wished to receive a bath/shower before going to her appointments, however, had not received assistance. R27 stated an unidentified certified nursing assistant (NA) came in to provide assistance with a sponge bath, however, R27 wanted a shower to be able to wash her hair as it had not been washed in the weeks since admission. R27 stated the NA put it down that she refused her bath. R27 reported when she asked when she could receive a shower, was told she had to wait for the next shower day. R27 stated Nobody knows how to do a shower. R27 stated neither PT/OT had worked with her regarding the transfer required for completing a bath and shower. FM-A stated R27's hair had not washed since admission and R27 had expressed desire to shower prior to appointments due to lack of bathing since admission, and desire to be clean for medical appointments.
On 5/20/25 1:01 p.m., R27 had been delivered her noon meal. R27 stated the tray lacked sugar and cream for coffee, as well as straws to use with her beverages. R27 stated she had requested this from staff however, they had not returned with the items. R27 stated this was the same case with breakfast. A tray slip was observed on resident tray, which identified R27 requested sugar and cream for coffee, and straws for all beverages. R27 stated she was unaware she was scheduled to receive a bath this afternoon, however, stated she would like her hair washed and linens changed.
On 5/20/25 at 4:10 p.m., R27 was observed in her room. R27 stated the shower was completed and hair was washed twice. R27 identified the linens were placed back on bed properly, however, noted they had not been changed.
On 5/20/25 at 3:49 p.m., an interview was held with both registered dietitian (RD) and regional culinary director (RCD), about availability of menus and the Bistro option for alternates. RD stated residents were provided with a regular menu and bistro menu upon admission. RD was unsure as to when updated menus were provided to those who remained in their rooms for meals. RD and RCD both stated the Bistro menus were available in the dining room for ordering alternatives. RD was unsure if Bistro menus were delivered to rooms for those who did not dine in the dining room. RD stated if there were specific requests by a resident, this was indicated on the tray slip and these requests should be facilitated by the dietary staff. R27's tray slip was reviewed at time with RD, and it was noted although the preferences/requests were on the dietary slip, it was not identified in the place where it was normally listed.
During interview on 5/21/25 at 9:27 a.m., physical therapy assistant (PTA)-A stated she participated in the therapy for R27. At present time, PTA-A stated they were working with R27 on core strength, transfers into and out of bed, and in/out of wheelchair. PTA-A stated they were also working on range of motion (ROM) for lower extremities and joint mobility. PTA-A stated R27 has been an EZ Stand transfer for nursing staff since 4/29/25. Occupational therapist (OT)-A joined the conversation and stated both PT/OT are working with wheelchair positioning. OT-A stated OT-A does not have a specific goals for showers. OT-A stated she had not been informed by nursing staff of any concerns regarding showers, therefore, that had not been part of the therapy plan.
During interview on 5/21/25 at 10:08 a.m., the clinical coordinator (CC)-A stated R27 had received assistance to complete bathing on 5/20/25. CC-A stated R27 was unable to complete showers/baths prior to that time related to incisions on her stomach following a laparoscopic procedure (A procedure completed with a scope through several small incisions on the abdomen). CC-A stated R27 required clearance from the medical provider because of the laparoscopic incisions. CC-A stated they had offered to complete a shower on an earlier occasion however, R27 had declined the shower related to the time of day. CC-A stated if it is not their shower day, staff were instructed to accommodate the request if we had extra time. CC-A stated she would expect staff would have offered it multiple times until she agreed to it. CC-A stated lack of shower, or washing of hair, for extended time would not feel very good. Residents were assigned a time for bathing/showering based on their room placement. They tried to work with residents a different day/time was requested however, it was not always possible. CC stated she was unaware of any concerns regarding bathing status until resident care conference on 5/15/25. CC stated R27 had received sponge baths since her admission however, she was unsure if her hair was washed. CC stated when there were recommendations for OT/PT this was relayed to staff. CC stated if staff had concerns with provision of care, PT/OT was consulted. CC stated when trays were delivered to residents in their room, it would be her expectation for staff to respond to requests made by residents upon receipt of their tray.
During interview on 5/21/25 at 4:54 p.m., the director of nursing (DON) stated baths were scheduled on a weekly basis. This was completed based on their designated time based upon room placement. DON stated if the resident did not care for the time slot, there may be some flexibility in adjusting it, however, that was not always possible. DON stated We try to be flexible but there is only so much wiggle room in that. If a bath was refused, and it was requested on another day, and the aides had time, it may occur, otherwise the next bath/shower would be completed the following week on the routinely scheduled time. Upon inquiring why a shower was not completed for R27, DON stated that if the person had a laproscopic surgery, they would not have a shower if there were restrictions placed per the doctor's orders upon admission or following the procedure. If there were not restricted orders, the individual could receive a shower. A request was made for verification of orders in place upon admission to abstain from showers, however, DON failed to provide order which identified shower restrictions were in place upon admission.
Upon review of R27's After Discharge Orders, from 4/28/25, the notes indicated resident had a laparoscopic procedure, however, had not restricted resident from receiving showers
A review of the standing orders, filed 5/20/25 electronically, lacked indication for shower restrictions for those with laparascopic surgical sites. The document did refer to the policy Skin and Wound Management. The document, not labeled with R27's name, was identified as being signed by the provider 2/1/25.
A review of the policy, Skin Assessment and Wound Management, dated 2/25 lacked indication as to management of a laparoscopic surgical site.
The facility policy, titled Activities of Daily Living (ADL's) Maintain Ability Policy, dated 3/31/23, was reviewed. The statement of intent reads as follows:
It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident ' s quality of life by ensuring all
staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident ' s preferences, choices, values and beliefs. Upon review of the procedure, the policy indicated: The facility will provide care and services for the following activities of daily living: . d. Dining-eating, including meals and snacks, . The policy also identified: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, .
A policy was requested for resident choices and food preferences, but was not received.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to consistently provide clean bed linens for 1 of 1 res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to consistently provide clean bed linens for 1 of 1 residents (R27) reviewed for choices and provision of assistance with activities of daily living (ADLs).
Findings include:
R27's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R27 was cognitively intact. The assessment identified R27 received assistance with ADLs including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). R27's medical diagnoses included multiple sclerosis (MS) and malnutrition (an imbalance of energy and nutrients consumed.
R27's care plan dated 5/2/25, identified R27 had a self care deficit related to post surgical status, weakness and MS. The goal indicated R27 will accept assistance with self cares and will be dressed, groomed, and bathed per preferences. R27's care plan also identified R27 had alteration in mobility related to post surgical status, weakness and MS.
On 5/19/25 at 5:58 p.m., R27 expressed frustration she had not received a bath/shower since she had arrived and expressed frustration regarding lack of change of bed linens. R27 stated she was unsure as to when the bedding had last been changed. R27 routinely remained in bed for meals due to mobility concerns.
During interview on 5/20/25 at 1:01 p.m., R27 stated she was unaware she was scheduled to receive a bath this afternoon however, stated she would like her hair washed and linens changed. R27's bottom sheet had come off at the foot of the bed, and linens were noted to have small bread like crumbs and some tannish colored coffee spills on the top sheet. R27 ate all meals sitting in bed due to mobility concerns.
On 5/20/25 at 3:10 p.m., it was noted R27's bedding was placed back on the mattress and was folded back, however, linens had not been changed, as evidenced of by tannish colored spots on bedding previously observed.
On 5/20/25 at 4:10 p.m., R27 was observed back in her room. R27 stated the shower was completed and hair was washed twice. R27 identified the linens were placed back on bed properly, however, noted they had not been changed as the same tannish spots previously noted remained in the same location on the sheets.
During interview on 5/21/25 at 10:08 a.m., the clinical coordinator (CC)-A stated linens should have been changed while she was in the shower. CC-A stated linen changes were done routinely on bath days, and in between as indicated if they were soiled.
The facility policy, titled Activities of Daily Living (ADL's) Maintain Ability Policy, dated 3/31/23, was reviewed and the statement of intent reads as follows:
It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident ' s preferences, choices, values and beliefs. The policy lacked information regarding maintaining a clean, hygienic environment for residents, including provision of fresh bath and bed linens.
A facility policy for change of bed linens was requested and was not provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a baseline care plan was developed to ensure all care need...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a baseline care plan was developed to ensure all care needs were adequately addressed for 1 of 1 residents (R29) reviewed for range of motion.
Findings include:
R29's admission Minimum Data Set (MDS) dated [DATE], indicated R29 experienced moderate cognitive impairment. R29 was identified to have functional limitation of range of motion on one side with impairment on one side. R29 required assistance with activities of daily living (ADLs), including dressing, grooming, bathing, and mobility. R29's medical diagnoses included sequalae of cerebral infarction (details of cerebral infarction (stroke-and its effects it can cause to the brain including, but not limited to, change in mobility, loss of movement of one side of the body, vision problems, memory loss and difficulty with problem solving, emotional and behavioral changes, and seizures), heart failure (a condition where the heart is not able to pump enough blood for the body's needs for blood and oxygen), hypertension (high blood pressure), diabetes (a group of diseases which affects how the body uses blood sugar), muscle weakness, difficulty in walking and unsteadiness of his feet.
A review of R29's medical record was completed. R29 was admitted on [DATE] (Friday). R29's 48-hour care plan was initiated on 2/3/25 and locked (no further entries were allowed) on 2/14/25.
R29's 48-hour care plan identified the following:
Self-care deficit related to L(left) side(d) weakness, impaired vision:
The following goals were identified for R29:
Resident will accept assistance with self-cares.
Resident will be dressed, groomed and bathed per preferences.
The following interventions were also identified:
Occupational Therapy (OT) per MD (medical doctor) order
Follow OT instructions.
Assist with bathing with assist of one.
Assist with dressing (Specify) [There were no specific interventions identified with this.]
Mobility: Alteration in mobility related to left (L) sided weakness and impaired vision.
The following goals were identified:
Resident will move safely within their environment.
The following interventions were outlined:
Physical Therapy (PT) per MD order.
Follow PT instructions.
Assist with ambulation (Specify) [There were no specific interventions identified with this.]
Assist with movement in bed and in/out of bed. [There were no specific interventions identified with this.]
Assist with transfers with one to two assist. [The care plan lacked specification whether transfers were to be completed with one or two.]
Fall Risk related to (L) side weakness, impaired vision:
The following goals were identified:
Resident will be safe and free from falls.
The following interventions were included:
Follow PT and OT instructions for mobility function.
Follow resident specific fall prevention plan:(Specify) [There were no specific interventions identified with this.]
Monitor and document on safety. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if
possible. Educate resident/family/ caregivers/IDT (Interdisciplinary Team) as to causes.
Alteration in elimination:
The following goals were identified:
Resident will be continent during waking hours.
Resident will continue to have at least one (1) continent void daily (qd).
Resident will be free from signs/symptoms of UTI (urinary tract infections). [The care plan lacked indication of what symptoms were to be monitored for.]
The following interventions were identified:
Assist of one (1) with toileting.
Provide assistance with peri-cares morning (AM), bedtime (HS) and as needed (PRN).
Provide incontinent products and assist to change PRN.
Alteration in psychosocial well-being. Resident is adjusting to nursing home placement, change in routine, and care needs:
The following goals were identified:
Resident's psychosocial needs will be met.
The following interventions were identified:
Will monitor safety concerns and evaluate PRN: smoking, elopement, suicide risk etc
Will monitor mood state, refer PRN.
Will monitor and respond to unmet needs.
Alteration in Cognition. On 12/4/24 Resident was psychologically assessed in hospital and was determined that resident has insight deficits in terms of his stroke and function. Resident DX cerebral infraction, hyperlipidemia, type 2 diabetes, essential hypertension, chronic heart failure.
The following goals were identified:
Resident will communicate his/her basic needs as able.
The following interventions were identified:
Allow resident time to communicate his/her needs/wants.
Document changes in orientation.
Alteration in mood and behavior. Resident has hx of visual hallucinations and hx of insomnia. Verbalizes sexual comments to female staff. Refuses medications. DX (diagnosis) cerebral infraction, hyperlipidemia (high level of cholesterol-lipids/fats in the bloodstream, type two (2) diabetes, essential hypertension, chronic heart failure:
The following goals were identified:
Resident will respond to interventions by staff to calm and redirect.
Resident's mood/behavioral state will remain stable.
The following interventions were identified:
MDS section D/PHQ 9 will be conducted per regulation and PRN.
Monitor and document mood state/behaviors upon occurrence. Non-Pharm (pharmacological-interventions completed which do not include medications).
Inform resident that comments are inappropriate. Change subject to topic related to his family or therapy goals.
Redirect prn.
Provide emotional support, validation, and comfort measures prn.
Resident will have an appropriate discharge plan. Resident will have appropriate discharge plan. Resident is at risk for long term care. Resident diagnosis (DX) cerebral infraction, hyperlipidemia, type 2 diabetes, essential hypertension, chronic heart failure.
The following goals were identified for R29:
Resident/family will make safe and appropriate decisions regarding d/c (discharge).
The following interventions were indicated:
Staff will make necessary referrals as needed in order to carry out resident's d/c goals.
Resident is categorically a vulnerable adult while resident resides in a Skilled Nursing Facility. Resident is at risk for decreased cognitive and physical abilities related to diagnosis including: cerebral infraction, hyperlipidemia, type two (2) diabetes, essential hypertension, chronic heart failure.
The following goal was identified:
Resident will remain free from abuse and/or neglect through his next review.
The following interventions were identified:
Monitor for signs of emotional distress or mood and behavior changes.
Safety monitoring will be implemented as needed to ensure residents safety (i.e. 15 min checks,1:1, etc.)
Staff will continue to follow the facility vulnerable adult & abuse reporting policy.
The local Ombudsman, Adult Protection, Police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.
R29's MHM 48 Hour Baseline Care Plan, dated 2/1/25, identified several sections to record R29's needs and the care plan interventions which would be provided. However, the following sections of the care plan were left blank and not completed:
Communication
Nutrition
Psychotropic Medication Use
Respiratory
Skin
Hospice
Dialysis
Smoking and,
Enhanced Barrier Precautions.
The baseline care plan lacked indication R29 was a type two diabetic, with nutritional needs, insulin administration, and lacked instruction to staff for monitoring of blood sugars to be provided by staff. The care plan lacked direction to staff to monitor for signs and symptoms of hyper or hypoglycemia (High or low blood sugar). Additionally, although resident was identified as having visual impairment, the care plan lacked any goals or interventions regarding the impairment itself, only how it may increase potential for falls.
During interview on 5/23/25 at 1:05 p.m., director of nursing (DON) verified R29's care plan had not been completed within 48 hours. DON stated this was to completed at the time of admission and was to have been completed within that time. This was to completed by the nurse who admitted the resident. DON stated the 48 hour baseline care plan was important and it determined what care was needed by the staff, and directed staff on how to complete the care.
A facility policy was requested for the development of a 48-hour care plan, but was not received.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview and document review, the facility failed to revise resident care plans with updated interventions for 1 of 1 residents (R27) reviewed for choices and activities of dail...
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Based on observation, interview and document review, the facility failed to revise resident care plans with updated interventions for 1 of 1 residents (R27) reviewed for choices and activities of daily.
Findings include:
R27's admission Minimum Data Set (MDS) assessment, dated 5/2/25, indicated R27 was cognitively intact. The assessment identified R27 received assistance with activities of daily living (ADL's) including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). The MDS identified it was very important to R27 to choose between a tub bath, shower, bed bath, or sponge bath, and somewhat important to choose what clothes she wished to wear. R27's medical diagnoses included multiple sclerosis, malnutrition (an imbalance of energy and nutrients consumed), thrombocytosis (increase platelet count), pseudobulbar affect (a condition characterized by uncontrollable and inappropriate episodes of laughing or crying, often disconnected from person's actual emotion state). R27 received routinely schedule pain medication, as well as availability of additional pain medication as needed.
R27's care plan, print date of 5/21/25, identified R27 had alteration in mobility related to post hysterectomy (surgical removal of uterus), weakness, and MS (multiple sclerosis- a disease that causes breakdown of the protective covering of nerves. Multiple sclerosis can cause numbness, weakness, trouble walking, vision changes and other symptoms). This was initiated on 5/2/25. The care plan directed staff to follow ACP (Associated Clinic of Psychology) recommendation to offer reminders re: her options re: (regarding) transfers and offer of reassurance from staff. The care plan identified R27 was to receive physical therapy (PT) per medical doctor (MD) and to follow PT instructions. Staff were directed to assist with movements in bed and in/out of bed. Staff were directed to assist with transfers with assist of one. The care plan also identified R27 had a self-care deficit related to post hysterectomy, weakness, MS. The goal statement indicated resident will be dressed, groomed and bathed per preferences. The identified R27 was to receive occupational therapy (OT) per MD (medical doctor) and staff were directed to follow OT instructions. The care plan identified R27 was to receive assist of one with bathing and dressing. The care plan lacked information regarding resident's transfer into/out of wheelchair, wheelchair positioning, and amount of time to be up in wheelchair. Although the care plan indicated R27 was to be dressed, groomed, or bathed per preferences, the care plan lacked direction as to what R27 had expressed as her preference. The care plan lacked any direction as to work with R27 with transfers and mobility related to side effects of MS. Additionally, the care plan lacked direction to staff as to how bathing was to be completed, and how dressing changes were to be managed. R27 was admitted after she had undergone a laparoscopic hysterectomy and had four small surgical sites which were covered with dressings.
A therapy communication from physical therapy, dated 4/29/25, indicated R27 was to be transferred with use of an EZ stand (a mechanical lift used to assist with transfers). The form indicated R27 was to be up in chair three times a day.
The nursing assistant care sheet, updated 5/21/25, indicated R27 was to transfer with the EZ stand and did not ambulate. The care sheet also identified R27 received assist of one with dressing, bathing, and toileting. The care sheet indicated R27 received assist for set up for grooming and eating. The care sheet indicated R27 was able to make her needs known. The care sheet lacked direction to assist R27 up in the chair three times a day. The care sheet lacked any information as to any interventions to be implemented to make the transfers and mobility go easier.
On 5/19/25 at 5:55 p.m., R27 stated the certified nursing assistants (CNA) don't know how to transfer, position, perform her cares, or move her due to her rigidity. R27 stated the staff were unsure how to transfer her to and from bed/wheelchair. R27 stated she had spastic rigidity (a response when it was difficult to flex joints related to the spasm). R27 stated if allowed time, she was able to relax and move as needed, however, stated were not allowing her the time and moved her quickly, when still displaying rigidity.
On 5/21/25 at 9:27 a.m., occupational therapist (OT)-A stated they are working with R27 with wheelchair positioning. OT-A stated R27 was to be up in wheelchair daily for quality of life.
On 5/21/25 at 10:08 a.m., licensed practical nurse (LPN), clinical coordinator (CC)-A stated physical therapy (PT) evaluated the safe way for R27 to transfer and move. This information was relayed to staff to implement. CC-A stated this information was to be on the care sheet so that staff were aware of how to care for R27. She was uncertain if R27's spastic rigidity was addressed in care plan, or care sheet. R27 was also on medication to help with spasms. CC-A stated most recent care conference was held on 5/15/25. CC-A stated at that time, R27 identified concerns regarding her hair not being washed, and not receiving a shower. Although this was identified on 5/15/25, and implemented on 5/20/25, the care plan and care sheet lacked indication of resident preference for bathing and desire to wash her hair.
On 5/21/25 at 4:54 p.m., the director of nursing stated the care plan should be reflect resident preferences, as well as how care was to be delivered. DON stated the care plan was to be updated at the time changes implemented. DON stated this would include recommendations made by physical therapy. DON stated the care conferences were attended by CC-A. DON stated changes made to the care sheets were also to be reflected on the care plan, and should be completed at the same time. The care plan and care sheet should both accurately reflect what cares were to be performed by staff, as they direct staff as to what cares were to be performed.
A request for the facility policy for care plan updates was requested but not received.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to provide routine bathing assistance for 1 of 1 residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to provide routine bathing assistance for 1 of 1 residents (R27) reviewed for activities of daily living (ADLs).
Findings include: Findings include:
R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact. The assessment identified R27 received assistance with activities of daily living (ADL's) including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). The MDS identified it was very important to R27 to choose between a tub bath, shower, bed bath, or sponge bath, and somewhat important to choose what clothes she wished to wear. R27's medical diagnoses included multiple sclerosis (MS), malnutrition (an imbalance of energy and nutrients consumed), thrombocytosis (increase platelet count), pseudobulbar affect (a condition characterized by uncontrollable and inappropriate episodes of laughing or crying, often disconnected from person's actual emotion state). R27 received routinely schedule pain medication, as well as availability of additional pain medication as needed.
R27's care plan, with a print date of 5/21/25, identified that R27 had a self care deficit related to post surgical status, weakness and MS. The goal indicated R27 will accept assistance with self cares and will be dressed, groomed, and bathed per preferences. The care plan directed staff to follow through with instructions provided by occupational therapy (OT) and physical therapy (PT). Staff were also directed to provide with assist of one with dressing and bathing. R27's care plan also identified R27 had alteration in mobility related to post surgical status, weakness and MS. The care plan indicated R27 was to receive assist with movement in and out of bed and was to receive assist of one with transfers, however lacked further instructions. Although R27's care plan indicated R27 was on enhanced barrier precautions (increase precautions implemented to prevent the spread of infection) related to surgical incisions, the care plan lacked indication as to how the surgical sites were to be managed, additionally lacked any restrictions in showering related to incisions.
The Nursing Assistant care sheet dated 5/21/25, indicated R27 was to receive assistance to transfer with an EZ stand (a mechanical lift to aid in transfers) and did not ambulate. The NA care sheet outlined R27 required assist of one with dressing, bathing, toileting, and required set up for grooming and eating. The care sheet provided no additional instructions.
On 5/19/25 at 5:48 p.m., R27 and Family member (FM)-A were present in room. R27 expressed frustration she had not received a bath/shower since she had arrived. FM-A affirmed that R27 had doctor's appointments last week and wished to receive a bath/shower before going to her appointments, however, R27 was not assisted with this. R27 stated a certified nursing assistant (CNA) came in to provide assistance with a sponge bath, however, R27 wanted a shower to be able to wash her hair as it had not been washed in the weeks since admission. R27 stated the CNA put it down that she refused her bath. R27 reported when she asked when she could receive a shower, was told she had to wait for the next shower day. R27 stated Nobody knows how to do a shower. R27 stated neither PT/OT had worked with her regarding the transfer into the shower chair required for completing a bath and shower.
On 5/20/25, 1:01 p.m. R27 stated she was unaware she was scheduled to receive a bath this afternoon, however, stated she would like her hair washed.
On 5/20/25, at 4:10 p.m. R27 was observed back in her room. R27 stated the shower was completed and hair was washed twice. R27 stated this was the first time her hair had been washed for approximately 3 weeks.
During interview on 5/21/25, at 9:27 a.m. the physical therapy assistant (PTA) stated she participated in the therapy for R27. At present time, PTA stated they were working with R27 on core strength. PTA stated they were also working with R27 to be able to transfer into and out of bed, and in wheelchair. OT stated OT did not have a specific goals for showers, as they had not been informed by nursing staff of any concerns regarding showers, therefore, that had not been part of the therapy plan.
During interview on 5/21/25, at 10:08 a.m. the clinical coordinator (CC)-A stated R27 had received assistance to complete bathing on 5/20/25. CC-A stated R27 was unable to complete showers/baths prior to that time related to incisions on her stomach following a laparoscopic procedure (A procedure completed with a scope through several small incisions on the abdomen). CC-A stated R27 required clearance from the medical provider because of the incisions. CC-A stated staff had offered to complete a shower on an earlier occasion, however, R27 had declined the shower related to the time of day. When asked if they had a second opportunity to receive a shower before the next scheduled bath day, CC-A stated if it was not their shower day, staff were instructed to accommodate the request if they had extra time. CC-A stated she would expect staff would have offered it multiple times until she agreed to it. CC-A stated lack of shower or washing of hair for extended time would not feel very good. CC-A stated residents were assigned a time for bathing/showering based on their room placement. When asked if resident's were allowed to choose an alternate time which worked better for them, CC-A stated they tried to work with residents, however, it was not always possible. CC-A stated she was unaware of any concerns regarding bathing status until resident care conference on 5/15/25. CC-A stated R27 had received sponge baths since her admission, however, she was unsure if her hair was washed.
During interview on 5/21/25, at 4:54 p.m. the director of nursing (DON) stated baths were scheduled on a weekly basis. This was completed based on their designation based upon rooms. DON stated if the resident did not care for the slot, there might have been some flexibility in adjusting it, however, that was not always possible. DON stated We try to be flexible but there is (was) only so much wiggle room in that. DON stated if a bath was refused, and it was requested on another day, and the aides had time, it may occur, otherwise the next bath/shower would be completed the following week on the routinely scheduled time. Upon inquiring why a shower was not completed for R27, DON stated that if the person had a lap surgery, they would not have a shower if there were restrictions placed per the doctors orders upon admission. If there were not restricted orders, the individual could receive a shower. A request was made at this time for the specific order restricting showers for R27 from the time of her admission, however, was not provided by the DON.
Upon review of R27's abbreviated discharge orders from 4/28/25, there were no orders identified for wound care to laparoscopic sites, or restrictions for showering.
Upon review After Discharge Orders, from 4/28/25, the notes indicated resident had a laparoscopic procedure, however, had not restricted resident from receiving showers. A review of the information in this documentation lacked indication of this restriction.
A review of the standing orders, filed 5/20/25 electronically, lacked indication for shower restrictions for those with laparascopic surgical sites. The document did refer to the policy Skin and Wound Management. The document, not labeled with R27's name, was identified as being signed by the provider 2/1/25.
A review of the policy, Skin Assessment and Wound Management, dated 2/25 lacked indication as to management of a laparoscopic surgical site.
A review was made of resident task documentation for bathing was completed upon receipt. During the time frame of 4/28/25 through 5/7/25, there were both daily (times four) and twice daily entries (6) where the response to bathing being entered as NA, indicating not applicable. R27's documentation from 5/8/25 through 5/23, had daily entries of NA on three days, and twice daily entries of NA on 10 occasions. The documentation reflected no entries for 5/20/25, the day R27 received assistance bathing. The documentation lacked any date where resident had been assisted with bathing since her admission of 4/28/25.
A follow up interview was completed with CC-A on 5/23/25, at 1:03 p.m. CC-A stated the results NA of the task documentation indicated that staff had not provided R27 with assistance to bath during the periods of 4/28/25-5/23/25 , with the exception of assistance to bathe on 5/20/25
On 5/23/25, at 1:05 p.m. the director of nursing stated the expectation of assigned tasks was that the staff would complete them as directed.
The facility policy, titled Activities of Daily Living (ADL's) Maintain Ability Policy, dated 3/31/23, was reviewed. The statement of intent reads as follows:
It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident ' s preferences, choices, values and beliefs. Upon review of the procedure, the policy indicated: The facility will provide care and services for the following activities of daily living: a. Hygiene -bathing, dressing, grooming, and oral care . The policy also identified: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure the hospice plan of care had been integrated ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure the hospice plan of care had been integrated with the facility care plan for 1 of 1 resident (R35), identified to receive hospice services.
Findings include:
R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 had impaired cognition. R35 received assistance with activities of daily living (ADLs) including dressing, grooming, bathing, and mobility. R35's medical diagnoses included unspecified encephalopathy, cancer, atrial fibrillation (an abnormal heart rhythm which has been known to lead to complications including stroke, blood clots, and heart failure), hypertension (high blood pressure), arthritis (inflammation of joints), dementia, anxiety, depression, visual hallucinations (seeing something that is not there), adjustment disorder with anxiety, chronic pain syndrome, fibromyalgia (symptoms of widespread chronic pain, headaches, depression and other symptoms).
R35's care plan printed 5/22/25, identified R35 received Hospice Cares. The care plan directed staff to maintain communication with Hospice and keep them informed of resident's condition as needed. Staff were also directed to keep Hospice informed of any changes in resident's condition. Utilize Hospice Care Standing Orders per policy. Involve Hospice care workers in care conferenc. See Hospice plan of care and visit schedule.
On 5/20/25, at 3:52 p.m. R35 was observed at this time, resting on her bed, with blanket in place. Resident had an individual in room, playing guitar, and singing to resident. Resident was awake and interacting with visitor.
On 5/21/25 at 5:15 p.m., a review of the Hospice file was completed. It was noted that there were calendars in place in the file to record visits of the various Hospice staff. There was only entries on the March calendar, the other calendars were blank. The calendar from March identified RN (registered nurse) visits were completed on 3/20, 3/24, and 3/27. The calendar lacked any indication of visits by others. There were no entries on the calendars labeled for April and May. Additionally, in the Hospice file, there was a document titled Hospice Aide visit log. This document had entries for 3/28, 4/4, 4/10, and 4/17. There were no further entries beyond 4/17.
During interview on 5/21/25 at 5:27 p.m., the licensed practical nurse clinical coordinator (CC)-A stated the Hospice nurse was at the facility at least once or twice a week, and checked in with her when she came. CC-A stated the frequency of visits depends on the week. CC-A stated she was unaware of a calendar in the Hospice folder. CC-A stated R35 had a HHA (Home Health Aide) come out, however, was unaware of the frequency, and stated, I think once a week. CC-A stated there were other therapies which were involved, including music therapy and a Hospice social worker, however, was unaware of a schedule. if there were were questions, staff were to contact Triage for Allina Hospice, which was in the special instructions on the chart. Hospice was invited to the care conferences and did participate in the initial conference for R35. CC-A stated the Hospice care plan would be in the medical record, however, upon review of the Hospice section, CC-A confirmed only the Hospice encounter notes were present.
On 5/21/25 5:34 p.m., the director of nursing (DON) reviewed records as identified above, as well as reviewed the medical record for the Hospice care plan. DON confirmed the Hospice care plan was not scanned into the Hospice information section and was not available for review.
During interview on 5/21/25 at 5:41 p.m., licensed social worker (LSW)-A stated the social worker from Hospice was there to visit for sure every other week, if not weekly. LSW-A stated she was not notified when Hospice social worker would be coming to visit R35. LSW verified the care plan from Hospice should be filed under Hospice in miscellaneous in the electronic record. LSW-A stated Hospice was invited to care conferences, and did attend the initial care conference.
Attempts on 5/22/25 to contact Hospice case manager were not successful.
A review of the document Allina Health Hospice and Palliative Nursing Home Agreement Medicare/MA Respite Residential dated May 22, 2014 was completed. The document identified the facility shall coordinate with Hospice in developing a plan of care for Hospice patient. The document indicated the facility will assist with periodic review and modification of plan of care. The document directed that the facility will consult with Hospice, as reasonable necessary, with respect to any modification of the plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview and document review, the facility failed to provide routine assistance with range of motion (ROM) to to improve strength, mobility and improve circulation of left arm f...
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Based on observation, interview and document review, the facility failed to provide routine assistance with range of motion (ROM) to to improve strength, mobility and improve circulation of left arm for 1 of 1 (R29) reviewed for ROM.
Findings include:
R29's care plan, dated 2/14/25, indicated R29 was a fall risk related to left side(d) weakness, impaired vision. The care plan directed staff to follow PT (physical therapy) and OT (occupational therapy) instructions for mobility function. The care plan additionally identified R29 had self care deficit related to left sided weakness. The care plan directed staff R29 was to receive OT as ordered by provider. Staff were also directed to follow OT instructions.
A review of the Interdisciplinary Team (IDT) Conference notes was reviewed and it was noted in the document dated, 2/13/25, R29 was receiving assist with from therapy for ROM with left arm.
A review of the subsequent IDT notes of 3/28/25 indicated The IDT note indicated the nurse practitioner had reviewed swelling in left forearm and ordered a compression wrap for his left arm. At the care conference, family member (FM)-B inquired of use of a sling, however, this was to be used only with transfers to encourage resident to use his left arm.
The IDT care conference notes of 5/2/25, identified ongoing concerns with swelling of the left forearm and use of the compression wrap was to be continued, as well as continued use of sling only with transfers.
A review of the group two (2) nursing assistant care sheet, updated 5/21/25, indicated R29 had an ROM program.
A review of the task list documentation from 4/23/25-5/21/25, directed staff to provide ROM to LUE (left upper extremity): all planes (the extent or limit to which a part of the body can be moved around a joint or a fixed point) one (1) direction ten (10) times each w/ (with) extended hold *signs in room on wall to help staff. Upon review of the documentation, it was noted entries for all dates, with the exception of 4/27, 4/28, and 5/17, indicated NA (not applicable-not performed). On 4/27, 4/28, and 5/17, the notation indicated the amount of repetitions as 5 (five).
On 5/19/25 at 3:15 p.m., R29 was observed to be sitting in the wheelchair. His right had was noted to resting in an open position on his lap. R29 was observed to have his left arm, with left hand in an open postion, rested on pillow resting on arm rest/lap. R29 stated he had received therapy, however, stated therapy had stopped. R29 stated staff were to perform exercises, gesturing to the multiple page documents posted to the wall with directions as to what to do, however, stated no one does this.
On 5/22/25 at 12:14 p.m., R29 was observed to have a visitor at that time, who was observed as she provided assistance to R29 with range of motion for R29. The resident visitor (RV)-1, who identified herself as a friend, stated she assisted R29 with his exercises when she was here, and indicated she followed the directions on the wall. The visitor indicated they liked to come and make R29's day better.
On 5/22/25, at 12:24 p.m., certified nursing assistant (CNA)-D stated cares performed for residents were documented on the tasks listing. CNA-D looked at this and identified R29 was to receive ROM to the left upper extremity, as indicated on the tasks section of the medical record. CNA-D stated that she had not performed this yet today, but planned to perform.
On 5/22/25, at 2:35 p.m. and interview was held with CNA-B and CNA-C. CNA-B stated it was rare to complete ROM in general. CNA's B and C both stated the most important tasks were completed, which included feeding assists and showers, however, ROM was infrequently done for the residents assigned.
On 5/23/25 at 1:03 p.m., licensed practical nurse (LPN)/clinical coordinator (CC)-A indicated upon review of the task listing for R29, completion of ROM was lacking for all days with the exceptions of 4/27, 4/28, and 5/17. CC-A stated the documentation indicated staff were not completing ROM. CC-A stated it was her expectation that staff should have been completing ROM. CC-A verified the care sheet directed staff to perform the ROM program. CC-A stated she was unaware the ROM was not consistently completed.
On 5/23/25, at 1:05 p.m. the director of nursing stated she had reviewed the information as documented on the tasks sheet and identified it had not been done often. DON stated it was her expectation that ROM was completed as directed, on a daily basis as outlined.
A facility policy, Activities of Daily Living (ADLs)/Maintain Abilities Policy, dated 3/31/23, identified the intent as being: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident ' s quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident ' s preferences, choices, values and beliefs. Within the policy, it was identified under the procedure the following: 1. Based on the comprehensive assessment of a resident and consistent with the resident ' s needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility policy lacked specific identification as to process/policy for performance of ROM, however, when asked for a more specific policy, the facility stated ROM was addressed within the ADL's policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and document review, the facility failed to assess and analyze a fall with significant injury for 1 of 2 residents (R11) reviewed for falls.
Findings include:
R11's m...
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Based on observation, interview and document review, the facility failed to assess and analyze a fall with significant injury for 1 of 2 residents (R11) reviewed for falls.
Findings include:
R11's minimum data set (MDS) completed for significant change dated 3/5/25, was noted to be cognitively intact and able to communicate her thoughts, needs, and wishes. R11 was identified as using a walker and wheelchair for mobility. R11 received assistance to complete her activities of daily living (ADLS), however, actively participated with cares. R11's medical diagnosis included anemia (low levels of healthy red blood cells or hemoglobin), coronary artery disease (a build up in the walls of the blood vessels which supply blood to the heart), hypertension (high blood pressure), diabetes (a group of diseases which affects how the body uses blood sugar), difficulty in walking/unsteadiness on her feet, muscle weakness, peripheral autonomic neuropathy (nerve damage which affects the system which controls involuntary body functions such blood pressure and heart rate, and weakness. The MDS identified R11 had a history of falls with no injury since the last assessment period.
R11's Care Areas Assessment, dated 3/5/25, indicated areas to focus on for specialized care included activities of daily living (ADLs-including transfers and mobility), falls, pressure ulcers, pain and use of psychotropic (use of medication affect mood state and behavior) medication.
R11's care plan, date of print 5/21/25, identified R11 was a fall risk related to: decreased mobility, psychotropic meds, intermittent confusion, and history of fall. Staff were directed to ensure wheelchair breaks were locked and wheelchair remained close to resident when transferring. R11 was identified as being impulsive at times. Staff were directed to remind R11 to slow down when transferring. This problem statement was identified as being initiated on 4/16/21. The care plan directed staff to monitor and document on safety, as well as review information on past falls and attempt to determine cause of falls. Staff were directed to record possible root causes, and were also directed to remove any potential causes if possible. The care plan directed staff to educate resident/family/caregivers/IDT(interdisciplinary team) as to causes.
On 5/19/25 at 5:32 p.m., during interview R11 was seated in wheelchair and was propelling herself into her room. R11 stated everything was going well and reported no concerns to surveyor.
On 5/21/25 at 12:49 p.m., R11 was observed walking in the hallway in gripper socks using a rolling walker. R11 was walking with occupational therapist (OT)-A who was bringing wheelchair up behind R11. R11 was observed to have abruptly stopped and sat down in wheelchair. OT-A instructed R11 of need to verbalize need/desire to sit down. OT-A did not have the wheelchair brakes on. OT was able to safely assist R11 to a seated position.
During record review on 5/19/25 at 7:53 p.m., a progress note, written on 4/30/25 at 2:07 p.m., identified: Resident was sent to hospital after a fall accident with therapy. Res had a cut under left eye and hit on head.
A subsequent note from 4/30/25 at 6:43 p.m., identified the head/brain/facial bones and cervical spine were assessed with computerized tomography (CT-an imaging test which helps healthcare providers detect injuries). This was completed related to R11 having experienced a fall with facial injuries. The findings included the following: Head CT: Intracranial contents: No intracranial hemorrhage (bleeding into the brain), extraaxial collection(collections of fluid within the skull, but outside the brain), or mass effect (a space occupying lesion which may increase intracranial pressure, and displace soft tissues of the brain). No CT evidence of acute infarct (tissue death). Chronic lacunar infarcts in the right basal ganglia (small deep infarcts primarily caused by chronic hypertension, atherosclerosis, and diabetes). Mild presumed chronic small vessel ischemic changes (changes related to decrease blood flow). Mild generalized volume loss. No hydrocephalus (build up of fluid in the brain). Head CT: No acute intracranial findings(no hemorrhage, shift, or mass effect). Mild generalized cerebral volume loss and presumed chronic microvascular ischemic changes of the white matter.
A review of the narrative notes lacked indication of a fall analysis was completed. The initial entry did identify the fall occurred with therapy, however, it lacked further information related to the incident to attempt to determine the root cause or possible interventions to prevent this from recurring in the future.
On 5/20/25 at 2:55 p.m., an interview was completed with licensed practical nurse (LPN)/clinical coordinator (CC)-A. Upon review of the electronic record, CC confirmed there were no forms on file to indicate a review of the fall had been completed. CC-A indicated the process was to have included a risk management report. The presence of a risk management report would have triggered her to have completed an Incident Review and Analysis Document. CC-A stated this should have been completed to look at the potential root cause was for the fall, and to place interventions to decrease the potential for having this occur again.
On 5/22/25 at 11:57 a.m., the director of nursing (DON) stated upon review of the medical record, there were areas to document on the medication administration record (MAR) to prompt assessment of resident following the fall, however, there was no formalized fall analysis. The DON stated a risk management report should have been completed. DON stated from the risk management report, the CC would complete an Incident Review and Analysis document. This information provided details of the fall to allow for analysis of the incident to look for root cause, and identify potential interventions to be implemented to prevent future falls. DON stated this documentation should have been completed at the time of the incident.
The facility policy, Fall Prevention and Management, dated 2/2024 identified the purpose of this protocol is to identify residents at risk for falls, implement fall prevention interventions, provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy identified a Fall Risk Evaluation was completed to identify and document the resident ' s risk factors for falls upon admission, annually, with a significant changed in condition, and as needed. The policy identified after the initial actions after the fall, and stabilization of the resident has been completed, nursing staff will complete an incident review and analysis. The policy identified the staff were to clarify the details of the fall, such as when the fall occurred, where it occurred and what the individual was trying to do at the time the fall occurred. The policy directed nursing staff to try to identify possible or likely causes of the incident. This would refer to resident-specific evidence including medical history, known functional impairments, etc. Staff will monitor and document the resident ' s response to and the effectiveness of interventions put in place to prevent further falls for 72 hours post fall.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate monitoring for tardive dyskinesia (TD-...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate monitoring for tardive dyskinesia (TD- a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications) was implemented for 1 of 5 residents (R35) reviewed for unnecessary medications.
Findings include:
R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 had impaired cognition. R35 was noted to receive assist with activities of daily living (ADLs) including dressing, grooming, bathing, and mobility. R35's medical diagnoses included unspecified encephalopathy (brain disease, damage, or malfunction which encompasses a range of conditions that could cause brain dysfunction, which might manifest as confusion, memory loss, personality changes, or severe symptoms like coma), cancer, atrial fibrillation (an abnormal heart rhythm which has been known to lead to complications including stroke, blood clots, and heart failure), hypertension (high blood pressure), dementia, anxiety, depression, visual hallucinations (seeing something that is not there), adjustment disorder with anxiety, chronic pain syndrome, and fibromyalgia (symptoms of widespread chronic pain, headaches, depression and other symptoms).
R35's care plan printed 5/22/25, indicated R35 had alteration in cognition related to confusion, disorientation to place and time. Poor insight to her deficits or cognitive loss. Poor historian. Sundowning type behaviors of crying and calling out. Has decreased in intensity since admission. R35's diagnoses included major neurocognitive disorder, with behavioral disturbance, encephalopathy due to medical illness (various infections), visual hallucinations, and low vision due to retinal pigmentation disease. The care plan directed staff to follow recommendations from mental health provider. The care plan lacked indication of baseline monitoring for side effects of antipsychotic medication.
R35's Medication Administration Record (MAR), printed 5/20/25, indicated R35 received the following medications:
- Risperidone 1 milligram (mg) by mouth at bedtime for agitation/delirium. Start date of 5/5/25. Risperidone is a medication classified as an antipsychotic medication. This is a medication that works by changing certain signals in your brain which affect how you feel and act.
- Risperidone 0.5 mg by mouth two times a day for delirium/ agitation. Start date 5/5/25.
A review of R35's medical record lacked indication that an Abnormal Involuntary Movement Scale (AIMS) evaluation had been completed. AIMS evaluation was a test developed to measure involuntary movements known as tardive dyskinesia (TD).
A request was made for the documentation of AIMS testing for R35, and it was noted by the facility there was no AIMS on resident record, per documentation on the form titled Request for Documentation for Unnecessary Medications.
On 5/20/25 at 3:52 p.m., R35 was observed in her room, resting on her bed, with blanket in place. R35 had a visitor in her room, playing her guitar, and singing to resident. Resident was observed to be awake, and was interacting with her visitor.
During interview on 5/22/25 at 1:46 p.m., the director of nursing (DON) stated the AIMS evaluation was important to assess if the residents had specific side effects of TD. DON stated this was to be done at the time of admission and every six months for residents receiving antipsychotic medications. DON stated this was last done on 5/20/25, however, had not been completed until after information had been requested by surveyors.
The facility policy, titled Psychotropic Medication Use Policy, created 4/25, identified the facility that DISCUS (Dyskinesia Identification System Condensed User Scale) or AIMS testing will be completed at baseline, semi-annually and monthly times 3 upon discontinuation for antipsychotic medications.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and document review, the facility failed to ensure medications had both open dates and expiration dates marked on the medications so staff new how long the medications ...
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Based on observation, interview and document review, the facility failed to ensure medications had both open dates and expiration dates marked on the medications so staff new how long the medications were good for. This had the ability to affect all residents on the transitional care unit (TCU) who received medications.
Findings include:
On 5/21/25 at 12:21 p.m., a review of the TCU medication care and treatment cart was performed. Three different insulin dial up pens were observed without open dates or expiration dates documented on the pens. Three different inhalers were also observed without open dates or expiration dates.
During an interview on 5/21/25 at 12:36 p.m., licensed practical nurse (LPN)-A reviewed the medications and confirmed there were no open dates or expiration dates on the medications. LPN-A could not report when the medications were opened or how long they were good for once the medications were opened. LPN-A did not know how long insulins or inhalers were good for after opened and stated, I need to check with my supervisor.
On 5/22/25 attempts to contact the pharmacy consultant were not successful.
During an interview on 5/22/25 at 12:27 p.m., the director of nursing (DON) stated an expectation that medication would be dated with both the open date and expiration date, so staff were aware how long they were good to administer. Administering medication beyond the expiration date could result in the resident responding differently to the medication as the potency may change.
A facility policy on dating and disposal of multi-use medication was requested, however, none was provided
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure food served to the residents was palatable, at...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure food served to the residents was palatable, at a pleasing temperature, and in a timely manner for 4 of 4 residents R145, R29, R33, and R93 reviewed for food concerns.
Findings include:
R145's admission Minimum Data Set (MDS) dated [DATE], indicated R145 was cognitively intact. R145 was independent with all aspects of eating and was independent with mobility. R145's medical diagnoses included gastroesophageal reflux disease (GERD-acid indigestion) and diabetes (a disease which impacts the body's ability to process sugar in the blood).
On 5/19/25 at 2:22 p.m., R145 stated the food was never warm. R145 went on to state she would love a hot meal. R145 stated the coffee was cold and the food was inconsistent. R145 did not indicate she had requested an alternate meal/new plate, or fresh coffee.
R29's admission MDS dated [DATE], indicated R29 experienced moderate cognitive impairment. The assessment indicated R29 was independent with eating. R29's medical diagnoses included sequalae of cerebral infarction (details of cerebral infarction (stroke-and its effects it can cause to the brain including, but not limited to, change in mobility, loss of movement of one side of the body, vision problems, memory loss and difficulty with problem solving, emotional and behavioral changes, and seizures), heart failure (a condition where the heart is not able to pump enough blood for the body's needs for blood and oxygen), hypertension (high blood pressure), diabetes (a group of diseases which affects how the body uses blood sugar), and muscle weakness.
On 5/19/25 at 3:36 p.m., R29 stated today the tray (at noon) was late. R29 stated there should be alternates for food. Today, there were no alternates ready for pork. R29 stated the culinary director went to make something as an alternate and provided chickens strips. R29 went on to state the food is late all the time.
R33's admission MDS, completed on 3/3/25, indicated R33 had moderate cognitive impairment. R33 was independent with eating. R33's medical diagnoses included hyponatremia (low sodium (salt), a non-cancerous brain tumor, myocardial infarction (heart attack), generalized weakness, and unsteadiness.
On 5/19/25 at 5:30 p.m., R33 stated the food is so-so. R33 commented the alternates available are the same things all the time. The food is not consistently hot, and described the food received with meal trays as pretty much warm. R33 stated she had not requested staff to warm up the meal tray if received at less than desired temperature.
On 5/19/25 at 11:25 a.m., the culinary director (CD) stated mealtimes at the facility were at 8:00 a.m., 12:00 p.m., and 5:00 p.m.
On 5/19/25 at 12:13 p.m., observation was completed in the dining room. Meal service was to begin at 12:00 p.m. At this time, beverages were being served by dietary aide (DA)-A, however, the noon meal had not begun being served.
On 5/19/25 at 12:14 p.m., temperature logs were received from 5/16/25 to the present time on 5/19/25 at 12:14 p.m. The culinary services cook (CSC)-A stated she had temped the foods earlier yet had not recorded them. The temperature log reflected no temperatures had been entered for 5/16/24-5/19/25. Upon review of the temperature logs, it was noted from 5/1/25 -5/15/25, there were 11 meals out of 45 where temperatures were not recorded.
On 5/19/25 at 12:25 p.m., the first meal was served, 25 minutes after the start of the designated mealtime. Upon initiation of meal service, it was identified there were no alternatives to the pork cutlet served. It was also identified that an alternate meat would need to be prepared as there were three residents who did not consume pork products. CD proceeded to the kitchen to prepare an alternate protein.
On 5/20/25 at 12:01 p.m., meal service observation was initiated at this time in the dining room. DA-A was serving beverages to those residents present. At 12:17 p.m., the steam table arrived in the serving kitchen. At 12:24 p.m., it was noted the first meals were served to three residents. At 12:30 p.m., all residents have been served in the dining room.
On 5/20/25 at 12:47 p.m., R93 stated it was a small lunch. Quality and quantity is always small. Timing is (was) always a thing. R93 stated he had enough to eat however, expressed concerns regarding the quality. R93 stated there was often an extended wait for meals.
On 5/20/25 at 3:20 p.m., an interview was completed with the Regional Culinary Director (RCD), and Registered Dietitian (RD). RCD stated checking of the temperature of foods, should occur right before the meal was serve, and should be completed with every meal. RCD stated she was surprised there were concerns regarding foods as they used heating pellets to keep the plates warm, heated plates, and domed covers. RCD stated there may be some concerns regarding delivery once food was sent out for tray service. RCD stated if the food was reported to be not up to temperature, the food would be either reheated or the resident would be served a new plate. RCD stated she had heard mealtimes have been delayed at times. RCD and RD stated there were routine Food Council meetings to review resident concerns, and stated these meetings were often held on the same day as Resident Council. A request was made for Food Council meeting minutes; however, none were received.
A facility policy, titled Meal Times, review 9/2012, identified it was the policy of the facility to serve meals to meet the standards of the surveying agencies, specifying no more than 14 hours between the evening meal of one day and the breakfast meal of the next day. Although the policy included a section which indicated Meal times will be: there lacked indicated times for breakfast, noon, and evening. The policy indicated the Hospitality Services Manager was responsible to monitor the system to assure adherence. The policy went on to state all staff were responsible for following this schedule.
A facility policy titled Food and Nutrition Services, revised October of 2017, identified Each resident was provided with a nourishing, palatable, well-balanced diet that met his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy identified the meals and/or nutritional supplements would be served within 45 minutes of either resident request or scheduled meal time. The policy also identified Meal times are posted in the facility common areas.
A facility policy titled Food Preparation and Service, revised April of 2019, identified proper hot and cold temperatures were maintained during food service. It also identified the temperature of foods held in steam tables were monitored throughout the meal by food and nutrition services staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and document review, the facility failed to consistently date fresh and frozen items at the time they were opened, or placed in a container, and failed to remove items ...
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Based on observation, interview and document review, the facility failed to consistently date fresh and frozen items at the time they were opened, or placed in a container, and failed to remove items which were beyond the acceptable date of use from the refrigerator. The facility also failed to consistently verify the temperatures of freezers were within the desired range to assure food integrity and follow through on the temperatures outside of the desired range. The staff also failed to consistently implement the use of hair nets and beard restraints while preparing and serving food. In addition, food temperature monitoring lacked consistency of completion following food preparation and prior to serving. This had the potential to affect all 32 current residents, as well as staff and visitors who ate the food from the kitchen.
Findings include:
Food storage:
On 5/19/25 at 11:31 a.m., the culinary director (CD) reviewed the products of the refrigerator at this time. The CD stated food items should be used within seven days of placing in the refrigerator. The following items were noted to be in the refrigerator and outside of the stated parameters:
A five-pound box of bacon, with half of the box remaining was observed to be in an opened paper box which was not sealed. This was removed by the CD.
A bottle of lemon juice which was noted to be 32 ounces, with half of a bottle remaining. The manufacturer expiration date was noted to be 3/25. The bottle had been dated
on 3/24 as being opened.
A stack of sliced cheese, approximately one and a half inches in height, was wrapped in plastic wrap, and was dated 5/8/25. The wrapping was not secured, and one corner
of the cheese was opened with cheese crumbling off. The package of cheese was free from mold. The CD removed the cheese from the refrigerator to be repackaged.
A one pound package of butter, was observed to be partially unwrapped, and noted to have approximately half of the block remaining. This was undated. This removed from the refrigerator and disposed of.
A six quart container was observed to be in the refrigerator with two quarts of black olives remaining. This was noted to be dated 5/1/25. This was removed from the refrigerator and disposed of.
An open package of ham, containing six slices of ham was observed to be dated 5/6/25. This was removed from the refrigerator and disposed of.
A one-pound package of bologna, white in color, with watery substance observed at the bottom of the packaging was noted to be dated 3/31/25. This was disposed of.
A bag of precooked sausage, dated 5/8/25, was observed to be in the refrigerator. CD stated they had just placed this in the refrigerator on Friday, 5/16/25, however, acknowledged staff would be unaware of the date of 5/8/25 being the date received on delivery and not the date the bag was placed in the refrigerator. CD stated precooked foods could be stored seven days.
A sandwich size baggy of chopped up onions was observed in the refrigerator, dated 5/7/25. There was a watery substance at the bottom of the bag, and the onions were soft to touch. This bag was removed and disposed of.
On the upper shelf of the refrigerator, there was an undated plastic cup, approximately two ounces in size, of sour cream. This item was removed and disposed of.
The dry storage room was surveyed and it was noted to have two onions which had two inches of green sprouts out of the top of them. The onions were noted by the CD to be soft and spoiled and were disposed of.
A review of the food items in the freezer was completed and the following was identified.
Within the freezer, there was noted to be two chunks of ham in a plastic bag, dated 5/14/25, which CD noted to weigh approximately one and a half pounds which had a
large amount of ice crystals surrounding the chunk of ham and laying in the bottom of the bag. A second bag of ham was also noted to be in a plastic bag, covered with
many crystals, both on the ham and in the bottom of the bag. This bag was measured at three pounds. CD stated she was unsure if the ham was not cooled down properly to cause formation of ice crystals. Both bags of ham were removed and disposed of.
A four-pound bag of fully ice encrusted fajita blend vegetables was observed. This contained a pepper and onion mix. This was not opened and undated. This was removed and disposed of. A review of other frozen vegetables was completed with no other vegetables noted to be encased with ice.
A bag of chili sauce was found thawed in freezer, with a date of being opened as 5/13/25, however, was not frozen. The bag was noted to weigh was almost three pounds. CD was unsure why this would have been dated 5/13/25, and yet be thawed to touch.
On 5/20/25 at 3:20 p.m.,Regional Culinary Director (RCD) stated foods are dated upon arrival/receipt. RCD stated food products should then be dated with date opened. RCD stated if the food product was a cooked product, it was to be used within three days. RCD stated if it was cheese, it was to be discarded after seven days. Ham was to be disposed of within seven days.
A facility policy, Food Receiving and Storage, revised October 2017, identified foods were to be received and stored in a manner that complied with safe food handling practices. The policy indicated all foods stored in the refrigerator or freezer were to be covered, labeled, and dated (use by date). Although the policy identified to products were to be dated, it lacked definition as to what the time frames were for the food products to be used by, with the exception being that beverages must be dated when opened and discarded after twenty four hours.
A policy titled Refrigerators and Freezers, undated, indicated the facility will ensure safe refrigerator and freezer maintenance, temperature and sanitation, and will observe food expiration guidelines. The policy stated all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of deliver) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared foods in the refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. All expired items were to be discarded. Although the policy addresses the use by date, the policy lacks specifications to what the parameters are to be used for determining the use by date.
Monitoring of freezer temperatures:
On 5/19/25 at 12:04 p.m., a review was completed of the freezer temperature log for freezer A. The log indicated the temperature was to be less than zero degrees, if temperature was higher than zero the staff were directed to contact the culinary manager ASAP (as soon as possible). Upon review of the log, it was noted the temperature was identified as being greater than zero degrees Fahrenheit on four occasions: on 5/12/25, the temperature was recorded as 2.6, on 5/13/25, the temperature was recorded as 2, on 5/14/25, the temperature was recorded as 13.5 degrees Fahrenheit. The log was noted to lack temperature monitoring in the afternoon on four dates (5/14/25, 5/15/25, 5/16/25, 5/18/25) CD stated she was unaware of the freezer temperature being greater than zero degrees. CD stated when the temperature was greater than zero degrees, the staff were to report this to the CD and follow up was to be initiated with maintenance.
On 5/20/25 at 3:31 p.m., RCD stated the freezer at the time the temperature was out of range on the freezer, it may have been going under a defrost. RCD stated the temperature was to be monitored on the inside of the freezer. RCD stated she had reviewed the log. RCD stated when irregularity was noted, staff were to allow the freezer to cycle through and go back and recheck the temperature. RCD stated if the abnormality persisted, the CD was to follow up with maintenance, or other departments as indicated.
A policy titled Refrigerators and Freezers, undated, indicated the facility will ensure safe refrigerator and freezer maintenance, temperature and sanitation, and will observe food expiration guidelines. The policy outlined that the temperatures of the freezer was to have been less than zero degrees Fahrenheit. The policy directed the supervisor to take immediate action if temperatures were out of range. Actions needed to correct the temperatures were to be recorded on the tracking sheet, including the repair personnel and/or department contacted.
Hair nets and beard restraints:
On 5/19/25 at 12:18 p.m., CD was observed to wearing a hair net; however, the sides of her hair were not completely contained within the hair net. CD was observed with hair net not partially covering her hair in the kitchen, and in the serving kitchen.
On 5/20/25 at 12:26 p.m., RCD was observed in the serving kitchen. Although RCD was observed to have a hair net in place, it lacked coverage of her bangs, which were noted to be uncovered on her forehead.
On 5/20/25 at 3:43 p.m., registered dietitian (RD) stated hair nets were to be worn in the kitchen, and outside of the kitchen when serving food. RD stated hair nets were to be worn so it covered all of the person's hair. Hair was to be tucked in, no matter what part of your hair it was.
On 5/20/25 at 3:47 p.m., RDC acknowledged her bangs were not covered up by her hairnet and stated I know better.
On 5/20/25 at 5:13 p.m., dietary assistant (DA)-B, was observed placing tablecloths on serving tables in the dining room. DA-B's hair was observed to be braided and pulled back away from her face, however, there were areas around forehead and ears where the hair net was not restraining/containing the hair. Upon interview, DA-B stated she was unaware her hair was outside of the hair net, and stated it was important for hair nets to be used so that the hair would not get into the food.
On 5/21/25 at 4:45 p.m., DA-C was observed in the dining room setting up tables for the evening meal. DA-C was observed to have a hair net in place to cover his head, however, DA-C was also observed to have facial hair present with a light mustache and beard. DA-C was not wearing any facial hair restraint at this time.
On 5/21/25 at 4:55 p.m., RDC was observed walking by at the time DA-C was preparing the dining room. Surveyor inquired of RDC if DA-C typically used a facial hair restraint? RDC stated, He typically does, for sure. 5/21/25 at 4:59 p.m., RDC approached surveyor and stated she had followed up on use of beard nets at the facility. RDC stated the facility lacked beard nets in house. RDC stated in the interim, DA-C would cover face with a face mask.
A facility policy, Food Preparation and Service, revised April of 2019, identified under Food Service/Distribution that Food and nutrition services staff (were to) wear hair restraints (hair net, hat, beard, restraint, et.) so hair does not contact food.
Temperature monitoring of meals served:
On 5/19/25 at 12:14 p.m., temperature logs were received from 5/16/25 to the present time on 5/19/25 at 12:14 p.m. The culinary services cook (CSC)-A stated she had temped the foods earlier yet had not recorded them. The temperature log reflected no temperatures had been entered for 5/16/24-5/19/25. Additional logs were requested from the CD from the start of the month. Upon review of the temperature logs, it was noted from 5/1/25 -5/15/25, there were 11 meals out of 45 where temperatures were not recorded. CD stated the temperatures were to be checked prior to serving the meals, and indicated the temperatures were to be logged immediately after they are checked.
On 5/20/25 at 3:32 p.m., RCD stated staff were to check the temperature of foods right before the meal was served. RCD stated there were interventions to maintain food temperatures which included heating pellets, heating plates, domed plates. If the food was not maintaining the desired temperature, her concern would be related to the delivery process, function of the steam table being on, and equipment being efficiently used.
A facility policy titled Food Preparation and Service, revised April of 2019, identified under Food Preparation, Cooking and Holding Time/Temperatures that food thermometers used to check food temperatures were clean, sanitized, and calibrated for accuracy. The policy identified under Food Service and Distribution, that the proper hot and cold temperatures were maintained during food service. The policy indicated the temperature of foods held in steam tables were monitored throughout the meal by food and nutrition services staff. The policy lacked definition as to when the temperatures were to be initially taken prior to meals, and the parameters when the temperatures are to be rechecked.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure urinary leg bags were effectively secured to pre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure urinary leg bags were effectively secured to prevent falling on the floor and being rolled over by wheelchair for 1 of 1 residents (R28) reviewed for urinary catheter. In addition, the facility failed to conduct ongoing surveillance for the infection control program to ensure tracking and trending of symptomatic illnesses not on antibiotics in the facility. This deficient practice had the potential to affect all 32 residents currently residing in the facility.
Findings include:
R28's admission Minimum Data Set (MDS) dated [DATE], indicated R28 had moderate cognitive impairment and required assistance with activities of daily living (ADL's) including dressing, grooming, bathing, and transfers. R28 was noted to have an indwelling catheter. R28's medical diagnoses included an artificial openings of the urinary tract, benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland in men which can lead to various urinary problems in men), renal insufficiency (a condition which the kidneys are not functioning at their full capacity), urinary tract infections, diabetes (a group of diseases which affects how the body uses blood sugar), specialized disorders of the bladder, and dementia.
R28's care plan printed 5/21/25, identified R28 was on enhanced barrier precautions related to nephrostomy bag, was a fall risk related to nephrostomy tubes (a tube that drains urine from the bladder when the urine is unable to leave the body normally), had alteration in mobility related to nephrostomy tubes, and had self care deficit related to bilateral nephrostomy tubes. R28's lacks direction as to management of the nephrostomy bags, cares to be provided to the sites, and direction as to securing of nephrostomy bags for resident to maintain dignity, provide good infection control practices, and prevent falls.
The Group one (1) CNA (certified nursing assistant) work list, updated 5/21/25, identified R28 was dependent with toileting and had nephrostomy tubes. The list lacked any further direction to staff as to how provide cares for the nephrostomy tubes and bags.
On 5/19/25 at 3:59 p.m., R28 was observed next to the Transitional Care Unit (TCU) nurses station. R28 was positioned between the medication (med) cart and the wall, allowing room for wheelchairs to pass. R28 was observed to have urinary leg bag dragging below the left leg of his pants, with urinary leg bag laying on the floor. R28 was observed to moving in a back and forth motion and was observed to roll over his leg bag with the wheel of the wheel chair. Certified nursing assistant (CNA)-A was observed to walk by, pushing another resident. CNA-A observed R28's leg bag on the floor and went to correct this. CNA-A then stated to licensed practical nurse (LPN)-B she needed to help R28, and advised LPN-B to get gloves. CNA-A proceed to step away from residents to go and wash her hands. LPN-B proceeded to propel the resident CNA-A had been assisting to their room. While R28 was left unattended, he proceeded to roll back over the leg bag, which remained on the floor. LPN-B then returned and assisted R28 to his room. CNA-A returned to the nurses station after washing her hands, and stated she had observed R28's leg bag caught in the wheelchair, and that was why she stopped to help. CNA-A stated when she assisted R28, she was not wearing gloves, so needed to wash her hands. CNA-A stated she alerted LPN-B, who was at the medication cart, to provide assistance while she washed her hands.
On 5/19/25 at 5:17 p.m., a follow-up interview was completed with LPN-B. LPN-B stated she had assisted the resident being pushed by CNA-A to their room, and then returned to the nurses station to help R28. LPN-B stated she assisted R28 to his room, and assisted with placement of leg bag, and tightened his leg band. LPN-B stated she had seen the leg bag on the floor. LPN-B stated with the leg bag being on the floor, there would be the exposure to bacteria, germs and added that was why she had fixed it.
On 5/22/25 at 10:36 a.m., R28 was observed as he received personal cares. CNA-B proceeded with cares wearing a gown and gloves as required for cares. CNA-B was observed with appropriate infection control practice of hand hygiene and glove use. CNA-B proceeded to secure nephrostomy bags to R28's legs. The band CNA-B was using was a wider width strap, approximately two inches wide, such as a band used to secure a catheter tube to the upper thigh. CNA-B identified when using a leg bag, there were usually straps which threaded through the leg bag, however, these straps were not available for use. Upon observation of the leg bags, it was noted the area on the leg bag where straps would be threaded through had not been used. CNA-B stated the straps provided were too large for the bags to secure well to R28's legs. CNA-B stated she had asked about different straps, but this is what they give us. CNA-B stated the problem with positioning of the leg bags is related to how they sit on his legs. CNA-B then strapped leg bag to just below the knee, securing the large band at the top of the leg bag. There was no strap available to secure the bottom of the leg bag to the leg.
During interview on 5/22/25 at 11:32 a.m., LPN Clinical Coordinator (CC)-A stated R28's leg bags should be secured properly on his legs and should not be on the floor due to concerns with dignity, as well as concerns for infection control, adding it was a sanitary issue. CC-A stated if the leg bag was laying on the floor, and run over by the wheelchair, there was a potential for the nephrostomy tubes to be pulled out or displaced. CC-A stated it was her expectation if a leg bag was observed to be laying on the floor, they were to be immediately assisted to their room to secure the bag properly. CCA stated they have tried a variety straps they have tried to find the best fit. CC-A stated she was unaware the current strap was not working effectively.
During interview on 5/22/25, at 11:50 a.m., director of nursing (DON) stated the urinary leg bag should not be on the floor. DON stated the leg bags were to be secured, adding they typically came with a strap for the top and for the bottom, and stated she was unsure why this was not being used. DON identified concerns for infection control if the leg bag was observed to be laying on the floor. DON stated the leg bag should have been checked/changed. DON stated the leg bag was to be secured to the leg. DON stated the leg bags typically come with straps and they were to be used to secure the leg bags to the leg. DON stated this was important to prevent the tubes from being pulled/tugged on, as well as the potential for the leg bag from being on the floor.
A facility policy, Indwelling Catheter Care Procedure, dated 7/21/23, was provided upon request for a policy for care and management of urinary drainage bags. This policy lacked information as to management of urinary drainage bag, including placement and process to secure, to ensure privacy, dignity, and prevention of opportunity for contamination.
On 5/21/25 at 10:00 a.m., a line list was requested to show all residents who had symptoms of illness that were not on antibiotics for 5/25 but was not provided.
During an interview on 5/21/25 at 10:00 a.m., the director of Nursing (DON), who was also the facility infection preventionist stated there was no process in the facility to keep a list of residents that had symptoms but were not on antibiotics. She would review the progress notes almost every day and would make mental notes of anybody with symptoms of respiratory concerns or gastrointestinal concerns. There was no actual list made of the residents with symptoms to keep track of the symptoms or to trend when and where they occurred. When the resident progress notes were reviewed and she remembered there were other residents who had similar symptoms, she would look at them to see if they were similar. The DON did not review the staff with illness, that was the administrator. They very rarely met to discuss staff who were sick to see if staff and residents had similar symptoms.
During an interview on 5/21/25 at 10:24 a.m., the administrator stated she was the staff member notified when there was a call in. Sometimes, staff called into the facility and other times they called the administrator directly. The facility did ask why a person was calling in sick but did not require them to report symptoms for the purpose of tracking and trending. I would report to the DON symptoms that I felt might affect the resident and the facility but did not meet with her regularly to discuss all symptoms.
Facility policy Infection Prevention and Control Program last revised 11/24 indicated surveillance tools were used to recognize the occurrence of infections, recording their number and frequency, detected outbreaks and epidemics, monitored employee infections, and detected unusual pathogens with infection control implications. Data gathered during surveillance would be used to oversee infections and spot trends.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident in 8 of 39 rooms (room #s 4,7,17,20, 21, 29, 35 and 36) which affected seven residents (R144, R92, R27, R5, R192, R21, and R2) who currently resided in these rooms.
Findings include:
During the entrance conference on 5/19/25 at 11:34 a.m., the facility administrator stated there had been no changes in resident room sizes, and there were waivers in place for room numbers: 4,7,17, 20, 21, 29,35, and 36 which did not meet the required minimum square footage.
The following double resident rooms did not meet the required minimum square footage per resident:
room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident (empty).
room [ROOM NUMBER] = 152.5 square feet, or 76.25 square feet per resident (R144).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R92).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (empty).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R27).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R5).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R192, R21).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R2).
Interview on 5/22/25 at 8:35 a.m., R92 stated she did not have a roommate at that time, but she had roommates before. Resident stated the size of the room was not an issue. She did not believe past roommates had complaints about the room size or functionality either.
Interview on 5/22/25 at 8:53 a.m., Administrator confirmed one of the waivered rooms had two residents in it. Administrator stated the facility planned to keep these rooms available for double occupancy if needed based on census. Administrator provided list of rooms with waivers dated 4/28/25, it included room numbers, measurements, and square footage of each of the eight rooms.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure both recertification survey results, as well ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure both recertification survey results, as well as additional complaint investigations, were available for review. This had the potential to affect all 32 residents residing in the facility, as well as family, visitors and staff.
Findings include:
On 5/19/25 at 2:09 p.m., a folder, titled Twin [NAME] Survey Results, was observed outside the Social Services office. This folder contained the survey results from the recertification 4/22/24 through 4/24/24. The folder also contained the complaint investigation survey results from 10/17/24, 1/9/24, and 1/21/25.
On 5/19/25 at 2:15 p.m., the administrator stated she was responsible for managing the posting of survey results. Administrator stated the complaint investigations were in the file for review. Administrator stated she was aware the 2567 (Formal documentation of the recertification process findings, as well as the outcome of the survey investigations) was to be available for review by residents, families, staff and visitors.
On 5/21/25 8:08 a.m., licensed social worker (LSW) stated on 5/19/25, she had removed some survey results from the folder prior to writer's review of the folder as she had seen the papers in the folder were in disarray. LSW stated at this time, all of the papers from investigations completed were returned to the administrator for placement in survey results folder. Administrator walked by at that time, and surveyor and administrator returned to the administrator's office for review of the documents. The survey folder was obtained from administrator at that time for comparison to surveys completed, as documented in Aspen Central Office (ACO-an online computerized federal documentation site which contains the surveys completed for facilities, including both recertification and complaint investigations).
On 5/21/25, at 8:10 a.m., a review was completed of ACO documentation. The last facility recertification survey prior to this was completed 4/24/24. Upon review of the complaint investigations from the last recertification, it was identified documentation was present in ACO for the following dates: 4/30/24, 6/6/24, 7/30/24, 11/7/24, 10/17/24, 12/18/24, 1/9/25, 1/21/25, 2/18/25, 2/19/25 and 5/1/25. Upon review of the survey results in ACO, it was noted the following investigations had deficiencies cited: 10/17/24, 11/27/24,1/9/25, 1/21/25, 2/18/25, 2/19/25, and 5/1/25. Of these surveys, the survey results were only present in the facility survey folder for the following dates: 10/17/24, 1/9/24, and 1/21/25, as had been noted on 5/19/25, at 2:09 p.m
On 5/21/25, at 8:41 a.m. an interview was held in follow up with the administrator. At this time, the adminstrator stated she did not need to have the additional dates provided as had not previously printed out, or placed, any additional survey information in the survey folder aside from what was outlined above. The administrator stated she was aware the 2567's were required to be available for review from all surveys, including recertifications and complaint investigations.
An untitled, undated document was received upon request for the policy for posting of survey results. This document, identified as Minnesota Statute § 144A.10, Subdivision 3, mandated that skilled nursing facilities (SNFs) posted correction orders and notices of noncompliance in a conspicuous and readily accessible place within the facility. The document further identified this requirement ensured transparency and allowed residents, families, and the public to be informed about the facility's compliance status. The policy identified facilities were required to post copies of each correction order and notice of noncompliance received after their most recent inspection or reinspection.
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide an individualized care plan for 1 of 3 residents (R1) rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide an individualized care plan for 1 of 3 residents (R1) reviewed for smoking plans.
Findings include:
R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a diagnosis of cerebral infarction (stroke). The MDS indicated R1 required assistance with personal care, transfers, and mobility.
R1's care plan dated 4/30/25 directed R1 had a history of smoking at the facility, and was noncompliant with the smoking policy. R1's care plan indicated he had been noted to be smoking in his room, and he was educated on the safety risk to himself and others. The care plan listed interventions of resident can smoke outside with family, and was deemed unsafe to store/handle his own smoking materials. The goal listed on R1's care plan was he would not smoke while at the facility.
The undated facility care sheet (nursing assistant and nurse care guide) lacked a smoking plan or plan for supervision for R1.
R1's Smoking assessment dated [DATE] indicated R1 was caught smoking in his room, and per the administrator was not allowed to smoke while at the facility. R1's chart lacked a Smoking Assessment after 4/16/25.
On 4/28/25, a progress note indicated social worker (SW)-A reviewed the facility smoking policy with R1, concerns of borrowing cigarettes from other residents, and staffing limitations on frequent supervised smoking.
On 5/1/25, at 8:52 a.m. R1 stated he was aware smoking was prohibited inside the facility. He smoked in his room on 4/25/25 and 4/26/25, but denied prior incidents of smoking inside the facility. He did not have smoking materials in his possession.
On 5/1/25, at 9:30 a.m. SW-A stated staff were performing safety checks every 15 minutes to assess for smoking immediately following the smoking incident on 4/26/25.
On 5/1/25 at 10:02 a.m. nursing assistant (NA)-A stated R1 was not allowed to smoke at the facility unless he had family with him to take him outside. Staff were made aware of care plans via the care sheets provided. NA-A verified the care sheets lacked any information on R1's smoking plan, smoking restrictions, and safety checks.
On 5/1/25 at 11:14 a.m. nurse practitioner (NP)-A stated R1 was not safe to smoke by himself. The current plan was for family to assist and supervise him with smoking. R1 should have his smoking materials kept at the nursing station.
On 5/1/25 at 12:51 p.m. agency staff licensed practical nurse (LPN)-A stated she was not aware of R1's recent unsafe smoking practices or restricted smoking privileges. The care sheet lacked direction regarding R1's smoking plan, and she was not provided verbal direction from the previous nurse on duty.
On 5/1/25 at 1:13 p.m. the administrator stated staff knew to keep an eye on him by word of mouth. She expected this to be shared in nurse-to-nurse reporting. R1's smoking privileges had been suspended, and would be re-evaluated in two weeks.
On 5/1/25 at 1:16 p.m. the director of nursing (DON) stated the smoking plan was not included on the care sheets. She expected the nurses to share this in their nurse-to-nurse reports.
The facility policy Care Planning dated 11/24 directed the care plan shall be used in developing the resident's daily care routines, and will be used by staff personnel for the purposes of providing care or services to the resident. The plan of care will be utilized to provide care to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide adequate supervision for 1 of 3 residents (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) reviewed for safe smoking, after R1 was discovered smoking in his room on multiple occasions.
Findings include:
R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a diagnosis of cerebral infarction (stroke). The MDS indicated he required assistance with personal care, transfers, and mobility.
R1's care plan dated 4/30/25 directed R1 had a history of smoking at the facility, and was noncompliant with the smoking policy. R1's care plan indicated he had been noted to be smoking in his room, and he was educated on the safety risk to himself and others. The care plan listed interventions of resident can smoke outside with family, and was deemed unsafe to store/handle his own smoking materials. The goal listed on R1's care plan was he would not smoke while at the facility.
The undated facility care sheet (nursing assistant and nurse pocket care guide) lacked a smoking plan or plan for supervision for R1.
R1's smoking assessment dated [DATE] indicated R1 was caught smoking in his room, and per the administrator was not allowed to smoke while at the facility. R1's chart lacked a smoking assessment after 4/16/25.
On 4/16/25 at 5:36 p.m., a progress note indicated on 4/15/25 at 4:21 p.m. the administrator received a call informing her R1 was smoking in his room. Administrator noticed ashes on tray table and a cigarette which had been lit and burnt out.
On 4/25/25 at 5:56 p.m. a progress note indicated R1 was smoking in his room at 5:40 p.m.
On 4/26/25 at 12:40 a.m. a progress note indicated the odor of cigarette smoke was coming from R1's room. A nurse observed R1 sitting in his wheelchair, throwing cigarette ashes into a cup of milk. Staff removed the cigarette and left the room. When the nurse re-entered the room, R1 was observed smoking another cigarette, with ashes all over the floor.
On 4/26/25 at 1:31 a.m. a progress note indicated R1 was smoking a cigarette (in his room).
On 5/1/25 at 9:30 a.m. SW-A stated R1 was discovered smoking in his room by a staff member on 4/25/25 and again on 4/26/25. R1 had refused to relinquish his smoking materials. The smoking policy was reviewed with R1 on 12/12/24, 4/16/25 and 4/28/25. R1 was only allowed to smoke if he was supervised by family. Staff were performing safety checks every 15 minutes to assess for smoking immediately following the smoking incident on 4/26/25.
On 5/1/25 at 9:30 a.m. SW-A stated R1 was discovered smoking in his room by a staff member on 4/25/25 and again on 4/26/25. R1 had refused to relinquish his smoking materials. The smoking policy was reviewed with R1 on 12/12/24, 4/16/25 and 4/28/25. R1 was only allowed to smoke if he was supervised by family. Staff were performing safety checks every 15 minutes to assess for smoking immediately following the smoking incident on 4/26/25.
On 5/1/25 at 10:02 a.m. nursing assistant (NA)-A stated R1 was not allowed to smoke at the facility unless he had family with him to take him outside. Staff were made aware of care plans via the care sheets provided. NA-A verified the care sheets lacked any information on R1's smoking plan, smoking restrictions, and safety checks.
On 5/1/25 at 11:14 a.m. nurse practitioner (NP)-A stated R1 was not safe to smoke by himself. The current plan was for family to assist and supervise him with smoking. R1 should have his smoking materials kept at the nursing station.
On 5/1/25 at 12:51 p.m. agency staff licensed practical nurse (LPN)-A stated she was not aware of R1's recent unsafe smoking practices or restricted smoking privileges. The care sheet lacked direction regarding R1's smoking plan, and she was not provided verbal direction from the previous nurse on duty.
On 5/1/25 at 1:13 p.m. the administrator stated R1 was caught smoking in his room on the evening of 4/25/25. R1 had been away from the facility for a short time that evening. When he returned to the facility later that night, he lit up a cigarette three more times. This was the second time in the past two weeks R1 was caught smoking in his room. NA-A took R1 outside on 5/1/25 because he wanted to get some fresh air. Once they came back inside, NA-A reported R1 smoked a cigarette while outside, as he had possession of smoking materials. The staff knew to keep an eye on him by word of mouth. She expected this to be shared in nurse-to-nurse reporting. R1's smoking privileges had been suspended, and would be re-evaluated in two weeks.
On 5/1/25 at 2:04 p.m. NA-B stated R1 told her he was going to smoke in his room if he couldn't smoke outside on 4/25/25. R1 had smoked almost a full cigarette when she discovered him smoking in his room.
On 5/1/25 at 2:24 p.m. NA-A stated he brought R1 outside around 12:00 p.m., as R1 stated he wanted to get fresh air. While outside, R1 took a cigarette and lighter out of his picket and proceeded to smoke. Once they were back inside the building, he informed the administrator immediately.
The facility policy Resident Smoking dated 10/24, directed all smoking devices, including electronic devices, will be lit/used in designated smoking areas only. Residents who choose to smoke will be evaluated upon admission, quarterly, annually and if significant change in condition/cognition exists or resident exhibits inability to follow safe smoking practices. Residents requiring supervision will receive assistance with smoking, in accordance with facility and resident specific practices as identified on the individual resident care plans.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and document review the facility failed to notify the physician of a significant medication error for 1 of 3 residents (R3) who did not receive prescribed blood pressure medication ...
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Based on interview and document review the facility failed to notify the physician of a significant medication error for 1 of 3 residents (R3) who did not receive prescribed blood pressure medication for five days.
Findings include:
R3's admission Record indicated he admitted to the facility 12/3/24. R3's diagnosis included chronic atrial fibrillation (A-fib), pain, chronic kidney disease and weakness.
R3's Order Summary Report dated 12/1/24 through 12/31/24, identified the following order: diltiazem hydrochloride (HCl) extended release (ER) coated beads oral capsule extended release 24 Hour 120 milligrams (mg). Give 120 mg by mouth in the morning for A-Fib.
R3's Medication Administration Record dated December 2024, displayed the following for R1's diltiazem order:
12/4/24, 9- other/ see nurses notes.
12/5/24, 9- other/ see nurses notes.
12/6/24, 9- other/ see nurses notes.
12/7/24, indicated medication was administered.
12/8/24, 5- Hold/ see nurses notes.
R3's Progress Notes identified the following:
12/4/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120 mg.
Give 120 mg by mouth in the morning for A-Fib. Medication not available.
12/5/24, Copy of signed encounter note documented by nurse practitioner (NP). I certify that the following medications have been reviewed and reconciled. Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 120 MG, Give 120 mg by mouth in the morning for A-Fib, 120 mg, active. 12/4/2024.
12/5/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120 mg.
Give 120 mg by mouth in the morning for A-Fib.
12/6/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120 mg.
Give 120 mg by mouth in the morning for A-Fib.
12/8/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120 mg.
Give 120 mg by mouth in the morning for A-Fib. Resident not on medication. Pharmacy discontinued orders upon admission.
12/9/24, Resident was sent to hospital due to being unresponsive for couple of minutes while doing physical therapy.
During interview on 1/17/25 at 9:17 a.m., the director of nursing (DON) stated she was not sure why the pharmacy would say the medication was not supposed to be ordered. The DON stated not receiving the diltiazem could lead to increased blood pressure. The DON stated if a medication was not available, staff should have let her know. RN-B was present and said staff should also have updated the physician.
During interview on 1/17/25 at 11:24 a.m. nurse practitioner (NP)-A stated she had not been made aware R3 had not been receiving his diltiazem. NP-A stated she was present at the facility the day R3 had the unresponsive episode and said R3 had nodded off but then was able to wake up a little bit. NP-A stated not receiving the diltiazem could have caused the unresponsive episode and could cause an irregular heartbeat and potentially some dizziness and would certainly have cause the spike in his blood pressure.
Facility policy Medication Error Procedure dated 1/2020, indicated when a medication error occurs, the person responsible for the error or the person finding the error will complete the Medication Error Reconciliation Report and contact the medical provider to inform them of the error.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure prescribed blood pressure medication and oxygen was adminis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure prescribed blood pressure medication and oxygen was administered for 2 of 3 residents (R3 and R1) reviewed. R3 had an in increase in blood pressure and R1 had an empty oxygen tank and was sent to the emergency room.
Findings include:
R3's admission Record indicated he admitted to the facility 12/3/24. R3's diagnosis included chronic atrial fibrillation (A-fib), pain, chronic kidney disease and weakness.
R3's Order Summary Report dated 12/1/24 through 12/31/24, identified the following order: diltiazem hydrochloride (HCl) extended release (ER) 24 Hour, 120 milligrams (mg). Give 120 mg by mouth in the morning for A-Fib.
R3's Medication Administration Record dated December 2024, displayed the following for R1's diltiazem order:
12/4/24, 9- other/ see nurses notes.
12/5/24, 9- other/ see nurses notes.
12/6/24, 9- other/ see nurses notes.
12/7/24, indicated medication was administered.
12/8/24, 5- Hold/ see nurses notes.
R3's Progress Notes identified the following:
12/4/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120 mg.
Give 120 mg by mouth in the morning for A-Fib. Medication not available.
12/5/24, Copy of signed encounter note documented by nurse practitioner (NP). I certify that the following medications have been reviewed and reconciled. Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 120 MG, Give 120 mg by mouth in the morning for A-Fib, 120 mg, active. 12/4/2024.
12/5/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120 mg.
Give 120 mg by mouth in the morning for A-Fib.
12/6/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120 mg.
Give 120 mg by mouth in the morning for A-Fib.
12/8/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120 mg.
Give 120 mg by mouth in the morning for A-Fib. Resident not on medication. Pharmacy discontinued orders upon admission.
12/9/24, Resident was sent to hospital due to being unresponsive for couple of minutes while doing physical therapy.
12/9/24, Chief concern/reason for transfer: Unresponsive. Vital signs; blood pressure 153/35.
During interview on 1/17/25 at 9:07 a.m., licensed practical nurse (LPN)-B stated she administered R3's medication on 12/8/24 and said she noticed the other nurses had noted the medication was not available. LPN-A stated she was worried because it was an important medication, so she called the pharmacy to find out why it had not been delivered. LPN-B stated the pharmacy told her R1 was not supposed to be taking the diltiazem. LPN-B stated she had reported the medication error to the nurse manager, LPN-A.
During interview on 1/17/25 at 9:11 a.m., LPN-A stated she was not aware R3 had not been receiving the diltiazem. LPN-A stated normally staff would let her know and she would call the pharmacy or ask the nurse to call.
During interview on 1/17/25 at 9:17 a.m., the director of nursing (DON) stated she was not sure why the pharmacy would say the medication was not supposed to be ordered. The DON stated not receiving the diltiazem could lead to increased blood pressure. The DON stated if a medication was not available, staff should have let her know. RN-B was present and said staff should also have updated the physician. At 9:45 a.m., RN-B stated she had called the pharmacy, and they said they had no record of the order. RN-B said it looked like when the orders were sent to the pharmacy a page must have been missing.
During interview on 1/17/25 at 11:24 a.m. nurse practitioner (NP)-A stated she had not been made aware R3 had not been receiving his diltiazem. NP-A stated she was present at the facility the day R3 had the unresponsive episode and said R3 had nodded off but then was able to wake up a little bit. NP-A stated not receiving the diltiazem could have caused the unresponsive episode and could cause an irregular heartbeat and potentially some dizziness and would certainly have cause the spike in his blood pressure.
R1's admission Record indicated he admitted to the facility 6/29/22 and identified diagnosis that included Chronic Obstructive Pulmonary Disease (COPD), tobacco use, hypokalemia, depressive disorder, insomnia, and cognitive communication deficit.
R1's quarterly Minimum Data Set, dated [DATE], identified intact cognition and indicated he received Oxygen therapy at the facility.
R1's care plan dated 7/19/24, identified and alteration of oxygen/gas exchange and respiratory status related to respiratory failure and COPD. The care plan directed staff to remind R1 not to turn up oxygen (O2) without nurse consent, monitor saturation levels as ordered, administer O2 as ordered and monitor and document on respiratory status.
R1's Order Summary Report dated 1/1/25, identified an order dated 8/1/24; O2 per nasal annular 2-5 liters to keep saturation level greater than or equal to 88%, to prevent hypoxia every shift.
R1's Progress Notes identified the following:
1/10/25, R1's blood pressure obtained with result of 94/57 millimeters of mercury (mmHg), heart rate high at 120 beats per minute (bpm) and O2 sat low at 74%. R1's oxygen was empty after assessments O2 tank was refilled and turned back to 3 liters. Vitals were reassessed and were blood pressure 104/56 mmHg, heart rate 119 (bpm), O2 89%.
1/11/25 at 1:17 a.m., R1 complained of not feeling well. Had generalized weakness, slight congestion, nausea. Medicated with Zofran 4 mg for nausea. R1 told nursing assistant (NA) he wanted to be sent out. When this writer asked resident about being sent out, he refused.
1/11/25 at 5:10 a.m., R1 was diaphoretic, lethargic, and continued to be nauseated. R1 had a large loose diarrhea. Expiratory crackles audible in right lower lobe. B/P 98/58, T 98.4, P 63, O2 saturation of 92% on 3L. Pt stated, I feel like I'm going to die. Order received to send R1 to emergency department (ED) for evaluation. Emergency services present to transport to hospital.
An Emergency Medical Services (EMS) report dated 1/11/25, indicated on 1/11/25 at 4:56 a.m. EMS was dispatched to facility and arrived onsite at 4:55 a.m. R1 was assessed by EMS. Pulse, 114, respirations 34. R1 was confused, skin was pale, diaphoretic, and making incomprehensible sounds. O2, 4 liters per nasal cannula was given at 5:19 a.m. and R1's response improved. O2 10 liters was initiated at 5:32 a.m. with improved response. Additional information indicated upon EMS arrival R1 was lying on his right side, breathing was shallow and when EMS stimulated R1 he only groaned. EMS noted R1's nasal cannula was attached to a portable O2 tank that was on his wheelchair and the tank was empty. EMS changed his nasal cannula to the large O2 tank. By the time the reader picked up a reading R1's saturation level was at 75%. EMS noticed R1 was diaphoretic and soaked through his gown and sheets. R1 was moved to the ambulance and placed on a re-breather mask and his saturation level moved to 96%.
During interview on 1/16/25 at 3:00 p.m., registered nurse (RN)-A stated the night R1 went to the hospital he had not been feeling well and said the NA told her he wanted to see the nurse and wanted to go to the hospital. RN-A stated when she saw R1 he told her he wanted to stay at the facility. RN-A stated R1 had been having diarrhea and felt nauseated and said the NA's cleaned him up. RN-A said when she went back to check on R1 she assessed him and said his blood pressure was low, he was not running a fever and his O2 levels were okay. RN-A stated she called and got an order to send R1 to the ED. RN-A said when she went back to tell him, he was sweating and in the fetal position and said by the time the paramedics arrived R1 was sweating to the point his sheets were wet.
During interview on 1/17/25 at 9:56 a.m. The director of nursing (DON) stated R1 had gone into the hospital due to a change of condition. The DON stated the hospital had notified the facility that R1's O2 tank had been empty when EMS arrived at the facility.
During interview on 1/17/25 at 10:21 a.m., the administrator stated the hospital had reported concerns about R1's O2 tank being empty. The administrator then clarified and said the facility had access to the hospital documentation and the concern was identified when the notes were read. The DON who was present during the interview stated the facility was conducting audits of all residents who had orders for O2 but stated they had not completed any yet. The administrator stated staff had received education related to how to fill an O2 tank but stated no education had been completed related to the facility's process for ensuring tanks were filled.
Facility policy Medication Error Procedure dated 1/2020, indicated when a medication error occurs, the person responsible for the error or the person finding the error will complete the Medication Error Reconciliation Report and contact the medical provider to inform them of the error. The policy further indicated the relative significance of medication errors is a matter of professional judgment. Follow three general guidelines in determining whether a medication error is significant or not:
- Resident Condition - The resident's condition is an important factor to take into consideration. If the
resident's condition requires rigid control, a single missed or wrong dose can be highly significant.
- Drug Category - If the medication is from a category that usually requires the resident to be triturated to a
specific blood level, a single medication error could alter that level and precipitate a reoccurrence of
symptoms or toxicity. This is especially important with a medication that has a Narrow Therapeutic
Index.
- Frequency of Error - If an error is occurring repeatedly, there may be more reason to classify the error as
significant. For example, if a resident's medication was omitted several times, it may be appropriate, depending on consideration of resident condition and medication category, to classify that error as significant.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide timely notification for change in condition to the physic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R3) reviewed for quality of care.
Findings include:
R3's admission Record dated 12/28/24 indicated R3's diagnoses included and type two diabetes mellitus.
R3's annual Minimum Data Set (MDS) dated [DATE] indicated R3 had moderate cognitive impairment.
R3's care plan dated 1/2/25, indicated R3 had type two diabetes mellitus, with staff interventions to monitor blood sugars, and keep the provider informed per resident orders.
R3's Provider Order dated 12/28/24 indicated blood glucose checks before meals and bedtime. Call the provider if blood sugars less than 75 or greater than 400.
R3's orders dated 12/28/24 included insulin Aspart subcutaneous solution pen-injector 100 unit/milliliter (ml). Inject 20 units subcutaneously with meals and 10 units as needed for diabetes mellitus. May take additional 10 units for higher carb meal daily, up to 70 units total in 24 hours.
On 1/4/25 at 3:44 p.m. vital signs indicated R3's blood sugar was 53 mg/deciliter (dl).
On 1/4/25 at 8:39 p.m. vital signs indicated R3's blood sugar was 54 mg/dl.
On 1/6/25 at 5:14 a.m. a progress note indicated R3's blood sugar was 77, resident was alert to self and on call provider gave order to recheck blood sugar (BS), vital signs and mental status in an hour and update the provider if it remained less than 75.
On 1/6/25 at 7:37 a.m. vital signs indicated R3's blood sugar was 65 mg/dl.
On 1/6/25 at 8:03 a.m. vital signs indicated R3's blood sugar was 65 mg/dl.
R3's medical record lacked indication R3's provider was notified for blood sugars less than 75 on 1/4/25, and 1/6/25.
On 1/8/25 at 10:49 a.m. licensed practical nurse (LPN)-A stated R3's BS checked on 1/6/25 was 65 at 7:37 a.m. by registered nurse (RN)-A, but he did not know if the provider was notified.
On 1/8/25 at 1:11 p.m. nurse practitioner (NP)-A stated staff were instructed to call back the provider if R3's blood sugar remained low. She could not find anything in the system suggesting the facility called her back on 1/6/25 when R3's blood sugar did not improve. She also was not notified of R3's low blood sugar of 54 on 1/4/25. Staff were expected to follow the provider orders.
On 1/8/25 at 1:29 p.m. RN-A stated she was new to the facility, so LPN-A agreed to help her with R3's care on 1/6/25. She reported R3's low blood sugar of 65 to LPN-A, but she did not call the provider. She thought LPN-A notified the provider since he had been caring for R3.
On 1/8/25 at 2:54 p.m. RN-B stated she was the only nurse on the floor on 1/4/25, and recall caring for R3. R3's blood sugar of 5 had been reported to her, but she was so busy, and she forgot to notify the provider.
On 1/9/24 at 12:12 p.m., the director of nursing (DON) stated staff were to follow the resident's care plan and the provider's orders.
The facility policy Notification of Changes dated 3/24 directed the facility staff to make appropriate and timely notification to the physician and delegated non-physician practitioner when there is a change in the resident's condition that may require physician intervention.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide 1:1 supervision during meals to ensure a res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide 1:1 supervision during meals to ensure a resident who was identified as a choking risk was supervised while eating for 1 of 3 residents (R2) reviewed for 1:1 supervision during meals.
Findings include:
R2's admission Record dated 4/24/24 indicated R2's diagnoses included muscle weakness, dysphagia, and oropharyngeal phase.
R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had mechanical altered diet, required change in texture of food, and required staff supervision for all meals and drinks.
R2's care plan dated 8/21/24, indicated R2 had potential alteration in nutrition related to dysphagia, oropharyngeal phase, and needed 1:1 supervision with meals with reminders to swallow foods and liquids.
R2' Provider Orders dated 8/21/24 indicated regular diet mechanical soft texture, regular (thin) consistency fluids, 1:1 feeding and drinking, remind to swallow. No straws per speech therapist.
On 1/7/25 at 12:53 p.m. R2 was observed in her wheelchair (W/C) in her room by herself eating ice cream. R2 fed herself the ice cream, and did not swallow what was in her mouth before she took more bites. R2 started coughing. R2 continued feeding herself the ice cream and started coughing continuously. No staff were providing 1:1 supervision.
On 1/8/25 at 9:18 a.m. R2 was observed in her W/C in her room by herself. A bowl of oatmeal was on the bedside table. R2 fed herself the oatmeal, and did not swallow what was in her mouth before she took more bites. R2 started coughing. No staff were providing 1:1 supervision.
On 1/8/25 at 9:29 a.m. R2 stated she tried the oatmeal and the sausage that were on her plate. They were not good, so she ate just a little. No staff were in the room to help her with her meals.
On 1/8/25 at 9:35 a.m., nursing assistant (NA)-B entered R2's room, and asked R2 if she was done with her meal. NA-B removed the oatmeal, and left a small cup, and a water pitcher with a straw in it on the table, and left the room.
On 1/8/25 at 2:04 p.m. NA-A stated R2 usually ate in the dining room, but yesterday morning she was vomiting in the dining room and wanted to go back to her room. He was aware R2 required supervision while she was eating, but staff got busy and did not stay with her.
On 1/8/25 at 2:15 p.m. NA-B stated the care guide sheet directed R2 was to be supervised with all meals and drinks. She got busy today and was not able to provide 1:1 supervision while R2 was eating. When she heard R2 coughing, she reported to the trained medication aide (TMA)-A.
On 1/9/25 at 11:14 a.m. speech therapist (ST)-A stated she recommended R2 to have 1:1 close supervision at all meals to prevent aspiration and choking. 1:1 supervision meant nursing staff were to sit with R2 when she received her meal until she was done eating. Staff was also to provide cues and reminders to swallow one bite at the time. If R2 did not have 1:1 supervision with meals, she could choke, aspirate, or get pneumonia.
On 1/9/24 at 12:12 p.m., the director of nursing (DON) stated staff were to follow the resident's care plan and assist them per speech therapist recommendations. She said 1:1 supervision meant staff sit next to the residents when they were eating to remind them to swallow.
On 1/9/25 at 2:27 p.m. NP-A stated R2 had to be supervised for all meals and drinks. Failure to supervise R2 during meals time would put her at risk for aspiration.
The facility policy Activities of Daily Living (ADLs) dated 3/31/23 directed staff to provide a person-centered care and services including supervision for each resident related to resident's physician orders.
Oct 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure staff implemented the care plan for 1 of 3 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure staff implemented the care plan for 1 of 3 residents (R3) when staff failed to reposition and check and change incontinent brief for R3 who required assistance with activities of daily living (ADLs).
Findings include:
R3's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition with no behaviors identified. R3 required substantial to maximal assistance with personal hygiene, dressing, roll left and right, and dependent on staff for toileting hygiene, shower/bath, all transfers, and mobility in a manual wheelchair. R3 was always incontinent of bowel and bladder. R3's active diagnoses included: CVA (cerebrovascular accident) (stroke), hemiplegia (one sided paralysis/weakness), diabetes mellitus (DM), and at risk for pressure ulcers.
R3's care plan dated 10/16/24, identified self-care deficit and decreased mobility, instructed staff to check and change and reposition every two to three hours and as needed (PRN) every shift.
Nursing assistant care sheet last updated 10/16/24, identified R3 required turn, reposition, check, and change every two to three hours and PRN. R3 was identified as incontinent of bowel and bladder.
Observation on 10/16/24 at 9:30 a.m. and 10:00 a.m. R3 laid on left side in bed awake covered with blankets. R3's room had a smell of urine.
Observation on 10/16/24 at 10:30 a.m. and 11:12 a.m. R3 laid on left side in bed eyes closed covered with blankets. R3's room had a smell of urine.
Observation/interview on 10/16/24 at 11:58 p.m. R3 laid in bed on left side, television on, and door open. R3 had a night gown on, pillow was placed behind her back, and smelled of urine. R3 stated she was unable to reposition herself, had laid in same position since before 6:30 a.m. and became uncomfortable.
During an observation/interview on 10/16/24 at 1:04 p.m. nursing assistant (NA)-A entered R3's room and removed a lunch tray and exited the room. R3 laid in bed on left side, pillow behind her back, covered with blankets and television on. R3's room had a smell of urine. NA-A immediately returned to R3's room and R3 stated she really would have liked to have been dressed by now. NA-A stated, today we are running behind schedule. NA-A stated R3 had been in bed longer than she should have, got left behind, so busy, while everyone else was being taken care of. NA-A stated R3 normally was one of the first residents up early in the morning. NA-A exited room and then returned with towels and linens. R3's brief was saturated with urine and NA-A cleaned R3's peri area from front to back. NA-A rolled R3 onto her right side and wiped her buttocks clean. R3's skin was intact without redness. NA-A told R3, sorry you got left in bed way too long today. At 1:34 p.m. NA-B entered R3's room with a total lift machine, hooked up loops to lift sheet located underneath R3. NA-A lifted R3 off the bed with lift machine and lowered her down onto the wheelchair. NA-A removed the lift sheet loops, NA-B tucked them behind R3, combed her hair and NA-A pushed R3 in wheelchair out of the room. NA-B removed the sheets from R3's bed and stated R3's bed had a large yellow urine stain saturated all the way to the mattress in the middle of the bed where R3's bottom was positioned. NA-B stated unsure of when R3 was changed last had not been in her room since she arrived at 6:30 a.m. (8 hours ago). NA-B stated R3 was usually incontinent of bowel and bladder and her incontinent brief should have been checked and changed every two to three hours.
During an interview on 10/16/24 at 2:32 p.m. NA-A stated arrived at facility at 6:30 a.m. and just after 1:00 p.m. (over 6 ½ hours) was the first time R3 had her incontinent brief checked and changed. NA-A stated breakfast and lunch were brought to her room, R3 could feed herself, liked to stay in bed, but her incontinent brief should have been checked and changed every two to three hours. NA-A stated she understood R3 was a priority, should have been gotten up right after breakfast, and not ok to be left for that many hours without her incontinent brief check and changed. NA-A stated she had stopped in twice, once around 8:40 a.m. and again at 12:00 p.m., checked on R3 and adjusted her top half due to leaning over to one side. NA-A stated she should have offered to change her incontinent brief. NA-A stated she charted when a resident was incontinent but not each time and no documentation as to when she was repositioned.
During an interview on 10/17/24 at 2:15 p.m. family member (FM) stated R3 was always a very clean person and as to how she looked. FM stated would have bothered R3 to have laid in bed without assistance and not able to move and/or get herself cleaned up for the day.
During an interview on 10/17/24 at 10:42 a.m. administrator stated she was aware of lack of charting consistency and accuracy to show what the NA's have completed regarding toileting/cares. Administrator stated a lot of the residents chose to stay in bed. Administrator stated staff would be expected to follow the resident care plan and when indicated incontinent brief should have been checked and changed every two to three hours. Administrator indicated she expected staff to have provided personalized cares to each resident which meant they would receive adequate care they need. Administrator was unable to provide a bath aide every day. Administrator stated staff were also expected to toilet and reposition residents according to the care plan. Administrator verified staff were expected to document once a day if the resident was repositioned, toileted, and if they had a bath done, rather than every time it happened, was not possible with their workload.
During an interview on 10/17/24 at 12:05 p.m. clinical coordinator/licensed practical nurse (LPN)-A stated staff would be expected to check and change R3's incontinent brief and reposition her every two to three hours to prevent skin breakdown and made sure she was comfortable. LPN-A stated was not acceptable to have left R3 from 6:30 a.m. to after 1:00 p.m. without changing her incontinent brief and being repositioned.
Facility policy Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23, identified was the facility's responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff understood, honor and support the principles of quality of life and care and services provided are person-centered for each resident. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure staff implemented the care plan for 1 of 3 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure staff implemented the care plan for 1 of 3 residents (R3) when staff failed to reposition and check and change incontinent brief for R3 who required assistance with activities of daily living (ADLs).
Findings include:
R3's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition with no behaviors identified. R3 required substantial to maximal assistance with personal hygiene, dressing, roll left and right, and dependent on staff for toileting hygiene, shower/bath, all transfers, and mobility in a manual wheelchair. R3 was always incontinent of bowel and bladder. R3's active diagnoses included: CVA (cerebrovascular accident) (stroke), hemiplegia (one sided paralysis/weakness), diabetes mellitus (DM), and at risk for pressure ulcers.
R3's care plan dated 10/16/24, identified self-care deficit and decreased mobility and instructed staff to check and change and reposition every two to three hours and as needed (PRN) every shift.
Nursing assistant care sheet last updated 10/16/24, identified R3 required turn, reposition, check and change every two to three hours and PRN. R3 was identified as incontinent of bowel and bladder.
Observation on 10/16/24 at 9:30 a.m. and 10:00 a.m. R3 laid on left side in bed awake covered with blankets. R3's room had a smell of urine.
Observation on 10/16/24 at 10:30 a.m. and 11:12 a.m. R3 laid on left side in bed eyes closed covered with blankets. R3's room had a smell of urine.
Observation/interview on 10/16/24 at 11:58 p.m. R3 laid in bed on left side, television on, and door open. R2 had a night gown on, pillow was placed behind her back, and smelled of urine. R3 stated she was unable to reposition herself, had laid in same position since before 6:30 a.m. and, became uncomfortable.
During an observation/interview on 10/16/24 at 1:04 p.m. nursing assistant (NA)-A entered R3's room and removed a lunch tray and exited the room. R3 laid in bed on left side, pillow behind her back, covered with blankets and television on. R3's room had a smell of urine. NA-A immediately returned to R3's room and R3 stated she really would have liked to have been dressed by now. NA-A stated, today we are running behind schedule. NA-A stated R3 had been in bed longer than she should have, sort of got left behind, so busy, while everyone else was being taken care of. NA-A stated R3 normally was one of the first residents up early in the morning. NA-A exited room and then returned with towels and linens. R3's brief was saturated with urine and NA-A cleaned R3's peri area from front to back. NA-A rolled R3 onto her right side and wiped her buttocks clean. R3's skin was intact without redness. NA-A told R3, sorry you got left in bed way too long today. At 1:34 p.m. NA-B entered R3's room with a total lift machine, hooked up loops to lift sheet located underneath R3. NA-A lifted R3 off of the bed with lift machine and lowered her down onto the wheelchair. NA-A removed the lift sheet loops, NA-B tucked them behind R3, combed her hair and NA-A pushed R3 in wheelchair out of the room. NA-B removed the sheets from R3's bed and stated R3's bed had a large yellow urine stain saturated all the way to the mattress in the middle of the bed where R3's bottom was positioned. NA-B stated unsure of when R3 was changed last had not been in her room since she arrived at 6:30 a.m. (8 hours ago). NA-B stated R3 was usually incontinent of bowel and bladder and her incontinent brief should have been checked and changed every two to three hours.
During an interview on 10/16/24 at 2:32 p.m. NA-A stated arrived at facility at 6:30 a.m. and just after 1:00 p.m. (over 6 ½ hours) was the first time R3 had her incontinent brief checked and changed. NA-A stated breakfast and lunch were brought to her room, R3 could feed herself, liked to stay in bed, but her incontinent brief should have been checked and changed every two to three hours. NA-A stated she understood R3 was a priority, should have been gotten up right after breakfast, and not ok to be left for that many hours without her incontinent brief check and changed. NA-A stated she had stopped in twice, once around 8:40 a.m. and again at 12:00 p.m., checked on R3 and adjusted her top half due to leaning over to one side. NA-A stated she should have offered to change her incontinent brief. NA-A stated she charted when a resident was incontinent but not each time and no documentation as to when she was repositioned.
During an interview on 10/17/24 at 2:15 p.m. family member (FM) stated R3 was always a very clean person and as to how she looked. FM stated would have bothered R3 to have laid in bed without assistance and not able to move and/or get herself cleaned up for the day.
During an interview on 10/17/24 at 10:42 a.m. administrator stated she was aware of lack of charting consistency and accuracy to show what the NA's have completed regarding toileting/cares. Administrator stated a lot of the residents chose to stay in bed. Administrator stated staff would be expected to follow the resident care plan and when indicated incontinent brief should have been checked and changed every two to three hours. Administrator indicated she expected staff to have provided personalized cares to each resident which meant they would receive adequate care they need. Administrator was unable to provide a bath aide every day. Administrator stated staff were also expected to toilet and reposition residents according to the care plan. Administrator verified staff were expected to document once a day if the resident was repositioned, toileted, and if they had a bath done, rather than every time it happened, was not possible with their workload.
During an interview on 10/17/24 at 12:05 p.m. clinical coordinator/licensed practical nurse (LPN)-A stated staff would be expected to check and change R3's incontinent brief and reposition her every two to three hours to prevent skin breakdown and made sure she was comfortable. LPN-A stated was not acceptable to have left R3 from 6:30 a.m. to after 1:00 p.m. without changing her incontinent brief and being repositioned.
Facility policy Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23, identified was the facility's responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff understood, honor and support the principles of quality of life and care and services provided are person-centered for each resident. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, facility failed to practice competent, safe, and sterile technique when adm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, facility failed to practice competent, safe, and sterile technique when administering intravenous (IV) medication via peripherally inserted central catheter (PICC) (enters a peripheral vein and extends to the supervisor vena cava of the heart) 1 of 1 resident (R6) reviewed for medication administration.
Findings include:
R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 was admitted to facility from hospital. R6 was admitted with an IV access and had diagnoses of a multidrug resistant organism (microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents), and paraplegia (paralysis that affected the lower half of the body and ability to walk).
R6's orders included:
Flush pulsating before medications with 10 cubic centimeters (cc) saline, PICC line per nurse. Start date 10/2/24.
Meropenem 1 gram (gm) /100 milligram (mg) normal saline (NS) 100 milliliters (ml) infuse over 30 minutes at 200 ml /per hour. PICC line per nurse. Start date 10/15/24 discontinue 10/22/24.
During medication administration observation on 10/16/24 at 4:30 p.m. licensed practical nurse (LPN)-A sanitized hands, completed verification of the medication Meropenem IV and NS flush with the order and electronic medication administration record (EMAR). LPN-A entered R6's room, applied gloves, open prepackaged NS syringe that contained 10 ml of solution, and expelled a small amount of fluid out of the syringe. LPN-A wiped off the end of R6's PICC with an alcohol swab then connected the NS syringe. LPN-A pushed the fluid into R6's PICC line without pulling back to check placement. LPN-A removed NS syringe and end cap from antibiotic IV tubing and attached it to the end of R6's PICC without cleansing the end of it off first, then opened the clamp to the antibiotic tubing. LPN-A removed gloves, gown, and sanitized hands, and exited the room. LPN-A approached medication cart and documented in EMAR.
During an interview on 10/16/24 at 4:45 p.m. LPN-A stated in about 30 minutes planned on returning to R6's room, antibiotic tubing would be disconnected, and PICC flushed with another 10 ml of NS. LPN-A verified he did not pull back to see if blood return to verify placement, that was not the standard of practice anymore. LPN-A stated he did not wipe of the end of the PICC line prior to attaching the antibiotic tubing, was not necessary because it had been hooked up right away directly straight to the antibiotic and there was no need to. LPN-A stated he had received some facility orientation such as a tour and showed around when he first started at facility. LPN-A stated IV education was not provided and he had gone by what he had learned in nursing school.
During an interview on 10/17/24 at 2:06 p.m. floor manager/registered nurse (RN)-A stated the nursing staff were expected to cleanse of end of IV PICC line prior to each time it was accessed to help prevent bacteria from getting into the line and cause infection. RN-A stated nursing staff were expected to attach the NS syringe and drawback to get blood return to assure it was positioned in the correct spot where it needed to be administered. RN-A stated she was unsure if agency staff were required to have completed the same skills education for a PICC line, would check on this. No further response was received.
On 10/17/24 at approximately 2:30 p.m. surveyor requested LPN-A's orientation/skills documentation. Facility was unable to provide the documents.
On 10/23/24 at 12:16 p.m. director of nursing (DON) emailed surveyor and indicating LPN-A was agency staff, the facility did not provide education on IV administration skills for agency staff. DON stated the agency staff were oriented to the building such as location of supplies and linens, location of bathroom and dining room. DON stated the current administration was unable to find orientation documentation for LPN-A. DON stated the facility has had many new management members, processes were being changed to ensure adequate record keeping was being completed. DON stated agency staff were expected to have followed the standards of nursing practice and what was learned in college. DON stated going forward the orientation process for agency staff would include education on policies and procedures for PICC line flushing and medication administration.
An Attempt to contact the facility pharmacist was unsuccessful.
Facility PICC flushing skills check off list undated, identified perform hand hygiene, put on gloves to comply with standard precautions. Perform vigorous mechanical scrub of the needless connector for at least five seconds using an antiseptic pad; allow it to dry completely. Trace the tubing from the patient to its point of origin to make that you are accessing the correct port. While the sterility of the syringe tip is maintained, attach a prefilled 10 ml syringe containing preservative-free normal saline solution to the needless connector. Unclamp the catheter and slower aspirate for blood return, that is the color and consistency of whole blood. If blood return is not obtained, take steps to locate and external cause of obstruction. Remove and discard the syringe. Perform a vigorous mechanical scrub of the needless connector for at least five seconds using an antiseptic pad; allow it to dry completely. Administer IV fluid through the catheter, as prescribed, or proceed with locking the device if indicated.
Facility orientation check list undated, identified New Employee: complete and return to the DON within 30 days of first day of orientation. Skills: basic resident cares, body mechanics and resident safety, documentation and communication, technical skills and vital signs, urine collection, oxygen use, accurately record, reports, and documents, housekeeping, and maintenance indicated for NA's.
Facility policy Flushing midline and central line IV catheters dated April 2017, identified flushing when giving medication. Disinfect needless connection device with alcohol wipe. Remove air bubbles from syringe. Connect 10 ml syringe containing preservative-free 9 % normal saline to catheter via needless connection device. Aspirate slowly for blood return to ensure patency of catheter. Flush with preservative-free 9 % normal saline using push-pause method. Disinfect needleless connection device with alcohol wipe. Connect primed medication tubing to needleless connection device. Administer medication.
Apr 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R21), reviewed and observed for self-administration of medications.
Findings include:
R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognition and was independent with all activities of daily living (ADLs). R21's diagnoses included stroke, hemiplegia (left side), depression, asthma, muscle wasting and atrophy, muscle weakness, cellulitis, and long-term use of anticoagulants.
During record review on 4/24/24, R21's electronic health record (EHR) indicated a signed orders completed by certified nurse practitioner (CNP)-A on 4/12/24 directinh staff to leave melatonin and trazadone at bedside when giving R21 medications and R21 would take medications when ready for bed. Order lacked parameters of time when medications could be left.
R21's EHR lacked assessment for self-administration of medications.
During interview on 4/24/24 at 9:15 a.m., trained medication aide (TMA)-A stated if a resident could self-administer medications that there would be an order on the MAR. TMA-A stated she had left R21's scheduled melatonin and trazadone beside several times, especially before she left at the end of her shift.
During interview on 4/24/24 at 10:32 a.m., director of nursing stated in order for a resident to be able to self-administer medications, an assessment needed to be completed to ensure that the resident is able to safely administer and store medications. DON stated R21 does not have an order to self-administer medications. DON stated that she was not aware of the order from the provider on 4/12/24 stating the okay to leave melatonin and trazodone bedside. DON confirmed order was entered into R21's EHR and stated that an assessment needed to be completed with R21 first before initiated and that assessment was not completed. DON stated she was the one who completed those assessments and staff were suppose to update her when order from provider is received regarding self-administration of medication.
The facility Self-Administration of Medications policy, dated 2/2024, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The interdisciplinary team considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident:
A.
The medication is appropriate for self-administration.
B.
The resident is able to read and understand medication labels.
C.
The resident can follow directions and tell time to know when to take the medication.
D.
The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff.
If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure reasonable accommodation of need related to r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure reasonable accommodation of need related to repositioning device for 1 of 1 resident (R21) reviewed for bed rails.
Findings include:
R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognition and was independent with all activities of daily living (ADLs). R21's diagnoses included stroke, hemiplegia (left side), depression, asthma, muscle wasting and atrophy, muscle weakness, cellulitis, and long-term use of anticoagulants.
During observation and interview on 4/22/24 at 6:17 p.m., R21 did not have bed rails on bed. R21 stated he had chronic right shoulder pain, used to have bed rails in room one and have asked several times for bed rails to be put on bed in room two to assist him with repositioning and/or getting in and out of bed due to pain.
During observation on 4/23/24 at 9:30 a.m., R21's bed did not have bed rails on bed.
During observation on 4/24/24 at 8:29 a.m., R21's bed did not have bed rails on bed.
During record review on 4/23/24, R21 was assessed for bed rails on 3/16/24, with bed rails being installed to bed in room one. R21 moved from room one to room two on 4/1/24 and bed rails were never installed on bed in room two. R21 had the proper assessment and orders for bed rails in electronic health record (EHR) both completed on 3/16/24.
During interview on 4/24/24 at 9:15 a.m., TMA-A stated R21 was independent with transfers and utilized bed rails to roll in bed and to get up from bed.
During record review on 4/24/24, maintenance request log from the past 30 days was reviewed with no work order for installing bed rails to bed in room [ROOM NUMBER].
During interview on 4/24/24 at 10:32 a.m., director of nursing (DON) stated when a resident moved to a new room, their original bed usually gets moved with the resident. If bed does not move with resident, a work order is placed with maintenance to have bed rails installed on new bed. DON confirmed that R21 did not currently have bed rails on bed and that R21 did have orders and the assessment to have and properly use the bed rails. DON stated bed rails are important for the resident for ease of mobility, independence and to assist with pain management.
Bed rail policy was requested and was not received.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident in 8 of 39 rooms (room #s 4,7,17,20, 21, 29, 35 and 36) which affected nine residents (R1, R187, R12, R16, R5, R23, R18, R6 and R27) who currently resided in these rooms.
Findings include:
During the entrance conference on 4/22/24 at 11:42 a.m., the facility administrator stated there had been no changes in resident room sizes, and there were waivers in place for room numbers: 4,7,17, 20, 21, 29,35, and 36 which did not meet the required minimum square footage.
The following double resident rooms did not meet the required minimum square footage per resident:
room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident (R12).
room [ROOM NUMBER] = 152.5 square feet, or 76.25 square feet per resident (R187).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R18).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R23).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R1).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R6).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R5).
room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R16, R27).
04/22/24 at 12:46 p.m., R6 (room [ROOM NUMBER]) stated currently the room is meeting his needs as he has no roommate and is utilizing all of 150 square feet to store some of his personal items including a power wheelchair.
04/22/24 at 1:12 p.m., R5 (room [ROOM NUMBER]) stated he is utilizing only his side of the room and has no concerns with the amount of space he has.
04/22/24 at 7:41 p.m., R12 (room [ROOM NUMBER]) stated currently the room is meeting her needs as she has no roommate and is utilizing all of 150 square feet to store some of her personal items.
04/23/24 at 3:53 p.m., R16 (room [ROOM NUMBER]) stated he is utilizing only his side of the room and has no concerns with the amount of space he has.
04/22/24 at 7:46 p.m., R18 (room [ROOM NUMBER]) stated currently the room is meeting her needs as she has no roommate.
04/23/24 at 3:53 p.m., R27 (room [ROOM NUMBER]) stated he is utilizing only his side of the room and has no concerns with the amount of space he has.
04/22/24 at 7:38 p.m., R187 (room [ROOM NUMBER]) stated currently the room is meeting his needs as he has no roommate and is utilizing all of 150 square feet.
During interview on 4/23/24 at 3:56 p.m., trained medication aide (TMA)-A stated that some rooms are tight with space in the rooms that have two residents. TMA-A stated she had not heard any complaints from any residents regarding the size of the room and/or complaints about roommate.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and document review, the facility failed to ensure the services of a registered nurse (RN) were available onsite for 8 consecutive hours seven days a week. This had the potential to...
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Based on interview and document review, the facility failed to ensure the services of a registered nurse (RN) were available onsite for 8 consecutive hours seven days a week. This had the potential to affect all 30 residents who reside at the facility.
Review of the facility staffing schedules dated 10/1/23 through 12/31/23, identified there was not eight consecutive hours of RN coverage for 10/1/23, 10/8/23, 10/14/23 and 10/15/23.
When interviewed 4/24/24 at 8:09 a.m., trained medication aide (TMA)-A stated there were only two licensed nurses employed with the facility which resulted in having to utilize agency licensed nurses. TMA-A stated she was unaware of any day or date when a registered nurse was unavailable for eight consecutive hours and verified a licensed nurse was always on duty. TMA-A stated she was unaware of any situation in which a resident needed cares from an RN and had not received them.
When interviewed on 4/24/24 at 8:45 a.m., the administrator verified there was no RN on for eight consecutive hours on 10/1/23, 10/8/23, 10/14/23 and 10/15/23. The administrator stated the facility policy and practice was to have a RN on duty in the building eight consecutive hours but had call-ins for those four dates so only a licensed practical nurse (LPN) was on duty. The administrator stated after the call ins on those dates the facility now books two RNs for open shifts in case one calls in.
Mar 2024
2 deficiencies
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and document review, the facility failed to ensure room temperature and refrigerated food items were properly stored, labeled, and dated when the original packaging wa...
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Based on observation, interview, and document review, the facility failed to ensure room temperature and refrigerated food items were properly stored, labeled, and dated when the original packaging was opened. This deficient practice had the potential to affect all 36 residents who ate food prepared in the kitchen.
Findings include:
During a kitchen observation on 3/15/24 at 8:45 a.m. with the culinary director (CD)-A, the following items were observed in the food preparation sink:
- Two packages of sealed frozen pork sausage in a clear plastic container filled with water.
- [NAME] onions floating in water in a clear plastic container, balanced on top of the container with the frozen pork.
- A bucket of soapy water with soiled utensils, to the left of the two stacked containers.
The following items were opened without any dates in the dry storage area:
- One package of Crispy Onions
- One bag of Stovetop stuffing
The following items were opened without any dates in the refrigerator:
- Two bowls containing yogurt and berries.
- One package of imitation crab meat was opened.
- One package of tortillas.
The following items with manufacturer's labels to keep refrigerated after opening, were observed opened, and in the lower food cabinet at room temperature:
- One plastic container of sweet and sour sauce.
- One plastic container of teriyaki sauce.
- One glass container of lemon juice.
- One plastic container of grated parmesan cheese.
The following items were observed on the lower food cabinet shelves:
- A cup of light pink liquid was observed in the cabinet, without a label or date.
- A box of SOS soap filled reusable steel wood pads was observed next to the food products.
A personal weekly pill organizer was observed to be on the kitchen food prep counter. [NAME] (C)-A moved the pill organizer to a closed cabinet in the kitchen. The pill organizer was closed with filled with several medications.
An uncovered beverage cup with unknown liquid was observed on the food preparation counter, next to an open pound of butter.
On 3/15/24 at 8:45 CD-A verified the above findings. CD-A stated the situation with the food preparation sink was very concerning. CD-A stated they do not typically wash dishes in the food preparation sink. CD-A stated she was aware the cold water should be running over the frozen pork to thaw it in a safe manner. CD-A stated she expected all food items to be labeled with the date they were opened and in a sealed container or bag. CD-A stated the uncovered dishes of yogurt and berries, in the refrigerator, were from the day prior. CD-A stated the shelves in the lower cabinet have to be cleaned. It's gross. CD-A stated cleaning products should be stored separately from food products. CD-A stated the personal pill organizer belonged to cook-A and did not belong in the kitchen. CD-A stated the open beverage belonged to the cook (C)-A. Further, CD-A she stated they were aware open beverages should not be near food preparation areas and the open beverage belonged to C-A.
On 3/15/24 at 8:56 a.m., C-A stated the light pink liquid in the lower food cabinet was used oil. C-A stated the oil was used for making egg rolls.
On 3/15/24 at 900 a.m. the following items were observed with CD-A in the resident personal food item refrigerator/freezer:
- Leftovers labeled with a resident's name but lacked the date.
- One container of Miracle Whip with an expiration date of 7/12/23.
- One 8 oz open bottle of Diet Coke.
- A bright blue substance on the walls of the freezer.
CD-A verified the above findings. CD-A stated all food items in the resident refrigerator were to be labeled with name and date. CD-A stated she was responsible to wipe down the refrigerator weekly and toss items without a label and those that were expired. CD-A stated she thought the bright blue substance may be from an ice pack.
On 3/15/24 at 10:55 a.m., C-A stated food was to be covered and dated. C-A stated she was aware her open beverage should not be near food preparation areas.
An undated facility document posted on the resident personal item refrigerator directed:
- Food that is unclean, spoiled, or unsafe will be disposed of properly.
- Any food that is not labeled will be disposed of properly.
All food needs to be labeled with the following:
- Resident name
- Resident Room number
- Date food was placed in refrigerator
Refrigerator and freezer cleanliness will be maintained by the facility staff. Cleaning of the refrigerator will occur every Friday.
The facility Food Receiving and Storage policy dated 10/17 directed foods shall be received and stored in a manner that complies with safe food handling practices.
- Dry foods that are stored in bins will be removed from original packaging, labeled, and dated.
- All foods stored in the refrigerator or freezer will be covered, labeled, and dated.
- Beverages must be dated when opened and discarded after 24 hours.
- Other opened containers must be dated and sealed or covered during storage.
- Pesticides and other toxic substance and drugs will not be stored in the kitchen area or in storerooms for food or food preparation equipment and utensils.
- Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.
The facility Handling Food Brought in for Resident's Individual Consumption policy dated 1/17 directed:
- Food brought into the facility for particular residents will be assessed by facility staff on an individual basis. Food that is obviously unclean, spoiled, or unsafe will be disposed of properly.
- The container must be labeled with resident name and date the item was received.
- Food must be disposed of properly after 3 days.
- Refrigerator and freezer cleanliness will be maintained by facility staff. Spills are to be cleaned promptly.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, interview, and document review, the facility failed to maintain sanitary conditions in the kitchen. This had the potential to affect all 36 residents who ate food prepared in the...
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Based on observation, interview, and document review, the facility failed to maintain sanitary conditions in the kitchen. This had the potential to affect all 36 residents who ate food prepared in the kitchen.
Findings include:
On 3/15/24 at 8:45 a.m., during a tour of the kitchen with the culinary director (CD)-A, a thick brown substance was observed on the base boards of the kitchen and under the counters, refrigerators, freezers, dry storage shelves, oven, and dishwashing area. The microwave, the toaster, and lower shelves were also covered in the thick brown substance. The vent between the dry storage area and the food preparation area of the kitchen, located approximately 8 feet high, located above the food preparation sink had a dark gray fuzz matter. The ceiling vent, over the counter where food dishes were prepared had a dark brown fuzz matter covering the vent and extending approximately 3 feet in all directions beyond the vent across the ceiling. The ceiling material was peeling back and angled downward toward the floor in an approximate 6 inch by 6 inch area. The ceiling material had a bubbled appearance surrounding the vent.
CD-A verified the above findings. CD-A described the thick brown substance on the floor as build up. CD-A stated the kitchen was in need of a deep clean. CD-A stated the vent between the dry storage and food prep area was not cleaned often enough. CD-A stated the facility had a contractor coming out to look at the ceiling. CD-A stated the ceiling had been in this condition for a long time. CD-A stated it was her responsibility to ensure sanitation of the kitchen.
The facility Dietary Guidelines policy dated 9/12 directed sanitary conditions are maintained in the storage, preparation, and distribution of food. Effective procedures for cleaning all equipment and work areas are followed consistently.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure 1 of 3 residents (R1) received a copy of their medical reco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure 1 of 3 residents (R1) received a copy of their medical record per request in a timely manner, within 2 working days upon request excluding weekends and holidays.
Findings include:
R1's significant change Minimum Data Set (MDS) dated [DATE], noted R1 had intact cognition.
An authorization to release medical records dated 4/19/23, noted R1 was requesting any and all medical records from 5/1/22 to present and that she would like it for personal review on a flash drive. The form noted R1 had difficulty signing so she gave verbal consent.
A progress note dated 4/24/23, noted R1 requested medical records on a flash drive that had to be ordered, had arrived that day. R1 was given the flash drive at that time, a copy of her request form, and a copy of receipt in an envelope.
During an interview on 5/2/23, at 12:40 p.m. R1 stated she had requested medical records a couple of times and finally got them. R1 stated she requested the information verbally, she was unable to write. R1 stated the first time she requested her records, it took a month and a half to get them but the second time she requested, it only took 2 weeks.
During an interview on 5/2/23, at 1:08 p.m. the administrator stated if a resident verbally requested medical records, she would ask the resident to fill out a written request, if the resident was unable to then the administrator would fill out a form on the residents behalf so there is a written record of the request.
A facility policy titled Charges Associated with Release of Medical Records last revised on 4/11/23, noted current or former residents upon written request of medical records noted the records would be provided within 30 days.
Apr 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, observations, and resident and staff interviews, the facility failed to ensure 2 of 6 residents (R18 a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, observations, and resident and staff interviews, the facility failed to ensure 2 of 6 residents (R18 and R137) reviewed for Activities of Daily Living (ADLs) received grooming services consistently per their plan of care. R18 and R137 were not bathed per their plans of care.
Findings include:
R18's admission Record, indicated the resident was admitted on [DATE] with diagnoses including acute and chronic respiratory failure and end stage renal disease.
R18's admission Minimum Data Set (MDS) dated [DATE], identified, mild cognitive impairment, and had not been bathed during the assessment period.
R18's undated Activities of Daily Living (ADL) care plan indicated the resident had a self-care deficit related to her diagnosis of end stage renal disease and respiratory failure. Interventions included, Assist with bathing.
The facilities undated Shower Schedule was reviewed and indicated all showers were scheduled by room number, one time weekly, rather than by resident preference. The schedule indicated R18's showers were to be given on Tuesdays.
R18's Shower Records, dated 3/23/23 through 4/13/23, indicated R18 had not been bathed since her admission to the facility. No refusals were documented in the resident's record.
R18 was observed seated in her wheelchair in her room on 4/11/23 at, 11:16 a.m. and 3:42 p.m. on 4/11/23 at 3:50 p.m., and on 4/12/23, at 11:13 a.m. and 5:45 p.m. The resident appeared disheveled during all of the observations.
When interviewed on 4/11/23, at 3:50 p.m. R18 stated, I have had not had a shower since I've been here. I need a shower. I have been using the wipes to clean myself up. R18's family member, who was in the room visiting the resident at the time of the interview, stated she visited the resident in the facility almost daily, confirmed the resident had not been bathed since admission R18 stated, They said one bath a week and one bedding change a week and that's it.
During a follow-up interview with R18 on 04/12/23 at 5:45 p.m., she stated she normally took a shower every night at home, and this was her preference related to bathing in the facility, as well. She stated she had not been asked about her bathing preferences since she had been admitted to the facility.
R137's admission Record, indicated the resident was admitted on [DATE] with diagnoses including alcoholic cirrhosis of the liver and liver failure.
R137's admission MDS dated [DATE], identified cognitively intact and required extensive assistance for bathing.
R137's undated Activities of Daily Living (ADL) care plan, indicated the resident had a self-care deficit related to his diagnosis of cirrhosis of the liver. Interventions included, Assist with bathing.
The facilities undated Shower Schedule was reviewed and indicated all showers were scheduled by room number, one time weekly, rather than by resident preference. The schedule indicated R137's showers were to be given on Fridays.
R137's Shower Records, dated 3/29/23 through 4/13/23, indicated R137 was bathed one time during that period, on 3/30/23. No refusals were documented in the resident's record.
R137 was observed seated in his wheelchair in his room on 4/11/23 at 12:35 p.m., on 4/12/23 at 10:13 a.m., 11:07 a.m. and 2:34 p.m., and 4:28 p.m. The resident was disheveled, and his hair was uncombed during all of the observations.
During an interview with R137, and his family member on 4/11/23 at 12:35 p.m., both stated the resident had not had a shower since he was admitted to the facility on [DATE]. The resident stated he had been in the hospital for 13 days before being admitted to the facility, and had not been given a shower there, either. The resident's wife confirmed R137 had been given a sponge bath on 03/30/23, and stated, He needs a shower.
During a follow-up interview with R137 on 4/12/23 at 4:28 p.m., he stated he thought he had been given a sponge bath on the second or third day after he was admitted to the facility, but had not had a shower or a bath since. R137 said his preference was to receive a bath every three days.
During an interview with nursing assistant (NA)-A on 4/12/23 at 4:55 p.m., she indicated she was familiar with R18 and had been working at the facility for about six weeks, and stated residents received showers once per week based on the shower schedule located at the nurse's station. NA-A confirmed showers were given based on room number rather than resident preference. She stated all showers were documented in the NA documentation in the facility's electronic medical record (EMR). NA-A stated she had never given R18 or R137 a shower.
During an interview with NA-B on 4/12/23 at 5:18 p.m., he stated he had never given R18 or R137 a shower, and confirmed showers were given based on room number rather than resident preference. NA-B also confirmed showers were documented in the NA documentation in the facility's EMR. He stated If someone refused a shower, R for refused was to be documented on the resident's shower record, and the nurse was to be notified so he or she could write a progress note about the refusal.
During an interview with the director of nursing (DON) on 4/13/23 at 9:01 a.m., she confirmed showers were generally done once per week, based on each resident's room number. She stated her expectation was that showers were to be done based on resident preference. She stated, Showers have been an issue with agency staffing, and (staff) not getting them done.
The facility's Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 03/31/23 read, in pertinent part, Based on the comprehensive assessment of the resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable; and The facility will provide care and services for the following activities of daily living: a. Hygiene - bathing, dressing, grooming and oral care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, observations, and staff and resident interviews, the facility failed to ensure a urinary catheter in u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, observations, and staff and resident interviews, the facility failed to ensure a urinary catheter in use for 1 of 1 residents (R137) reviewed for use of a urinary catheter was necessary. The resident's catheter was not removed per physician's order.
Findings include:
R137's admission Record, indicated the resident was admitted on [DATE] with diagnoses including alcoholic cirrhosis of the liver and liver failure.
R137's admission Minimum Data Set (MDS) dated [DATE], identified cognitively intact, and had an indwelling urinary catheter.
R137's undated Catheter Care Plan, indicated the resident had altered elimination related to cirrhosis. The care plan indicated the resident had a urinary catheter in place. Interventions included, Monitor foley catheter output, and Change Foley catheter per policy, and Foley catheter care per policy.
R137's Hospital Discharge Orders dated 3/29/23, included, Remove Foley in 5 days. Up to void with post void residual check by bladder ultrasound each shift for 24 hours and as needed for voiding difficulties. Straight catheterize if post void residual [greater than] 300 cc [cubic centimeters]. Call MD [Medical Doctor] if patient straight catheterized twice.
R137's Order Summary Report, dated 4/13/23, revealed no orders for the resident's urinary catheter or associated catheter care. The report also did not reveal orders for the removal of R137's catheter with associated monitoring of post void residual.
R137's comprehensive record was reviewed, and no assessment related to the resident's use of the urinary catheter could be found.
R137's Provider Encounter Note, dated 4/4/23, included, Remove Foley catheter. Check post-void residuals each shift x [times] 48 hours and as needed for voiding difficulties. Straight cath [catheter] if Post-Void Residual is >300 cc. Replace foley catheter if straight cath [catheter] is needed for third time.
R137's Provider Encounter Note, dated 4/6/23, included, Foley catheter is in place, no documentation as to whether or not it was removed and replaced versus never removed. Urine is dark orange/brown presumably from bilirubin staining. Plan: 1. Remove Foley catheter with PVRs [post void residual checks] x 48 hrs. [hours].
R137's Medication Administration Records (MARS) and Treatment Administration Records (TARS) identified, the resident's catheter was still in place in his bladder as of 4/13/23. The records indicated no attempted removal of the catheter or post void residual trial for the resident.
R137's Provider Encounter Note, dated 4/10/23, included, Re-ordered catheter removal. Family reports they beilieve (sic) (R137) has been refusing the catheter removal. Per discssion (sic) with (R137), he understands the risks and benefits, and says he is agreeable to catheter removal now.
R137 was observed in his room on 4/11/23 at 10:59 a.m. and 11:34 a.m., and on 4/12/23 at 10:15 a.m. 2:35 p.m., 3:34 p.m., and 4:30 p.m The resident had a urinary catheter in place in his bladder during all the observations.
R137 was interviewed on 4/11/23 at 10:59 a.m. he indicated his urinary catheter had been placed at the hospital. He stated an attempt was made to remove the catheter at the hospital, but he was unable to void at that time and so the catheter had been replaced. He stated no attempts to remove the catheter had been made since he had been admitted to the facility on [DATE]. He had not been approached about it's removal.
During a follow-up interview with R137 on 4/12/23 at 4:30 p.m., he indicated staff had replaced his catheter bag the previous Monday (4/12/23) due to it was leaking but no attempts had been made to remove the catheter that week. He stated, I guess they are just going to leave it in.
During an interview with registered nurse (RN)-A and RN-B on 4/12/23 at 3:34 p.m., they both indicated R137 had initially refused to have his catheter removed and stated they hadn't heard anything about removing the resident's catheter since. RN-A stated she was not aware of any current order to remove the resident's catheter.
During an interview with the director of nursing (DON) on 4/13/23 at 9:12 a.m., she stated, I thought it (R137's urinary catheter) was removed. The DON confirmed the order to remove the resident's catheter had not been entered into the resident's electronic medical record and stated, I will check on it. The catheter should have been taken out.
The facility's policy related to urinary catheter use was requested on 4/13/23 at approximately 9:00 a.m. During an interview with the DON on 4/13/23 at 1:35 p.m., she stated the facility did not have a policy addressing the use of urinary catheters.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, observations and staff interviews, the facility failed to ensure a medication error rate of less than ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, observations and staff interviews, the facility failed to ensure a medication error rate of less than 5%. Three errors were made with a total of 25 opportunities for error, resulting in a 12.0% error rate. The errors involved one resident (R87), who was not given two medications because they were not available in the facility and whose lidocaine patch was not removed per physician's order.
Findings include:
R87's admission Record, dated 4/13/23, indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension, displaced fracture of right tibia, multiple fractures of ribs, and edema.
R87's Order Summary Report, dated 4/13/23, indicated orders for torsemide (a diuretic medication used to decrease fluid overload) 10 milligrams (MG) twice daily, Aspirin 81 MG Enteric Coated once daily, and Lidocaine patch (a patch used for pain control) 4% on for 12 hours and off for 12 hours to upper back.
Registered nurse (RN)-A was observed administering R87's medication on 2/12/23 at 9:16 a.m. RN-A was unable to locate aspirin 81 MG in the facility and was unable to administer the medication. The nurse was able to locate torsemide 20 MG tablets but was unable to locate 10 MG tablets and was unable to administer the medication. When RN-A applied the resident's lidocaine patch, the resident's patch from the previous day was still on R87's upper back (even though it was ordered to be removed the prior evening).
During an interview with RN-A on 4/12/23 at 9:45 a.m., she indicated she was not able to cut the torsemide tablet in half and so would need to order the correct dosage from the pharmacy. She stated she was unable to locate enteric coated aspirin 81 MG tablets and would have to order this medication from the pharmacy, as well. She stated the medications were expected to be available in the facility by later that evening or the next morning. In addition, RN-A stated the resident's lidocaine patch applied the previous day should have been removed the evening prior per physician's orders.
During an interview with the director of nursing (DON) on 4/13/23 at 9:21 a.m., she confirmed the torsemide and aspirin enteric coated should have been available in the facility for administration to R87. She stated physician's orders should have been followed for the removal of the resident's lidocaine patch.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident in 8 of 39 resident rooms (room#s 4, 7, 17, 20, 21, 29, 35 and 36) which affected 9 current residents (R9, R16, R140, R141, R29, R26, R17, R11, R22 and R28) who currently resided in these rooms.
Findings include:
During the entrance conference on 4/11/23, at 10:53 a.m. the facility administrator stated there had been no changes in resident room sizes, and there were waivers in place for room numbers: 4, 7, 17, 20, 21, 29, 35 and 36, which did not meet the required minimum square footage.
The following double resident rooms did not meet the required minimum square footage per resident:
room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident (currently a conference room)
room [ROOM NUMBER] = 152.5 square feet, or 76.25 square feet per resident, (R9, R16)
room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident, (R140, R141)
room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident, (R29, R26)
room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident, (R17)
room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident, (R11)
room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident, (R22)
room [ROOM NUMBER] = 155 square feet, or 77.5 square feet per resident, (R28)
On 4/12/23, at 9:30 a.m. R29 (room [ROOM NUMBER]) stated he had no concerns regarding the size of the room.
On 4/12/23, at 9:40 a.m. R28 (room [ROOM NUMBER]) stated she had no concerns regarding the size of the room. R28 stated she likes the extra space and used the extra bed for things
On 4/12/23, at 10:17 a.m. R140 (room [ROOM NUMBER]) stated she had no concerns regarding room size.
On 4/12/23, at 10:17 a.m. R141 (room [ROOM NUMBER]) stated no concerns with the her room.
On 4/12/23, at 10:00 a.m. R26 (room [ROOM NUMBER]) stated he had no concerns regarding the size of the room.
On 4/12/23, at 1:00 p.m. R22 (room [ROOM NUMBER]) stated she had no concerns regarding the size of the room. R22 stated she uses the extra bed for, my stuff.
On 4/12/23, at 1:05 p.m. R17 (room [ROOM NUMBER]) stated he had no concerns regarding the size of the room.
On 4/12/23, at 4:40 p.m. R16 (room [ROOM NUMBER]) stated he spends most of his time out with the other residents, and normally only in the room to sleep
On 4/13/23, at 9:30 a.m. R11 (room [ROOM NUMBER]) stated he had no concerns regarding the size of the room.
On 4/13/23, at 10:30 a.m. R9 (room [ROOM NUMBER]). who was just back from the hospital stated he had no concerns with the room size, while he is there only to to nap or sleep at night.
4/12/2023, at 1:00 p.m. nursing assistant (NA-A) stated the rooms are tight in the rooms that have two residents in them, but the residents currently in them are not lifts and are able to self transfer into their own wheel chair or walk like R26.
4/12/2023, at 9:40 a.m. registered nurse (RN-B) stated that the room sizes in the smaller double rooms currently work ok. There is not a lot of medical equipment for any of them and all residents are able to get out on their own, with the exception of R11 who is dependent on staff for transfers. However he is in the room alone.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to immediately report, no later than 2 hours, an allegation of abuse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to immediately report, no later than 2 hours, an allegation of abuse to the State Agency (SA) for 1 of 1 residents (R1) reviewed for abuse.
Findings include:
R1's annual Minimum Data Set, dated [DATE], identified R1 had diagnosis which included traumatic spinal cord dysfunction, quadriplegia,(paralysis of all four limbs) and borderline personality disorder. Indicated R1 was cognitively intact and required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting.
R1's care plan revised 11/21/22, revealed R1 was a vulnerable adult and was at risk for abuse/neglect related to R1 residing in a skilled nursing facility (SNF). The care plan directed staff to follow the facility vulnerable adult & abuse reporting policy.
The facility SA report dated 11/29/22, at 8:15 a.m. indicated R1 stated nursing assistant (NA-A) was rough while assisting R1 to reposition during the evening shift on 11/28/22. The report identified NA-A was not to return to the facility until the investigation was completed.
During an interview on 12/6/22, at 2:54 p.m. R1 stated on the evening of 11/28/22, while NA-A was assisting NA-B to reposition R1, NA-A placed her hand down on R1's hip really hard and quickly flipped R1 over onto her side. R1 indicated NA-A was not trying to hurt her however had turned her too quickly and startled her.
During an interview on 12/6/22, at 3:19 p.m. licensed practical nurse (LPN-A) stated at 5:30 a.m. on 11/29/22, R1 had told her on the evening of 11/28/22, NA-A had roughhoused her when repositioning her. LPN-A stated R1 had informed her NA-B was also present in the room and had witnessed the incident. LPN-A stated she immediately called and reported the allegation of abuse to the director of nursing (DON) however had not reported the allegation of abuse to the SA.
During an interview on 12/6/22, at 3:54 p.m. NA-B indicated on 11/28/22, at 9:30 p.m. while NA-A and NA-B were repositioning R1, NA- A grabbed R1's shoulder and left leg and quickly turned R1 onto her side. NA-B indicated R1 appeared upset and NA-B had asked NA-A to exit the room. After NA-A left the room, R1 stated to NA-B she did not feel safe and felt NA-A had been rough with her. NA-B indicated she had planned on calling the facility the next morning to report the allegation of abuse however did not do so.
During an interview on 12/7/22, at 10:14 a.m. DON stated LPN-A had called her around 5:30 a.m. on 11/29/22, to report the allegation of abuse towards R1. DON stated when she arrived to work around 8 a.m. that morning, she spoke to R1 regarding the allegation of abuse. DON confirmed after talking to R1, she immediately reported the allegation of abuse to the administrator.
During an interview on 12/7/22, at 10:24 a.m. administrator stated she was notified of the allegation of abuse towards R1 on the morning of 11/29/22. Administrator confirmed NA-B had not reported anyone the allegation of abuse towards R1 to anyone and verified the repot to the SA was filed late. Administrator stated her expectation was any allegation of abuse would have been reported to the SA immediately but no later than 2 hours.
A facility policy titled Abuse Prohibition/Vulnerable Adult Plan revised 4/11/22, stated all staff were responsible for reporting any situation that was considered abuse or neglect along with injuries of unknown origin (including suspicious bruises, skin tears, or other injuries), misappropriation of resident property, or involuntary seclusion. Policy further stated suspected abuse should be reported to OHFC online reporting process no later than two hours after forming the suspicion of abuse.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Minnesota facilities.
Concerns
- • 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Estates At Twin Rivers Llc's CMS Rating?
CMS assigns The Estates At Twin Rivers Llc an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Minnesota, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is The Estates At Twin Rivers Llc Staffed?
CMS rates The Estates At Twin Rivers Llc's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 49%, compared to the Minnesota average of 46%. RN turnover specifically is 70%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at The Estates At Twin Rivers Llc?
State health inspectors documented 38 deficiencies at The Estates At Twin Rivers Llc during 2022 to 2025. These included: 37 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates The Estates At Twin Rivers Llc?
The Estates At Twin Rivers Llc is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MONARCH HEALTHCARE MANAGEMENT, a chain that manages multiple nursing homes. With 50 certified beds and approximately 35 residents (about 70% occupancy), it is a smaller facility located in ANOKA, Minnesota.
How Does The Estates At Twin Rivers Llc Compare to Other Minnesota Nursing Homes?
Compared to the 100 nursing homes in Minnesota, The Estates At Twin Rivers Llc's overall rating (1 stars) is below the state average of 3.2, staff turnover (49%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting The Estates At Twin Rivers Llc?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is The Estates At Twin Rivers Llc Safe?
Based on CMS inspection data, The Estates At Twin Rivers Llc has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Minnesota. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Estates At Twin Rivers Llc Stick Around?
The Estates At Twin Rivers Llc has a staff turnover rate of 49%, which is about average for Minnesota nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Estates At Twin Rivers Llc Ever Fined?
The Estates At Twin Rivers Llc has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Estates At Twin Rivers Llc on Any Federal Watch List?
The Estates At Twin Rivers Llc is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.