The Terrace At Crystal Llc

During a follow up observation and interview on 6/1/26 at 4:54 p.m., R20's call light was still on the wall in the same position. R20 stated he would like his call light and nursing assistant (NA)-A was brought into the room and verified verbally he would not have been able to reach his call light, and it should have been within reach.During an interview on 6/2/26 at 1:25 p.m., NA-B stated all residents should have a call light within reach.

The purpose of having assessments and care plan interventions was resident safety.

During an interview on 6/4/26 at 2:01 p.m., the director of nursing (DON) stated call lights should always be within reach for safety reasons.The facility's undated Answering the Call Light policy identified when the resident was in bed or confined to the chair be sure the call light was within easy reach of the resident in order to respond to the resident's requests and needs.

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During an interview on 6/4/26 at 2:01 p.m., the director of nursing (DON) when a resident was on an antipsychotic either the nurse working on the floor or the manager would place the order on the TAR to signal nursing to complete the AIMS assessment.

Completed AIMS assessments would be documented in R6's medical record under assessments The purpose completing an AIMS assessment is mainly for the purpose of medication adjustments and so the pharmacy could review to see if any changes or side effects which may require medication adjustment.

The facility's AIMS Assessment policy dated 6/4/26, identified an AIMS assessment was required for residents prescribed a second-generation antipsychotic such as quetiapine. A baseline assessment should be completed prior to starting an antipsychotic and every 3 months or sooner if changes for the elderly.

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discharge. DON stated nursing would assisting with the nursing part meaning any assessments

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The Terrace at Crystal LLC 3245 Vera Cruz Avenue North Crystal, MN 55422

During an interview on 6/3/26 at 12:51 p.m., licensed practical nurse (LPN)-B stated that she sent documents such as the order summary, medication administration record, etc., but was unsure if a written transfer notice, which included information like ombudsman information and appeal rights, or a written bed hold notice was given on transfer to the hospital. RN-E stated she would have to follow up with the registered nurse (RN)-D, the nurse manager for the unit.

During an interview on 6/4/26 at 9:29 a.m., RN-D stated she did not believe they had a process to give residents a written notice of transfer, which included information like ombudsman information and appeal rights. RN-D stated she would email the resident representative to see if they wanted a bed hold, but the email did not include information such as the duration of the state bed-hold policy, the reserve bed payment policy, or the nursing facility's policy regarding bed-hold periods.The facility's undated Emergency Transfer or Discharge policy, indicated that if an emergency transfer or discharge to the hospital occurred, staff should prepare a transfer form.

The policy did not indicate what was included in this transfer form.

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During an interview on 6/1/26 at 1:55 p.m., R10 was observed lying in bed with the television on. R10 stated she has not had a care conference recently, and indicated the last one was more than 3 months ago.

R10's Social Service Conference form, dated 1/16/26, indicated a care conference was held with R10, R10's family member, nurse manager and social services. R10's progress notes dated 1/30/26 to 6/3/26 were reviewed and lacked indication of any care conference held or scheduled.

During an interview on 6/3/26 at 1:29 p.m., registered nurse manager (RN)-D stated care conferences were arranged by social services and should be held quarterly, with any significant changes, and as needed. RN-D stated care conferences should follow the MDS assessment.

During an interview on 6/3/26 at 1:46 p.m., social services (SS)-A stated they were responsible for care conferences and have been having their assistant help schedule care conferences. SS-A stated the expectation would be care conferences are held upon admission, quarterly, with significant changes, at discharge, or when requested. SS-A stated the facility was behind on care conferences when she started but the care conferences had been caught up. SS-A reviewed R10's medical record and verified R10's last care conference was 1/16/26. SS-A verified R10 had the following MDS assessments: quarterly 1/21/26, significant change in status 2/3/26 and 2/22/26, and a quarterly on 5/25/26. SS-A verified her assistant had not scheduled the care conferences and put it on the calendar. SS-A stated R10 should have had a care conference.

During an interview on 6/3/26 at 1:53 p.m., R10's family member (FM)-B stated they typically attended care conferences either in person or via phone for R10. R10 stated they believed the last care conference was in January. R10 stated the next care conference was not scheduled, however R10 received a call from the facility to schedule during interview with the surveyor.

During a follow up interview on 6/3/26 at 2:17 p.m., SS-A stated she thought she had the care conferences caught up and R10's must have been missed. SS-A stated R10's care conference had just been scheduled.

During an interview on 6/4/26 at 11:21 a.m., director of nursing (DON) stated social services was responsible for coordinating care conferences. DON stated care conferences followed the MDS schedule. DON stated a resident should have a care conference every time a MDS assessment was completed such as a significant change, quarterly, annual, or admission assessment. DON stated it was important to have care conferences with family and their representatives to discuss resident care, any issues so they can be addressed and to help ensure family involvement. A facility policy titled Care Conference Policy reviewed 12/9/25, indicated care conferences will be held at all required intervals, promptly after significant changes, and at any time upon request.

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The surveyor sat down. R60 was then observed to walk to the other side of the dining room, squat behind the far side of the steam table, with one hand on the steam table, and the other hand on the tall, metal, meal tray cart. R60 was then observed to pull a paper off of the wall behind him, appearing to use it to clean himself after having a bowel movement, and throw the paper to the side after use. R60 was then observed to pull pants back up and walk to the other side of the room. On further observation, stool was found on the far side of the steam table.- During this continuous observation, staff were not observed to use an interpreting service or the communication binder to attempt to speak with or assess R60's needs.The facility's Communication and Language Access Services policy dated 6/4/26, indicated the resident's primary language should be placed prominently in the electronic health record.

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(ADLs) and who were dependent on staff for their care.Findings include: R51's quarterly Minimum

hallucinations, delusions, no behaviors, or rejection of care. MDS indicated R51 was dependent on staff for personal hygiene (i.e., shaving, combing hair, washing/drying hands), toileting, showering, dressing and mobility needs. R51's care plan, printed 6/4/26, indicated R5 had an ADL self-care performance deficit related to fatigue and morbid obesity which included the following interventions: - prefers no facial hair, provide grooming on shower days and as needed which was initiated on 6/26/25- BATHING/SHOWERING: The resident is totally dependent on 2-3 staff to provide bath/shower weekly on Tues and Fri PM and as needed.

Resident prefers bed bath- PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on 2 staff for personal hygiene and oral care.

R51's progress notes, dated 5/1/26 to 6/3/26, were reviewed and lacked evidence of refusals of shaving or completion of shaving.R51's Weekly Skin/bath assessment, dated 5/29/26 was reviewed and identified R51 received a bed bath.

The audit form lacked evidence of facial shaving being offered or completed.R51's Weekly Skin/bath assessment, dated 5/22/26 was reviewed and identified R51 received a bed bath.

The audit form lacked evidence of facial shaving being offered or completed.R51's Weekly Bath Audit, dated 5/27/26 was reviewed and identified R51 received a shower.

The audit form lacked evidence of facial shaving being offered or completed.During an interview and observation on 6/1/26 at 11:59 a.m., R51 was observed with facial hair that was approximately 1/4 inch long. R51 stated the staff do not ask her if she wants to be shaved. R51 stated if she asked staff to shave her facial hair, the staff would but she found it embarrassing to have to ask to be shaved.On 6/3/26 at 12:33 p.m. R51 was observed to continue to have approximately 50 or so 1/4 inch long facial hairs on her chin and lower cheeks. R51 stated no staff had asked her if she wanted her facial hair removed and felt they should ask her daily or when they saw it. R51 stated, I don't wanna look like a man. On 6/3/26 at 1:00 p.m., registered nurse (RN)-A stated R51 required total staff assistance. RN-A stated nursing and aids should be asking if residents want to be shaved when they notice any facial hair. RN-A went and observed R51 facial hair. R51 was observed stating to RN-A she would like the facial hair removed and so she doesn't like looking like a man. RN-A stated R51's facial hair should have been and needed to be removed.On 6/3/26 at 1:25 p.m., registered nurse manager (RN)-D stated shaving was considered part of daily grooming. RN-D stated based on resident preferences, staff should be offering to shave or assist to shave resident anytime they provided cares. RN-D requested to review R51's medical record and provide additional information. No additional information was provided.On 6/4/26 at 11:21 a.m., director of nursing (DON) stated residents should be groomed per their preference. DON stated shaving should be offered with showers and as needed and documented if refused. A facility policy titled Activities of Daily Living (ADLs) Supporting, reviewed 11/2022, indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. hygiene (bathing, dressing, grooming, and oral care);b. mobility (transfer and ambulation, including walking);c. elimination (toileting);d. dining (meals and snacks); ande. communication (speech, language, and any functional communication systems).

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stated the facility was actively interviewing candidates for the Activities Director position because of

A policy dated 3/6/25 titled, Activity Programs, indicated activity programs were designed to meet the interests of and support the physical, mental and psychosocial well-being.

Activities were to be scheduled 7 days a week, and residents were given an opportunity to contribute to the planning.

Activities offered were based on the comprehensive resident-centered assessments.

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Observation further revealed no organized activities occurring on the third floor during survey activities. (See F-F679)R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15.

During an interview on 6/1/26 at 1:05 p.m., R3 stated she and another resident had attempted to organize activities themselves because no formal activities were occurring. R3 stated she never saw the Activities Assistant on the third floor, did not receive an activities calendar, and was not informed about activities occurring elsewhere in the facility. R3 stated residents on the third floor were bored because staff did not routinely provide activities or notify residents of scheduled events.During an interview on 6/2/26 at 2:10 p.m., Licensed Practical Nurse (LPN)-A stated activities primarily occurred on the second floor and acknowledged activities were often resident-run on third floor.

LPN-A stated activities were mainly on second floor to be honest.

During an interview on 6/4/26 at 8:22 a.m., the Nurse Manager and LPN-C stated activities occurred mostly on the second floor and reported they were unsure whether an activities calendar was available for residents.During an interview on 6/4/26 at 8:48 a.m., Activities Assistant (AA)-A stated the facility had not had an Activities Director since April 2026 and department heads had been assisting with activities. AA-A stated she primarily conducted activities on the second floor and acknowledged most organized activities occurred there. AA-A stated she did not have formal activities training and did not know many of the responsibilities previously performed by the Activities Director. AA-A stated there had not been an activities calendar during the previous month and, although a calendar had been developed for the current month, she had not printed or distributed it. AA-A stated she had not received training regarding the responsibilities of the Activities Director position and acknowledged she was relying on department heads for guidance regarding activity programming.

During an interview on 6/4/26 at 2:16 p.m., the Director of Nursing (DON) stated she was aware the facility did not have an Activities Director and acknowledged activities had not been routinely occurring on the third floor.

The DON stated the facility expected a monthly activities calendar to be available to inform residents of scheduled activities.

The DON stated the facility was attempting to hire an Activities Director but was unaware of where in the hiring process the facility was. A facility policy on the Activity Program, dated 3/2025, did not address the need for an activities director.

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During an interview on 6/4/26 at 2:16 p.m., the Director of Nursing (DON) stated nurses were expected to enter physician orders and referral information and the HUC was responsible for scheduling appointments as soon as possible.

The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection to ensure quick diagnosis and treatment for R31.

A call was placed to the provider on 6/5/26 at approximately 12:00 p.m., however a return call was not received.

R37 R37's comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated R37 was cognitively intact, and diagnoses included end stage renal disease, pericardial effusion (fluid build-up in the sac around the heart), atrial flutter (a heart rhythm disorder), chronic heart failure, and dependence on renal dialysis.

R37's care plan dated 1/6/26, indicated he was a vulnerable adult to complete treatments as ordered.

A physician's order dated 4/30/26, directed staff to, Please ensure ECHO (echocardiogram - an ultrasound test to assess heart function) is scheduled for on or before June 1, 2026, for diagnosis of pericardial effusion.

Review of R37's electronic medical record (EMR) lacked documentation that the ECHO had been scheduled, implemented, or completed.

During an interview on 6/4/26 at 12:04 p.m., Director of Nursing (DON) and Administrator stated it was important to follow care plans because they reflected residents' needs and person-centered care.

They stated it was important to follow physician orders because care was directed by the physician's orders.

The DON and Administrator stated physician orders received through the fax system were entered by a floor nurse and verified by a second nurse.

They stated medical records staff scheduled appointments and other items not related to medication administration.

They further stated nurse managers were responsible for overseeing implementation of physician orders and updating care plans.

The DON stated the order was not completed.

A policy titled, Lab and Diagnostic Test Results - Clinical Protocol, undated, indicated physicians were to order testing based on resident needs.

The policy indicated staff were to process test requisitions and arrange for ordered tests.

The policy further indicated test results were to be reported to the facility and reviewed by a nurse.

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During a follow up interview on 6/2/26 at 1:02 p.m., R31 stated she had not heard anything further about the eye doctor appointment.

When asked why she thought the appointment had not occurred, R31 stated, Cause they just don't make the appointments.

During an interview on 6/2/26 at 2:10 p.m., Licensed Practical Nurse (LPN)-A stated when there was an order in the EMR for a follow-up appointment, the health unit coordinator (HUC) downstairs was responsible for scheduling the appointment.

During an interview on 6/3/26 at 10:50 a.m., a health unit coordinator (HUC) assistant stated HUC staff were responsible for scheduling appointments when outside providers had not already arranged follow-up.

The HUC assistant stated she highlighted physician orders requiring follow-up appointments and provided them to the HUC responsible for scheduling.

When asked about R31's retinal specialist referral, the HUC assistant reviewed the medical record but was unable to determine whether the appointment had been scheduled or completed and stated she would continue looking into it.

During an interview on 6/4/26 at 8:22 a.m., Licensed Practical Nurse (LPN)-C, the nurse manager, stated he was unsure whether R31's retinal specialist appointment had been scheduled or completed and stated he would investigate.

During a follow-up interview on 6/4/26 at 11:15 a.m., LPN-C stated the HUC was out sick and he had been unable to obtain additional information. LPN-C stated he did not find any documentation in the EMR indicating the appointment had been scheduled or that R31 had been seen by the retinal specialist.

During an interview on 6/4/26 at 2:16 p.m., the Director of Nursing (DON) stated the expectation was that nurses entered physician orders and needed appointments into the EMR and the HUC scheduled follow-up appointments as soon as possible.An undated facility policy titled Clinical and Operational Policy: Vision Appointment Management stated the facility would ensure all residents had access to comprehensive vision care and would coordinate with external providers to deliver vision services safely and efficiently.

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During an interview on 6/1/26 at 12:47 p.m., R8 stated she smoked outside and took her oxygen tank and nasal cannula to the smoking patio. R8 stated she removed the nasal cannula from her nose and turned the oxygen off while smoking but kept the oxygen tank and tubing with he

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During an observation and interview on 6/3/26 at 10:44 a.m., activities assistant (A)-A brought R6 in his wheelchair to the commons area by hallways and elevator. R6's CDB was hooked on his wheelchair arm rest above the level of the bladder.

The catheter tubing contained urine that had not drained down. R6 stated he was moving the catheter tubing to try and get the urine to drain down into the CDB.

During an interview on 6/3/26 at 10:46 a.m., nursing assistant (NA)-J stated R6's catheter should be positioned below the level of the bladder for drainage.

During a follow up interview on 6/3/26 at 10:46 a.m., A-A stated R6 was at an activity for 1 and 1/2 hours.

Activities staff did not touch catheters, so his remained on his wheelchair arm rest for the past 1 and 1/2 hours, and no one from nursing did anything with his catheter while he was at the activity.

During a follow up observation on 6/3/26 at 10:49 a.m., NA-J put R6's CDB in a pillowcase and was attempting to connect the pillowcase to the stability bars under the wheelchair

During an interview on 6/3/26 at 10:50 a.m., NA-F stated CDB should be placed below the level of the bladder. she wasn't sure who placed R6's catheter bag above the level of the bladder.

During an interview on 6/3/26 at 10:54 a.m., registered nurse (RN)-A stated CDB should be below the level of the bladder for drainage. RN-A stated R6 was currently on antibiotics for a bladder infection.During an observation and interview on 6/3/26 at 10:52 a.m., RN-D was adjusting R6's catheter tubing so it would drain. RN-D confirmed verbally there was urine in the tubing, and it needed manual drainage.

During a follow up interview on 6/3/26 at 11:02 a.m., RN-D stated CDB should be below the level of the bladder so the bladder can empty.During another observation on 6/4/26 at 8:43 a.m., R6 was seated in the dining room with his CDB hooked on his wheelchair arm rest above the level of the bladder.

The catheter tubing contained urine that had not drained down.

Several unidentified nursing staff were in the area and did not intervene to place the CDB below the level of the bladder.

During an interview on 6/4/26 at 8:48 a.m., trained medication assistant (TMA)-A confirmed verbally R6's CDB was incorrectly placed above the level of the bladder and needed to be below the bladder to ensure drainage.

During an interview on 6/4/26 at 2:04 p.m., the director of nursing (DON) stated CDB should be positioned below the level of the bladder to ensure urine drains and does not backflow.The facility's undated Urinary Catheter Care policy identified the CDB should be held or positioned lower than the level of the bladder to prevent the urine in the tubing and CDB from backflowing into the bladder.

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initial comprehensive 30-day visit for 1 of 3 (R50) newly admitted residents reviewed.

Findings

cancer, kidney disease, malnutrition, and a seizure disorder.R50's census report dated 4/23/26, indicated R50 remained an active resident at the facility, had a primary payer source of Medicare A, and admitted to the facility on [DATE].R50's medical record was reviewed, and a progress note indicating a visit had been completed by a physician was not found.

During an interview on 6/5/26 at 8:52 a.m., the director of nursing (DON) stated that the physician should see the resident within the first 30 days of their stay.

The DON stated she would look for a note indicating that a physician had seen R50 during her stay and would provide the records.

Records indicating R50 had been seen by a physician were not received.The facility's Physician Visits policy dated 4/2013, indicated the attending physician will visit residents in a timely fashion, consistent with applicable State and Federal requirements.

The policy indicated that the attending physician must visit the resident once every thirty days for the first 90 days.

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minimal harm was posted to reflect accurate total number and actual hours worked per shift for licensed and registered staff for each shift on a daily basis.

This had potential to affect all 58 residents, staff, and

and staff schedules for the past month on 6/4/26, revealed the postings did not accurately reflect the actual staffing levels during each day.During interview with the director of nursing (DON) and the administrator on 6/4/26 at 12:29 p.m., DON stated the daily staff postings were filled out by the receptionist and did not reflect any changes throughout the day such as call-ins, no-shows, or staff picking up shifts.

The administrator stated expectation of the daily staff postings to reflect accurate shift numbers.During interview with receptionist (RC) on 6/4/26 at 12:54 p.m., RC stated when she arrives in the morning, she was expected to review the daily staff schedule that was sent to her from the staffing coordinator (SC) and to fill out the staff posting form. RC stated no one updated the daily posting with changes involving call-ins, no-shows, or picked up shifts.During review and interview with SC on 6/4/26 at 1:03p.m., SC stated she was responsible for the staff schedule and forwarding daily information to the receptionist and DON, But not the staff posting. SC stated she was not aware of anyone updating the daily staff postings to reflect call-ins, no-shows, or picked up shifts.

Review of May and June 2026 staff schedules and daily staff postings were reviewed with SC who verified they did not match.Facility policy on daily staff postings was requested and not received.

During an interview on 6/4/26 at 2:01 p.m., the director of nursing (DON) stated when a resident was on an antipsychotic either the nurse working on the floor or the manager would place the order on the TAR to signal nursing to complete the AIMS assessment.

Completed AIMS assessments would be documented in R6's medical record under assessments The purpose of completing an AIMS assessment is mainly for the purpose of medication adjustments and so the pharmacy could review to see if there were any adverse effects.The facility's AIMS Assessment policy dated 6/4/26, identified an AIMS assessment was required for residents prescribed a second-generation antipsychotic such as quetiapine. A baseline assessment should be completed prior to starting an antipsychotic and every 3 months or sooner if changes for the elderly.

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During an interview 6/4/26 at 12:33 p.m., dietary aid (DA)-A stated they had just finished serving all the food for the floor. DA-A stated they had prepared all the room trays and served all the residents in the dining room. DA-A verified they did not have a hairnet on. DA-A stated, we typically wear one during serving. DA-A added, they took the hairnet off during break and forgot to put it back on. DA-A stated they did not have to wear a beard net. DA-A stated, they never said anything about it. DA-A stated their beard/goatee was about 2 inches long.

During an interview 6/4/26 at 12:43 p.m., culinary district manager (CDM)-A stated all dietary staff were to wear hair nets, even if they were bald, and were to wear a beard net if they had more than a 5 o'clock shadow. CDM-A stated the expectation was anytime dietary staff were in the kitchen or serving/plating food on the floors; they were expected to wear hairnets and beard nets (if needed). CDM-A stated it's important to contain hair, so it doesn't drop into the food.

During an interview on 6/4/26 at 12:53 p.m., director of nursing (DON) stated it would be expected that staff serving food would wear hairnets and beard nets so hair doesn't get into food as that would be an infection control concern.

During an interview on 6/4/26 at 12:54 p.m., administrator stated it would be expected staff serving food would wear appropriate hair/beard nets to contain hair as that would be an infection control issue if hair got into the food. A facility policy titled Dietary Hair Restraints and Head Covering, dated 6/4/26, indicated all individuals entering food preparation, oof storage, warewashing, or plating areas must wear an approved, effective hair restraint that completely covers all head hair and, where applicable, facial hair.

Furthermore, the document indicated the following under section III: Approved Hair Restraints: 1.

Head Hair Restraints Hair Nets: Fine-mesh, commercial-grade hair nets that completely enclose thehair.

Dietary Caps/Hats: Clean, facility-approved baseball-style caps or chef hats maybe worn only if they are paired with a mesh hair net to capture stray hairs alongthe nape of the neck and ears.

Exclusions: Standard bandanas, visors, hair clips, or open-mesh caps without anunderlying fine hair net are strictly prohibited.2.

Facial Hair Restraints (Beard Nets) Any individual with facial hair (including beards, long mustaches, or stubble)exceeding 1/4 inch in length must wear an approved beard restraint/snood thatcompletely covers the jawline, chin, and mouth.

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During interview on 6/4/26 at 10:36 am, the infection preventionist (IP) stated nursing staff were only required to wear a gown when performing specific cares that related to the reason they were on EBP.

For example, if a resident was on EBP due to a catheter, then staff were only required to wear a gown when performing catheter cares.

The same would go for a wound, etc.

Staff were not required to wear a gown if they were transferring the resident or changing their brief or any other high contact cares.

The IP further stated nursing staff were expected to go from a clean area to a dirty area when bathing a resident or performing a brief change.

They should also be changing their gloves and performing hand hygiene in between cares and after gloves were removed.

The IP verified R15 was on EBP due to a wound and R23 was on EBP due to a catheter.

The facility policy regarding hand hygiene and glove use (undated), indicated to use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations: -Before and after direct contact with residents -Before moving from a contaminated body site to a clean body site during resident care -After contact with blood or body fluids -After removing gloves.

The facility policy regarding implementation of transmission-based precautions (undated), indicated long term care units must utilize EBP for residents with chronic, colonized Multidrug-Resistant Organisms (MDRO) or those with indwelling medical devices/chronic wounds without acute infection.

EBP requires gown and glove use only during high contact care tasks.

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maintenance supervisor stated he didn't know if he had any. No invoices were received.

The

raises and lowers. It further indicated: Warning- keep the batteries fully charged.

Place the battery on

charger will not allow the batteries to overcharge.

Never run the batteries completely flat. As soon as the audible warning sounds, complete the lifting operation in hand and place on charge. To avoid possible permanent damage to the battery, the battery should be placed on charge as soon as the display indicates the half empty battery symbol.

Never store the battery for long periods without regular charging throughout the storage period.

The facility policy titled Safe Patient Handling and Mechanical Lifts (undated), maintenance staff or floor nurses must verify that lift batteries are charged and emergency stop buttons are functional at the start of each shift.

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During interview on 6/2/26 at 1:50 p.m., NA-F stated NAs were responsible for making the residents beds stating We've been asking for bariatric sheets for months. We only have maybe 3 or 4 sets of bariatric sheets and they are always in room [ROOM NUMBER] because she makes laundry give them back to her. NA-F further stated they had reported not having enough bariatric sheets to the previous administrator and maintenance supervisor.

During interview on 6/3/26 at 11:23 a.m., NA-E stated NAs were responsible for putting sheets on the residents' beds and the reason some of the bariatric beds didn't have sheets was because the facility didn't have enough. NA-E further stated This is not a new thing, it's been a problem since January, There are not enough sheets that fit the bariatric beds. We keep telling management they need to buy a bigger size. If there aren't any sheets available to make the bed, we just use a blanket.R53R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of anxiety, morbid (severe) obesity, and sleep deprivation. It further indicated R53 required substantial assistance with toileting and partial assistance with transfers.

During observation and interview on 6/1/26 at 11:19 a.m., R53 was lying in bed on top of a blanket with parts of the bare mattress exposed. R53 stated the facility didn't have any sheets that fit her bed and she would prefer to lay on a fitted sheet (as opposed to a blanket) that fit the bed properly and didn't fall off all the time.

During observation on 6/3/26 7:40 a.m., R53 was lying in bed on top of a blanket with parts of the bare mattress exposed.

There wasn't a fitted sheet R53's bed.

During observation and interview on 6/4/26 at 8:37 a.m., NA-B brought R53's breakfast tray to her room. R53 was lying in bed on top of a blanket and there were parts of the bare mattress exposed. NA-B verified there wasn't a sheet on R53 beds and should have been.

During interview on 6/4/26 at 1:31 p.m., the director of nursing (DON), stated she would expect all residents to have sheets on their beds.The facility policy titled Making an Unoccupied Bed (undated), indicated the purpose of the policy was to provide a resident who gets out of bed a clean, comfortable bed. If further indicated the following procedure for equipment/supplies needed to make a bed:-1 pillowcase-2 sheets-1 blanket (if necessary)-1 bedspread (if necessary)-1 plastic drawsheet (per facility policy)-1 cotton drawsheet (if necessary)-disposable bed liner (if necessary)-laundry bag, soap and water, paper towels, and personal protective equipment (gloves, gowns, etc.)

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rooms down significantly.

The DOM stated that although he had been planning this, he had not yet

the wall/ceiling disrepair in R5's room, and although he couldn't say for sure, there appeared to be some water damage on R5's ceiling that would need to be repaired.

A facility policy titled Maintenance Service, revised 3/5/25, indicated the maintence department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

245289 06/05/2026

The Terrace at Crystal LLC 3245 Vera Cruz Avenue North Crystal, MN 55422

During an interview on 6/5/26 at 8:33 a.m., the director of nursing (DON) was informed that QAPI training records for NA-J were not found in the records provided.

The DON stated that she expected QAPI training to be completed annually, so NA-J should have completed the training.

The DON stated she would provide any additional records if found. No additional records showing NA-J had completed QAPI training in the last year were received.

The facility's undated Staff Development Program policy, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes.

The policy indicated that QAPI training was a mandatory in-service training class but did not indicate how often this training should be completed.

245289 06/05/2026

The Terrace at Crystal LLC 3245 Vera Cruz Avenue North Crystal, MN 55422

During an interview on 6/5/26 at 8:33 a.m., the director of nursing (DON) was informed that compliance and ethics training records for NA-J were not found in the records provided.

The DON stated that she expected compliance and ethics training to be completed annually, so NA-J should have completed the training.

The DON stated she would provide any additional records if found. No additional records showing NA-J had completed compliance and ethics training in the last year were received.

The facility's undated Staff Development Program policy, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes.

The policy indicated that ethics training was a mandatory in-service training class but did not indicate how often this training should be completed.

245289 06/05/2026

The Terrace at Crystal LLC 3245 Vera Cruz Avenue North Crystal, MN 55422