Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan - Holstein during CMS and state inspections, most recent first.
Food was not kept at an appetizing temperature for two residents. One resident with severe cognitive impairment said meals were served cold at least once or twice a week, and another resident said lunch and dinner were frequently cool because his table was served last. During meal observation, hot items on the memory care unit were measured below the facility’s stated 135-degree minimum, and the CDM confirmed the food should have been warmer.
Food items were found open without dates, including dairy, sauces, noodles, and frozen foods, and some items had best by dates that had passed. During lunch service, an AM shift cook handled broccoli, a hamburger bun, French fries, and tater tots with bare hands or without observed hand hygiene, including placing food back on a resident’s plate after it fell on the steam table and touching a bun after it fell on a debris-covered countertop. The CDM and Administrator stated the items should have been dated or discarded and that tongs should have been used.
Failure to Document and Communicate Use of Two Briefs: Staff applied two briefs to a resident with moderate cognitive impairment and urinary incontinence without documenting the intervention in the care plan or progress notes, and without documented resident or family discussion. The resident said the double brief was uncomfortable and not respectful, while staff described the practice as a recent trial or preference that was communicated on a CNA board and during huddles rather than in the EHR.
A resident with moderate cognitive impairment and diagnoses including anxiety disorder, bipolar disorder, impulse disorder, and intellectual disability was placed in a wheelchair seatbelt for fall risk. The resident was observed multiple times with the seatbelt fastened while sitting in the common area, and staff stated the resident could not consistently buckle or unbuckle it on her own. The EHR lacked documentation for restraint monitoring, restraint-free time, release frequency, direct supervision, and ongoing reevaluation, and the DON stated no restraint assessment or less restrictive measures were completed before the seatbelt was used.
A facility failed to follow infection prevention practices during personal care for one resident with a PEG tube on EBP and another resident needing toileting assistance. Two CNAs provided high-contact care without gowns for the resident on EBP, and during care for the other resident, one CNA continued using the same gloves through multiple tasks and missed expected hand hygiene moments. The DON acknowledged the missed hand hygiene and gown use during the observed cares.
The facility did not update care plans to reflect significant changes in the status and care needs of three residents, including a resident admitted to hospice, another who experienced a fall with a new intervention, and a third with notable weight loss and new diabetic management orders. These omissions were identified through clinical record review, staff interviews, and facility policy review.
A facility failed to document a resident's advanced directives upon admission. The resident's Care Plan lacked information on CPR preferences, and the EHR did not indicate a code status or advanced directive. The resident expressed a desire for CPR, but the DON was unaware of the missing documentation, stating staff should check the EHR for code status.
The facility failed to develop comprehensive care plans for three residents with severe cognitive impairments and various medical conditions. One resident's care plan lacked direction for diabetes management, another's did not address high-risk medication side effects, and a third's did not specify target behaviors or interventions for antidepressant use. The DON acknowledged these deficiencies, which contravened the facility's policy for individualized care plans.
The facility failed to provide adequate oral care for two residents with cognitive impairments, as required by their care plans. Despite needing assistance, there was insufficient documentation of oral hygiene in the EHR. Staff interviews confirmed that oral care was not consistently documented, and the DON acknowledged a mistake in task scheduling, leading to this deficiency.
A facility failed to provide adequate supervision and ensure the functionality of safety devices for two residents with severe cognitive impairments. One resident, at high risk for falls, was not provided with a gait belt during an incident where they were lowered to the floor after complaining of leg pain. Another resident, at risk for elopement, had a non-functional wander guard, with no documentation of daily checks as required. These deficiencies highlight lapses in adherence to care plans and safety protocols.
The facility failed to perform a gradual dose reduction (GDR) for a resident on Seroquel and did not document target behaviors or non-pharmacological interventions for another resident on psychotropic medications. The Director of Nursing confirmed the lack of GDR attempts, and staff interviews revealed missing documentation in care plans, contrary to facility policy.
The facility failed to ensure proper infection control during meal assistance. An RN was observed assisting two residents simultaneously without hand hygiene, and a CNA made direct contact with a fork's tines without replacing it. Staff interviews confirmed the facility's protocol requires hand hygiene between residents and utensil replacement if contact is made with eating surfaces.
A resident with severe cognitive deficits was subjected to abuse and restraint by two CNAs in a LTC facility. The resident, who required substantial assistance and exhibited behavior symptoms, was repeatedly pushed back into a chair and had her mouth covered by one CNA, while the other failed to intervene. The incident was initially witnessed but not reported immediately, highlighting a failure to adhere to the facility's abuse and neglect policy.
A resident with severe cognitive deficits was subjected to inappropriate handling by a CNA, who restrained her movements and covered her mouth, causing distress. Another CNA present did not intervene or report the incident. The facility failed to report the suspected abuse immediately and did not separate the alleged abuser from residents in a timely manner, violating their abuse prevention and reporting protocols.
A resident with severe cognitive deficits was subjected to inappropriate and punitive measures by CNAs in a LTC facility. The resident, who required substantial assistance and had a history of Alzheimer's disease, was restrained by being pushed into a chair and having her mouth covered to silence her. The incident was witnessed by the Activities Director and confirmed by video footage, revealing a lack of adequate training and competency testing in dementia care among staff.
The facility failed to accurately account for Schedule II medications for two residents, leading to discrepancies in administration records. A resident with severe cognitive deficits had discrepancies in Ativan administration, while another resident had leftover medications unaccounted for. Additionally, the facility did not secure medications properly, with a medication cart left unattended and a medication room door propped open. The Controlled Drug Count Record lacked proper documentation, indicating a lack of oversight in medication management.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature for 2 of 20 residents reviewed, including a resident with severe cognitive impairment and a resident with no cognitive impairment. Resident #21 had a BIMS score of 7 and stated that food was served cold at least once or twice a week and that he did not like cold food. Resident #51 had a BIMS score of 15 and stated that food was frequently cool and that he wanted it served warm; he reported that lunch and dinner were the meals most often served cold because his table was the last served. During observation of the memory care unit lunch meal, the first tray was placed in a heated transport at 12:00 PM, a sample plate was set aside, the transport returned to the unit at 12:08 PM, and the first plate was delivered to a resident at 12:10 PM. The sample tray temperatures were 119 degrees for apple glazed pork loin, 122 degrees for long grain and wild rice, and 116 degrees for broccoli. Staff also took the temperature of mechanical pork on the steam table after lunch service for IDDSI 5 and ITSIY 6 diets and recorded 117 degrees. The CDM stated the pork for those diets should be warmer and that the minimum temperature should be 135 degrees on the steam table, and that food delivered to residents on the memory care unit should also be a minimum of 135 degrees. The facility policy titled Food Temperature Monitoring stated hot food should be held above 135 degrees and served at 135 degrees or higher.
Food Storage and Hand Hygiene Deficiencies During Meal Service
Penalty
Summary
Food was not stored and handled in accordance with professional standards in the kitchen and during meal service. During an initial kitchen observation, multiple food items were found open without dates, including cottage cheese with an open date of 4/1/26 and a best by date of 3/26/26, carrots in water dated 3/31/26, parmesan cheese containers open without open dates, barbeque sauce outside of its store-bought container with an open date of 2/19/26, strawberry syrup open without an open date, and chopped garlic open without an open date. In dry storage, several bags of noodles were open without dates, and one bag of spaghetti noodles was completely open to the air without a seal or cover. In the freezer, bags of French fries, tater tots, onion rings, and potato wedges were open without dates. A toaster on the counter also had brown and white debris on top and in the crumb drawers. During lunch service, Staff A handled food in ways that did not follow the facility’s hand hygiene and food handling expectations. A piece of broccoli fell onto the steam table where plates were being plated, and Staff A picked it up with a fork and placed it back on the plate before serving it. Staff A also handled a hamburger bun with a paper towel in an ungloved hand, placed the bun on a plate, removed the paper towel, used tongs to place a hamburger on the bun, then moved the plate to the toaster area where the top bun fell onto a countertop with used utensils and food debris; Staff A picked it up with an ungloved hand and placed it on the hamburger without observed hand hygiene. Staff A also opened the freezer with one hand, obtained handfuls of French fries and tater tots with the other hand, placed them in the fryer, and returned to the steam table without hand hygiene. The CDM and Administrator stated that open food items should have dates, expired items should have been discarded, and tongs should have been used for the bun, fries, and tater tots.
Failure to Document and Communicate Use of Two Briefs
Penalty
Summary
The facility failed to provide dignity and respect to a resident when staff applied two briefs for incontinence without documented care plan interventions, documented resident or family discussion, or documented trial of alternative interventions. Resident #21 had a BIMS score of 12, indicating moderate cognitive impairment, and the MDS showed the resident required partial/moderate assistance with toilet hygiene. The EHR care plan did not include interventions for the use of two briefs, and progress notes did not show discussions with the resident or the resident's daughter about this practice. Resident #21 told the surveyor that staff put two briefs on her because she was incontinent, that she could tell when she needed to urinate, and that she did not like wearing two briefs because they were uncomfortable. She stated that sometimes she could not get to the bathroom in time and would void onto the chair and floor, and she did not think staff were treating her with respect by applying two briefs. During observation, the resident ambulated to the bathroom with a walker while staff provided care, and staff removed one brief while the second pull-up style brief remained in place. Staff interviews showed the practice had been communicated informally rather than documented in the resident's record. A CNA stated the resident had recently been double briefed because she voided heavily and it would get on her dressings, and another CNA said the resident took herself to the bathroom and staff would respond to her call light for a new brief. The DON stated the resident's preference was the reason for the two briefs, while the ADON stated they had spoken with the resident and daughter, trialed other brief options, and placed the information on a CNA communication board, but acknowledged the trials and discussions were not documented in the EHR or care plan at the time.
Physical restraint used without adequate assessment or monitoring
Penalty
Summary
The facility failed to protect a resident from the use of a physical restraint that the resident could not consistently remove on their own. Resident #9 had a BIMS score of 9 indicating moderate cognitive impairment and diagnoses including anxiety disorder, bipolar disorder, impulse disorder, and unspecified intellectual disability. The MDS documented use of a trunk restraint in the wheelchair, and the care plan identified a seatbelt for physical restraints related to fall risk with an initiation date of 3/12/26. The physician order stated to fasten the seat belt when the resident was up in the wheelchair. Review of the resident’s EHR showed no documentation of monitoring for complications related to restraint use, no restraint-free time, no length of time the restraint was anticipated to be used, no identification of who may apply it or how to apply it, no time and frequency for release, no direct monitoring and supervision during use, and no ongoing reevaluation for the need for the restraint. Observations on multiple days showed the resident sitting in a wheelchair in the common area with the seatbelt fastened across the lap while in front of the TV. A CNA stated the resident attempted to get out of the chair and that was why the seatbelt was used. Staff interviews showed the resident did not consistently remove or manipulate the seatbelt on her own. One CNA stated the resident could not buckle or unbuckle the seatbelt and that restraint-free time had not been provided except during bathing or when repositioned to bed. The DON stated the resident’s ability to unbuckle the seatbelt was inconsistent, that the resident would sometimes say the belt was unbuckled and then buckle it herself, and that more documentation should have been in place. The DON and ADON also stated they had not completed a restraint assessment before using the seatbelt and had not used less restrictive measures prior to its use. The resident’s mother stated she did not recall being notified about consent for the seatbelt and had not witnessed the resident removing it on her own.
Infection Prevention and Control Failures During Resident Care
Penalty
Summary
The facility failed to provide appropriate infection prevention practices during care for a resident with a PEG tube who was on Enhanced Barrier Precautions (EBP). Resident #9 had moderate cognitive impairment, a feeding tube in place, and a care plan requiring EBP related to PEG tube placement. The EBP signage outside the room directed staff to use gowns and gloves during high-contact care activities, including dressing, transferring, hygiene, changing briefs, toileting, and device care for feeding tubes. During an observed transfer to the toilet and personal care for Resident #9, two CNAs used gloves but did not apply gowns. The observation documented multiple instances of glove removal and reapplication, hand hygiene at some points, and care activities including removal of clothing and briefs, use of a mechanical full-body lift, peri care, brief application, and repositioning. The DON later stated there could have been more hand hygiene and more glove use during the resident’s care and stated the staff should have worn gowns when completing cares on Resident #9. The facility also failed to follow hand hygiene expectations during personal care for another resident. Resident #21 had moderate cognitive impairment and required partial/moderate assistance with toilet hygiene. During observed care, two CNAs completed hand hygiene and donned gloves, but one CNA continued using the same gloves while providing personal care after removing the first brief, handled peri cloths from the sink, and then removed gloves and assisted with dressing. The DON stated hand hygiene was expected with any change of gloves, after removal of the brief, after personal care, and when pants were pulled up. Facility policies reviewed by surveyors stated staff were to perform hand hygiene at required moments and to use gown and gloves for EBP during high-contact resident care activities.
Failure to Update Care Plans Following Changes in Resident Status and Interventions
Penalty
Summary
The facility failed to update and revise care plans to accurately reflect the current needs and interventions for three residents. For one resident with diagnoses including heart failure, renal insufficiency, diabetes mellitus, and hypertension, and who was admitted to hospice care, the care plan was not updated to reflect the hospice admission. Another resident with heart failure, renal insufficiency, peripheral vascular disease, and toxic liver disease experienced a fall, and although an intervention was documented in the progress notes, this intervention was not added to the care plan. A third resident with non-Alzheimer's dementia, diabetes mellitus, anxiety, and obesity experienced significant weight loss and had physician orders for daily blood sugar monitoring and diabetic medications with weight loss as a side effect, but the care plan was not updated to reflect these changes. Review of facility policy indicated that care plans are to be developed using an interdisciplinary team approach and must be updated to reflect the care currently required or provided for the resident, especially after significant changes in condition. Staff interviews confirmed that the expectation is for care plans to be updated when interventions or care needs change, but this was not done for the residents reviewed.
Failure to Document Advanced Directives for a Resident
Penalty
Summary
The facility failed to implement or follow through with advanced directives for a resident upon admission. The entry Minimum Data Set (MDS) indicated that the resident entered the facility on a specific date, but the Care Plan implemented did not document whether the resident wanted cardiopulmonary resuscitation (CPR) if needed. A review of clinical records showed a lack of documentation regarding the resident's code status or any advanced directive. The Electronic Health Record (EHR) did not indicate whether the resident required CPR or was designated as do not resuscitate (DNR). During an interview, the resident expressed a desire for CPR, but the Director of Nursing (DON) was unaware of the missing code status in the EHR, stating that staff are instructed to check the EHR for code status if CPR is required.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, each with severe cognitive impairments and various medical conditions. Resident #10, diagnosed with diabetes mellitus and other conditions, had a care plan that lacked direction for managing diabetes and insulin usage, including blood sugar monitoring and parameters for physician notification. Resident #16, who was on antidepressant and antipsychotic medications, had a care plan that did not address the potential side effects and monitoring requirements for these high-risk medications. The Director of Nursing acknowledged the expectation for these elements to be included in the care plan. Resident #31, with chronic kidney disease, diabetes, and other conditions, had a care plan that included antidepressant medication use but did not specify individualized target behaviors or non-pharmacological interventions. The resident's spouse confirmed the use of medication for behavior concerns, but the care plan lacked documentation of target behaviors and interventions. The Director of Nursing confirmed that target behaviors should be documented in the care plan and progress notes, but was unable to locate this information. The facility's policy requires individualized, comprehensive care plans with measurable goals, which was not adhered to in these cases.
Inadequate Oral Care Documentation for Residents
Penalty
Summary
The facility failed to provide adequate oral care for two residents, both of whom required assistance with oral hygiene due to cognitive impairments. Resident #22, with a BIMS score indicating they were rarely or never understood, required substantial assistance for oral hygiene. Despite the care plan instructing staff to assist with oral care every morning and evening, there was no documentation of oral care being performed in the last 30 days. Similarly, Resident #24, with severely impaired cognition and fully dependent on staff for oral care, had only three instances of oral hygiene documented in the same period, despite the care plan's directive for oral care twice daily or after each meal. Interviews with staff revealed a lack of consistent documentation practices, with oral care typically documented in the Electronic Health Record (EHR) once per shift. Staff members confirmed that if oral care was not documented, it was assumed not to have been done. The Director of Nursing acknowledged the absence of documentation and attributed it to a mistake in entering care tasks, which were set to be documented as needed rather than as a scheduled daily task. This oversight led to a deficiency in providing necessary oral care for the residents.
Inadequate Supervision and Safety Device Failures
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident with severe cognitive impairment and a high risk for falls. The resident, who required assistance with mobility and transfers, was not provided with a gait belt as directed in the care plan during an incident where they became unsteady and were lowered to the floor by a CNA. The resident had been complaining of right leg pain prior to the fall, which was not reported to the charge nurse until after the incident. The facility's investigation did not clarify whether a gait belt was used, and there was no follow-up on a request for physical therapy evaluation made a month prior to the incident. Another resident, also with severe cognitive impairment and at risk for elopement, was found to have a non-functional wander guard. The facility's records lacked documentation of daily checks for the placement and functionality of the wander guard, as required by the care plan and physician orders. The resident exhibited behaviors such as pacing, attempting to leave the facility, and hitting staff, indicating a need for close monitoring and functional safety devices. The facility's failure to ensure the proper use of safety devices and adequate supervision contributed to the deficiencies identified. The lack of documentation and follow-up on critical safety measures, such as the use of gait belts and the functionality of wander guards, highlights gaps in the facility's adherence to care plans and safety protocols.
Failure to Implement Gradual Dose Reductions and Document Target Behaviors
Penalty
Summary
The facility failed to complete a gradual dose reduction (GDR) for a resident who was taking Seroquel, an antipsychotic medication, for an adjustment disorder with mixed anxiety and depressed mood. The resident's clinical record lacked documentation of any GDR attempts in the past year, and there was no clinical rationale provided by a physician for continuing the medication without a GDR. The Director of Nursing (DON) confirmed that no GDR had been attempted since July 2023, despite the facility's policy requiring GDR attempts within the first year of initiating a psychotropic medication, unless clinically contraindicated. Another resident's care plan failed to include non-pharmacological interventions and targeted behaviors for monitoring and redirection, despite the resident receiving antipsychotic and antidepressant medications. The resident's electronic health record and progress notes did not identify specific target behaviors for the antidepressant medication, and staff interviews revealed that the care plan lacked documentation of these behaviors and interventions. The DON acknowledged that target behaviors and non-pharmacological interventions should be documented but were not found in the resident's records. The facility's policy on psychotropic medications emphasized the importance of gradual dose reductions and behavioral interventions unless clinically contraindicated. However, the facility did not adhere to these guidelines, as evidenced by the lack of GDR attempts and the absence of documented target behaviors and non-pharmacological interventions for the residents involved. This oversight indicates a failure to comply with federal regulations and facility policies regarding the management of psychotropic medications.
Inadequate Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during meal assistance, as observed on multiple occasions. On March 17, 2025, a Registered Nurse (RN), identified as Staff J, was seen assisting two residents with eating simultaneously without performing hand hygiene between assisting each resident. Additionally, Staff J was observed touching her face and continuing to assist the residents without sanitizing her hands. Similar observations were made on March 18, 2025, when Staff J again assisted two residents without hand hygiene between them. Furthermore, Staff K, a Certified Nurse Aide (CNA), was seen making direct contact with the tines of a fork while assisting a resident with eating, and continued to use the same utensil without replacing it. Interviews with various staff members, including a Certified Medication Aide (CMA), another CNA, and a Registered Nurse (RN), revealed that the facility's protocol prohibits assisting two residents at the same time without hand hygiene in between. They also confirmed that direct contact with the eating surface of utensils requires replacement of the utensil. The Director of Nursing (DON) reiterated these expectations, emphasizing the need for hand hygiene between residents and utensil replacement if contact is made with the eating surface. The facility's Infection Prevention and Control Program document, last revised in December 2024, mandates standard precautions, including proper hand hygiene for all residents.
Resident Abuse and Restraint by CNAs
Penalty
Summary
The facility failed to protect a resident from abuse, as observed in an incident involving two Certified Nurse Aides (CNAs), Staff E and Staff F. The resident, who had a severe cognitive deficit and required substantial assistance with daily activities, was subjected to punitive restrictions and restraints. Staff E was seen on video pushing the resident back into a chair multiple times, holding the resident's arms down, and placing a hand over the resident's mouth to silence her. Staff F, who was present during these actions, did not intervene or report the incident. The resident, who had a history of Alzheimer's disease and exhibited behavior symptoms such as verbal aggression and resistance to care, was described as restless, anxious, and confused during the incident. Despite the resident's attempts to stand and move, Staff E repeatedly restrained her by pushing her back into the chair and pinning her against the table. The resident's agitation increased as a result of these actions, leading to further attempts to stand and verbal outbursts. The incident was initially witnessed by Staff B, the Activities Director, who did not immediately report the abuse, believing it was not a significant concern. It was only after reviewing the video footage that the full extent of the abuse was recognized. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse and the importance of immediate reporting of any suspected violations, which was not adhered to in this case.
Failure to Report and Address Suspected Abuse
Penalty
Summary
The facility failed to report suspected abuse immediately and did not separate an alleged abuser from residents in a timely manner. A staff member witnessed a CNA covering the mouth of an agitated resident but delayed reporting the incident for over two hours. The incident involved Resident #1, who had a severe cognitive deficit and required substantial assistance with daily activities. The resident was diagnosed with Alzheimer's disease and exhibited behavior symptoms such as verbal aggression and resistance to care. On the day of the incident, a video review revealed that Staff E, a CNA, repeatedly pushed Resident #1 back into a chair and restrained her movements by holding her arms and covering her mouth. Staff F, another CNA present during the incident, failed to intervene or report the actions. The resident appeared agitated and distressed, attempting to stand multiple times, only to be forced back into the chair by Staff E. The situation escalated to the point where the resident was crying and appeared to be in emotional distress. The facility's investigation showed that the Director of Nursing was informed of the incident later in the day, after Staff E had left the facility. Staff B, who initially witnessed the incident, did not report it immediately, believing it was not a significant concern. The facility's policy on abuse and neglect required immediate reporting of any suspected mistreatment, which was not adhered to in this case. The actions of Staff E and the inaction of Staff F and Staff B contributed to the deficiency, highlighting a failure in the facility's abuse prevention and reporting protocols.
Inadequate Dementia Care and Use of Restraints
Penalty
Summary
The facility failed to ensure that staff displayed competent dementia care and safe interventions for a resident with severe cognitive deficits. The resident, who had a BIMS score of 3 indicating a severe cognitive deficit, required substantial assistance with daily activities and had a history of Alzheimer's disease, cancer, anemia, and a hip fracture. The care plan for the resident indicated the need for 24/7 supervision and specific interventions to manage her behavior, which included verbal aggression and resistance to care. On the day of the incident, Staff E, a CNA, was observed using inappropriate and punitive measures to control the resident's movements. The CNA was seen pushing the resident down into a chair, holding her wrists, and placing a hand over her mouth to silence her. These actions were taken despite the resident's visible agitation and attempts to stand, which were met with further restraint by the CNA. Staff F, another CNA present during the incident, failed to intervene or report the inappropriate actions of Staff E. The incident was witnessed by Staff B, the Activities Director, who reported hearing the resident screaming and observed Staff E's hand over the resident's mouth. The facility's video footage confirmed the inappropriate handling of the resident, including the use of physical restraint by pushing the chair against the table to prevent the resident from standing. Interviews with staff revealed a lack of adequate training and competency testing in dementia care, contributing to the inappropriate handling of the resident.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure accurate accounting of Schedule II medications for two residents, leading to discrepancies in medication administration records. Resident #3, who had severe cognitive deficits and was dependent on staff for daily activities, had discrepancies in the administration of Ativan, with the Individual Resident Narcotic Record (IRNR) showing more administrations than recorded on the Medication Administration Record (MAR). Similarly, Resident #4, who had intact cognitive ability and was independent in daily activities, had leftover medications that were not accounted for, and the facility's process involved destroying these without proper documentation. Additionally, the facility did not maintain secure storage of medications, as observed when a medication cart was left unattended with keys in the narcotic drawer, and the medication room door was propped open. The Controlled Drug Count Record also lacked proper documentation, with missing nurse initials on several dates, and a Licensed Practical Nurse pre-signed for shifts, indicating a lack of proper oversight and accountability in medication management.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Holstein
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Correctionville Specialty Care | 11.5 mi | ★★★★★ | 13 | 0 |
| Willow Dale Wellness Village | 12.2 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of Aurelia, Llc | 16.6 mi | ★★★★★ | 10 | 0 |
| Careage Hills Rehabilitation And Healthcare | 18.5 mi | ★★★★★ | 9 | 0 |
| Accura Healthcare Of Cherokee, Llc | 18.7 mi | ★★★★★ | 6 | 0 |
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