Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Luther Manor At Hillcrest during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow required fall and hazard prevention interventions for multiple residents. A resident with dementia and high fall risk sustained full‑thickness wounds to the knee after being found in bed with the knee against a very hot heater, and later had a fall with head and elbow injuries after being left alone in a wheelchair despite a care plan requiring that he not be left alone in his room. Another resident with severe cognitive impairment, care planned for 2‑person EZ stand transfers, was twice transferred improperly by a single CNA using a pull‑up bar and then a power recliner and gait belt, and was later found to have a fractured ankle. A third resident with repeated falls and gait problems was repeatedly observed standing and transferring in regular socks without shoes or gripper socks, with wheelchair foot pedals attached and brakes not effectively locked, contrary to care‑planned interventions, while staff reported inconsistent knowledge and communication of transfer and safety requirements.
Surveyors identified multiple food service sanitation deficiencies, including dietary staff and cooks wearing hairnets that did not fully contain their hair, leaving hair exposed while working in food preparation areas. Observations revealed unclean conditions in the freezer, dry storage, and ice machine, with spilled food, sticky residues, and visible films on equipment and surfaces. Dead cockroaches and debris were found under kitchen shelving, sinks, and the dish machine, and staff reported seeing both live and dead roaches despite ongoing pest control treatments. Review of cleaning logs showed that routine and deep cleaning tasks for kitchen and dish room floors were often not completed or not documented, contrary to facility policies requiring clean, pest‑free food service areas and proper use of hair restraints to prevent food contamination.
QAPI Program Lacked Documented Performance Improvement Activities: The facility failed to carry out QAPI activities to obtain feedback, use data, and conduct structured analysis of recurring issues. Surveyors cited repeated concerns involving F812, F865, F689, and F880 across multiple CMS 2567s and again on the current survey. Although QAPI meetings were held and the Administrator said department heads were involved, the facility could not locate documentation for performance improvement activities tied to the cited issues. The Administrator stated there were 32 PIPs in place and that F812 and F880 were ongoing issues.
A facility failed to maintain a safe, clean, and sanitary environment when live and dead cockroaches, droppings, and pest activity were observed in family room cabinets, a refrigerator, and a conference room near the kitchen. Residents reported seeing bugs and cockroaches in the building and dining room, while pest control confirmed ongoing roach treatment and identified the kitchen as the source of the infestation. The facility also had dirty dining room vents, dusty and debris-covered window screens, and refrigerators at nurses stations with dried spills, crusted residue, and expired or undated items, with staff giving inconsistent accounts of who was responsible for cleaning them.
Surveyors found that staff failed to provide complete perineal care after incontinence for two cognitively impaired, fully dependent residents who were always incontinent of bowel and bladder. In one case, CNAs did not separate skin folds, reused the same washcloth surface across multiple areas, and did not cleanse all required areas such as hips and one buttock before applying a clean brief. In the other case, a CNA removed a heavily soaked brief and performed only a single wipe to the rectal area, without cleansing the front peri area or buttocks. Staff interviews and facility guidance confirmed that all skin exposed to urine or stool should be washed front to back, with a clean cloth surface for each stroke, and that this did not occur during the observed care episodes.
Two cognitively intact residents did not receive timely meals when relying on room trays. One resident awoke to find no breakfast tray delivered, reported that staff did not wake her for breakfast and that she often did not receive meals, and instead ate food stored in a mini fridge supplied by family; facility documentation listed breakfast as not applicable for this resident. Another resident did not receive a lunch tray when meals were distributed; staff attempted to contact dietary via walkie talkie without response, and the resident later used the call light to report not having eaten before a CNA finally delivered a tray, after the stated lunch period. The CDM described reliance on meal tickets and walkie calls to identify needed trays, and the DON stated CNAs are responsible for room tray delivery and intake documentation and that residents are expected to be offered three meals daily.
A resident with impaired cognitive skills received wound care to a left knee abrasion in which an LPN failed to follow infection control practices by not removing gloves or performing hand hygiene after cleansing the wound and by applying triple antibiotic ointment directly from the tube to multiple open areas using a single gloved finger instead of sterile applicators. Other RNs, the wound nurse, and the DON described expectations consistent with the facility’s wound care policy, which requires glove removal, handwashing after dressing removal, use of a no-touch technique, and use of sterile applicators for ointment application, highlighting that the observed practice did not follow established procedures.
Failure to notify the physician when ordered bilateral leg reduction wraps were not applied. A resident with intact cognition and diagnoses including anemia, HTN, and lymphedema had wraps ordered daily, but staff documented multiple days when the wraps were not applied because the legs were too swollen. The resident was also observed without the wraps, and an LPN stated the wraps could be left off when the legs were weeping, while the DON and Administrator said staff were expected to follow the order and notify the physician if treatments were not being done.
A resident with intact cognition completed skilled therapy, and OT notified the SW of the end of services and the need for 24-hour care. However, the facility could not find the required CMS ABN forms, and the record did not show that the resident or family member was given, signed, or discussed the paperwork about possible liability for noncovered services.
A resident with severe cognitive impairment and max assist transfer needs fell when staff attempted to raise a recliner after the resident said she could walk. Although no head strike or visible injury was noted at the time, the EHR lacked documented VS, skin checks, or a progress note until the next morning, when the resident was found to have a bruised, swollen, painful ankle and could not move it. Staff interviews showed inconsistent understanding of post-fall follow-up expectations, and the DON stated staff should assess pain, reassess after a fall, and document findings.
Failure to offer and/or administer influenza vaccine to two residents. One resident had moderately impaired cognition, prior flu vaccinations, and documented POA consent for flu, COVID, and RSV vaccines, but the facility could not provide documentation of a later refusal after consent. Another resident had a BIMS score of 11/15, prior flu vaccinations, and no flu vaccine during the current season; the chart lacked documentation explaining why the vaccine was not offered or given. The DON and IP/ADON stated vaccinations were completed in the fall and consent would be obtained and documented before administration.
Missing Daily Nursing Staff Postings: The facility failed to ensure nursing staffing information was posted daily with the required details. Surveyors observed outdated postings at the nurses station and outside the SS Unit, and facility records showed missing schedules and incomplete unit postings that listed only CNA assignments without RN or LPN coverage. The DON said the scheduler emailed the posting to the charge nurse and that third shift usually handled it, while the Administrator acknowledged the gaps.
A resident with multiple chronic conditions and cognitive impairment was found to have multiple Rivastigmine transdermal patches applied simultaneously due to staff failing to remove the old patch before administering a new one. This led to increased confusion, agitation, and falls, ultimately resulting in hospitalization for acute encephalopathy. Staff interviews and record reviews revealed inconsistent practices in patch administration and documentation, as well as a lack of a specific facility policy for transdermal patch use.
A resident with a history of amputation and chronic pain did not receive prescribed opioid pain medication for several days due to lack of availability and delays in obtaining a new prescription. Despite repeated reports of severe pain and requests for medication, staff were unable to provide the medication, resulting in the resident being sent to the ED twice for pain management before the issue was resolved.
Nursing staff did not perform required shift-to-shift narcotic counts for a resident receiving scheduled opioid pain medication, resulting in a missing Tramadol cassette. Multiple RNs and an LPN confirmed that narcotic counts were not completed as per facility policy, which mandates end-of-shift counts by both outgoing and incoming nurses. This failure led to an unaccounted-for controlled substance.
The facility failed to maintain food safety standards, with observations of unclean kitchen conditions and improper glove use by staff, leading to potential cross-contamination. Staff B and Staff D were noted for not changing gloves between tasks, and the kitchen had open, undated food items and uncovered trash cans.
The facility failed to effectively implement Quality Assurance activities to address deficiency F812, as identified in both a previous and current survey. Despite regular QAPI team meetings and a revised QAPI Plan, the facility struggled to correct the issue, indicating ongoing challenges in addressing quality problems.
The facility failed to maintain professional standards in food storage and sanitation. Observations revealed uncovered food in storage, ineffective sanitizing solutions, and improper food transport without covers. Additionally, the puree process was conducted without cleaning between different food items. The acting Dietary Manager was unaware of these issues, and daily cleaning logs were missing.
The facility failed to serve food at appropriate temperatures during two observed meals. Residents reported that their food was not hot, and temperature checks confirmed that food items were below the required range. The facility lacked a dietary manager, and the food temperature log showed numerous missed documentation opportunities. Staff were not covering food trays between servings, and a microwave was often used to reheat food.
Failure to Implement Fall and Hazard Prevention Measures for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents for multiple residents. For one resident with coronary artery disease, hypertension, peripheral vascular disease, cerebrovascular accident, non‑Alzheimer’s dementia, severe memory problems, and severely impaired decision‑making, the MDS showed dependence on staff for personal hygiene and dressing, substantial assistance needed for bed mobility, and a history of falls. This resident was found with his left knee resting against a metal heater while lying on his side in bed, with his pants pulled up to the knee, resulting in open areas and later‑described superficial burns/abrasions to the left knee. Staff and hospice documentation and interviews described the wounds as skin tears, abrasions, popped blisters, or possible burns, with full‑thickness skin loss in multiple irregularly shaped areas and a large surrounding area of redness. Temperature checks of the heater in the resident’s room showed metal surface temperatures ranging from approximately 107°F to over 139°F, and staff acknowledged the resident’s knee had been against the heater and that the heater was hot or warm to the touch. The same resident, who was care planned as high risk for falls with an intervention that he not be left alone in his room in a wheelchair (identified by a “wheelchair star” tag), experienced a fall when CNAs left him alone in his room in his wheelchair while they went to get an EZ stand lift. He was later found face down on the floor in front of his wheelchair with an abrasion and hematoma to the forehead, a bruise to the nose, and a skin tear to the left elbow. Observations and interviews revealed that the star tag was not present on his wheelchair at the time of survey, some staff were unaware of or stated they no longer used the star program, and there was inconsistency in how staff were informed of residents’ transfer and supervision requirements. Staff interviews confirmed that the resident was not supposed to be left alone in his room in a wheelchair, and the DON stated staff did not follow the plan of care when they left him alone, after which he fell. Another resident with hypertension, diabetes, depression, severe cognitive impairment, and a need for maximal assistance with transfers was care planned to require two‑person assistance with an EZ stand lift. Despite this, one CNA transferred the resident alone using a pull‑up bar, and on a later date another CNA attempted to transfer the resident from an electric recliner using a gait belt and walker after the resident stated she could walk, rather than using the EZ stand with two staff as required. During the latter event, the CNA raised the power recliner, attempted to have the resident bear weight, and the resident slid out of the chair to the floor. The following day, the resident was found with a bruised, swollen, and painful right ankle, unable to move it, and an x‑ray showed a mildly displaced fracture of the lateral malleolus. Multiple CNAs and nurses reported inconsistent or unclear methods for determining transfer status (door signs, wing sheets, binders, magnets, or the electronic kardex), and agency staff reported they had not been educated on where to find transfer information. A third resident with repeated falls, weakness, gait abnormalities, and moderate cognitive impairment was care planned to ambulate with assistance of one and a front‑wheeled walker, to have gripper socks applied, to have auto‑lock brakes on the wheelchair, and to have wheelchair foot pedals removed unless being propelled. The care plan also directed removal of white socks from the room because the resident removed shoes and gripper socks. Observations on multiple days showed the resident repeatedly in bed or standing and transferring while wearing only white socks, without shoes or gripper socks, and often without a gait belt. The resident was seen standing from bed and transferring to a wheelchair without gripper socks or shoes, self‑transferring between bed and wheelchair, and ambulating in the room with wheelchair pedals attached and brakes not locked. During one observation, the resident stood up with the wheelchair brakes not effectively engaged, and the wheelchair rolled backward and bumped into furniture. Staff acknowledged the anti‑lock brakes were not functioning properly and required maintenance, and the DON later stated the resident was not supposed to have white socks in the room, indicating the care‑planned interventions to prevent falls and accidents were not consistently implemented.
Food Service Sanitation and Pest Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to procure, store, prepare, and serve food in accordance with professional sanitation standards, resulting in multiple instances of potential physical contamination in the kitchen. During several kitchen observations, multiple dietary staff, including the Dietary Director, cooks, and dietary aides, wore hairnets that did not fully contain their hair, leaving 1–3 inches of hair exposed over the ears and at the back of the head. Staff interviews confirmed that hair was expected to be fully covered and that hairnets should be worn immediately upon entering the kitchen, but the Dietary Director acknowledged she was not aware her own hair was outside the hairnet until it was pointed out. Surveyors also observed significant cleanliness issues in food storage and preparation areas. In the freezer, whipped cream was sprayed on the right wall and had not been cleaned for several months, despite the Dietary Director knowing about it. In dry storage, there was dry cereal on the floor under and around racks, a plate storage unit with a white granular and clear sticky substance on it, and multiple yellowish-orange splotches under pasta, spices, and baking product shelves. The ice machine had an off‑white film under the door and a sticky brown/orange substance on the inside rim. A blue paper attached to a work surface with tape and plastic left behind a sticky residue and visibly soiled tape and paper when removed. Floor sanitation and pest control issues were also documented. Dead cockroaches and debris were observed under the pots and pans shelf, sanitizing sink, and dish machine on multiple days, and staff acknowledged seeing both live and dead roaches in the kitchen recently. Cleaning logs for the kitchen and dish room floors showed that out of 112 scheduled AM and PM cleaning opportunities in January, floors were documented as swept/washed only 34 times, with numerous days showing no entries for any cleaning tasks and deep cleaning completed only 3 of 36 opportunities. The Dietary Director later acknowledged that the January and February cleaning sheets were not completed accurately and appeared to show the kitchen was not being cleaned. Pest control confirmed ongoing treatments since November, continued findings of live and dead roaches in the kitchen, and identified the kitchen as the source of the infestation. Facility policies required that food service areas be kept clean, free of debris and pests, and that staff wear hair restraints to prevent contamination, but these standards were not met.
QAPI Program Lacked Documented Performance Improvement Activities
Penalty
Summary
The facility failed to carry out QAPI activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting the facility. Survey findings cited repeated concerns in the CMS 2567 statements dated 10/17/24, 12/30/24, and 7/25/25, including F812 Food Procurement, Store/Prepare/Serve-Sanitary; F865 QAPI Program/Plan, Disclosure/Good Faith Attempt; F689 Free of Accident Hazards/Supervision/Devices; and F880 Infection Prevention & Control. The current survey, conducted 2/04/26 through 2/12/26, identified the same concerns again. The facility reported a census of 94 residents. Review of QAPI sign-in sheets showed meetings were held on 11/05/24, 2/13/25, 5/13/25, 7/01/25, 9/25/25, 10/22/25, 11/19/25, 12/17/25, and 1/14/26, but the facility was unable to locate documentation for performance improvement activities covering the cited CMS-2567 issues. During interview, the Administrator stated department heads were involved in QAPI meetings since September 2025 and that the committee should use grievance forms, survey results, nursing notes, clinical review meetings, resident concerns, walk around audits, and staff concerns to develop and prioritize performance improvement activities. She stated there were 32 PIPs in place, that fall monitoring was an active PIP, and that F812 and F880 were ongoing issues. The QAPI plan listed goals for stable workforce, fall with major injury reduction, turnover reduction, and antianxiety/hypnotic medication reduction, and the policy stated annual survey results were used to identify, collect, and evaluate data for committee review and prioritization.
Cockroach activity and unsanitary common-area conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment when live and dead cockroaches, along with droppings, were observed in the family room cabinets and refrigerator, and a cockroach was also seen in the conference room next to the kitchen. On 2/04/26, a live cockroach was observed traveling from the base of a cabinet under the sink in the family room into the cabinet, which contained a stained towel and an approximately 1/4 inch gap where the water pipe entered the wall. Later that day, the middle family room cabinets contained a live roach and four dead roaches surrounded by droppings. On 2/05/26, a live cockroach was again observed on the cabinet under the sink in the family room, and the dead cockroaches and droppings remained in the middle cabinet. A dead roach was also found in the family room refrigerator with food items present inside it. Resident interviews reflected awareness of pest activity in the building. Resident #84 reported there had been mice and cockroaches in the building, and Resident #31 reported seeing a black hard shell bug on her curtain a couple of weeks earlier that dropped to the floor and crawled under her night stand, and stated she had seen them in the dining room. During a follow-up discussion, the Administrator stated housekeeping was responsible for cleaning the family room. Pest control invoices showed treatments for cockroaches in the kitchen, family room, and other living areas on multiple occasions, and the pest control company stated the kitchen was the source of the infestation and confirmed finding dead and living roaches in both the kitchen and family room during treatment. The facility also failed to keep vents, windows, screens, and refrigerators clean. On 2/10/26, a dining room vent was observed covered in black substance, and other dining room vents had gray fuzz hanging from or covering the grates. The Maintenance man stated the vents were cleaned every 2 months, and the Administrator later stated she knew of the dirty vents from staff. On 2/12/26, refrigerators at the Bluff View and Sunshine Valley nurses stations had dried brown spills, crusted residue, and expired or undated food and drinks inside. The window screens at Bluff View nurses station had a large amount of dirt and debris, and the window glass was covered in substance and appeared hazy. Staff and leadership gave differing accounts of who was responsible for cleaning and monitoring the hall refrigerators, and the DON stated nursing had been cleaning them during a transition from environmental services staff.
Incomplete Perineal Care After Incontinence for Two Dependent Residents
Penalty
Summary
Surveyors identified a deficiency in the provision of complete perineal care after incontinence for two residents who were always incontinent of bowel and bladder and dependent on staff for toileting hygiene and transfers. Resident #11 had severe cognitive impairment, hypertension, diabetes, anxiety disorder, and depression, and a care plan directing frequent incontinence care with barrier ointment. During observed care, two CNAs used a limited number of washcloths, did not separate skin folds while cleansing the perineum, reused the same surface of a washcloth across multiple areas, and failed to wash the hip areas and the right buttock before applying a clean brief. This care did not include washing all areas that came into contact with urine or stool, including abdominal folds, buttocks, and hips, as described by facility staff expectations and the facility’s incontinent care checklist. Resident #84 had dementia, anxiety, severely impaired cognitive skills for decision making, and was always incontinent of bowel and bladder, with a care plan requiring routine and as-needed incontinence care and assistance with post-toileting hygiene. Surveyors observed a heavily soaked brief being removed, described as making a “plop” noise when it hit the trash can, indicating it was very wet. During subsequent care, a CNA used a wipe to swipe the rectal area one time and did not wash the front perineal area or the buttocks before standing the resident with a stand lift. Staff interviews confirmed that all skin areas exposed to urine should be washed front to back, using a clean surface of the cloth with each stroke, and that the front perineal area had not been cleansed for this resident during the observed episode.
Failure to Provide Timely Meals to Residents Receiving Room Trays
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were provided in a timely manner and in accordance with residents’ needs and preferences for two cognitively intact residents receiving room trays. For one resident with a BIMS score of 15/15, staff were overheard at the nurses’ station discussing that the resident had just awakened and did not have a breakfast tray. The resident later reported she did not get breakfast and that no one woke her up for breakfast, stating she frequently did not receive meals and that her son had purchased a mini fridge so she would always have food available. Surveyors observed the mini fridge in the room and a bag of doughnuts from her family on the overbed table, which the resident chose to eat instead of breakfast because it was close to lunchtime. Facility documentation for that morning’s breakfast was marked “NA” (not applicable) for the resident, indicating breakfast was not provided. For another resident with a BIMS score of 15/15, lunch trays were delivered to the unit, with trays identified either by orange sticky notes or meal tickets. After trays were distributed, staff used a walkie talkie to notify dietary that this resident did not have a tray on the cart, but no response was received. More than 30 minutes after initial tray delivery, the resident activated the call light and reported to a CNA that lunch had not yet been received. The CNA then delivered a room tray to the resident, which occurred after the facility’s stated lunch service window of 11:15 AM to 12:15 PM. The CDM reported that dietary is notified of needed trays via meal tickets or last-minute walkie calls and stated there had never been a problem with residents not being served, while the DON reported CNAs are responsible for taking trays to rooms and documenting intakes and that residents are expected to be offered three meals a day.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during wound care for Resident #80. The resident’s MDS assessment showed severely impaired cognitive skills for daily decision making. Hospice orders for the resident’s left knee wound directed staff to cleanse the wounds with wound cleanser, apply triple antibiotic ointment, cover with a non-adhesive dressing, and wrap with cotton gauze twice daily and as needed. During an observation of wound care to an abrasion on the resident’s left knee, the LPN (Staff E) removed the dressing and cleansed the wounds but did not remove her gloves or wash her hands after cleansing. She then used her gloved index finger to apply triple antibiotic ointment directly from the tube to four areas on the left knee, three of which had open skin, without using a different finger or an applicator for each area. Other nursing staff and leadership described wound care procedures that differed from what was observed. One RN stated that gloves should be changed after removal of a soiled dressing and that hands should be washed, and that a sterile applicator should be used for each wound area when applying ointment. Another RN explained that after setting up supplies and cleaning the wound, gloves should be removed, hands washed, and ointment applied with gloves on, changing gloves with each area unless treating the same area, followed by glove removal, handwashing, and application of a clean dressing. The facility wound nurse (an LPN) reported she observed Staff E put ointment on her gloved finger and said she would have expected use of an applicator and hand hygiene between cleansing and ointment application. The DON stated staff should wash hands and change gloves between cleansing the wound and applying ointment. The facility’s wound care policy directed staff to remove gloves and wash and dry hands thoroughly after dressing removal, to use a no-touch technique, and to use sterile tongue blades and applicators to remove ointments and creams from their containers.
Failure to Notify Physician When Ordered Leg Wraps Were Not Applied
Penalty
Summary
The facility failed to notify the physician when bilateral lower extremity reduction kit wraps were not applied as ordered for Resident #89. The resident had a BIMS score of 13 out of 15, indicating intact cognition, and had diagnoses including anemia, high blood pressure, and lymphedema. The TAR for January 2026 directed staff to apply the bilateral lower extremity reduction kit wraps at 8:00 AM and remove them at 8:00 PM, but the progress notes showed 18 of 31 days in January 2026 when staff did not apply the wraps because the legs were too swollen. On 1/6/26, the provider ordered that the resident needed compression wraps every day, yet the record lacked provider notification when the wraps were not applied to the bilateral lower legs due to swelling. On 2/4/26 and 2/5/26, the resident was observed not wearing the wraps, and on 2/5/26 the resident stated she did not mind wearing them and that staff had just not put them on. On 2/10/26, an LPN stated the resident had weeping edema on both lower legs and that the wraps could be left off when the legs were weeping so they would not be soiled by drainage, and said the physician was aware. The DON and Administrator stated their expectations were that staff follow physician orders and notify the physician if treatments were not being done.
Failure to Provide Required Medicare/Medicaid Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide the required CMS Skilled Nursing Facility Advanced Beneficiary Notice forms (CMS 10055 and CMS 10123) at the completion of skilled services for one resident. Resident #61 had an MDS documenting a BIMS score of 15/15, indicating intact cognition, and a therapy note stated that Occupational Therapy advised the social worker of therapy recommendations for 24-hour care at the end of skilled services. Therapy ended on 11/24/25, and the therapist confirmed that the discussion with the social worker occurred and that the social worker should have prepared the CMS forms documenting the end of services. Review of progress notes showed the social worker spoke with the resident and a family member about discharge planning, but the record did not include documentation that the required paperwork was discussed, signed, or provided. During interview, the resident said she did not recall talking with a social worker or other staff about costs associated with ending therapy and did not recall receiving or signing any paperwork. The facility administrator stated the former social worker responsible for ensuring the forms were completed no longer worked at the facility, and the facility could not find the resident’s CMS forms.
Inadequate post-fall assessment and documentation
Penalty
Summary
The facility failed to provide adequate assessment and intervention after a fall for one resident who had hypertension, diabetes, depression, severe cognitive impairment with a BIMS score of 7, and required maximal assistance for transfers. An incident report stated the resident told a CNA she could walk, but staff recognized she was an EZ stand/mechanical lift resident. As the CNA attempted to raise the recliner, the resident started to slide and was assisted to the floor. The resident did not hit her head and no visible injuries were noted at the time, and staff assisted her back into the wheelchair with three-person assist and a gait belt. The electronic health record did not show documentation of vital signs, skin assessment, or a progress note until the next morning. That later note documented that when the resident woke up, her right ankle was bruised, swollen, and painful to the touch, and she could not move it. Staff interviews reflected differing understandings of the fall follow-up process, including expectations for neurological checks, vital signs, skin checks, and documentation after a fall. One RN did not recall the resident having pain that night, while an LPN stated the resident did not complain of pain and no bruising or redness was seen during the night shift. Another LPN stated that the next morning the CNA reported the resident’s ankle really hurt, was terribly bruised and swollen, and she could not move it. The DON stated staff should assess for pain, reassess after a fall, and document findings in the electronic health record, with more frequent follow-up after a fall. The facility policy titled Falls - Clinical Protocol directed staff, with physician guidance, to follow up on any fall with associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma had been ruled out or resolved. The record and staff statements showed the resident did not receive documented vital signs, skin checks, or assessment in the hours after the fall, and the ankle injury was not documented until the following morning.
Failure to Offer and Document Influenza Vaccinations
Penalty
Summary
The facility failed to offer and/or administer the influenza vaccine for 2 of 5 residents reviewed. Resident #19’s annual MDS listed diagnoses of personal history of pulmonary embolism and localized edema, and the BIMS section was blank with staff indicating moderately impaired cognitive skills for daily decision making. An immunization consent form documented that the IP/ADON spoke with the resident’s POA, who gave verbal consent for the COVID, influenza, and RSV vaccines. IRIS records showed the resident had received the flu vaccine in multiple prior years, including January 2025, but an email from the IP/ADON stated the facility had consent for the fall 2025 flu vaccine and that the resident and spouse adamantly refused vaccination. The facility was unable to provide documentation showing the resident or spouse refused after consenting. Resident #64’s quarterly MDS showed a BIMS score of 11/15, indicating moderately impaired cognition, and documented that the resident did not receive the influenza vaccine in the facility for the current influenza season with none of the listed reasons for not receiving it. IRIS records showed prior flu vaccinations in several years, including 2024. An email from the IP/ADON stated the facility did not have consent for the vaccines on file and the resident did not have a vaccine at the facility. Progress notes did not document why the resident was not offered or given the vaccine. During interview, the DON and IP/ADON stated resident vaccinations were completed in the fall, the facility used IRIS documentation as part of the admission process for vaccination status, and verbal or written consent would be obtained prior to administration and documented.
Missing Daily Nursing Staff Postings
Penalty
Summary
The facility failed to ensure nursing department staffing information was posted daily with the required information for 3 of 6 days reviewed, with a census of 94 residents. Observations at the nurses station showed the staff posting was dated 2/02/26 on 2/04/26, dated 2/04/26 on 2/05/26, and dated 2/09/26 on 2/10/26. The staff posting outside the SS Unit memory care area was dated 2/06/26 on 2/10/26. The DON stated the only staff posting was by the nurses station and that the scheduler emailed it to the charge nurse, including the weekend schedule, for posting; she also stated third shift usually handled it and she was not aware postings were missing. Facility documents for 2/01/26 through 2/11/26 titled [Facility Name] Report of Nursing Staff did not include a staff schedule for 2/03/26, and the SS Unit Report of Nursing Staff did not include staff schedules for 2/01/26, 2/03/26, or 2/04/26 and documented only CNA assignments without RN or LPN coverage for the area. The Administrator acknowledged the gaps in staff posting and stated the DON was aware of it.
Failure to Remove Old Transdermal Patch Before Applying New Patch Resulting in Hospitalization
Penalty
Summary
A deficiency occurred when staff failed to remove an existing transdermal Rivastigmine patch before applying a new one to a resident with a history of coronary artery disease, hypertension, Parkinson's disease, and bipolar disorder. The resident, who required extensive assistance with daily activities and had documented cognitive impairment, was found to have multiple Rivastigmine patches on his body over several days. Medication administration records and staff interviews revealed that staff did not consistently locate and remove the old patch prior to applying a new one, and in some instances, staff could not find the previous patch but proceeded to apply another without a thorough body check or proper documentation. The resident subsequently exhibited increased confusion, agitation, and physical instability, including falls and hyperventilation. Staff discovered two patches on the resident during an episode of acute confusion, and further review indicated that the resident had as many as three patches on at one time. The resident's condition deteriorated, leading to hospital admission for acute encephalopathy. Medical records and interviews confirmed that the resident's mental status improved after the excess patches were removed and the medication was discontinued. Staff interviews highlighted inconsistent practices in patch administration, including failure to check for existing patches, improper documentation, and lack of adherence to protocols such as dating and initialing patches. The facility did not have a specific policy for transdermal patch administration, and staff were unclear about the correct procedures, contributing to the medication error and subsequent adverse event.
Failure to Provide Prescribed Pain Medication Resulting in Unmanaged Pain
Penalty
Summary
A deficiency occurred when a resident with a history of peripheral vascular disease, diabetes mellitus, and an above-knee amputation was not provided with their prescribed pain medication, Oxycontin, for several consecutive days. The resident's care plan included scheduled opioid pain management, and clinical documentation showed ongoing severe pain, including phantom limb pain and anxiety related to pain. Despite repeated documentation of pain and requests for medication, the facility failed to ensure the availability and administration of the prescribed pain medication from 8/13/25 to 8/18/25. During this period, medication administration records repeatedly noted that the pain medication was not available, and staff were awaiting a prescription from the primary care provider. The resident reported severe pain, rated as 10/10, and expressed distress and anger over the lack of medication. Staff documented communication attempts with the primary care provider and the orthopedic surgeon, but no new orders were obtained, and the medication remained unavailable. The resident's pain was not managed as required by the care plan and facility protocol, which instructed immediate contact with the prescriber if pain was not controlled. As a result of the unaddressed pain, the resident was sent to the emergency department on two occasions for pain management. Emergency department records confirmed that the resident sought care due to the lack of pain medication at the facility and received the necessary medication at the hospital. The resident returned to the facility with medication, but the issue persisted until the prescription was finally filled. Interviews with staff and the resident confirmed the ongoing pain and lack of medication during this period.
Failure to Reconcile Narcotic Counts Resulting in Missing Controlled Substance
Penalty
Summary
The facility failed to reconcile narcotic and controlled substance counts at the beginning and end of every shift for a resident who was receiving scheduled opioid pain medication. Clinical record review and staff interviews confirmed that nursing staff did not complete the required narcotic counts prior to exchanging keys or at shift changes, as mandated by facility policy and procedure. This lapse resulted in a missing narcotic cassette containing Tramadol, which was discovered during the process of administering medication to a resident with multiple diagnoses, including chronic pain and osteomyelitis. Multiple staff members, including RNs and an LPN, verified that narcotic counts were not performed as required, and acknowledged that it is the expectation to follow the facility's controlled substances policy. The facility's policy, dated April 2019, specifies that controlled medications must be counted at the end of each shift by both the outgoing and incoming nurse, with any discrepancies to be reported immediately to the director of nursing services. The failure to follow this policy led to the unaccounted-for controlled substance.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food service safety standards, as observed during a kitchen inspection. Staff B, a cook, was initially observed without a hair net, and the kitchen floor was littered with food debris such as grapes, crumbs, and cheese slices. Kitchen counters and shelves were found with open and undated food items, including cereal boxes, peanut butter, and juice containers. The stove and oven were covered with food particles and grease, and trash cans in the kitchen lacked lids. Additionally, several food prep areas were unclean, with food particles and flour present. During lunch service, the kitchen remained in disarray despite being mopped, with wet paper towels and carrot coins on the floor. The stove continued to have dried pasta and grease, and garbage containers were still uncovered. Staff members, including Staff C and Staff D, were observed using gloves improperly, failing to change them between tasks, and touching various surfaces and food items, leading to potential cross-contamination. Staff D, the Dietary Manager, and other staff members handled food and kitchen equipment without changing gloves, further compromising food safety. Interviews with staff revealed a lack of adherence to proper food safety protocols. Staff D, the Dietary Manager, acknowledged the need for food items to be dated and for gloves to be changed between tasks to prevent cross-contamination. However, observations indicated that these practices were not consistently followed. Staff F, the Regional Supervisor of Health Services, noted that garbage containers should have lids and that staff should not wear gloves in the kitchen, instead using utensils to handle food. Despite these acknowledgments, the facility's failure to maintain a clean and safe food preparation environment was evident.
Facility's QAPI Activities Fail to Correct Deficiencies
Penalty
Summary
The facility failed to effectively carry out Quality Assurance activities to address and correct deficiencies, as evidenced by the CMS Statement of Deficiencies form and staff interviews. The facility, with a census of 96 residents, was found to have ongoing issues related to deficiency F812, which was identified in both a previous survey and a current complaint survey. The Administrator acknowledged that the QAPI team met regularly to discuss Performance Improvement Projects (PIP) and collected data from various sources, including online programs, suggestion boxes, grievance forms, and findings from the Department of Inspections, Appeals, and Licensing. Despite having a PIP in place for the previous survey deficiency, the facility continued to struggle with addressing the identified issues. The facility's QAPI Plan, revised in December 2024, outlined a process for reviewing information to identify gaps or patterns in care systems that could lead to quality problems. The plan emphasized prioritizing areas with high risk, high frequency, or problem-prone issues and chartering a PIP team to oversee problem resolution. However, the facility's efforts were insufficient, as they failed to prevent the ongoing prevalence of the deficiency. The QAPI team was expected to use a systemic approach to analyze and understand the root causes of identified problems, but the deficiency persisted, indicating a lack of effective implementation of the QAPI Plan.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, and sanitation, as observed during a kitchen tour and hallway observations. In the dry storage area, a plastic spoon was found on the floor in a brown sticky substance, with a radio covered in a similar substance and food particles. In the walk-in cooler and freezer, a box of hamburger patties was left open and uncovered, with patties covered in ice crystals. The sanitizer bucket in the kitchen did not register any chemical sanitizer, indicating ineffective sanitization. Additionally, during hallway observations, food trays were transported without proper covers, exposing food to potential contamination. During the puree process, Staff A did not clean or sanitize the workspace between different food items, further compromising food safety. The acting Dietary Manager was unaware of the cleanliness issues and the open food in the freezer, and daily cleaning logs could not be located. The facility's policy required all food preparation and service areas to be maintained in a clean and sanitary condition, but this was not adhered to, as evidenced by the observations and the outdated cleaning schedule found in the binder.
Deficiency in Serving Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve food at an appropriate temperature and in a palatable manner during two observed meals. During the breakfast meal service, a resident reported that the food was not hot, and a temperature check of a test tray revealed that the oatmeal, french toast, and sausage were at approximately 125 degrees Fahrenheit. The facility had been using Health Care Services (H.C.S.) to manage the dietary department, but there was no dietary manager present at the time. During the lunch service, a test tray showed that the food temperatures were below the required range, with the country fried steak at 120 degrees and carrots at 110 degrees Fahrenheit. The dietary manager confirmed that food needed to be served between 140 and 160 degrees Fahrenheit. The report also highlighted that the steam cart temperatures were checked and found to be within the acceptable range, but staff were not covering food trays between serving residents. The facility's food temperature log book showed 38 missed opportunities where dietary staff failed to document food temperatures prior to serving. Residents expressed concerns about food palatability, with one resident reporting that their lunch tasted terrible and was not hot. The facility dietician and an LPN noted that the food service was slow, and a microwave was often used to warm up food that was not hot upon arrival from the kitchen.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 73 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dubuque
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ennoble Nursing And Rehab | 0.2 mi | ★★★★★ | 0 | 0 |
| Dubuque Specialty Care | 0.7 mi | ★★★★★ | 0 | 0 |
| Grand Meadows Senior Living & Health Care | 2 mi | ★★★★★ | 8 | 0 |
| Hawkeye Care Center Dubuque | 2.3 mi | ★★★★★ | 6 | 0 |
| Harmony Dubuque | 2.3 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.