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 Northcrest Specialty Care during CMS and state inspections, most recent first.
Call Lights Not Accessible or Functioning for Multiple Residents: Surveyors found that several residents did not have reliable access to call lights or a working alert system. A resident with intact cognition reported the call light became unpredictable, and staff confirmed it did not alert the nurse station board; other staff said some residents were using bells because call lights were not working properly. Two other residents, including one with dementia and one with severe cognitive impairment and extensive ADL dependence, were repeatedly observed with call lights out of reach or corded behind furniture, and staff acknowledged residents should have call lights within reach.
A resident’s admission MDS was completed late instead of within the required 14-day timeframe. The EMR showed the resident was admitted to the facility, and the MDS 3.0 Summary Page showed the admission MDS was signed off late. The MDS Coordinator acknowledged the late completion and stated she tracks due dates with a calendar and uses the RAI manual and a paper Section GG collection document to monitor MDS timing.
A facility failed to complete and transmit MDS assessments within required time frames for multiple residents. MDS tracking and EMR records showed late discharge assessments, missing discharge assessment documentation on one tracking page, and staff reported batching MDS transmissions weekly while believing they had one week to send records to the CMS database.
Incorrect PASRR Coding on MDS Assessments: The facility inaccurately coded PASRR status on the MDS for two residents. One resident had PASRR documentation showing serious mental illness and Level II findings with specialized behavioral health services, but the MDS stated no SMI/ID condition and left the PASRR condition section blank. Another resident’s MDS stated the resident was not Level II PASRR despite PASRR records showing Level II approval with specialized services, and the MDS Coordinator confirmed the coding was wrong.
An LPN failed to maintain infection control during a wound dressing change when a folded gauze pad fell onto an incontinent bed pad and was then placed directly on a resident’s spinal wound. The resident had a surgical incision, wound infection, DM, COPD, and required daily dressing care with Enhanced Barrier Precautions. The LPN acknowledged the error, and the DON stated the gauze should not have been used after contacting the bed pad.
A resident with intact cognition, a wheelchair, and diagnoses including amputation, AFib, HF, and PVD was documented as a current tobacco user, but the facility did not complete a timely smoking assessment that evaluated his ability to safely travel off property or in inclement weather. He was observed smoking on the facility sidewalk without signing out, while staff stated smoking was only allowed off property. Surveyors also found more than 50 cigarette butts on the grounds near the smoking area, and the facility had no receptacle for cigarette butts.
Persistent Urine Odor in Resident Room: Surveyors repeatedly observed a strong stale urine odor in and around a resident’s room, along with wet linens, a soiled brief on the floor, and a tacky floor surface. The resident had ongoing urinary incontinence, did not consistently use the call light, and admitted to throwing soiled items on the floor. Staff described routine cleaning and commode care, but the care plan lacked specific direction for managing the resident’s room odor, and the family reported finding urine-stained sheets and a urine-filled soaker pad on the floor.
A resident who was dependent on staff for dressing due to hemiplegia was observed wearing the same t-shirt from the previous night, which still had hair clippings from a recent haircut. Staff interviews indicated uncertainty about whether the resident had been changed or had refused a gown, and the facility's policy requiring assistance with ADLs was not consistently followed, resulting in inadequate grooming.
The facility failed to maintain proper food storage and sanitation standards, with undated and expired food items found in storage, and unsanitary conditions observed in the kitchen. The Dietary Manager was unaware of these issues despite regular audits, and cleaning practices were not effectively implemented.
The facility failed to implement Enhanced Barrier Precautions for residents with feeding tubes, dialysis access sites, and urinary catheters, as observed with three residents. Additionally, improper infection control practices were noted during medication administration, with staff handling medications with bare hands or without changing gloves. The DON acknowledged oversights in EBP implementation and confirmed the need for proper glove use during medication handling.
A resident with a history of cerebrovascular accident was incorrectly documented as taking an anticoagulant in the MDS assessment, when they were actually on antiplatelet medications like aspirin and clopidogrel. This error was confirmed by the ADON and DON, and the Reimbursement Specialist noted the misclassification, possibly due to confusion with bleeding risk documentation.
A resident with a history of bowel obstructions and peptic ulcer disease experienced nausea, vomiting, and loose stools without timely assessment or physician notification. Despite receiving medications, the resident's condition worsened, leading to an emergency room visit. Staff interviews revealed communication and documentation lapses regarding medication administration and condition changes.
A resident undergoing hemodialysis was not provided with food during their appointment, leading them to purchase their own lunch. Despite having a dietary care plan, there was no directive for staff to send meals with the resident. Staff interviews revealed a lack of communication and responsibility regarding meal provision for residents attending dialysis, resulting in the oversight.
A resident with a history of stroke and asthma did not receive the flu vaccine despite requesting it during admission. The DON confirmed the absence of documentation explaining the lack of vaccine administration, even though a flu clinic was held after the resident's admission. Facility policy required documentation of vaccine refusal or administration, which was not present in the resident's record.
A resident with a history of stroke and asthma did not receive the flu vaccine despite requesting it during her admission assessment. The facility lacked documentation explaining why the vaccine was not administered, even though a flu clinic was held after her admission. The facility's policy required documentation of vaccine refusal, which was not followed in this case.
A resident with multiple health conditions, including ESRD and diabetes, experienced inadequate skin care and assessment at the facility. Despite having a care plan for skin integrity concerns, the facility missed several scheduled skin evaluations and failed to administer prescribed treatments for itching. The resident's condition worsened, leading to hospitalization for pneumonia, metabolic encephalopathy, and fluid overload.
A facility failed to remove an old fentanyl patch before applying a new one for a resident. The resident reported the issue, and the old patch was eventually removed. Interviews with staff confirmed that the standard procedure was not followed.
Call Lights Not Accessible or Functioning for Multiple Residents
Penalty
Summary
The facility failed to provide working call light access in resident bathrooms and bathing areas, and surveyors found that 3 of 24 residents reviewed did not have reliable access to a functioning call system. The report identified Residents #42, #69, and #73 as affected, and the facility census was 87. The facility policy stated that call lights should be explained and demonstrated on admission and periodically as needed, kept plugged in and functioning at all times, defective call lights should be reported promptly, and when a resident is in bed or confined to a chair the call light should be within easy reach. Resident #73 had intact cognition with diagnoses including heart failure, orthostatic hypotension, high blood pressure, and kidney failure, and his care plan identified a fall risk with instructions to encourage call light use. He reported that the call light worked when he arrived but later became unpredictable, and he said it did not work on one occasion when he alerted staff. Surveyors observed that pressing the call light caused a small red light at the cord outlet to come on, but the staff alert board did not indicate the call. Staff A, a CNA, and Staff C, an RN, both tested the device and confirmed it did not alert the staff board. Staff C gave the resident a bell to shake, and other staff later stated that several residents on other halls had bells because call lights were not functioning properly. Resident #69 had moderately impaired cognition with diagnoses including non-Alzheimer's dementia, repeated falls, unsteadiness, weakness, and gait and mobility abnormalities, and her care plan directed staff to encourage call light use. Surveyors repeatedly observed that she sat in her room or chair with no call light within reach, while the cord hung behind furniture and under the bed. When asked how she would get help, she reached toward a wall reset button that did not activate the call light and stated she did not know where the cord was. Resident #42 had severely impaired cognitive skills and required extensive assistance with many activities of daily living, including toileting, bathing, dressing, transfers, and bed mobility. Surveyors observed her call light wrapped around the headboard and later coiled on the floor behind the bed, out of reach, while staff members acknowledged that residents should have call lights within reach and the DON stated all residents must have their call lights within reach at all times.
Late Completion of Admission MDS
Penalty
Summary
The facility failed to complete the MDS Assessment within 14 days of admission for 1 of 2 newly admitted residents reviewed, Resident #39. The EMR census documented that Resident #39 was admitted to the facility on [DATE], and the MDS 3.0 Summary Page showed the admission MDS was signed off as completed late on 9/5/25. During an interview, the MDS Coordinator stated the facility completed the resident’s MDS late, that she reviews the MDS list daily and uses a calendar to track due dates, and that she believed they had one week to complete the MDS. She also stated she used a paper document titled Section GG Collection Dates, which specified the day of admission counted as day 1 of the resident’s stay. The LTC RAI 3.0 User Manual directed that the admission MDS completion date is required no later than day 14 of the resident’s stay.
Late MDS Completion and Transmission
Penalty
Summary
The facility failed to encode and transmit MDS assessments to the CMS system within the required time frames for 3 of 4 records reviewed for MDS timing requirements. For Resident #36, the EMR census and MDS Discharge Return Anticipated Assessment both documented a discharge on 8/7/25, but the Section Z0400 signature date and MDS 3.0 Summary Page showed the assessment was completed late on 8/24/25, 24 days after discharge. Staff interviews revealed the MDS Coordinators tracked due dates with a calendar and attempted to batch transmit MDS documents weekly, with one staff member stating she thought they had one week to transmit the records and that they followed the RAI for completing the MDS. For Resident #39, the EMR census documented an admission on 8/12/25 and discharge on 8/18/25, and the Discharge Return Not Anticipated Assessment reflected the discharge date in A1600, but the RN signature date in Section Z0500 was 9/5/25 and the MDS 3.0 Summary Page identified the assessment as completed late on that date. For Resident #61, the EMR census documented a discharge on 9/30/25, while the MDS Tracking Page showed an Entry Tracking Form dated 9/16/25 and an admission MDS assessment dated 9/22/25; the tracking page lacked documentation of a discharge assessment, and a later review documented a Discharge Return Not Anticipated Assessment completed and waiting for transmission to the CMS database.
Incorrect PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code PASRR status on the MDS for 2 sampled residents. For Resident #6, a PASRR Level 1 Screen Outcome dated 10/2/25 documented a Level 1 Positive, No Status Change, and the explanation stated the resident had evidence of a serious mental illness, that the previous PASRR Summary of Findings remained valid for the stay, and that the facility should mark “yes” for A1500 and check the applicable PASRR condition in A1510. However, the resident’s MDS documented that she did not have a serious mental illness and/or intellectual disability related condition, and A1510 was left blank. The MDS also listed anxiety, depression, and post-traumatic stress disorder, and reflected use of antipsychotic, antianxiety, and antidepressant medications during the lookback period. Resident #6 also had a PASRR Level II Outcome dated 11/22/24 documenting the need for specialized services for behavioral health, yet staff reviewed the profile page and identified the resident only as PASRR level 1. For Resident #10, the annual MDS documented a BIMS score of 15 and stated the resident was not a level II PASRR. However, a PASRR dated 12/16/25 documented a Positive Level I, no status change, with a positive Level II already on file, and a PASRR dated 3/26/24 documented Level II approval with specialized services. During interview, the MDS Coordinator confirmed the annual MDS was coded incorrectly and stated Resident #10 is a level II PASRR. Staff reported they relied on the resident profile page and sometimes the PASRR documents in the medical record when coding PASRR status.
Infection Control Failure During Wound Dressing Change
Penalty
Summary
The facility failed to use infection control standards to prevent cross contamination when gauze that had fallen onto a bed pad was then placed directly on a resident’s spinal wound. Resident #65 had intact cognition, was frequently incontinent of urine and bowel, and had diagnoses including wound infection, diabetes mellitus, and COPD. The resident required surgical wound care and a nonsurgical dressing, and the physician ordered daily and as-needed spinal dressing changes with dry gauze and tape, with no cleansing agents or creams to be applied to the incision site. The care plan identified the resident’s surgical incision to the lower back and directed staff to provide incision care as ordered and use Enhanced Barrier Precautions. During observation, an LPN sanitized hands, donned gown and gloves, removed the old dressing, then removed gloves, sanitized hands, and donned new gloves before preparing gauze for the dressing change. One folded gauze pad fell onto the surface of the incontinent bed pad, and the LPN picked it up and placed it directly on the resident’s spinal wound. The LPN acknowledged the gauze had fallen onto the bed pad and stated it should not have been used. The DON stated that if the gauze dropped onto the bed pad, it should not have been used. The facility’s Dressings, Dry/Clean policy directed staff to open dry, clean dressings using clean technique, but it did not direct staff what to do if gauze or dressing came into contact with a contaminated surface.
Smoking policy not followed for resident and facility grounds not kept smoke free
Penalty
Summary
The facility failed to follow its smoking policies for Resident #70, who had a BIMS score of 15 and diagnoses including amputation, atrial fibrillation, heart failure, and peripheral vascular disease. The resident was documented as a current tobacco user and as independent with a manual wheelchair, but the clinical record lacked a smoking evaluation before the Safe Smoking Evaluation completed on 2/9/26. That evaluation identified the resident as an independent smoker, but it did not assess the resident’s ability to walk, wheel, or propel himself off property to smoke, and it did not evaluate his ability to maneuver outside in inclement weather such as rain, snow, or ice. The care plan initiated on 2/9/26 identified the resident as non-compliant with the smoking policy and stated he did not leave the property to smoke, with interventions directing staff to educate and redirect him. However, the care plan lacked direction on where to keep smoking supplies and did not identify where facility property ended or where smoking would be permissible. The Release of Responsibility for Leave of Absence form showed the resident did not sign out on the morning of 2/9/26, yet he was observed at 9:30 AM smoking in his wheelchair on the sidewalk on the north side of the facility, between a bench and the parking lot. The facility also failed to keep the grounds smoke free as declared by staff. The Administrator stated the facility was smoke free and that residents who wanted to smoke would need to do so off property when out with family, but later acknowledged the resident smoked on facility property and had not signed out. On 2/9/26 at 2:15 PM, surveyors observed more than 50 cigarette butts around a bench, under a mature evergreen tree, and on the north side of the parking lot, and the facility had no receptacle for cigarette butts. Staff interviews confirmed that smoking was occurring on the sidewalk by the bench and parking lot, and multiple staff members acknowledged that no one had assessed the resident’s ability to safely get to an off-property smoking area in good weather or inclement weather.
Persistent Urine Odor in Resident Room
Penalty
Summary
The facility failed to maintain a homelike environment free of odors. Survey observations repeatedly identified a strong, stale, musty urine odor in and around a resident’s room, including odors detected outside the doorway and wafting into the hallway during multiple observations. The resident was observed lying in bed and stated that urine would run out when she tried to stand. She also admitted that if her linens or brief were wet, she would throw them on the floor and did not really use her call light, saying staff would eventually come clean it up. The resident’s care plan for ADLs included an intervention describing her as non-compliant with toileting and using the call light, and noted that she would throw soiled briefs on the floor. The care plan did not include further direction for staff on what to do for the resident or how to address the odor in her room. Observations also revealed a wet blanket on the floor, a tacky floor surface, and later a strong urine odor from the mattress and floor. Staff reported the resident had ongoing incontinence, that urine would begin to leak as soon as she stood, and that the floor became wet and sticky in the room. Housekeeping and nursing staff described routine cleaning practices, including daily weekday room cleaning and reduced weekend cleaning, but the record lacked documentation of more than daily cleaning for the resident’s room. Staff stated the commode was rinsed rather than deeply cleaned, that the mattress was not routinely specially cleaned unless requested, and that the room odor had been discussed with management. The family member reported finding urine stains on the sheets and a urine-filled soaker pad on the floor and said the problem had improved for a time but had worsened again. The administrator acknowledged the room had a urine odor and that the resident had been moved to a room with laminated flooring to make it easier to maintain.
Failure to Provide Adequate Grooming and Dressing Assistance
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for upper and lower body dressing due to hemiplegia following a stroke and depression, was observed to have inadequate grooming. The resident was seen wearing the same t-shirt from the previous night into the following day, and the shirt still had hair clippings from a haircut received the day before. The resident confirmed that his shirt had not been changed the previous night. Staff interviews revealed uncertainty about whether the resident had been changed into a gown or if he had refused, with staff acknowledging that sometimes the day shift or night shift would change the resident, but there was no clear documentation or recollection of the shirt being changed after the haircut. The facility's policy required staff to provide care and assistance with activities of daily living (ADLs), including dressing and grooming, for residents unable to perform these tasks independently. Despite this, the resident did not receive adequate assistance with changing clothes and removing hair clippings after a haircut, resulting in diminished grooming. The observations, interviews, and record review confirmed that the necessary support for maintaining personal hygiene and grooming was not consistently provided as required by facility policy.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards, as observed during a kitchen tour. In the dry storage area, there was an undated bin of rice, snack bins with unwrapped cheese puffs and corn chips, and an open, undated package of chicken and herb stuffing. Additionally, expired lemon bar mix and gluten-free chocolate chip cookies were found. In the walk-in freezer, an open, undated package of fajita vegetable blend and a box of southern style biscuits with open flaps and ice crystals were noted. The freezer floor had ice chunks and food particles. The Dietary Manager (DM) was unaware of the presence of these items and had previously audited the kitchen for expired items. During a second observation, a cart of clean dishes was placed near a floor drain covered with food particles, foil bits, and dust webs. The Assistant Dietary Services Manager (ADSM) mentioned the drain was previously used for a portable steam table but was not in use at the time of the survey. The DM stated that expired food was regularly audited and expected staff to label opened food with an 'O' and the date. A cleaning schedule was provided, indicating that staff were responsible for sweeping, mopping, and checking for outdated food daily, but these practices were not effectively implemented.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring high-contact care activities, such as those with feeding tubes, dialysis access sites, and urinary catheters. Resident #132, who had a feeding tube, did not have a CDC EBP sign on her room door until 1/27/25, despite having orders for EBP due to her feeding tube. Staff F, a registered nurse, confirmed that EBP was not implemented until 1/27/25, and Resident #132 reported that nurses only began using gowns and gloves the day before. The Director of Nursing (DON) acknowledged that some residents, including Resident #132 and #128, were missed in the EBP implementation. Resident #128, who had an arteriovenous fistula for dialysis, also did not have a CDC EBP sign on her room door. Despite having a care plan directing the use of EBP, Resident #128 reported that nurses did not wear gowns and gloves when assessing her fistula. The DON admitted that Resident #128's EBP implementation was overlooked, particularly because she was admitted over the weekend. Additionally, the facility failed to maintain proper infection control practices during medication administration. Staff G, a Certified Medication Aide, was observed handling medications with bare hands, while Staff I, a Registered Nurse, used gloves but did not perform hand hygiene or change gloves between tasks. This improper handling of medications was observed with multiple residents, including Resident #34, #43, and #63. The DON confirmed that staff should use clean gloves if they need to touch medications and should not handle pills with bare hands.
MDS Assessment Error for Antiplatelet Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident who was on antiplatelet medications, leading to a deficiency in accurately reflecting the resident's medication status. The resident, who had a diagnosis of cerebrovascular accident (CVA), was documented in the MDS as taking an anticoagulant medication within the lookback period. However, upon review, it was found that the resident was actually taking aspirin and clopidogrel, which are antiplatelet medications, not anticoagulants. This misclassification was identified during a clinical record review and staff interviews. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the resident did not receive an anticoagulant medication. The Reimbursement Specialist acknowledged that the MDS assessment was incorrectly coded, possibly due to confusion with clinical documentation on bleeding risk. The facility's use of traveling MDS Coordinators may have contributed to the error. The LTC RAI 3.0 User's Manual specifies that antiplatelet medications should not be coded as anticoagulants, highlighting the importance of accurate coding to reflect the resident's status as required by federal regulations.
Failure to Timely Assess and Notify Physician for Resident with GI Issues
Penalty
Summary
The facility failed to provide timely assessment and physician notification for a resident with a history of bowel obstructions and peptic ulcer disease who exhibited symptoms of nausea, vomiting, and loose stools. The resident, identified as having moderately impaired cognition, was dependent on staff for toileting hygiene and was documented as incontinent of bowel. Despite these conditions, the facility did not conduct necessary abdominal assessments or notify the primary physician provider in a timely manner. The resident experienced multiple episodes of nausea and vomiting over several days, during which various staff members administered medications such as Milk of Magnesia and ondansetron without conducting proper assessments or notifying the physician. The progress notes consistently lacked documentation of abdominal assessments or physician notifications, even as the resident's symptoms persisted and worsened. It was only after the resident's condition became severe, with symptoms including abdominal distension and firm abdomen, that the resident was sent to the emergency room. Interviews with staff revealed a lack of clarity and communication regarding the administration of as-needed medications and the reporting of changes in resident conditions. Staff members were unsure of the protocols for notifying nurses and physicians, and there was a noted absence of a Change of Condition Evaluation form in the resident's electronic health record during the critical period. This deficiency in communication and documentation contributed to the delay in addressing the resident's acute medical needs.
Failure to Provide Meals for Resident During Dialysis
Penalty
Summary
The facility failed to provide food to a resident while they were out of the facility for renal dialysis. The resident, who was alert and oriented with intact cognition, was admitted to the facility and required hemodialysis at a local center. Despite having a dietary care plan in place, there was no direction for staff to send meals with the resident to dialysis appointments. On the resident's first dialysis appointment since admission, they left the facility in the morning and returned in the late afternoon without being provided any food, resulting in the resident having to purchase their own lunch. Interviews with staff revealed a lack of communication and responsibility regarding the provision of meals for residents attending dialysis. The Registered Nurse and Certified Nursing Aide were unsure of who was responsible for ensuring meals were sent with residents, and the Assistant Dietary Services Manager was not informed of the resident's dialysis appointment. The Director of Nursing acknowledged the communication breakdown, particularly as the resident was admitted over the weekend, which led to the oversight in providing a meal for the resident during their dialysis appointment.
Failure to Administer Flu Vaccine to Resident
Penalty
Summary
The facility failed to administer the flu vaccine to Resident #9, who was one of six residents reviewed. Resident #9, who had a history of stroke and asthma, requested the flu and COVID vaccines during her admission assessment. However, she reported not receiving any vaccines while at the facility. The Director of Nursing (DON) confirmed that there was no documentation in Resident #9's record explaining why she did not receive the vaccine, despite a flu clinic being held in October after her admission. The facility's policy required documentation of vaccine refusal or administration, but no such documentation was found in Resident #9's medical record.
Failure to Administer Flu Vaccine to Resident
Penalty
Summary
The facility failed to administer the flu vaccine to one resident, despite the resident's request during her admission assessment. The resident, who had a history of stroke and asthma, reported during an interview that she did not receive any vaccines at the facility, including the flu and COVID vaccines, which she had requested upon arrival. The facility's documentation did not include any record of why the resident did not receive the flu vaccine, even though a flu clinic was held at the facility after her admission. The Director of Nursing confirmed that there was no documentation explaining the absence of the vaccine administration for the resident, and the facility lacked an original consent or declination form. The facility's policy on influenza vaccination, revised in October 2019, stated that all residents without medical contraindications should be offered the vaccine annually, and any refusal should be documented. However, this procedure was not followed in the case of the resident, leading to the deficiency noted in the report.
Failure to Provide Adequate Skin Care and Assessment
Penalty
Summary
The facility failed to provide appropriate assessment and intervention for a resident with multiple health conditions, including anemia, malnutrition, ESRD, diabetes, and heart failure. The resident required staff assistance for mobility and had a care plan in place to address skin integrity concerns due to venous insufficiency. Despite this, the facility did not consistently perform weekly skin evaluations as directed, missing several scheduled assessments in April and May. Additionally, the staff failed to administer prescribed Benadryl cream for itching from May 21 to May 29, 2024. The resident's clinical records indicated ongoing skin issues, including a rash and blisters on the lower extremities, which were not adequately addressed. The resident experienced itching and skin breakdown, leading to open wounds and infections. Despite receiving new orders for treatment, such as Nystatin powder and Eucerin cream, the resident continued to suffer from skin issues, and the facility did not document or manage these concerns effectively. The resident's condition worsened, resulting in a hospital admission for pneumonia, metabolic encephalopathy, and fluid overload. The facility's failure to conduct regular skin assessments and administer prescribed treatments contributed to the resident's deteriorating condition. The staff did not follow the facility's policy on skin breakdown management, which required documentation and intervention for new skin concerns. The lack of timely and appropriate care led to the resident's hospitalization and subsequent discharge to a care facility with hospice services.
Failure to Remove Old Pain Medication Patch Before Applying New One
Penalty
Summary
The facility failed to ensure the proper removal of a pain medication patch before applying a new one for a resident. On 3/3/2024, a Certified Medication Aide (CMA) applied a new fentanyl patch to the resident without removing the old one. The resident reported the issue to the nursing staff the following morning, revealing that two patches were present on his body. The resident initially refused to have the old patch removed until he could speak with the Advanced Registered Nurse Practitioner (ARNP). Upon assessment, the ARNP found no overdose symptoms, and the old patch was eventually removed with a witness present. Interviews with the facility's staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), confirmed that the standard procedure is to remove the old patch before applying a new one. The facility's policy on administering medications also supports this practice. The resident's pharmacist indicated that having two patches on simultaneously might result in a small amount of additional medication from the old patch, but it is designed to deliver medication for only three days. The facility's policy and the pharmacist's input highlight the importance of adhering to proper procedures for transdermal medication administration.
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 166 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 Waterloo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Waterloo | 3.7 mi | ★★★★★ | 17 | 1 |
| Ravenwood Specialty Care | 3.9 mi | ★★★★★ | 17 | 0 |
| Friendship Village Retirement | 3.9 mi | ★★★★★ | 4 | 0 |
| Pillar Of Cedar Valley | 4.5 mi | ★★★★★ | 13 | 0 |
| Pinnacle Specialty Care | 6 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Northcrest Specialty Care.
100% money-back within 48 hours.
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.