Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Northgate Care Center during CMS and state inspections, most recent first.
An LPN, RN, and other nursing staff pre-set multiple residents’ oral meds and insulin in advance instead of preparing and administering them at the time of the pass, and camera footage later showed the practice continued after staff had already been educated. Staff also failed to prime an insulin pen before giving it to a resident with DM, and the DON confirmed priming was expected under facility procedure.
QAPI process failed to prevent repeated F760 citations for significant medication errors. Prior surveys found one resident received 6 medications not prescribed and was hospitalized overnight for observation, and later two residents had significant med errors, including one receiving 5 non-prescribed meds and another continuing to receive a discontinued med. The Administrator stated the facility completed prior POCs and audits, and the DON worked the floor, but no cause for concern was found.
Medication storage and preparation were deficient when surveyors found oral meds pre-set in cups on two med carts for multiple residents, rather than handled one resident at a time. Surveyors also observed insulin pens in an unlocked container at the nurse’s station, with some pre-dialed and needles attached, and a staff member reported a narcotic was included in the pre-set meds. The administrator said she did not know why meds were being set up in advance, and the pharmacist stated insulin pens should be locked in pharmacy-labeled packaging and insulin should not be pre-dialed until administration.
A facility failed to follow infection control practices when six insulin pens were stored together in an unlocked container with their lids off after an RN pre-dialed them for later use. The facility also failed to use EBP during wound care for a resident with bilateral heel pressure ulcers, and an LPN did not perform proper glove changes and hand hygiene while cleansing and dressing the wound. The IP and DON stated the resident should have been on the EBP list and that gowns, gloves, and hand hygiene were required during wound care.
Failure to obtain informed consent for PRN psychotropic medications: A resident with unspecified dementia with psychotic disturbance had orders for IM ziprasidone and ABHR gel for agitation, aggression, and anxiety, but the chart lacked documentation of family consent and education on risks, benefits, and adverse effects. The DON confirmed psychotropic consents were not completed in the EHR, and the facility policy required informed consent before starting or increasing psychotropic meds.
A resident with a BIMS of 13 and diagnoses including non-Alzheimer’s dementia, anxiety, and depression was receiving Seroquel for agitation and anxiety despite no documented hallucinations, delusions, or behavioral symptoms on MDS review. The chart showed no completed GDR for the antipsychotic, the care plan lacked specific non-pharmacological interventions, and the DON and Medical Director both stated the resident was no longer exhibiting the behaviors that had prompted the medication.
MDS assessments failed to accurately reflect the status of three residents. One resident had an active catheter order and obstructive uropathy, one resident had a facility-acquired unstageable heel pressure ulcer, and one resident had a PASRR Level II outcome with diagnoses of anxiety and schizophrenia, but each MDS was coded as not having the condition or PASRR status. The DON and MDS Coordinator both confirmed the residents should have been coded accurately.
Skin Monitoring and Neuro Check Documentation Failure: A resident with scalp cancer and dementia requested help for a scalp lesion, but staff did not document routine assessment or treatment of the area, and the lesion changed from loose dry skin to a large red scab with no clear documentation of what occurred. The facility also failed to maintain neuro assessment documentation after certain falls for a resident with severe cognitive impairment, including unwitnessed falls and a witnessed fall with head impact; one unwitnessed fall had no neuro checks completed, and for two others the facility could not locate the neuro sheets.
Two residents with significant mobility and cognitive impairments did not consistently receive restorative AROM and walking programs as documented, and nursing records lacked routine review of participation, progression, or decline. Interviews showed the DON, MDS Coordinator, and CNA were using EHR tasks for restorative services, but the facility had no formal restorative program or policy and did not complete routine progress notes or evaluations.
A resident with severe cognitive impairment, seizure disorder, dementia, and a history of repeated falls had multiple unwitnessed and witnessed falls, including falls that resulted in ER transfers and fractures. The facility did not complete root cause analyses for several falls or ensure the fall interventions matched the reason each fall occurred, and the DON stated there was no formal tracking sheet for each fall and no root cause analysis.
Two residents experienced deficiencies in care when staff failed to properly assess and intervene after a fall and during wound development. One resident with cognitive impairment and a history of falls was moved multiple times after a fall without a thorough assessment, and was also given medications intended for another resident. Another resident with multiple comorbidities had a blister that was not assessed for two weeks, leading to infection. Staff interviews and documentation confirmed failures to follow facility policies for assessment and reporting.
Staff failed to adhere to infection control protocols during direct care, including performing wound treatments without changing gloves between tasks, not sanitizing treatment supplies before returning them to storage, and conducting procedures in public areas without proper barriers. Supplies were handled and returned to carts without sanitization, and hand hygiene was not performed between resident contact and touching surfaces or oneself.
Two residents did not receive care in a manner that maintained their dignity and privacy when an LPN conducted a physical assessment and a dressing change in a public dining/lounge area, in view of others. The LPN was unaware of facility policies regarding privacy during treatments, despite having signed a job description emphasizing the importance of resident rights and dignity.
A resident was given medications intended for another individual, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The facility did not promptly notify the resident's family or representative of the medication error and condition change, as required by policy. The family only became aware of the incident after receiving information from the hospital, rather than from facility staff.
A resident with multiple diagnoses, including heart failure and a history of pressure ulcers, was readmitted with active skin issues that were documented but not fully assessed or addressed in the care plan. The care plan failed to include interventions for the resident's current skin conditions, despite facility policy requiring comprehensive assessment and care planning.
Two residents experienced significant delays in call light response, with one waiting over two hours and another reporting frequent extended waits. CNAs confirmed that staff shortages and management wage caps contributed to the inability to consistently meet the facility's 15-minute call light response policy.
Two residents were affected by significant medication errors when a CMA, distracted by interruptions, administered another resident's medications to the wrong individual, and another resident continued to receive an outdated Seroquel regimen due to a failure to update medication orders. These errors were identified through video review, clinical records, and staff interviews.
Staff failed to maintain accurate and complete medical records for two residents, including improper documentation of a fall assessment and a discrepancy in controlled substance records. An LPN documented an assessment that was not performed, as confirmed by video review and interviews, and a medication was recorded as destroyed but was actually administered to another resident.
A resident was mistakenly given another resident's medications, including Seroquel, due to a CMA's distraction from a personal call. This resulted in over-sedation and hypoglycemia, leading to the resident's hospital admission for observation.
The facility failed to maintain sanitary conditions during meal service. A cook was observed touching the drinking rim surfaces of glasses with bare hands and pushing a beverage cart without sanitizing it or performing hand hygiene. The facility lacked a policy on appropriate hand placement during food service, and further observations revealed multiple staff members handling milk jugs without performing hand hygiene.
Pre-set Medication Passes and Unprimed Insulin Pen
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when multiple nurses prepared medications in advance rather than administering medications they had prepared themselves at the time of administration. On the morning of 2/22/26, observation of the North and South medication carts showed numerous resident oral medications already placed in cups with paper labels on top, and several insulin pens were observed in an unlocked container at the nurses’ station, with some pens pre-dialed to dosage amounts. Staff interviews confirmed that an LPN and an RN had set up medications ahead of time for multiple residents, including morning pills and insulin, and that this practice was being used to save time and accommodate staffing issues. Staff interviews further showed that the pre-setting of medications was not an isolated event. An LPN stated she began setting up morning medications around 5:00 AM and that this was how medications were commonly handled at the facility. Another RN reported she had set up about 20 residents’ morning medications and insulin pens for another nurse, placing pills in cups with resident names written on paper cups and leaving insulin pens together in one container. On 2/27/26, camera footage and staff interviews showed two nurses again standing at the medication carts and appearing to set up morning medications in advance. One RN stated she was setting up medications for about 20 residents and later passed those medications, while an LPN stated she set up her own medications so she could grab and deliver them more quickly. The report also identified a specific insulin administration issue involving a resident with diabetes mellitus. During observation, an LPN turned the dial on an insulin pen to 16 units for the resident but did not prime the needle before administration. The LPN stated she was not aware the pen needle needed to be primed. The DON stated she expected the insulin pen needle to be primed as the facility’s standard procedure. The resident’s MAR showed orders for Humalog KwikPen with breakfast and additional sliding-scale doses based on blood sugar readings. The facility policy required medication preparation and administration to follow the 6 rights and instructed staff to prepare medications for administration at the time they were to be given.
QAPI Process Failed to Prevent Repeated Significant Medication Errors
Penalty
Summary
The facility failed to make a good faith attempt to ensure effective QAPI and QAA processes regarding significant medication errors after F760, Residents are Free of Significant Medication Errors, was cited on 3 of 4 onsite surveys since 9/1/2024, including the current survey. The facility had a census of 44 residents. Review of prior CMS-2567 reports showed that on the survey ending 9/22/2024, the facility was cited for F760 related to one of three residents who received 6 medications that were not prescribed and was hospitalized overnight for observation. Review of the CMS-2567 for the survey ending 11/14/2025 showed the facility was cited again for F760 related to two of three residents with significant medication errors: one resident received 5 medications that were not prescribed, and another resident continued to receive a medication that had been discontinued. On the current survey, the Administrator stated in interview on 3/4/26 at 10:07 AM that the facility completed plans of correction on prior F760 tags and did audits, and that the DON worked the floor and they did not find any cause for concerns from those audits. The facility’s QAPI Plan dated 10/3/25 stated that the QAPI plan addressed systematic analysis and systemic action through root cause analysis, continuous cycle evaluation, communication of performance improvement project efforts, and annual re-evaluation of the QAPI plan, and that the QAPI committee was responsible and accountable for ensuring corrective actions were effective.
Medication Storage and Preparation Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles when surveyors observed the facility’s two medication carts containing residents’ oral medications already set up in advance for medication passes. On 2/22/26, the South cart had 21 plastic cups with pill medications and white paper cups with resident names written on them in the top drawer, and the North cart had 18 similar cups prepared in the same manner. Staff interviews confirmed that medications for multiple residents were being set up ahead of administration, including morning medications prepared around 2:30 AM to 5:00 AM for later passes, and one staff member reported setting up about 20 residents’ medications at a time. The facility also failed to keep insulin pens and a controlled substance secured as required. Surveyors observed 6 insulin pens in an unlocked container at the nurse’s station, with insulin needles attached and the pens pre-dialed to doses, along with 3 additional insulin pens in the same container. A staff member reported that one narcotic, Lyrica, was included in the pre-set medication preparation. The administrator stated she did not know why nurses were setting up medications in advance, and the pharmacist stated nurses should handle one patient at a time, insulin pens should remain in pharmacy-labeled packaging and locked when not in use, and insulin should not be pre-dialed until administration time.
Infection Control Failures During Medication Storage and Wound Care
Penalty
Summary
The facility failed to implement infection control measures when six morning insulin pens for six residents were observed stored together in an unlocked plastic container at the nurses station with their lids off and touching each other. Staff interviews confirmed that an RN had pre-dialed the insulin pens and placed them together in the container for another nurse to administer later, and the DON acknowledged staff had been educated not to set up medications in this manner. The facility’s medication administration policy directed medication to be removed from the locked medication cart and verified before administration, but the observed storage practice did not follow that process. The facility also failed to provide Enhanced Barrier Precautions during wound care for a resident with bilateral heel pressure ulcers. The resident’s record showed a BIMS score of 15/15, stage 4 pressure ulcers to both heels, and physician orders for wound treatment. The care plan documented the heel pressure ulcers and wound treatments, but it did not direct use of EBP. Observation showed no EBP sign on the resident’s door, and the LPN performed wound care without a gown, despite the facility’s EBP policy stating that residents with wounds, including pressure ulcers, should use gowns and gloves during high-contact care. During the wound care observations, the LPN also failed to complete routine glove changes and hand hygiene as required. After removing contaminated items and cleansing the wound, the LPN changed gloves multiple times without performing hand hygiene between changes, applied a clean dressing without changing gloves after wound cleansing, and handled clean items and the garbage without appropriate hand hygiene steps. The Infection Preventionist stated the resident should have been on the EBP list, that gowns and gloves should be used for wound care, and that hand hygiene should occur between glove changes. The DON also stated the resident should have been on EBP and that staff should have changed gloves and performed hand hygiene during the dressing change.
Failure to Obtain Informed Consent for PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide informed consent regarding the risks and benefits of as needed psychotropic medications for one resident reviewed for antipsychotic use. Resident #7 had orders for ziprasidone 20 mg IM every 12 hours as needed for severe agitation related to unspecified dementia with psychotic disturbance, and ABHR gel containing lorazepam, diphenhydramine, haloperidol, and metoclopramide applied every 4 hours as needed for aggression and anxiety related to unspecified dementia with psychotic disturbance and anxiety disorder, both ordered for 14 days then discontinued. Review of the resident’s progress notes from 12/1/25 through 2/25/26 did not show documentation of family consent or education about adverse side effects and the risks and benefits of these as needed antipsychotic medications. The resident’s care plan stated he was receiving antipsychotic, antidepressant, and antianxiety medications to manage impulsivity and keep him calm. The DON stated psychotropic medication consents are completed in the EHR and that this resident did not have consents completed for ziprasidone and ABHR gel. Review of the EHR assessments showed no completed psychotropic medication consent for these medications, and the Administrator stated the resident’s family was very hard to contact. The facility policy required informed consent from the resident and/or representative before initiating or increasing psychotropic medication use, including discussion of benefits, risks, alternatives, and black box warnings.
Unnecessary psychotropic medication use without documented non-pharmacological interventions
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were in place and that an antipsychotic was used for a relevant diagnosis rather than for agitation for one resident. Resident #38’s MDS documented a BIMS score of 13 out of 15, indicating no cognitive impairment, and listed diagnoses of non-Alzheimer’s dementia with other behavioral disturbances, anxiety, and unspecified depression. The assessment also documented no hallucinations, delusions, physical or verbal behaviors directed toward others, other behavioral symptoms, rejection of care, or wandering. Record review showed the resident had been receiving Seroquel 50 mg daily for agitation and anxiety disorder since 10/24/2024. Progress notes from 1/1/2025 through 2/22/2026 showed no completed gradual dose reduction for the Seroquel, and a prior gradual dose reduction request on 8/27/25 was denied by the physician with documentation that the benefits outweighed the risks and the medications enhanced function. The care plan noted use of an antipsychotic medication and an attempt to use non-pharmacological intervention prior to psychotropic medications, but it lacked non-pharmacological interventions. The DON stated the resident did not have behaviors or psychotic episodes and that the Seroquel was being used to treat anxiety, while the Medical Director stated the resident could do some gradual dose reduction because he was not as aggressive as he had been in the past.
MDS assessments failed to reflect catheter use, pressure ulcer, and PASRR status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents based on their current status at the time of assessment. Resident #38 had an active order to continue use of a catheter, documented in the Medication Review Report signed by the physician on 1/28/26, and the MDS dated [DATE] recorded that he did not have a catheter despite a diagnosis of obstructive uropathy and a BIMS score of 13 out of 15. Resident #37 had a right heel unstageable facility-acquired pressure ulcer identified on 10/4/25 and documented in a wound evaluation dated 12/2/25, but the MDS dated [DATE] stated that he did not have a pressure ulcer even though his BIMS score was 15 out of 15. Resident #8 had a current PASRR Level II outcome dated 5/27/24, indicating a Level II determination, and the MDS dated [DATE] did not code a PASRR Level II outcome even though the resident had diagnoses of anxiety and schizophrenia and a BIMS score of 15 out of 15. During interviews, the DON stated that the MDS Coordinator should have coded Resident #38 as having a catheter, Resident #37 as having a pressure ulcer, and Resident #8 as PASRR Level II. The MDS Coordinator also acknowledged that each resident did have the condition or status that should have been reflected on the MDS.
Skin Monitoring and Post-Fall Neuro Assessment Documentation
Penalty
Summary
The facility failed to provide routine skin monitoring and treatment for a resident with cancerous lesions on the scalp and a resident request for assessment/treatment. Resident #36 had diagnoses including cancer, hypertension, and dementia, and her MDS documented a BIMS score of 12 out of 15. Her medication review included an order for hydrogen peroxide to the scalp twice daily. During observation, she told staff she had been asking for about 2 hours for someone to take care of a skin site on her head. The scalp area was observed with loose dry skin measuring about 3 inches by 1 inch with red beefy skin underneath, and the next day the loose dry skin was no longer present and a large red scab was observed. The progress notes from the surrounding days lacked documentation and treatment regarding what happened to the loose skin on her scalp. Her care plan documented a history of open areas on the scalp related to skin cancer and a scalp infection, and the physician stated the scalp sites had been present since at least 2021 and were consistent with squamous cell carcinoma. The facility also failed to maintain documentation that neurological assessments were performed after certain falls for a resident with severe cognitive impairment and multiple fall events. Resident #7’s MDS documented a BIMS score of 8 out of 15, dependence on staff for walking and moving in a wheelchair, frequent incontinence, and diagnoses including seizure disorder, anxiety, intellectual disabilities, and dementia with psychotic disturbances. The facility’s fall records showed an unwitnessed fall, a witnessed fall with head impact, and another unwitnessed fall; for two of these events, the facility stated neuro checks were completed in progress notes but the paper neuro sheets could not be located, and for one unwitnessed fall no neuro assessments were completed. The facility’s fall policy required neurological assessment for unwitnessed falls and for witnessed falls when the resident hits their head.
Failure to Provide and Monitor Restorative Programs
Penalty
Summary
The facility failed to provide restorative programs as directed for two residents reviewed for restorative services and did not develop or implement a restorative treatment policy for staff to follow. Resident #36’s MDS documented moderate cognitive impairment, need for assistance with walking and wheelchair mobility, and impairment on one side affecting upper and lower extremity function. An observation found limited ROM in both arms and legs. Her record showed restorative AROM and restorative walking programs were in place, but the documentation survey report showed multiple missed or not offered sessions in January and February 2026, including no completion or offering of the AROM program for the entire month of February. Resident #7’s MDS documented severe cognitive impairment, dependence on staff for walking and wheelchair mobility, and frequent urinary and bowel incontinence, with diagnoses including seizure disorder, anxiety, intellectual disabilities, and dementia with psychotic disturbances. His record showed one restorative AROM program in place, but the documentation survey report showed repeated instances in January and February 2026 where the program was not completed or not offered, along with refusals. For both residents, progress notes lacked nursing review of restorative program participation and any progression or decline over the reviewed periods. Interviews with the Administrator, DON, MDS Coordinator, and CNA showed the restorative programs were entered into the EHR as tasks, but the facility did not have a formal restorative program or a policy for restorative services. The DON and MDS Coordinator stated they did not complete routine progress notes or evaluations of the restorative programs, and the CNA stated she provided the programs as time and resident mood allowed and would report decline if noticed.
Failure to Analyze Repeated Falls and Update Care Plan
Penalty
Summary
The facility failed to complete a root cause analysis after each fall for a resident with severe cognitive impairment, seizure disorder, anxiety, intellectual disabilities, and dementia with psychotic disturbances, and failed to ensure that fall interventions were related to the reason the fall occurred. The resident’s MDS documented a BIMS of 8 out of 15, dependence on staff for walking and wheelchair mobility, and frequent incontinence of urine and bowel. His Care Plan identified him as at risk for unavoidable falls related to a history of falls, epilepsy, BPH, dementia, intellectual disability, anxiety disorder, impulsivity, and poor decision making, with multiple fall interventions added over time. The record showed multiple falls between September 2025 and February 2026, including unwitnessed and witnessed falls in another resident’s room, the dining room, and at the nurses station. The facility’s documentation included neurological assessments, progress notes, and incident reports, but review found that several falls did not have a root cause analysis and did not have relevant interventions put in place to address the fall. The falls identified as lacking root cause analysis and related interventions included falls on 9/14/25, 9/19/25, 11/24/25, 11/27/25, 12/26/25, and 12/29/25. The resident also sustained major injuries from falls. After an unwitnessed fall in the dining room on 11/4/25, he was sent to the ER and returned with a traumatic closed fracture of the left ulnar styloid and a traumatic closed torus fracture of the left distal radius, with a wrist splint ordered for 6 weeks. After a witnessed fall in the dining room on 1/8/26, he was sent to the ER and returned with a closed fracture of the distal ulna on the right side, with a splint and sling ordered. The DON stated falls were reviewed daily in IDT meetings but there was no formal tracking sheet for each fall and no root cause analysis, and the facility policy required additional post-fall interventions and Care Plan updates.
Failure to Assess and Intervene After Falls and Wound Development
Penalty
Summary
Staff failed to properly assess and intervene for two residents, resulting in deficiencies in care. One resident with significant cognitive impairment, visual deficits, and a history of falls was observed via facility video to have fallen after tripping over her catheter tubing. Staff present did not immediately respond to the fall, and when they did, they moved the resident multiple times without performing a thorough assessment as required by facility policy. The resident complained of severe leg pain, but staff continued to move and ambulate her without using a gait belt or completing a full assessment, including vital signs and range of motion. The resident was later sent to the emergency department, where a femur fracture was diagnosed. Interviews confirmed that staff did not follow the facility's fall policy, which required a nurse to assess the resident on the floor before moving her, and that documentation of the incident was delayed and incomplete. Additionally, the same resident was administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was not fully reported to the emergency department, as only one of the four medications was disclosed. Staff interviews revealed confusion and lack of adherence to medication administration and error reporting protocols. The Director of Nursing confirmed that the nurse's assessment after the fall was not as thorough as expected and that vital signs were not taken as required. A second resident, with diagnoses including heart failure, diabetes, and dementia, was readmitted with a right trochanter blister. The facility failed to assess the blistered area for two weeks, with no measurements or detailed assessment documented during that period. When the wound was eventually assessed, it had worsened, showing signs of infection and requiring antibiotic treatment. The Director of Nursing confirmed that staff failed to assess the resident's wound as required.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to follow appropriate infection control practices during direct care for three residents. In one instance, an LPN washed and gloved her hands before removing a supportive boot and wound dressing, then performed physician-ordered treatment to multiple areas of a resident's foot using the same gloves. After completing the treatment, the staff member placed unused and/or prescribed treatment supplies into a plastic bag and returned it to the resident's supply basin without sanitizing the surfaces. The Director of Nursing confirmed these observations. Additionally, another staff member performed a dressing change for a resident in a public dining/lounge area without placing a barrier between the table and treatment supplies, and failed to sanitize the supplies before returning them to the treatment cart. This staff member also palpated another resident's hip with bare hands, then touched the resident, furnishings, and herself without washing her hands. The same staff member later confirmed she did not use a barrier or sanitize items as required.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents during care activities, as evidenced by direct observation, video footage review, clinical record review, and staff interviews. In one instance, a Licensed Practical Nurse (LPN) approached a resident seated in a recliner in the dining/lounge area, pulled out the resident's sweatpants at the waistband, and placed her hands inside to palpate the resident's left hip area following a fall. This examination was conducted in the presence of another resident seated approximately 12 feet away, in direct view. The video footage also showed the LPN pressing on the resident's hip, looking under the resident's pajama bottoms, and returning to palpate the area again after donning gloves, all in a public area. In another instance, the same LPN performed a dressing change on a different resident's foot while the resident's leg was resting on a chair in the dining/lounge area, directly across from the first resident. During an interview, the LPN confirmed that she performed the foot treatment in the dining area and was not aware of the facility's policy and procedure regarding treatments and privacy. The facility's policies, as acknowledged by the LPN, require the promotion of resident rights, dignity, and privacy during care, which were not upheld during these incidents.
Failure to Notify Family of Medication Error and Condition Change
Penalty
Summary
The facility failed to notify the family member or representative of a resident after a significant medication error occurred. According to clinical record review and interviews, a resident was mistakenly administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was documented as a late entry in the progress notes, and the family was not directly informed by the facility until several days later. Instead, the family learned of the incident through the hospital's History and Physical report, rather than from facility staff. Interviews with the resident's family confirmed that they were not notified by the facility about the administration of the four incorrect medications. The facility's policy and the LPN's job description both require immediate notification of the resident, physician, and family or legal representative in the event of a significant change in condition or medication error. Despite this, the facility only informed the hospital about one of the medications and delayed direct communication with the family, failing to follow established procedures for notification.
Incomplete Care Plan for Resident with Active Skin Issues
Penalty
Summary
Facility staff failed to maintain a complete and accurate care plan for a resident who was readmitted with multiple diagnoses, including heart failure, diabetes mellitus, non-Alzheimer's dementia, altered mental status, adult failure to thrive, and abnormal weight loss. Upon readmission, the resident was documented as having a right trochanter blister and a scabbed area on the coccyx, with a history of pressure ulcers and being at risk for further ulcer development. However, the care plan did not address these active skin issues or specify expected interventions for their management. Clinical documentation showed that the initial assessment upon readmission noted the presence of skin issues but did not provide further assessment details such as measurements, condition of surrounding skin, drainage, or odor. The facility's own Skin Quick Reference Guide required a head-to-toe assessment, documentation, and initiation of care plan interventions, but these steps were not completed as required. The care plan remained incomplete and failed to reflect the resident's current needs related to skin integrity.
Failure to Provide Adequate Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple interviews and policy review. One resident reported waiting 2.5 hours for a response to her call light, using the wall clock to time the delay, and expressed frustration over being left in bed in the morning because there were not enough staff available to assist with her transfer, which required 2-3 staff members. Another resident confirmed experiencing extended wait times for staff to respond to call lights, with no particular time of day being worse than others. Certified Nursing Assistants (CNAs) interviewed acknowledged challenges in responding to call lights within the facility's 15-minute policy, citing being occupied in other resident rooms and overall staffing shortages. Staff attributed these issues to difficulties in hiring and retaining healthcare workers, as well as management decisions such as wage caps. The facility's call light policy, revised in September 2023, emphasizes prompt responses, but staff interviews indicated that timely responses were not consistently achieved.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that two out of three residents were free from significant medication errors. In one instance, a Certified Medication Aide (CMA) administered the correct physician-prescribed medications to a resident, but later, due to interruptions including a phone call and a resident's pressure alarm, the CMA mistakenly gave the same resident medications that were prescribed for another resident. The medications erroneously administered included Melatonin, Mirtazapine, Alprazolam, and Apixaban, which were not intended for the resident who received them. This error was confirmed by a review of video footage, clinical records, and a written statement from the Director of Nursing (DON). In another case, a resident continued to receive both Seroquel 12.5 mg and Seroquel 25 mg in the morning, despite a physician's order changing the regimen to Seroquel 25 mg in the morning and 12.5 mg at noon and supper. This discrepancy was discovered during staff rounds, indicating that the medication order change was not properly implemented, resulting in the resident receiving an incorrect dosage for an extended period.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by discrepancies in documentation and assessment following a fall incident. In one case, a resident fell from a recliner in the day room, was witnessed by a nurse, and subsequently complained of left leg pain. Although the progress note indicated that the resident was assessed for physical abnormalities and vital signs while on the floor, video footage revealed that staff did not perform these assessments before moving the resident. The resident was assisted to her feet and walked despite refusing to bear weight on her left leg, and was later found to have a minimally displaced fracture of the left femur. The LPN responsible for the documentation was unable to recall details of the assessment and could not explain where the documented information originated, as confirmed by the DON during an interview. Additionally, there was a discrepancy in the controlled substance record for another resident. The record indicated that Xanax was destroyed, but the DON later confirmed that the medication was actually administered to a different resident. The LPN involved had signed a job description acknowledging the requirement for accurate, contemporaneous charting and completion of medical records in accordance with nursing policies. These failures to accurately document care and medication administration were not in accordance with accepted professional standards and facility policy.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to administer the correct medications to a resident, resulting in the resident receiving another resident's medications, including an anti-psychotic medication, Seroquel. This error led to the resident experiencing over-sedation and hypoglycemia, necessitating hospital admission for observation. The resident, who had no cognitive impairment and did not typically take anti-psychotic medication, was minimally arousable and had a low blood sugar level, likely due to the sedative effects of the Seroquel. The incident occurred when a Certified Medication Aide (CMA) became distracted after receiving an upsetting personal call before the noon medication pass. Despite performing the correct checks, the CMA inadvertently administered the wrong medications to the resident. The error was identified immediately upon returning to the medication cart, and the resident's doctor and the Director of Nursing (DON) were informed. The resident was subsequently sent to the hospital for evaluation and observation.
Sanitary Conditions Not Maintained During Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions during meal service, as observed during the noon meal on 4/22/24. Staff A, a cook, was seen serving 28 glasses to 19 residents while touching the drinking rim surfaces with her bare hands. Additionally, Staff A pushed the beverage cart throughout the dining room without sanitizing the cart handle and did not perform hand hygiene during the meal service. The Dietary Manager, Staff B, confirmed that staff are trained to avoid touching the drinking rims of glasses and the tines of silverware, and to hold plates by the edge and base. However, the facility lacked a policy regarding dining services and appropriate hand placement during food service. Further observations on 4/23/24 revealed multiple staff members handling milk jugs by the handle without performing hand hygiene prior to touching the jugs.
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 50 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 Waukon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Waukon | 0.8 mi | ★★★★★ | 9 | 1 |
| Wellington Place | 13.3 mi | ★★★★★ | 0 | 0 |
| Thornton Manor Nursing And Care Center | 13.6 mi | ★★★★★ | 0 | 0 |
| The Highlands | 15.8 mi | ★★★★★ | 2 | 0 |
| Ossian Care Center | 17.1 mi | ★★★★★ | 15 | 0 |
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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.