Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Salem Lutheran Home during CMS and state inspections, most recent first.
A resident with dementia, chronic pain, and an order for fentanyl 75 mcg/hr received a patch that still had the plastic backing on it, so the medication was not delivered. The error was later discovered when the patch was changed, and the resident had increased PRN morphine use during the period the patch was ineffective. The record also showed the error was not documented in the clinical record and the PCP was not notified per policy.
A resident with intact cognition, multiple chronic conditions, and a psychosocial care plan for past trauma reported that a CNA was rude, mean, and disrespectful, including allegedly throwing the resident’s call light, delaying toileting care, and yelling at her when they were alone. The resident said she feared backlash and did not report it sooner, and later stated she was treated with kindness, dignity, and respect after the CNA was no longer in the building.
Failure to Notify Physician of Fentanyl Patch Error: A resident with severe cognitive impairment, chronic pain, and multiple comorbidities had a fentanyl patch applied without being activated because the plastic backing was left on. The error was documented with increased PRN morphine use, but the clinical record lacked documentation of the medication error and the PCP was not notified, despite facility policy requiring prompt reporting to the physician, resident, and/or responsible party.
Failure to report and investigate injuries of unknown origin: Two residents with significant cognitive impairment and anticoagulant use had unexplained bruising documented, including a wrist bruise and bruising under an eye with pain. The clinical record lacked documentation of an investigation and lacked evidence that DIAL was notified, despite the facility policy requiring immediate reporting of alleged abuse, neglect, and injuries of unknown origin to leadership.
Failure to Investigate Injuries of Unknown Origin: The facility did not document or complete investigations for two residents with unexplained bruising. One resident with severe cognitive impairment and anticoagulant use had a bruise on the wrist, and another resident with memory impairment, hallucinations, and anticoagulant use had bruising under the eye with pain. The DON and Administrator confirmed the records lacked incident documentation, and leadership stated they were unaware of the bruises when asked.
Delayed response to resident call lights was identified after resident interviews and call light logs showed that call lights were not answered within the expected 15 minutes for multiple residents. A resident with intact cognition and dependence for ADLs, another resident with BIMS 15 and significant mobility and bladder issues, and a third resident with BIMS 15 and dependence for all ADLs all reported long waits, and logs showed response times ranging from over 17 minutes to more than 46 minutes. The Administrator, CNA, and DON acknowledged the 15-minute expectation was not being met.
Improper destruction of a fentanyl patch: Staff found that a resident’s fentanyl patch had been applied with the plastic backing still attached, making it essentially unused, but it was not destroyed per policy. The resident had severe cognitive impairment and chronic pain treated with fentanyl and PRN morphine. Facility staff later confirmed that controlled substance patches were expected to be destroyed by two staff members using the approved process and documented on the narcotic record.
Incomplete Documentation of Injuries of Unknown Origin: The facility failed to maintain complete clinical records for two residents with bruising of unknown origin. One resident with severe dementia and anticoagulant use had a documented bruise on the wrist, but the record lacked documentation of the incident. Another resident with severe memory and decision-making impairment, hallucinations, and anticoagulant use had bruising under the eye with pain, but the record lacked documentation of the injury investigation. The DON confirmed the missing documentation.
A nurse failed to provide dignity and respect to a resident during a smoking-related incident, where the resident was yelled at by an LPN for being outside with staff. The resident, who was cognitively intact, felt upset and disrespected by the interaction. Staff interviews revealed confusion about the facility's smoking policy and property boundaries, and administrative staff provided inconsistent information. The incident was not formally investigated or documented, and the facility's policy on resident dignity was not upheld.
Two residents requiring assistance with bathing did not consistently receive opportunities for baths or showers as scheduled, with missed baths often attributed to staffing shortages and inadequate documentation of refusals. Staff interviews confirmed that residents sometimes went several days without bathing, and there was no facility policy specifying bathing frequency.
A resident with significant cognitive and medical impairments was reported by family to be missing valuable personal items, including rings, which were documented on the admission inventory. Despite facility policy requiring updated inventories and replacement of lost items, the property was not found or replaced, and inventory records were not kept current.
A background check for an LPN was not completed before employment, contrary to facility policy requiring such checks to prevent abuse, neglect, and theft. The oversight was confirmed by both Human Resources and the DON during interviews.
Two residents with newly identified or possible serious mental disorders or related conditions were not referred for a Level II PASRR evaluation after initially receiving a negative Level I screen. Both residents had new or existing diagnoses and were receiving psychotropic medications, but the required referral to the state-designated authority for further assessment was not completed, as confirmed by staff and documentation review.
Two residents requiring oxygen therapy did not have their oxygen tubing changed and documented according to facility policy and professional standards. Staff and the DON confirmed tubing should be changed weekly, but observations found outdated or undated tubing and no documentation to verify changes were completed.
Staff failed to follow infection prevention and control protocols during care for two residents with indwelling devices and wounds. A CNA did not perform hand hygiene or clean the catheter drainage port before emptying a drainage bag, while an LPN inconsistently used hand hygiene and PPE during wound care, did not maintain clean technique, and failed to date dressings. Facility policies required hand hygiene and Enhanced Barrier Precautions, but these were not consistently followed, as confirmed by the IP and DON.
A resident with moderate cognitive impairment and significant care needs reported being left on a bed pan for several hours without a call light and later experiencing disrespectful care from a CNA, who was suspected of being under the influence. The incident was not documented in the EHR, not investigated, and not reported to the State Agency as required by facility policy, despite management being aware of the allegation.
A resident with moderate cognitive impairment and total dependence on staff for toileting was left on a bed pan for five hours without a call light, resulting in pain and distress. The event was not documented in the EHR, and no follow-up assessments were performed.
A facility failed to ensure proper medication administration, affecting several residents. One resident did not receive all prescribed medications, while another received clonazepam late. A third resident's pulse was not checked before medication administration due to a pacemaker. An RN improperly disposed of medications in a sharps container, affecting 16 residents. The facility's medication administration policy was not followed.
A resident's Ozempic pen was misappropriated in an LTC facility, leading to a delay in medication administration. The resident, with no cognitive impairment, was on diabetic therapy. An agency RN was seen on camera handling the pen inappropriately, which was not accounted for afterward. Staff interviews confirmed the pen should not have been handled during the overnight shift. The facility's policy on preventing misappropriation of resident property was violated.
A staff member failed to maintain sanitary practices during food service by using the same tongs for multiple tasks, placing butter packets directly on food, and handling food without proper hand hygiene. These actions violated the facility's food handling policy.
The facility failed to properly prepare and serve the appropriate portions of pureed and minced & moist diets for residents. Staff did not adhere to specified portion sizes, using a volume method instead of the required alternate texture conversion chart. This resulted in incorrect portion sizes being served, failing to meet the nutritional needs of residents.
The facility failed to protect resident information from unauthorized access. An open laptop screen with resident EHR information and a sheet with resident details were left visible. A CNA noted this was not usual practice, and an RN used the sheet as a 'cheat sheet.' The facility's policy requires strict adherence to confidentiality and HIPAA regulations.
The facility failed to ensure proper hand hygiene and catheter care for residents. A CNA did not perform hand hygiene during toileting and catheter care, and placed a measuring container directly on the floor. Another CNA failed to perform hand hygiene between feeding two residents. Additionally, a catheter drainage bag was improperly managed, and hand hygiene was not performed during catheter care, violating facility policies.
A facility failed to provide a bed hold notice to a resident or their representative during a hospital transfer. The resident was discharged with return anticipated, but the required documentation was missing. The facility's policy mandates providing a state-specific form at discharge, which was not completed, as confirmed by the Administrator and DON.
A facility failed to complete a PASRR for a resident diagnosed with new mental disorders during their stay. Initially, the resident showed no evidence of serious mental illness, but later developed unspecified paranoia, leading to increased medication. Despite policy requirements, the facility did not conduct a new PASRR, and staff interviews revealed a lack of awareness of PASRR regulations.
The facility failed to create comprehensive care plans for three residents, each with cognitive impairments and on psychotropic medications. The care plans did not include target behaviors for medication monitoring, contrary to facility policy requiring individualized plans with measurable goals.
The facility failed to update care plans for three residents, leading to discrepancies in the documented and actual care provided. One resident required a mechanical lift for transfers post-procedure, but the care plan did not reflect this need. Another resident with Alzheimer's had inconsistent fall intervention documentation, and a third resident's care plan lacked reference to necessary edema wear. Staff were aware of these needs through informal notes, but the care plans were not updated accordingly.
A resident with COPD and other medical conditions was observed receiving oxygen at 4 LPM, contrary to the physician's order of 2 LPM during the day and 3 LPM at night. The facility's policy and care plan directed staff to follow the physician's orders, but this was not adhered to, as confirmed by the MAR and observations. The DON acknowledged the need to follow the physician's orders.
The facility failed to identify target behaviors for psychotropic medication use for two residents with severely impaired cognition and multiple diagnoses. Both residents were prescribed various psychotropic medications without specified target behaviors in the physician orders or care plans. Additionally, the facility lacked a policy on psychotropic medications or Gradual Dose Reductions (GDRs).
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for two residents. One resident experienced a 47-minute delay, while another had a 21-minute delay. Staff and the Administrator confirmed frequent staffing shortages and delayed responses.
The facility failed to follow proper infection prevention practices during blood sugar monitoring for three residents with type 2 diabetes mellitus. Staff did not perform hand hygiene before and after procedures, and one staff member used a dropped lancet.
Failure to Activate Fentanyl Patch Resulted in Medication Error
Penalty
Summary
A resident with severe cognitive impairment, hallucinations and delusions, resistance to care, and diagnoses including non-Alzheimer's dementia, arthritis, anxiety, depression, diabetes mellitus, hypertension, and neurogenic bladder was ordered fentanyl 75 mcg/hr for chronic pain. The resident’s plan of care identified chronic pain and risk for opioid overdose/complications related to fentanyl use. The resident also had documented pain and required opioid medication for pain management. On 4/1/26, staff applied a fentanyl transdermal patch but failed to remove the plastic backing from the patch before placing it on the resident. When the patch was later removed on 4/3/26, staff discovered that the backing was still attached, meaning the patch had not been activated and the resident had not received medication through that patch. The medication error report documented the resident’s response as an increase in PRN morphine use, and the pain level summary showed repeated pain scores and multiple administrations of liquid morphine during the period the patch was ineffective. The facility’s records showed that the medication error was identified when the patch was replaced, but the clinical record lacked documentation of the error and the primary care physician was not notified as required by facility policy. Staff statements confirmed the patch had not been activated, that it was placed in the narcotic box after removal, and that the physician was not notified. The facility’s medication error policy stated that medication errors are to be reported promptly and that a significant medication error includes omission or failure to administer an ordered dose.
Failure to Treat a Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat Resident #4 with respect and dignity in a manner that promotes maintenance or enhancement of quality of life. Resident #4’s MDS documented a BIMS score of 15, indicating intact cognitive decisions, and noted diagnoses including heart failure, hypertension, diabetes mellitus, hemiplegia, anxiety, and depression. The care plan identified a psychosocial well-being deficit related to past trauma and included interventions focused on discussing feelings, supporting realistic goals, and providing opportunities for the resident and family to participate in care. During an interview on 5/12/26, Resident #4 stated that Staff A, CNA, was rude, mean, and disrespectful, and alleged that the CNA threw the resident’s call light and told the resident she did not need to be changed and could wait. The resident said these actions occurred when they were alone in the room and that she did not report the behavior earlier because she feared backlash from Staff A. Subsequent interviews and progress notes documented the resident’s continued complaints that Staff A yelled at her, threw the call light once, was mean, did not return her water pitcher, and changed her brief too quickly and not well enough. The resident stated that since Staff A had not been in the building, staff had been treating her with kindness, dignity, and respect. The facility Administrator later confirmed that staff are expected to treat all residents with dignity and respect and follow the Resident Dignity policy.
Failure to Notify Physician of Fentanyl Patch Medication Error
Penalty
Summary
The facility failed to notify the physician of a medication error involving Resident #1’s fentanyl transdermal patch, which was found not to have been activated for 48 hours. Resident #1’s MDS documented severe cognitive impairment with a BIMS score of 7, hallucinations and delusions, resisting care, dependence on staff for activities of daily living, chronic pain, and diagnoses including hypertension, diabetes mellitus, neurogenic bladder, non-Alzheimer’s dementia, arthritis, anxiety, and depression. The care plan identified chronic pain and risk for opioid overdose/complications related to fentanyl 75 mcg/hr, with interventions to notify the health care provider if pain interventions were unsuccessful or if there was a significant change in pain. The progress notes documented fentanyl transdermal patch 75 mcg/hr ordered every 2 days, and the medication error report showed the patch error on 4/1/26 with increased PRN morphine use as the resident response. Review of the clinical record lacked documentation of the medication error and lacked documentation that the primary care physician was notified. Staff later confirmed that the patch had been applied with the plastic backing still on, that the backing remained on when the patch was placed in the narcotic box, and that the physician was not notified of the error per facility policy. The Administrator, ADON, and DON acknowledged the record lacked documentation of the error and that staff failed to notify the primary care physician.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse, neglect, and injuries of unknown source were reported to DIAL within 2 hours for 2 residents. For Resident #2, the record showed severe cognitive impairment with a BIMS score of 1, dementia, muscle weakness, hypertension, repeated falls, and anticoagulant use. A skin observation documented a purple bruise on the right wrist measuring 2 cm by 1.5 cm with no swelling and no pain, but the clinical record did not contain documentation of an investigation for the injury of unknown origin. For Resident #9, the record showed short- and long-term memory impairment, severe decision-making impairment, hallucinations, delusions, resisting care, malnutrition, anxiety, schizophrenia, and anticoagulant use. A skin observation and progress note documented brown bruising under the left eye with pain, no swelling, and refusal to allow staff to touch the area. The resident later had no recollection of any incident that caused the bruising, and the clinical record lacked documentation of an investigation for the injury of unknown origin. The DON confirmed the clinical record lacked documentation of the incidents for both residents, and the Administrator acknowledged that staff are expected to report allegations of abuse or injuries of unknown origin immediately and start an investigation. The record also lacked documentation of an incident report showing that DIAL was notified. The facility policy stated that alleged or suspected abuse, neglect, and injuries of unknown origin are to be promptly reported and investigated, with immediate reporting to the Administrator or designated leadership.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for 2 residents. Resident #2 had a purple bruise on the right wrist measuring 2 cm by 1.5 cm, documented on the skin observation tool, with no swelling and no complaint of pain. Resident #2 had a BIMS score of 1, severe cognitive impairment, diagnoses including non-Alzheimer's dementia, muscle weakness, hypertension, and repeated falls, and was receiving anticoagulant therapy related to a history of thrombosis and emboli. Resident #9 also had a bruise of unknown origin, documented as brown bruising underneath the left eye with pain and no swelling. Resident #9 had short- and long-term memory impairment, severe decision-making impairment, hallucinations, delusions, and resisting care, with diagnoses including malnutrition, anxiety, and schizophrenia. Resident #9 was also receiving anticoagulant therapy related to a history of pulmonary embolism, and the care plan directed staff to monitor, document, and report bruising or sudden changes in mental status. For both residents, the clinical record lacked documentation of an investigation of the bruising. The DON and Administrator confirmed the records lacked documentation of the incidents and stated staff were expected to follow the facility policy for injuries of unknown origin. The Administrator, DON, and ADON stated they were unaware of the bruises when asked and confirmed no assessment was completed because the bruises had not been reported to them.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift as evidenced by delayed response to resident call lights. Based on resident interviews, call light logs, and the facility policy, staff did not answer call lights within 15 minutes for 3 of 4 residents reviewed. The facility had a census of 46 residents. The Call Light Policy revised 7/8/25 stated that residents should always have a method of calling for assistance and that requests should be responded to as soon as possible, with the call light turned off and the resident's request inquired about. Resident #4 had an MDS documenting a BIMS score of 15, intact cognitive decisions, and dependence on staff for all ADLs, transfers, and personal care, with diagnoses including heart failure, HTN, DM, hemiplegia, anxiety, and depression. The resident stated staff took over 15 minutes to answer the call light, and the call light report showed response times of 34 minutes 21 seconds, 46 minutes 40 seconds, and 31 minutes 4 seconds. Resident #5 had an MDS documenting a BIMS score of 15, dependence on staff for ADLs, and diagnoses including heart failure, HTN, neurogenic bladder, and quadriplegia; the resident stated call lights took over 15 minutes to be answered, and the report showed a call light on for 21 minutes 53 seconds. Resident #11 had an MDS documenting a BIMS score of 15, dependence on staff for all ADLs, always incontinent of bladder, and diagnoses including anemia, heart failure, HTN, DM, CVA, depression, and unsteadiness on feet; the resident stated call lights took over 15 minutes to be answered, and the report showed response times of 17 minutes 28 seconds and 31 minutes 22 seconds. The Administrator, a CNA, and the DON acknowledged that call lights were expected to be answered within 15 minutes.
Improper destruction of a fentanyl patch
Penalty
Summary
The facility failed to properly destroy a resident’s fentanyl transdermal patch in accordance with its policy and procedure for controlled substances. The resident had severe cognitive impairment with hallucinations and delusions, required substantial to maximal assistance with activities of daily living, and had chronic pain treated with fentanyl 75 micrograms per hour, along with PRN morphine use noted in the record. On 4/3/26, staff discovered that the old fentanyl patch still had the plastic backing on it, meaning it had not been properly applied and was essentially unused. The patch had been dated and initialed on 4/1/26. Instead of being destroyed per policy, the patch was handled by staff after the error was identified, and the incident record stated that the patch should have been discarded after removal. The report also noted that no messages were sent to the Administrator or DON regarding the incident at the time it occurred. Facility staff later confirmed that the expectation was for two staff members to destroy fentanyl patches, either two nurses or a nurse and a medication aide, using the facility’s approved destruction process. The facility’s policy stated that controlled substance patches should be destroyed by two licensed nurses, or by a nurse and pharmacist, and that disposal should be documented on the resident’s narcotic record. The medication disposition policy also required controlled substances to be destroyed with two witnesses to ensure accuracy of the count.
Incomplete Documentation of Injuries of Unknown Origin
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents with injuries of unknown origin. One resident had severe cognitive impairment with a BIMS score of 1, diagnoses including non-Alzheimer's dementia, muscle weakness, hypertension, and repeated falls, and was receiving anticoagulant therapy. A skin observation documented a purple bruise on the right wrist measuring 2 cm by 1.5 cm with no swelling or pain, but the clinical record did not contain documentation of the bruise. The DON later confirmed the record lacked documentation of the incident and stated staff were expected to follow the facility's documentation policy. A second resident had short- and long-term memory impairment, severe decision-making impairment, hallucinations, delusions, resisting care, malnutrition, anxiety, schizophrenia, and anticoagulant use related to a history of pulmonary embolism. A skin observation and progress note documented brown bruising under the left eye with pain, no swelling, and refusal to allow staff to touch the area. When later observed, the resident could not recall any incident that caused the bruising. The clinical record lacked documentation of the investigation of the injury of unknown origin, and the DON confirmed the missing documentation and the expectation for staff to follow the facility's documentation policy.
Failure to Maintain Resident Dignity During Smoking Incident
Penalty
Summary
A deficiency occurred when a nurse failed to provide dignity and respect to a resident during an incident involving smoking outside the facility. The resident, who had no cognitive impairment as indicated by a BIMS score of 15, requested to be taken outside to smoke. Staff members, including CNAs, assisted the resident outside, which led to a confrontation with an LPN. The LPN went outside and yelled at the resident and the staff, telling them that staff were not allowed to take residents outside to smoke. The resident reported feeling upset and stated that the nurse did not treat her with dignity or respect during the incident. The resident also expressed feeling bad for being the reason staff were yelled at and noted that some staff treated her well while others did not. Interviews with staff revealed confusion and inconsistency regarding the facility's smoking policy. Staff A, a CNA, stated that she was written up for taking the resident outside but the write-up was later destroyed due to conflicting policies. Staff B, another CNA, confirmed the incident and described the LPN as using a stern and unfriendly tone, which upset the resident. Both CNAs indicated uncertainty about the rules for staff assisting residents with smoking and whether the sidewalk was considered facility property. The LPN involved admitted to being loud and stern but denied yelling at the resident, stating her intent was to enforce facility rules. Administrative staff, including the DON and Administrator, provided conflicting information about the smoking policy and property boundaries. The DON stated that staff were not to take residents outside to smoke, but acknowledged this was not specified in the written policy. The Administrator confirmed that the sidewalk was not facility property and that only non-employee friends or family could assist the resident with smoking outside. There was no formal written investigation or documentation of the incident, and the DON did not speak directly to the resident about the event. The facility's policy on resident dignity emphasized maintaining respect and self-worth, but the actions during this incident did not align with those standards.
Failure to Consistently Provide Bathing Opportunities Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to assist residents with activities of daily living by not consistently offering or providing opportunities for bathing to two of three residents reviewed. One resident, with diagnoses including arthritis, anxiety disorder, bipolar disorder, COPD, and fibromyalgia, required moderate to total assistance with personal hygiene and toileting. Despite being cognitively intact, this resident and their family reported that staff would ask about bathing preferences but would not return, later documenting refusals that did not occur. Electronic health records showed inconsistent bathing frequency, with some months showing only a few baths and refusals not always documented in progress notes. Another resident, also cognitively intact and requiring maximal assistance with bathing, reported receiving baths 2-3 times a week but noted that if a bath was missed, it was sometimes not rescheduled promptly. Documentation for this resident also showed irregular bathing schedules and lacked consistent refusal documentation. Staff interviews revealed that residents were expected to be bathed twice a week, but missed baths were common due to staffing shortages, with staff sometimes moving baths to the next day or relying on medication aides for assistance. Staff also indicated that refusals should be documented in progress notes and communicated to nurses, but this was not always done. Multiple staff members acknowledged that it was not uncommon for residents to go several days without bathing due to call-ins and short staffing. Review of facility policy found no written policy regarding the frequency of bathing.
Failure to Protect Resident's Personal Property from Loss
Penalty
Summary
A resident with progressive neurological conditions, cancer, non-Alzheimer's dementia, depression, and altered mental status was found to be missing personal property, specifically a wedding ring and a birthstone ring. The resident was unable to participate in interviews due to cognitive impairment, and the loss was reported by a family member. The facility's records included an inventory of personal effects from admission, which listed a ring and a watch, but there was no evidence that the inventory had been updated or that the missing items were replaced. The family reported the missing items to the facility, and documentation showed that Social Services was informed and discussed the matter with the Administrator. Despite the facility's policy requiring inventories to be completed at admission and updated as new items are acquired, staff interviews revealed that the inventory sheets were not kept current. The Social Services staff confirmed that a grievance was filed and the items were never found or replaced. The DON stated that inventory sheets should be accurate and updated, and that lost items should be replaced, but this did not occur in this case. The facility failed to protect the resident's personal property from loss or theft, as required.
Failure to Complete Background Check Prior to Staff Employment
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not completing a required background check prior to the employment of one staff member, an LPN. Review of the personnel file showed that the background check for this staff member was completed several months after the hire date. During interviews, both the Human Resources staff and the Director of Nursing confirmed that the background check was not performed before the staff member began working. The facility's policy prohibits employing individuals with findings of abuse, neglect, exploitation, or misappropriation of property, and requires background checks prior to employment to ensure compliance.
Failure to Refer Residents for Level II PASRR Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents, who were initially screened as negative for serious mental disorder, intellectual disability, or related conditions through the Level I Pre-admission Screening and Resident Review (PASRR), for a Level II PASRR evaluation after new or possible mental health diagnoses became evident. For one resident, the Minimum Data Set (MDS) indicated the use of multiple high-risk psychotropic medications and documented diagnoses including psychological insomnia, major depressive disorder, schizotypical disorder, and anxiety disorder. Despite these findings, there was no evidence in the electronic health record (EHR) of a Level II PASRR evaluation since admission, which was confirmed by the Director of Nursing (DON). Another resident's MDS showed intact cognition but included diagnoses of progressive neurological conditions, anxiety disorder, depression, psychotic disorder, and non-Alzheimer's dementia. The initial PASRR Level I screen did not identify active psychosis or hallucinations, but subsequent EHR documentation revealed new diagnoses of major depressive disorder, unspecified psychosis, and visual hallucinations. Staff interviews confirmed that a new PASRR should have been completed following these new diagnoses, in accordance with facility policy, but this was not done.
Failure to Change and Document Oxygen Tubing per Policy
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for two residents who required oxygen therapy. For one resident with intact cognition and an order for oxygen at night, the oxygen tubing was observed to be dated over two months prior, and the humidification bottle was also outdated. The resident was unsure how often the tubing was changed. Staff interviews revealed that oxygen tubing was supposed to be changed weekly on Wednesdays, as indicated in a master schedule and facility policy, but there were no sign-off sheets or documentation to confirm that this was being done. The Director of Nursing confirmed the expectation for weekly changes, and the facility policy required disposable equipment to be changed weekly and marked with the date and initials. For another resident with multiple diagnoses including heart failure and shortness of breath, the care plan identified oxygen therapy as needed, but the medication administration record did not include orders or instructions for changing the oxygen tubing. Observations on two consecutive days found the resident's oxygen tubing undated. A physician order to change and label the tubing weekly was only written after these observations. These findings demonstrate that the facility did not ensure oxygen equipment was changed and documented according to policy and professional standards for residents requiring oxygen therapy.
Failure to Implement Infection Control and Hand Hygiene Practices During Resident Care
Penalty
Summary
Staff failed to implement appropriate infection prevention and control practices during care for two residents with indwelling medical devices and wounds. For one resident with an indwelling catheter, a CNA donned gown and gloves without performing hand hygiene, placed a urine graduate on a barrier on the floor, and emptied the catheter drainage bag without cleaning the drainage port beforehand. The drainage port was only cleansed with an alcohol wipe after the bag was emptied, and the CNA left the room without performing hand hygiene. Both the Infection Preventionist and the Director of Nursing confirmed that hand hygiene should be completed and Enhanced Barrier Precautions (EBP) should be used at appropriate times during catheter and wound care, as outlined in facility policy. Another resident with multiple chronic conditions, including venous and arterial ulcers, required frequent wound care to both lower extremities. During wound care, an LPN demonstrated inconsistent hand hygiene, such as removing gloves and donning new ones without hand hygiene, and did not always use a gown when applying dressings to the buttocks. The LPN also failed to maintain a clean and dirty environment, placing opened bandages on her lap and under her arm, and continued to use supplies that had fallen on the floor without changing gloves or performing hand hygiene. Dressings were not dated, and the LPN was observed to request assistance from the Infection Preventionist, who had to don PPE to assist. Facility policies required adherence to the 4 Moments of Hand Hygiene and the use of EBP for residents with indwelling devices or wounds, including the use of gloves and gowns during high-contact care activities. Observations and interviews revealed that staff did not consistently follow these protocols, leading to lapses in infection control practices for both residents. The Director of Nursing and Infection Preventionist acknowledged these deficiencies, noting failures in hand hygiene, PPE use, and maintenance of clean and dirty technique during resident care.
Failure to Investigate and Report Alleged Resident Mistreatment
Penalty
Summary
The facility failed to investigate and report an alleged incident of mistreatment involving a resident with moderate cognitive impairment and significant physical dependencies. The resident, who had a history of cerebrovascular accident, hemiplegia, and diabetes, reported that a CNA left her on a bed pan for five hours without access to a call light and later acted disrespectfully and possibly under the influence while providing care. The resident did not initially report the incident to management due to fear but did inform a nurse, who later became the DON, and was told that steps would be taken. A review of the resident's electronic health record did not show any documentation of the incident or any assessments of the resident's cognitive or physical condition following the alleged event. Additionally, there was no record of the incident being reported to the State Agency as required. The DON, who had recently assumed her position, confirmed that the previous administration was aware of the incident, as it was discussed in management meetings, but no investigation or report to the State Agency was completed. Facility policy requires immediate reporting and investigation of alleged abuse, neglect, or mistreatment, including notification of designated agencies within specified timeframes. Despite these policies, the facility did not follow through with the required investigation or reporting procedures in this case, and the staff member involved was later terminated for unrelated reasons. The lack of timely investigation and reporting constituted a failure to comply with regulatory requirements for protecting residents from abuse and ensuring proper oversight.
Failure to Provide Timely Toileting Assistance and Documentation
Penalty
Summary
A resident with moderate cognitive impairment, a history of cerebrovascular accident, hemiplegia, and diabetes mellitus, was left on a bed pan for five hours without access to a call light. The resident was totally dependent on staff for toilet transfers and hygiene. During this period, the resident experienced significant pain and distress, and no staff checked on her throughout the night. The resident eventually located a call light in a drawer and used it to summon assistance. The incident was not documented in the resident's electronic health record, and there were no assessments recorded regarding the resident's cognitive or physical condition following the event. The Director of Nursing confirmed awareness of the incident and acknowledged the lack of documentation and assessment in the health record.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that staff followed professional standards while administering medications to residents, as evidenced by multiple incidents involving four residents. Resident #3, who had no cognitive impairment, expressed uncertainty about whether her medications were being administered as ordered. She had recently been hospitalized for heart failure and required increased oxygen. Resident #4 reported an incident where she did not receive all her medications as ordered, and Staff A, a registered nurse, failed to provide her with the complete set of medications, including her blood pressure medication. Resident #5, also with no cognitive impairment, stated that she did not receive all her medications on one occasion, specifically mentioning that her clonazepam was administered late. She also heard other residents complaining about similar issues. Resident #6 reported that Staff A did not check her pulse as required before administering her medications, which were given late in the afternoon instead of in the morning. This was particularly concerning due to her pacemaker and the need for accurate pulse readings before starting her day. The facility's investigation revealed that Staff A had disposed of medications improperly by placing them in the sharps container. Staff E, another registered nurse, discovered multiple pills in the sharps container and reported the issue to the Director of Nursing. The investigation identified that 16 residents' medications were found in the sharps container, and Staff A admitted to disposing of medications improperly. The facility's policy on medication administration was not followed, leading to the deficiency in medication management.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to protect a resident from financial exploitation, specifically regarding the misappropriation of an Ozempic pen, which is a medication used for diabetes management. The resident, who had a BIMS score of 15 indicating no cognitive impairment, was diagnosed with several conditions including diabetes mellitus and was on diabetic therapy. The resident's Ozempic pen, which had a significant co-pay cost, was reported missing after being delivered to the facility. The incident involved Staff D, an agency RN, who was captured on facility camera footage handling the Ozempic pen inappropriately. The footage showed Staff D entering the medication room, removing the Ozempic pen from the refrigerator, and placing it in her pocket. Despite her claims of restocking insulin pens as instructed by the off-going nurse, the footage and subsequent investigation revealed that the Ozempic pen was not accounted for, leading to a delay in the resident's medication schedule. Interviews with facility staff and the resident confirmed the misappropriation of the Ozempic pen. Staff members stated that the pen should not have been handled during the overnight shift as it is administered weekly. The resident acknowledged a delay in receiving her medication due to the missing pen but reported no further issues after the incident. The facility's policy on abuse and neglect, which includes the right of residents to be free from misappropriation of property, was not adhered to in this case.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to maintain sanitary practices during food service, leading to potential cross-contamination. During an observation, a staff member used the same tongs to handle both plastic wrap and food items, such as rolls, and also used the tongs to remove aluminum foil from a casserole pan. Additionally, the staff member placed butter packets directly onto residents' plates, allowing them to touch the food. The staff member also placed her hand on the steam table counter and then used food scissors to cut meat for residents without performing hand hygiene. Furthermore, she moved pans around the steam table area and continued serving food without washing her hands. These actions were contrary to the facility's policy on food handling, which requires the use of proper utensils and single-use gloves.
Failure to Properly Prepare and Serve Diet Portions
Penalty
Summary
The facility failed to properly prepare and serve the appropriate portions of pureed and minced & moist diets for residents, as observed during a lunch service. The lunch menu specified certain portion sizes for pureed and minced & moist diets, but staff did not adhere to these specifications. Staff I, the cook, prepared minced & moist diets by mincing pork chops with chicken broth without measuring the contents, and similarly, pureed pork chops were prepared without accurate measurement. Additionally, pureed carrots and minced peaches were also prepared without proper measurement, leading to incorrect portion sizes being served. The facility's dietary staff used a volume method for portioning instead of the alternate texture conversion chart, which was not followed as per the facility's policy. The Dietary Manager confirmed that the staff used the volume method, and Staff I admitted to not measuring the minced & moist meat. The policy on portion control indicated the use of a specific disher size for portioning, which was not adhered to during the preparation and serving of meals. This resulted in the failure to meet the nutritional needs of residents on pureed and minced & moist diets, as the appropriate serving sizes were not determined or provided.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information from unauthorized access, as observed during a survey. An open laptop screen displaying resident Electronic Health Record (EHR) information was left unattended, and a sheet containing resident names, room numbers, blood glucose results, and insulin information was found face-up on a cart. Staff D, a Certified Nurse Aide (CNA), acknowledged that the information is usually not left visible and that the screen is typically locked. Staff F, a Registered Nurse (RN), admitted to using the sheet as a 'cheat sheet' to avoid forgetting the information. The facility's confidentiality policy, revised in May 2024, mandates that individuals with access to confidential information must handle it in accordance with legal and regulatory requirements. The Administrator confirmed that staff should adhere to Health Insurance Portability and Accountability Act (HIPAA) policies.
Inadequate Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to provide proper hand hygiene during toileting and urinary catheter care for two residents. During an observation, a Certified Nursing Assistant (CNA) assisted a resident to the bathroom, removed soiled gloves, and failed to perform hand hygiene before donning new gloves. The CNA also placed a graduated measuring container directly on the floor, contrary to the facility's catheter policy, which requires a barrier between the container and the floor. The facility's Personal Protective Equipment (PPE) policy was not followed, as the CNA did not perform hand hygiene after removing gloves. In another instance, a CNA assisted two residents with eating lunch and failed to perform hand hygiene between feeding the residents. The CNA used the same hand to wipe one resident's mouth and then handled the other resident's utensils without performing hand hygiene. This action was against the facility's hand hygiene policy, which mandates maintaining adequate hand hygiene by adhering to specific infection control practices. Additionally, the facility failed to properly manage an indwelling catheter for a resident. The catheter drainage bag was observed hanging on the side of the resident's trash can, which is not in accordance with proper catheter care procedures. During catheter and peri-care, a CNA did not perform hand hygiene throughout the procedure, despite handling the resident and catheter equipment. The facility's catheter care policy requires hand hygiene between resident contact and catheter care, which was not adhered to in this instance.
Failure to Provide Bed Hold Notice for Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative when the resident was transferred to a hospital. This deficiency was identified during a review of clinical records, resident interviews, and facility policy. Specifically, the Minimum Data Set (MDS) assessment for the resident documented a discharge with return anticipated, but the facility did not complete the required bed hold notice for the hospital admission. The resident was admitted to the hospital and returned to the facility two days later, yet the clinical record lacked documentation of the bed hold notice. The facility's bed hold policy, last reviewed in December 2024, mandates that a state-specific form be provided at the time of discharge, detailing the duration of the bed hold policy. However, this procedure was not followed in this instance, as confirmed by the Administrator and Director of Nursing during an interview.
Failure to Complete PASRR for Resident with New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) for a resident who was diagnosed with new mental disorder diagnoses since admission. The resident, identified as Resident #20, had a Minimum Data Set (MDS) assessment indicating no cognitive deficit and was diagnosed with anxiety disorder, depression, and psychotic disorder. Initially, a PASRR Level I Screen Outcome indicated no evidence of a serious mental illness or intellectual or developmental disability requiring PASRR intervention. However, during the resident's stay, a psychiatrist added a new diagnosis of unspecified paranoia and increased the resident's medication for hallucinations and paranoia. Despite these changes, the facility did not conduct a new PASRR as required by their policy, which mandates contacting the designated state agency for a Level II screening if a resident is diagnosed with a mental disorder while in the facility. Staff interviews revealed a lack of awareness and understanding of PASRR regulations, with the Social Services staff indicating that a new PASRR would be completed if there were a change in behaviors, and the Administrator admitting limited knowledge of PASRR requirements beyond the initial admission screening.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for three residents, as identified during a survey. For Resident #5, the quarterly Minimum Data Set (MDS) assessment indicated moderately impaired cognition and several diagnoses, including cancer and non-Alzheimer's dementia. The resident required varying levels of assistance with activities of daily living (ADLs) and was on antipsychotic and antidepressant medications. However, the care plan did not include the target behaviors for these medications, which are essential for staff monitoring. Similarly, Resident #18, with severely impaired cognition and multiple diagnoses such as anxiety and schizotypal disorder, was on several psychotropic medications. The care plan included some behaviors but failed to specify target behaviors for all medications. Resident #39, also with severely impaired cognition, was on antidepressant and antianxiety medications, but the care plan lacked target behaviors for staff to monitor. The facility's policy required individualized, comprehensive care plans with measurable goals, which were not met in these cases.
Failure to Update Care Plans for Resident Needs
Penalty
Summary
The facility failed to update and revise care plans to reflect the current transfer needs and interventions for three residents. Resident #24, who had undergone a Kyphoplasty procedure due to a compression fracture, required the use of a mechanical lift for transfers. However, the care plan inaccurately instructed staff to use a forward wheeled walker and assist of one person during the day, and a non-mechanical stand aide at night. This discrepancy was noted despite the resident's clear need for a mechanical lift, as observed and reported by the resident and staff. Resident #42, diagnosed with Alzheimer's disease and severe cognitive impairment, required complete dependence on staff for mobility and positioning. Observations showed the resident in a tilt-in-space wheelchair and a low wide bed with fall interventions such as a fall mat and call light. However, staff interviews revealed inconsistencies in awareness and implementation of these interventions, with some staff unaware of all necessary fall precautions, indicating a lack of proper communication and updates in the care plan. Resident #16, with severe cognitive impairment and a diagnosis of unspecified dementia, required the use of a wheelchair and wore edema wear for bilateral lower extremities. Despite this, the care plan did not reference the use of edema wear, although staff were aware of its necessity through quick notes at the nurses' station. The Director of Nursing acknowledged the mismatch between the care plans and the quick notes, indicating a failure to update the care plans to reflect the current interventions required for the resident.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that physician's orders for oxygen therapy were followed for a resident with multiple medical conditions, including COPD, Atrial Fibrillation, Chronic Kidney Disease, Heart Failure, and deep venous thrombosis. The resident, who had intact cognition, was observed receiving oxygen at a flow rate of 4 liters per minute, contrary to the physician's order of 2 liters per minute during the day and 3 liters per minute at night. This discrepancy was noted during an observation on August 9, 2024, and was confirmed by the Medication Administration Record for the same date. The facility's policy on oxygen administration, revised in July 2024, instructed staff to adjust the oxygen concentrator's flow rate according to the physician's orders. However, the resident's care plan, which was revised on August 9, 2024, also directed staff to provide oxygen therapy per the physician's order, yet the correct flow rate was not maintained. The Director of Nursing acknowledged that staff should adhere to the physician's orders, indicating a lapse in following established protocols for oxygen administration.
Failure to Identify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to identify target behaviors for the use of psychotropic medications for two residents, leading to a deficiency. Resident #18, with severely impaired cognition and multiple diagnoses including anxiety, depression, and schizotypal disorder, was prescribed several psychotropic medications such as Abilify, Trazodone, Duloxetine, Seroquel, and Buspirone. However, the physician orders did not specify target behaviors for these medications, and the care plan only mentioned 'hollering out' as a behavior without detailing target behaviors for the other medications. Similarly, Resident #39, also with severely impaired cognition and diagnosed with anxiety, depression, and adjustment disorder, was prescribed medications including Bupropion, Clonazepam, Hydroxyzine, and Venlafaxine. The physician orders for these medications also lacked specified target behaviors, and the care plan did not include target behaviors for staff to monitor. Additionally, the facility did not provide a policy regarding psychotropic medications or Gradual Dose Reductions (GDRs), and the Director of Nursing acknowledged that CMS guidelines should be followed.
Failure to Provide Adequate Nursing Staff for Timely Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely responses to call lights, compromising resident safety. Resident #9, who has no cognitive impairment and is frequently incontinent, reported that staff often took longer than 15 minutes to respond to her call light. On one occasion, the call light log showed a response time of 47 minutes and 59 seconds. Video footage confirmed that no staff entered Resident #9's room for 30 minutes after the call light was activated. Staff interviews corroborated the issue, with multiple staff members stating that they often worked short-staffed and that call lights frequently took longer than 15 minutes to be answered, particularly on the morning in question. Resident #10, who also has intact cognition and requires assistance with toileting, reported that call lights often took longer than 15 minutes to be answered, especially during evening and overnight shifts. The call light log showed a response time of 21 minutes and 7 seconds for Resident #10 on a specific date. The facility's policy mandates that call lights be answered promptly, ideally within 15 minutes. The Administrator acknowledged that call lights had exceeded the 15-minute response time on several occasions over the past month, indicating a systemic issue with staffing levels and response times.
Infection Prevention Deficiency During Blood Sugar Monitoring
Penalty
Summary
The facility failed to provide appropriate infection prevention practices during blood sugar monitoring for three residents. Resident #4, who had a diagnosis of type 2 diabetes mellitus, was observed being pushed into an unoccupied room by Staff C. Staff C applied gloves without completing hand hygiene, handled various items including the blood glucose machine and insulin, and administered insulin without performing hand hygiene before or after the procedure. Staff C also failed to perform hand hygiene before administering medication to another resident immediately afterward. Resident #5, also diagnosed with type 2 diabetes mellitus, was observed by Staff D who applied gloves without hand hygiene before performing blood glucose monitoring. Staff D left the room to complete hand hygiene only after the procedure. Similarly, Resident #6, with the same diagnosis, was attended to by Staff C who did not perform hand hygiene before applying gloves and continued to use a lancet that had been dropped on the ground. Staff C then administered insulin without proper hand hygiene. The facility's policy required hand hygiene before and after entering a resident's room, before clean tasks, after glove removal, and before and after medication administration. The Administrator confirmed that the facility's expectation was for hand hygiene to be completed as per the policy.
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 72 citations issued within 25 miles in the last 12 months — 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 Elk Horn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Exira Care Center | 9.4 mi | ★★★★★ | 7 | 0 |
| Friendship Home Association | 10.8 mi | ★★★★★ | 2 | 0 |
| Heritage House | 13.8 mi | ★★★★★ | 8 | 0 |
| Elm Crest Retirement Community | 14.3 mi | ★★★★★ | 8 | 0 |
| Atlantic Specialty Care | 14.3 mi | ★★★★★ | 9 | 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.