Average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mini-cassia Care Center during CMS and state inspections, most recent first.
Kitchen staff failed to properly label and store food items and did not follow hand hygiene and glove-use practices during meal prep. Observations found opened food items in the fridge, freezer, and pantry without required open or used-by dates, including resident-labeled foods stored with kitchen items. Staff were also observed handling trash and then returning to cooking without washing hands, and changing tasks while continuing food prep without proper hand hygiene or glove changes.
Failure to provide a dignified dining experience: Four residents with significant diagnoses, including Parkinson’s disease, schizophrenia, cerebral palsy, TBI, and dysphagia, were brought to the assistive dining room for lunch but were not served their trays until more than 50 minutes after the posted mealtime. While other residents were already being assisted with eating, these residents were left watching the meal service, and the DON stated they should have been served at the same time as the others or not brought in until their trays were ready.
Call lights were not kept within reach for five residents reviewed for residents' rights. Residents with diagnoses including bipolar disorder, stroke, TBI, Alzheimer's disease, schizophrenia, PTSD, diabetes, schizoaffective disorder, OCD, and unsteadiness on feet were observed with call lights placed under beds, hung on wall hooks out of reach, or coiled and pinned so they could not independently access them. An LPN and the DON stated the call lights should have been within the residents' reach.
The facility failed to maintain a clean, safe, and homelike environment. Surveyors observed dirty hallway vents, ceiling areas with residue, damaged walls, protruding door panel edges, missing tile and cracked flooring in shower areas, and multiple unsanitary conditions in resident rooms, including cracked light covers with bugs, uncovered soiled items, and substances on floors, mattresses, bed sheets, and bedside tables. Two residents’ wheelchairs also had dried substances and hair buildup, and staff acknowledged some areas needed repair or cleaning.
Failure to follow bowel management protocol: three residents had extended periods without a BM and no documented nursing interventions despite the facility’s protocol requiring specific measures after 2, 3, 4, and 5 days without a BM. The residents had significant diagnoses including schizophrenia, Parkinson’s disease, stroke, TBI, and Alzheimer’s disease, and the RNC confirmed the missing BM-related interventions in the chart.
The facility failed to promptly notify resident representatives when two residents fell and had changes in condition. One resident with dementia and anxiety fell in the TV room and sustained a chin laceration, and another resident with schizophrenia, anxiety, and an unsteady gait had a witnessed fall in her room with a left upper arm skin tear. In both cases, the provider was notified and treatment orders were received, but the records did not document representative notification at the time of the events.
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A resident with chronic respiratory failure with hypoxia and diabetes had physician orders for continuous O2 and compression stockings, but was observed without either in place. The care plan did not document the oxygen or compression stocking interventions, and the DON stated refusals also were not documented.
Power strips were used improperly for two residents during room observations. One resident with hemiplegia, seizures, and anxiety had multiple cords plugged into a power strip placed on a pillow at the head of the bed and surrounded by linens, while another resident with schizoaffective disorder and HTN had a nebulizer sitting on bed linens at the foot of the bed and plugged into a power strip because staff said there were not enough outlets in the room. The facility policy stated power strips shall not be used with medical devices in resident care areas.
Failure to maintain ordered continuous O2: A resident with stroke and COPD was observed without his NC while a CNA waited for a portable O2 unit to be filled. The CNA then applied the NC but did not turn on the liquid portable O2, and later wheeled the resident to the nurse’s station to have the nurse set the unit to the ordered liter flow. The resident’s physician had ordered continuous O2 2L to 4L NC.
A nurse aide was employed beyond the allowed 4-month period without completing a State-approved CNA training and competency evaluation program. The aide had been hired but had not yet started CNA classes, and the HR Director stated the course should have been completed within 120 days of hire.
Missing Daily Nurse Staffing Information: The facility failed to post complete daily staffing information on the Daily Staffing sheets. The sheets reviewed did not include the actual hours worked by RNs, LPNs, and CNAs, and many also did not list the facility name. The Administrator and RNC acknowledged the required information was missing from the staffing sheets.
An LPN administered Humalog insulin to a resident with stroke, aphasia, and diabetes without priming the insulin pen as required by manufacturer instructions. The LPN dialed the ordered 5-unit dose but did not prime the pen with 2 units before injection, and later stated she was unaware of the need to prime it. The DON confirmed insulin pens should be primed according to the manufacturer's instructions.
An expired bottle of Colace gel tablets was found in the South Hall med cart during an audit with an LPN present. The facility’s policy requires checking the expiration or beyond use date before administering meds, but the LPN stated the bottle should have been discarded and had not been; the DON also stated it should have been removed from the cart.
Improperly Covered Garbage and Refuse: The facility failed to keep trash receptacles covered in the kitchen and outside in the alleyway. A 55-gallon trash can in the main food prep area had a hole cut in the lid and was overflowing, and outside trash cans had lids left open with empty box material on the ground nearby. The RNC stated the kitchen garbage cans needed a tight-fitting lid without holes and that the outside cans should always have their lids closed.
A facility failed to maintain infection control practices for a resident using nebulizer treatments and for two residents during meal assistance. A resident’s nebulizer equipment was observed dry and unbagged when not in use, despite policy requiring storage in a plastic bag, and an LPN confirmed it should have been bagged. During lunch, a CNA assisted two residents with eating using the same hand without hand hygiene between residents and wiped both residents’ mouths without gloves or hand hygiene; the RNC confirmed hand hygiene should have been performed when switching between residents.
Surveyors found that kitchen equipment, including a baking sheet and two skillets, had black, encrusted residue that was not properly cleaned, as confirmed by the Food Services Manager. This failure to maintain clean food-contact surfaces did not meet FDA Food Code standards and had the potential to affect all residents consuming food prepared in the facility.
Surveyors found that the main shower in the south wing was unsanitary, with mold-like spots on the floor and drain, red residue on shower chairs, and a missing end cap on the wall bar exposing a sharp metal edge. Facility leadership confirmed the shower was in disrepair, should have been closed, and had not been properly cleaned.
Two residents with serious mental illness diagnoses had inaccurate MDS assessments, where section A1500 was incorrectly marked 'no' despite PASRR level II screenings confirming their conditions. These errors were identified through record review and staff interviews.
A resident with major depressive disorder and PTSD was admitted under a 30-day PASRR Level II exemption for medical reasons. The facility did not submit the required PASRR Level II evaluation when the resident remained past the exemption period, as was necessary for continued compliance.
A resident with Alzheimer's disease, depression, anxiety, and behavioral disturbances was admitted without the required PASRR Level I and II screenings, despite documented mental health diagnoses and use of antipsychotic medications. The initial PASRR screening from another state failed to identify mental illness or dementia, and no further evaluation was conducted, as confirmed by staff interviews and record review.
Two residents admitted with complex medical and behavioral health needs did not have baseline care plans developed within 48 hours of admission, as confirmed by the DON and review of medical records.
A resident with a history of stroke, diabetes, hypertension, and COPD experienced worsening leg swelling, and although physician orders for diuretics were in place, the care plan did not include any interventions or treatment planning for edema. The DON confirmed that this aspect of care was not addressed in the care plan as required.
A resident with a seizure disorder, dementia, and hemiplegia had physician orders for two emergency seizure medications that lacked clear instructions on which medication to administer first or under what conditions. The DON acknowledged the orders were not specific and needed clarification, resulting in a failure to meet professional standards of quality.
Multiple residents with complex medical conditions were affected by significant medication errors, including administration of incorrect medications, wrong dosages, and missed doses. These errors were confirmed by the DON and documented in medication error reports, highlighting failures in medication administration practices.
Improper Food Storage, Labeling, and Hand Hygiene in Kitchen
Penalty
Summary
Kitchen staff failed to appropriately store and label food items in accordance with the facility’s Food Receiving and Storage policy and the FDA Food Code. On observation in the kitchen, an opened bag of lettuce had a used-by date of 8/2/26, a container of pink liquid punch had no open or used-by date, and several opened resident-labeled food items were stored in the kitchen refrigerator, including tomato cocktail, cream cheese, potato salad, a jar of mayonnaise, and a package of sandwich bologna. In the reach-in freezer, an opened bag of frozen egg omelets and an opened bag of pizzas had no open or used-by dates. In the pantry, an opened gallon container of vanilla syrup had a used-by date of 6/17/26, and an opened 12 oz pancake syrup bottle had a used-by date of 8/2/26. Kitchen staff also failed to follow hand hygiene and glove-use practices during food preparation. One staff member was observed handling food waste with bare hands, lifting the trash can lid with bare hands, and then returning to cooking duties without washing hands before pouring soup into bowls for residents. Another staff member was observed cutting celery with gloved hands, opening a cupboard and moving bowls, then returning to the cutting task and handling the cut celery without changing gloves or performing hand hygiene. The same staff member removed one glove to get glasses to read a recipe, then donned another glove without washing hands before resuming food preparation. The Maintenance Manager, acting as food service manager, stated that food items in the refrigerator and freezers should have been labeled with used-by dates and that proper hand hygiene practices were not being followed.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 4 of 8 residents reviewed for respect and dignity. The facility’s Assistance with Meals policy stated that staff will serve resident trays and help residents who require assistance with eating, and that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. The facility’s Dignity policy stated that each resident shall be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem, and that residents are supported in exercising their rights during care. Resident #4 had diagnoses including Parkinson’s Disease and major depressive disorder. Resident #13 had diagnoses including schizophrenia and abnormal involuntary movement. Resident #19 had diagnoses including spastic quadriplegic cerebral palsy and anxiety disorder. Resident #44 had diagnoses including traumatic brain injury and dysphagia. During observation of the assistive dining room during the lunch meal, eight residents were present and only four were being assisted with eating after their meals had been delivered. Residents #4, #13, #19, and #44 were not served their lunch trays until after 12:10 PM, more than 50 minutes past the posted lunch mealtime, and were observed watching other residents who were already being assisted with their meals. The DON stated these residents should have been served at the same time as the other residents or not brought into the dining room until their trays were ready.
Call Lights Not Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for 5 of 18 residents reviewed for residents' rights: Residents #29, #50, #51, #56, and #57. The facility's policy, "Answering the Call Light," revised September 2022, stated that call lights should be accessible to residents when in bed, from the toilet, from the shower or bathing facility, and from the floor. Resident #51, who had diagnoses including acquired absence of the left leg below the knee, bipolar disorder, and anxiety disorder, was observed with the call light button under the bed against the wall and not accessible. Resident #56, who had diagnoses including stroke, traumatic brain injury, and Alzheimer's disease, was observed lying in bed without the call light button, which was hanging on a wall hook about five feet high and out of reach; she was unable to self-ambulate, could not get out of bed, and did not verbally communicate. Resident #29, who had diagnoses including schizophrenia, PTSD, and diabetes, was observed with the call light plugged into the wall above the bed, hanging down to the floor under the bed and not within independent reach. Resident #57, who had diagnoses including schizophrenia, anxiety, and unsteadiness on feet, was observed with the call light plugged into the wall above the bed with the cord coiled and pinned to itself and not within independent reach. Resident #50, who had diagnoses including schizoaffective disorder and OCD, was observed with the call light plugged into the wall near the foot of the bed, coiled and pinned to itself and not within reach. Staff interviews confirmed the call lights for these residents should have been within reach and were not.
Cleanliness, Safety, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, and homelike environment. Surveyors observed multiple areas of disrepair and cleanliness concerns throughout the building, including shower room flooring with dark residue and chipped, open penetrations, hallway vents and ceiling areas with black, gray, and cobweb-like substances, wall gouges, and dining room ceiling vents and lights with dry splattering and rust-colored residue. The facility’s maintenance manager and maintenance director stated they were aware of some of the shower room and panel issues and knew repairs were needed. Surveyors also observed unsafe conditions in resident areas and common spaces. Plastic door panels outside two rooms had protruding edges, the south hall shower room had two large holes where tile was missing and a smaller crack, and staff acknowledged the flooring needed correction. In resident rooms, surveyors observed cracked light covers containing bugs, gouges in walls and railings, a missing bathroom door, a thick black substance at a room entrance threshold, and uncovered soiled items such as an isolation bin with soiled linen and a bedpan on the floor under the sink. Equipment cleanliness concerns were also identified. Two residents’ wheelchairs had dried substances on the cushions and wheels, with hair accumulated in the wheel mechanisms, and a CNA stated night shift should have cleaned the wheelchairs. In another room, surveyors observed mattresses with dried brown and white substances, a mattress leaning against the wall with dried white substance, dried substances on the floor and bed sheets, and a bedside table with dried brown substance. Facility logs reviewed did not document cleaning of hallway vents, mats, or mattresses at the bedside, and the Housekeeping Supervisor stated vents should have been cleaned and that nurse aides were responsible for cleaning body fluids from mattresses and mats before housekeeping cleaned them.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to follow its Bowel Management - Clinical Protocol for residents who did not have a bowel movement within the required time frame. The protocol dated April 2026 directed staff to assess, monitor, and manage bowel and bladder function according to individualized needs and physician/provider orders, with specific interventions beginning on Day 2, Day 3, Day 4, and Day 5 without a BM. For Resident #31, the record documented no BM from 7/27/26 at 2146 to 7/31/26 at 2130, with no documented nursing interventions during that period. Resident #31 had diagnoses including schizophrenia and alcohol abuse. Resident #4’s record documented no BM from 7/9/26 to 7/12/26 with no documented nursing interventions related to the lack of BM during that time. Resident #4 had diagnoses including Parkinson’s Disease and major depressive disorder. Resident #56’s record documented no BM from 7/21/26 to 7/28/26 and again from 7/29/26 to 8/2/26, with no documented nursing interventions during those periods. Resident #56 had diagnoses including stroke, traumatic brain injury, and Alzheimer’s disease. On 8/5/26, the RNC stated that Residents #4, #31, and #56 had no documented BM-related interventions for July and the first part of August 2026 and should have.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to ensure residents’ representatives were immediately notified when residents fell or had a change in condition. The facility policy, revised in February 2021, stated that the resident, attending physician, and resident representative are to be promptly notified of changes in the resident’s medical or mental condition and/or status. Survey review found that this did not occur for 2 of 4 residents reviewed for changes in condition. Resident #7, who had diagnoses including major depressive disorder, dementia, and anxiety, fell while walking out of the doorway in the TV room and sustained a laceration to the chin. The provider was notified and orders were given for steri-strips and monitoring, but the record did not document that the resident’s representative was notified at the time of the fall. Resident #57, who had diagnoses including schizophrenia, anxiety, and unsteady gait, had a witnessed fall in her room and sustained a skin tear to the left upper arm. The provider and DON were notified and treatment orders were received, but the record did not document that the resident’s representative was notified at the time of the event.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Care Plan Not Updated for Oxygen and Compression Stocking Needs
Penalty
Summary
The facility failed to ensure a resident’s care plan was revised to reflect current needs and interventions. The facility’s policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and that care plans are revised as resident information and conditions change. Resident #55 was admitted with multiple diagnoses including chronic respiratory failure with hypoxia and diabetes, and had physician orders for compression stockings to the right leg and continuous oxygen at 1-2 L/min via nasal cannula as tolerated. On 8/4/26, Resident #55 was observed in her room with a portable liquid oxygen unit on the back of her wheelchair and an oxygen concentrator at bedside, but she was not wearing oxygen or compression stockings. CNA #2 stated the resident did not have oxygen on and should have. Review of the resident’s care plan showed it did not document the use of oxygen or compression stockings. The DON stated the care plan had not documented the use of oxygen or compression stockings and should have, and that refusals should have been documented but were not.
Power strips used on beds with resident equipment
Penalty
Summary
The facility failed to ensure residents were free from accident hazards for 2 of 18 residents whose rooms were observed for environmental safety. The deficiency was identified during observation, staff interview, policy review, and review of OSHA standards, and involved the use of power strips in resident care areas in a manner inconsistent with the facility's Electrical Safety for Residents policy, which states that power strips shall not be used with medical devices in resident care areas. Resident #41, who had diagnoses including hemiplegia, epileptic seizures, and anxiety, was observed lying in bed with three electrical cords plugged into a power strip that had been placed on his pillow at the head of the bed and surrounded by bed linens. The resident stated he used the power strip to charge his cell phone and other personal equipment because he could not reach the wall outlet. Resident #15, who had diagnoses including schizoaffective disorder and hypertension, was observed with a nebulizer machine at the foot of the bed on top of bed linen and plugged into a power strip at the wall outlet. Staff stated there was a shortage of outlets in the room and that the nebulizer was placed on the resident's bed and connected to the power strip so it could be used. The medical record documented an order for albuterol sulfate inhalation nebulizer solution four times daily for pneumonia.
Failure to Maintain Ordered Continuous Oxygen
Penalty
Summary
The facility failed to ensure that Resident #6 received continuous oxygen via nasal cannula as ordered by the physician. The facility’s Oxygen Administration policy dated February 2024 stated staff were to verify a physician’s order and place the appropriate oxygen device on the resident, with oxygen started at the ordered flow rate. Resident #6 was admitted and later readmitted to the facility with diagnoses including stroke and COPD, and the physician’s order dated 6/25/26 specified oxygen 2L to 4L NC continuous. On 8/3/26 at 10:17 AM, Resident #6 was observed sitting in a wheelchair in his room without his oxygen cannula on while CNA #1 stood next to him. CNA #1 stated he was taking Resident #6 out of the room but was waiting for the portable oxygen unit to be filled. When the liquid oxygen unit arrived, CNA #1 attached the tubing and applied the nasal cannula but did not turn on the portable oxygen unit. At 10:26 AM, CNA #1 wheeled Resident #6 to the nurse’s station and waited for the nurse to turn the portable oxygen on to the resident’s liter flow. The resident’s care plan documented oxygen as ordered and to check room air saturation as ordered, wean as able/ordered. On 8/4/26 at 4:40 PM, the RNC stated the CNA should not have taken Resident #6 off oxygen and should have had the nurse set the liquid portable unit to the proper liter flow before placing it on the resident.
Nurse Aide Training and Competency Requirements Not Met
Penalty
Summary
The facility failed to ensure that a full-time employee working as a nurse aide completed a State-approved training and competency evaluation program within 4 months of hire. The facility’s Nurse Aide and Certified Nurse Aide Hiring Policy stated that an individual may not be employed as a nurse aide for more than four months unless the applicable federal and state requirements for nurse aide employment have been met. Review of the personnel file for Nurse Aide #1 showed the aide was hired on 10/1/25 but had not started a CNA course as of the survey review. The HR Director stated on 8/5/26 that Nurse Aide #1 was scheduled to begin classes on 8/17/26 and acknowledged the course should have been completed within 120 days of hire.
Missing Daily Nurse Staffing Information
Penalty
Summary
Nurse staffing information was not accurately posted daily for each shift. During observation and staff interview, the facility failed to ensure the Daily Staffing sheets for 5/1/26 through 8/4/26 included the required actual hours worked by RNs, LPNs, and CNAs, and many of the sheets also did not document the facility's name. The State Operation Manual, Appendix PP, S483.35(g), requires daily posting of the facility name, current date, total number and actual hours worked by RN, LPN/LVN, and CNA staff directly responsible for resident care per shift, and resident census. On 8/5/26 at 11:00 AM, the surveyor observed the missing information on the staffing sheets, and at 2:30 PM the Administrator and RNC stated the required information was missing from the daily staffing sheets.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when it did not follow insulin pen preparation instructions for Resident #8. Resident #8 was admitted with multiple diagnoses including cerebral infarction (stroke), aphasia, and diabetes, and had a physician order for Humalog (Lispro) insulin pen-injector 100 units/ml to be injected subcutaneously at 5 units before meals for type 2 diabetes. During observation on 8/4/26, an LPN removed the Humalog insulin pen from the medication cart and dialed it to the ordered 5 units, but did not prime the pen with 2 units before administering the dose. The insulin was then given to Resident #8. When interviewed shortly afterward, the LPN stated she did not prime the insulin pen and was unaware of the need to do so before administering insulin. The DON stated insulin pens should be primed according to the manufacturer's instructions and had not been.
Expired Medication Found in Medication Cart
Penalty
Summary
Medications were not properly stored and an expired medication was found in the South Hall medication cart during an audit with an LPN present. The facility’s policy, Administering Medications, revised March 2025, states that the expiration or beyond use date on the medication label is checked prior to administering. During the cart audit, one bottle of Colace gel tablets was observed with a manufacturer expiration date of 7/26 printed on the bottle. The LPN stated the bottle should have been discarded and had not been, and the DON later stated the expired medication should have been removed from the medication cart and had not been.
Improperly Covered Garbage and Refuse
Penalty
Summary
Garbage and refuse were not properly covered in the kitchen and outside trash area. Based on observation and interview, the facility failed to ensure garbage cans were kept closed with lids to minimize attracting pests and rodents into the kitchen. In the main food prep area, a 55-gallon trash can had a hole cut in the lid so it could not be securely closed, and the trash can was overflowing with trash. Outside the kitchen in the alleyway, the larger trash cans had two lids wide open, and some empty box material was on the ground just outside the kitchen. The RNC stated that the kitchen garbage cans need to have a tight-fitting lid without holes and that the garbage cans outside in the alley should always have their lids closed and had not.
Infection Control Practices Not Maintained During Nebulizer Use and Meal Assistance
Penalty
Summary
The facility failed to maintain infection control prevention practices for 3 of 3 residents observed for infection control. The facility’s policy for administering medications through a small volume handheld nebulizer stated that when equipment is completely dry, it should be stored in a plastic bag with the resident’s name and date on it. Resident #15, who had diagnoses including schizoaffective disorder and hypertension, had a physician order for Albuterol Sulfate inhalation nebulizer solution four times daily for pneumonia, and the MAR documented the treatments were being given as ordered. On 8/4/26, Resident #15’s nebulizer equipment was observed lying on the bed, dry, not in use, and unbagged. An LPN stated the nebulizer should have been stored in a bag when not in use, and the RNC later confirmed it was not appropriately bagged after use to prevent contamination. The facility also failed to follow its assistance with meals policy, which stated that employees assisting residents with meals must be trained and demonstrate competency in preventing foodborne illness, including personal hygiene and safe food handling. Resident #6, who had diagnoses including stroke and COPD, and Resident #56, who had diagnoses including stroke, traumatic brain injury, and Alzheimer’s disease, were observed during lunch while CNA #1 assisted both residents with eating. CNA #1 used the same right hand to assist both residents without hand hygiene between residents, repeatedly picking up each resident’s spoon and placing food in their mouths. CNA #1 also wiped both residents’ mouths with their own cloth napkins without gloves or hand hygiene. The RNC later stated CNA #1 should have used hand hygiene when switching eating assistance between residents and had not.
Failure to Clean Kitchen Equipment According to FDA Food Code
Penalty
Summary
Surveyors observed that kitchen equipment, specifically a baking sheet and two skillets, were not properly cleaned. The baking sheet used for preparing honey buns had a black residue along its edge that flaked off easily, while the two skillets had a ring of dark, encrusted residue on both their interior and exterior surfaces that could not be scraped off. The Food Services Manager confirmed that the pans should not have this black, encrusted coating and acknowledged that they should be replaced. These findings indicate that the facility failed to clean food-contact surfaces of cooking equipment in accordance with professional standards and the FDA Food Code, which requires such surfaces to be free of encrustations that could impede proper cooking or attract insects. The deficiency had the potential to affect all 56 residents who consumed food prepared by the facility, as they were exposed to food prepared with inadequately cleaned equipment.
Unsanitary and Unsafe Shower Room Conditions
Penalty
Summary
Surveyors observed that the main shower in the south wing was not maintained in a sanitary or safe condition. Specifically, brown and black spots resembling mold were present on the shower floor and near the drain, and the shower chairs had a ring of red residue built up on the underside of the seat. Additionally, the edge of the shower wall bar was missing an end cap cover, exposing a sharp metal ridge. Facility leadership, including the CRN, DON, and Administrator, acknowledged that the shower was in disrepair, should have been closed, and that proper cleaning between uses and daily deep cleaning had not occurred. These conditions resulted in the shower room not being clean or in good repair, as required.
Inaccurate MDS Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents with serious mental illness diagnoses. For one resident admitted after a fracture with diagnoses including bipolar disorder and generalized anxiety disorder, the medical record contained both a PASRR level I and an abbreviated PASRR level II screening, both identifying serious mental illness. However, the resident's Admission MDS Assessment incorrectly documented 'no' in section A1500, indicating the resident was not considered to have a serious mental illness or intellectual disability, despite the PASRR level II findings. Similarly, another resident with a diagnosis of bipolar disorder had a PASRR level I and an abbreviated PASRR level II screening, both confirming serious mental illness. While the MDS assessment initially reflected this, subsequent annual MDS assessments incorrectly marked 'no' in section A1500, failing to indicate the presence of a serious mental illness as determined by the PASRR level II screening. These inaccuracies were confirmed by the Regional MDS Nurse during staff interviews.
Failure to Complete Timely PASRR Level II Evaluation for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with multiple mental health diagnoses, including major depressive disorder and post-traumatic stress disorder (PTSD), received a timely evaluation through the State's Level II Pre-Admission Screening and Resident Review (PASRR) process. Upon admission, the resident was granted a 30-day PASRR Level II exemption due to medical issues, with instructions to submit updated documentation if the resident remained in the facility beyond 30 days. Despite the resident staying past the 30-day exemption period, the required PASRR Level II submission was not completed at that time. The oversight was later acknowledged by facility staff, who confirmed that the PASRR Level II should have been submitted when the resident's stay exceeded 30 days.
Failure to Complete Required PASRR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a PASRR (Preadmission Screening and Resident Review) was properly completed for a resident with multiple mental health diagnoses. The resident was admitted with Alzheimer's disease, depression, and anxiety, and was documented as having additional mental health conditions such as anxiety, insomnia, and dementia with behavioral disturbances. The resident was prescribed both antidepressant and antipsychotic medications, and her care plan included interventions for behavioral symptoms such as restlessness, agitation, and aggression toward others. Despite these documented mental health issues and behaviors, the PASRR Level I screening from Nevada indicated no mental illness, intellectual disability, related conditions, or dementia, and no referral for further evaluation was made. Further review revealed that the resident's admission MDS assessment documented significant cognitive impairment, hallucinations, delusions, and behavioral symptoms that interfered with social interactions and activities. The resident received antipsychotic medication daily during the assessment period. Staff interviews confirmed that the PASRR Level I was incorrect and that the required PASRR Level I and II screenings for Idaho were not completed upon admission, resulting in the deficiency.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, as required by its own policy. For one resident with diagnoses including schizophrenia, anxiety disorder, and neuroleptic induced parkinsonism, there was no documentation of a baseline care plan in the medical record. Similarly, another resident admitted with low back pain, a right leg fracture, altered mental status, diabetes, and opioid dependence also did not have a baseline care plan documented. The Director of Nursing confirmed that baseline care plans were not completed for these residents.
Failure to Address Edema in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was comprehensively written to address all of her needs, specifically omitting interventions and treatment planning for edema. The resident, who was admitted following a stroke with additional diagnoses of diabetes, hypertension, and COPD, reported increased swelling in her right leg that was only partially relieved by elevating her legs. Despite having multiple physician orders for diuretics to treat edema, the care plan did not include any documentation or interventions related to this condition. The Director of Nursing confirmed that the resident's edema treatment and interventions were not included in the care plan, acknowledging that they should have been.
Failure to Clarify Emergency Seizure Medication Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for one resident with a seizure disorder, dementia with agitation, and right-sided hemiplegia. Record review revealed that the resident had physician orders for two emergency seizure medications—lorazepam oral concentrate and midazolam nasal solution—without clear instructions specifying which medication should be administered first or under what circumstances. The Director of Nursing confirmed that the orders were not specific enough and required clarification, indicating that the lack of clear directions could lead to improper administration of seizure medications.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by multiple incidents involving five residents. In each case, residents received either the wrong medication, the wrong dose, or missed their prescribed medication. For example, one resident with Alzheimer's disease, schizophrenia, and muscle spasms was prescribed lorazepam 0.5 ml twice daily for anxiety but was administered 1 ml on several occasions. Another resident with seizures and alcohol abuse was given another resident's Norco 5-325 mg instead of their prescribed Norco 10-325 mg. Similarly, a resident with arthritis and schizophrenia received another resident's Norco 10-325 mg instead of their own Norco 5-325 mg, and a resident with stroke and diabetes was also given the wrong dose of Norco. Additionally, a resident with schizophrenia, diabetes, and opioid dependence was supposed to receive lorazepam 1 mg daily for anxiety but was instead administered oxycodone 10 mg and did not receive their prescribed lorazepam. These errors were confirmed by the Director of Nursing (DON) through record review and staff interviews. The incidents were documented in Medication Error and Analysis reports, indicating a pattern of medication administration errors affecting multiple residents with complex medical histories.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parke View Rehabilitation & Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Countryside Care & Rehabilitation | 8.6 mi | ★★★★★ | 0 | 0 |
| Oak Creek Rehabilitation Center Of Kimberly | 28.5 mi | ★★★★★ | 27 | 0 |
| Twin Falls Transitional Care Of Cascadia | 32.6 mi | ★★★★★ | 19 | 0 |
| Serenity Transitional Care | 35.3 mi | ★★★★★ | 17 | 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 October 2026) and official state health department websites.