Below average — CMS composite of the measures below.
The next survey window likely opens 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 Dawson Place during CMS and state inspections, most recent first.
Insufficient licensed nurse coverage was identified when staffing schedules showed gaps in 24-hour RN/LPN coverage on two days. Although an administrative nurse reportedly worked the missing time slots, the nurse was salaried and did not clock in, so the facility had no documentation to verify coverage. The facility policy stated licensed nurses and CNAs would be available 24/7.
Failure to Provide a Qualified Dietary Manager: Dietary staff prepared breakfast in the kitchen for 36 residents, and staff verified that the dietary staff member was not a certified dietary manager. The facility’s policy required a qualified dietician or appropriately credentialed food and nutrition services manager to oversee food service operations, but the report documented that the facility did not have a full-time certified dietary manager in place.
Kitchen Food Service Area Not Maintained in Clean and Sanitary Condition: Surveyors observed grey lint on overhead fluorescent light fixtures above the food prep area, grease and fuzzy buildup on air vent grills above the stove and food prep area, and sticky grease and black fuzzy substance on an exhaust vent above the dishwashing area. Fire suppression pipes and spigots were also covered with a fuzzy gray substance. Dietary and maintenance staff both verified the conditions, and dietary staff stated she was unsure who was responsible for cleaning those areas.
Missing EBP Signage for Residents on Precautions: The facility failed to ensure that EBP signage was posted in or near the rooms of four residents on EBP. PPE was present in the rooms, but there was no signage inside or outside the rooms identifying the precautions or the PPE required before care. An RN stated the residents had yellow stickers outside the doors, while another RN stated the rooms should have signs with EBP and PPE information.
A resident with dementia, depression, and severely impaired cognition received antipsychotic meds for insomnia and dementia with agitation, but the EMR lacked a documented physician rationale, including failed nonpharmacological interventions and a risk-versus-benefit statement. The CAA noted the diagnosis was not approved, pharmacy requested a diagnosis for the antipsychotic use, and the resident was observed ambulating independently and expressing confusion about leaving the facility.
A resident with intact cognition and multiple urinary and chronic conditions was transferred to the hospital after becoming febrile, pale, shaky, and unable to stand; the hospital diagnosed sepsis from a UTI. The facility could not produce the required written transfer notice, bed-hold acknowledgment, or LTCO notification, and staff stated they only sent Ombudsman notices for discharges to home or another facility, not hospital transfers.
A resident with Parkinson’s disease, bipolar disorder, and DM had an insulin pump order documented in the EMR, but her care plan did not include staff direction for pump-related care. Surveyors found the care plan addressed depression and diabetic meds, while an RN and another administrative nurse acknowledged the pump information should have been included in the care plan.
The consultant pharmacist failed to complete and document monthly MRRs for multiple residents and did not identify or resolve an inappropriate psychotropic medication indication for a resident receiving Seroquel and Risperdal. One resident with dementia had antipsychotic orders without a documented clinical rationale, while two other residents had multiple months of missing pharmacist reviews. Staff reported the physician responses were not kept in a binder and were only recently being scanned into the EMR.
The facility failed to submit complete and accurate PBJ staffing data. CMS PBJ records showed no 24-hour licensed nurse coverage on several dates, but the facility's daily nursing coverage records showed licensed nurse coverage and adequate staffing. An admin staff member stated HR was responsible for PBJ submission during that period, and the facility policy required accurate staffing data to be reported to CMS through PBJ.
The facility did not conduct necessary nursing competency checks for staff, as confirmed by a CMA, a CNA, and an Administrative Nurse. Despite having a plan for ongoing education and training, the facility failed to implement the competency evaluation program, risking impaired quality of care for residents.
The facility failed to employ a full-time certified dietary manager for its 32 residents, placing them at risk for inadequate nutrition. Dietary Staff BB, who was overseeing meal preparation, was not certified, as confirmed by Administrative Staff A. The facility's policy required a qualified dietitian or certified dietary manager, which was not met.
The facility's kitchen failed to meet professional food service safety standards, as evidenced by moldy green peppers and expired bread found during an inspection. Additionally, cleanliness issues were noted with brownish-black substances on cabinet handles. Staff acknowledged these issues, which violated the facility's Food Storage Policy and placed residents at risk for foodborne illness.
The facility failed to implement Enhanced Barrier Precautions for two residents with medical devices and lacked a water management program for Legionella disease. Staff were unaware of EBP requirements, and there was no clear responsibility for initiating EBP. The maintenance department lacked procedures for managing waterborne pathogens, putting residents at risk.
A resident with chronic pain and bilateral osteoarthritis experienced inadequate pain management due to the facility's failure to implement non-medication interventions and notify the physician about frequent PRN oxycodone use. The resident's care plan lacked specific directions for non-medication pain relief, despite the facility's policy requiring such measures.
The facility failed to ensure nurse aides received the required in-service training hours, with three out of five aides not completing the mandatory 12 hours in the past year. This deficiency was due to inadequate monitoring systems and a lack of regular performance reviews, placing residents at risk for impaired care.
The facility failed to ensure that the Consultant Pharmacist identified and reported the absence of a 14-day stop date for PRN psychotropic medications for two residents. One resident, with multiple diagnoses including dementia, was prescribed lorazepam without a stop date, and another resident with severe cognitive impairment was prescribed Ativan PRN without a stop date. Despite multiple reviews, the Consultant Pharmacist did not make the necessary recommendations, placing the residents at risk for unnecessary medication side effects.
The facility failed to ensure PRN orders for psychotropic medications had a 14-day stop date or specified duration, as required by their policy. This deficiency was identified in three residents who were prescribed antianxiety medications without stop dates, placing them at risk for unintended effects. Despite the facility's policy mandating time-limited PRN psychotropic medications, the orders for lorazepam and Ativan lacked the necessary stop dates, leading to the identified deficiencies.
The facility failed to coordinate hospice care for two residents, leading to inadequate end-of-life care. Both residents had complex medical conditions and were receiving hospice services, but their care plans lacked details on hospice services and coordination with the facility. This deficiency was confirmed by an administrative nurse, highlighting a failure to integrate hospice care into the residents' overall care plans.
A facility failed to effectively implement an antibiotic stewardship program, leading to the inappropriate use of antibiotics for a resident with a history of UTIs. The resident was prescribed cephalexin without recent confirmation of infection signs or symptoms, and the facility's infection preventionists acknowledged a lack of proper documentation and communication with prescribers. Despite the facility's policy to promote appropriate antibiotic use, the deficiency placed residents at risk of unnecessary treatments.
The facility did not offer pneumococcal PCV20 immunizations to three residents as per CDC guidelines, despite having received an initial Pneumovax dose. Interviews revealed that the facility lacked documentation of offers or refusals for further vaccinations, and staff were unsure of the vaccination requirements, relying on the Infection Preventionist for guidance. This failure to follow the facility's policy placed residents at risk of pneumonia.
The facility failed to maintain one of two kitchen ovens in safe and operable condition due to a gas leak that was capped off 1.5 years ago. The Dietary Manager confirmed the issue, but the Administrative Staff was unaware of the oven's condition and the repair list. The facility also lacked a preventative maintenance policy.
Insufficient licensed nurse coverage on scheduled shifts
Penalty
Summary
The facility failed to ensure adequate nursing staff were available every day to meet resident needs and to maintain licensed nurse coverage on each shift. The facility had a census of 36 residents, and the sample included 12 residents. Review of the Facility Assessment, revised 06/23/25, stated the general staffing approach was to ensure sufficient staff were available at any given time, with nursing staff evaluated at the beginning of each shift and adjusted as needed to meet resident care needs and acuity. However, review of the nursing daily staffing schedules from 07/01/24 to 09/29/24 showed that on 08/10/24 and 09/21/24 there was a lack of licensed nurse coverage 24 hours a day. On 10/21/25 at 08:37 AM, Administrative Staff A stated she completed the daily nurse staffing schedules and that Administrative Nurse D worked during the missing time slot on those days, but because Administrative Nurse D was salaried and did not clock in, the facility had no documentation to verify that the nurse worked during the missing time slots. The facility's Staffing, Sufficient and Competent Nursing Policy, revised August 2022, stated licensed nurses and CNAs would be available 24 hours a day, seven days a week to provide competent resident care services.
Failure to Provide a Qualified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for 36 residents who received meals from the kitchen. During observation on 10/20/25 at 08:20 AM, dietary staff were seen preparing the breakfast meal in the kitchen. At 08:30 AM, Dietary Staff BB verified that she was not a certified dietary manager, and she stated the facility had five residents on a mechanical soft diet. On 10/22/25 at 01:00 PM, Administrative Staff A also verified that Dietary Staff BB was not certified. The facility’s undated Dietician policy stated that a qualified, competent, and skilled dietician would help oversee food and nutrition services, and that a food and nutrition services manager would oversee production, storage, and delivery of food. The policy further stated that if a dietician was not employed full-time, the director of food and nutrition services would be designated and would meet specified qualifications, including certification or equivalent credentials and experience. The report documented that the facility did not have a full-time certified dietary manager in place for the residents served from the kitchen.
Kitchen Food Service Area Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation of food preparation, surveyors found three overhead fluorescent light fixtures above the food preparation area with grey hanging lint, three overhead air vent grills above the cooking stove and food prep area covered with brownish grease and a gray fuzzy substance, and an exhaust vent above the dishwashing area covered with brownish-black sticky grease and black fuzzy substance. Multiple fire suppression spigots and connected metal pipes were also observed covered with a brownish, fuzzy gray substance. Dietary Staff BB verified the dirty register grills, dirty exhaust vent, and fuzzy substance on the fire suppression pipes and spigots and stated she had worked at the facility for three months and was unsure who was responsible for cleaning those areas. Maintenance Staff U also verified the overhead fluorescent lights covered with gray lint, the fire suppression pipes and spigots covered with a fuzzy gray substance, and the dirty register grills. The facility’s Sanitization policy stated the food service area is to be maintained in a clean and sanitary manner, and that kitchen and dining areas are to be kept clean and free from garbage, rodents, and insects.
Missing EBP Signage for Residents on Precautions
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) signage was posted in or near the rooms of residents identified as being on EBP. During the initial tour, four residents had PPE inside their rooms, but their rooms lacked signage inside or outside the rooms indicating that they were on EBP or identifying the PPE required before resident care. A facility list provided by the Administrative Nurse documented that four residents were on EBP. During interviews, the Administrative Nurse stated that residents on EBP had a yellow sticker on the trim outside the door and that PPE supplies were available in the rooms, but also stated that the residents should have a sign in their rooms with information about EBP and what PPE should be worn. Another Administrative Nurse stated that the residents did have yellow stickers outside their rooms, but was not certain about the signage aspect. The facility policy stated that signs are posted on the door or wall outside the resident's room and communicate the type of precautions and PPE required.
Unnecessary Psychotropic Medication Use Without Documented Rationale
Penalty
Summary
The facility failed to ensure an appropriate indication and documented physician rationale for a resident’s antipsychotic use, including unsuccessful attempts at nonpharmacological symptom management and a risk-versus-benefit statement for continued treatment. The resident had diagnoses of dementia, depression, and sleep apnea, and the MDS recorded severely impaired cognition, need for staff assistance with most ADLs, and use of antipsychotic and antidepressant medications during the observation period. The psychotropic drug use CAA documented Seroquel 50 mg nightly for insomnia and dementia, but also noted the diagnosis was not approved. The resident’s care plan addressed impaired cognitive function and directed staff to cue, reorient, supervise as needed, administer medications as ordered, and monitor for side effects and effectiveness. Physician orders included Seroquel 50 mg at bedtime for insomnia and later Risperdal 0.5 mg twice daily for dementia with agitation, but the EMR lacked a documented physician rationale for either medication. Pharmacy review requested a diagnosis for the antipsychotic use, and the pharmacist documented that antipsychotic use for dementia behavior is associated with increased mortality and hospitalization; however, the physician response was documented as no change, and later pharmacist review did not address the continued inaccurate diagnosis. Observations showed the resident in the dining room, ambulating independently to the room, and talking about getting out of the facility and not knowing how much longer he could stay.
Failure to Provide Required Transfer Notification and Ombudsman Notice
Penalty
Summary
The facility failed to provide a written notification of transfer to R5 or his representative for all applicable transfers/discharges, failed to ensure the written transfer notification contained the required information, and failed to notify the State Long Term Care Ombudsman of R5’s transfers/discharges. R5’s record showed diagnoses including overactive bladder, chronic kidney disease, malignant neoplasm of the urethra, benign prostatic hyperplasia, urinary incontinence, and hypertension. The Quarterly MDS documented a BIMS score of 15, indicating intact cognition. The care area assessment noted that R5 needed assistance with self-care and mobility and had chronic pain, and the care plan addressed bladder incontinence and a history of urinary tract infections. On 08/19/25, nursing documentation showed R5 was pale, shaking, febrile at 103.6 degrees, with blood pressure of 120/60, heart rate of 108, and oxygen saturation of 90%. He complained of back pain, was incontinent of loose stool, and was unable to stand, requiring a sit-to-stand lift with two staff members for transfer to a wheelchair and then to the hospital after the physician was notified. The hospital documented sepsis from a urinary tract infection and admission to the hospital, and R5 returned to the facility on 08/22/25. Upon request, the facility could not provide a written transfer notification or bed-hold acknowledgment for the hospital transfer, and could not provide documentation that the LTCO was notified of the transfer and return. Staff stated they sent Ombudsman notifications only when residents were discharged to home or another facility, not when transferred to the hospital, and the facility’s policy required written notice to the resident or representative, the State Long-Term Ombudsman, and inclusion of the reason for transfer, effective date, location, and appeal rights.
Care Plan Missing Insulin Pump Interventions
Penalty
Summary
The facility failed to ensure that Resident 3’s care plan was revised and that interventions were implemented to direct staff on care related to her insulin pump. Resident 3’s EMR documented diagnoses of Parkinson’s disease, bipolar disorder, and diabetes mellitus. Her annual MDS documented a BIMS score of 15, indicating intact cognition, and that she required maximal assistance with ADLs and received insulin regularly. Her CAA documented Parkinson’s disease, extensive assistance with all ADLs except eating, use of a sit-to-stand lift, diabetes, an insulin pump, wheelchair use, and dependence on staff to propel the wheelchair. Resident 3’s care plan, revised on 07/17/25, addressed depression related to Parkinson’s disease, medication review, and diabetic medications as ordered, but it did not include staff direction for care related to the insulin pump. Her order summary documented an order dated 03/18/25 for a MiniMed insulin pump with basal rate monitored and adjusted by the endocrinology clinic physician. During survey, Administrative Nurse E stated that the insulin pump was preprogrammed and set by endocrinologists and that the information should be on the care plan and would be added that day. Administrative Nurse D stated that the care plan should have included interventions regarding the insulin pump and that it had been revised that day to address its use and how staff should care for Resident 3 with it.
Missing MRRs and Unresolved Psychotropic Medication Indications
Penalty
Summary
The facility’s consultant pharmacist failed to complete and document monthly medication regimen reviews for all residents receiving medications, and failed to identify and resolve irregularities in psychotropic medication use for one resident. The facility’s policy required the consulting pharmacist to review each resident’s medication regimen at least monthly, review the medical record, and provide a written report of any non-life-threatening irregularity to the attending physician within 24 hours. The facility also required psychotropic medications to have a specific, documented clinical rationale, and stated that diagnosis alone did not necessarily warrant antipsychotic use. For one resident with diagnoses of dementia, depression, and sleep apnea, the record showed orders for Seroquel 50 mg at bedtime for insomnia and Risperdal 0.5 mg twice daily for dementia with agitation. The resident’s MDS documented severely impaired cognition and use of antipsychotic and antidepressant medications. The psychotropic drug use CAA documented Seroquel for insomnia and dementia, but also stated the diagnosis was not approved. The resident’s EMR lacked a documented physician rationale, including unsuccessful nonpharmacological interventions and a risk-versus-benefit statement, for either antipsychotic. The pharmacist’s review on 05/12/25 requested a diagnosis for the antipsychotic use and noted mortality and hospitalization concerns, but later reviews did not address the continued inaccurate diagnosis for the antipsychotic medications. The survey also found missing monthly pharmacy medication regimen reviews for two other residents. One resident with Parkinson’s disease, bipolar disorder, and diabetes had no documented consultant pharmacist reviews for September 2024, November 2024, December 2024, January 2025, and March 2025. Another resident with dementia, hypertension, atrial fibrillation, and depression had no documented consultant pharmacist reviews for September through December 2024 and January and February 2025. Administrative staff stated the emails with physician responses were not printed and kept in a binder, and that staff had only recently started scanning the MRRs into the EMR.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) based on payroll and other verifiable and auditable data. For FY Q4 2024, the CMS PBJ report showed no licensed nurse coverage for 24 hours on 07/07/24, 07/27/24, 07/28/24, 08/11/24, and 09/29/24, despite the facility's daily nursing staff coverage records showing licensed nurse coverage for 24 hours on those dates and indicating adequate licensed nurse coverage. During interview on 10/21/25, Administrative Staff A stated that human resources staff was responsible for submitting PBJ during that period and no longer worked at the facility. The facility's PBJ policy, revised May 2024, stated that complete and accurate direct care staffing information would be reported electronically to CMS through the PBJ system in the format specified by CMS.
Failure to Implement Nursing Competency Checks
Penalty
Summary
The facility failed to conduct or implement necessary nursing competencies for resident care needs, as identified through resident assessments and care plans. This deficiency was identified during interviews and record reviews. A Certified Medication Aide and a Certified Nurse Aide both reported that the facility had not provided any competency skill checks. Additionally, an Administrative Nurse confirmed that no competency checks had been performed with the staff. The facility's June 2024 Facility Assessment outlined a plan for ongoing education and staff training to ensure knowledge competency, which included online training, monthly in-service, peer mentoring, and instructor-led sessions. However, the facility did not implement this competency evaluation program, placing residents at risk of receiving impaired quality of care.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for the 32 residents who resided in the facility and received meals from the facility kitchen. This deficiency was identified during a review and observation of the facility's food and nutrition services. On the specified date, Dietary Staff BB was observed overseeing the preparation of the noon meal, which included baked honey-glazed ham, oven-browned potatoes, seasoned green beans, and Amish sugar cookies. However, it was verified that Dietary Staff BB was not a certified dietary manager, as she had completed the necessary classes but had not yet scheduled the exam. Further investigation revealed that the facility's policy required the employment of a qualified, registered dietitian or other clinically qualified nutrition professional, either full-time, part-time, or on a consultant basis. In the absence of a full-time qualified dietitian, the facility was supposed to designate a certified dietary manager or an individual with similar national certification. Administrative Staff A confirmed that Dietary Staff BB did not hold the necessary certification, which placed the residents at risk for inadequate nutrition due to the lack of a certified dietary manager overseeing the food and nutrition services.
Food Safety Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations in the kitchen. During an inspection, a walk-in refrigerator was found to contain an unlabeled and undated container with 10 green peppers that had a white substance on them, which was identified as mold by Dietary Staff (DS) CC. The staff member acknowledged the issue and discarded the peppers, noting that fresh vegetables were not maintaining their freshness as expected. Additionally, two loaves of whole grain bread with an expiration date that had already passed were found near the walk-in refrigerator. DS DD confirmed the expired bread and discarded it. Further inspection revealed that the upper white metal cabinets above the three-sink area had numerous brownish-black substances around the cabinet handles. Dietary Manager (DM) BB confirmed the cleanliness issue and stated that all staff were responsible for cleaning the kitchen, with specific tasks to be completed daily. The facility's Food Storage Policy, revised in 2016, required that food storage areas be kept clean and that food items be rotated using the first in, first out method, with items dated upon receipt. The failure to comply with these standards placed residents at risk for foodborne illness.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with an indwelling urinary catheter and another with an enteral feeding tube, during direct care contact. Observations revealed that a Licensed Nurse administered medication via a feeding tube and a Certified Nurse Aide emptied a catheter drainage bag without donning the appropriate personal protective equipment (PPE) or displaying signage related to EBP. Administrative staff were unaware of the EBP requirements, and there was confusion about who was responsible for initiating EBP for residents who required it. Additionally, the facility did not have a water management program in place for Legionella disease, which is crucial for preventing the spread of this bacterium through mist in large buildings. The maintenance department lacked information and procedures related to managing waterborne pathogens. The facility's policies outlined the responsibilities of the Infection Preventionist and Maintenance Supervisor in managing infection control and Legionella risk, but these were not effectively implemented, placing residents at risk of contracting or spreading infectious diseases.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as R15, who experienced ongoing pain. R15 had a history of bilateral osteoarthritis, chronic pain, and other medical conditions such as depression and congestive heart failure. The resident's care plan lacked specific directions for non-medication pain relief measures, despite the resident's frequent use of PRN pain medication, particularly oxycodone, which was administered multiple times over several months, primarily during nighttime hours. Observations and interviews revealed that R15 experienced significant pain, particularly in the left knee, which affected mobility and sleep. The resident reported difficulty using a urinal due to balance issues and required assistance from staff. A Certified Nurse Aide noted that R15 frequently complained of pain, especially in the left leg, and informed the charge nurse of these complaints. However, a Licensed Nurse was unaware of the increased use of oxycodone during the night and was unsure of any nonpharmacological interventions in place for R15. The facility's Pain Management policy required that pain management be part of each resident's care plan, including both medication and non-medication interventions. Despite this policy, the facility did not implement non-medication interventions for R15, nor was there evidence that the resident's physician was notified of the frequent use of PRN pain medication. This oversight placed R15 at risk for ongoing pain and impaired quality of life.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to provide regular in-service education based on the outcome of performance reviews and did not ensure that all nurse aides received the required number of in-service training hours per year. This deficiency was identified through a review of employment and in-service records, which showed that three out of five nurse aides employed for at least one year had not completed the mandatory 12 hours of in-service training in the past year. This lack of training placed residents at risk for impaired care. Interviews with facility staff revealed gaps in the monitoring and tracking of in-service training hours. Administrative Nurse D acknowledged having a system to monitor in-service hours, but it was not up to date, resulting in insufficient training hours for nurse aides. Additionally, Administrative Staff A was unaware of the absence of a system to track the completion of in-service hours and confirmed that performance reviews for nurse aides were not conducted regularly. The facility's assessment documented a commitment to providing ongoing education and training to ensure nurse aides' competencies, but this was not effectively implemented, leading to the identified deficiency.
Failure to Ensure Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist identified and reported the absence of a 14-day stop date or specific duration with physician rationale for the as-needed (PRN) psychotropic medications prescribed to two residents, R14 and R33. R14, who had diagnoses including protein-calorie malnutrition, hypertension, chronic kidney disease, anxiety, and dementia with behavioral disturbance, was prescribed lorazepam without a stop date. Despite multiple monthly reviews by the Consultant Pharmacist, no recommendation was made to include a 14-day stop date for the lorazepam, which was a requirement according to the facility's policy. This oversight was confirmed by Administrative Nurse D, who verified the absence of a stop date for the medication. Similarly, R33, diagnosed with an anxiety disorder and severe cognitive impairment, was prescribed Ativan PRN without a stop date. The Consultant Pharmacist's reviews for R33 also failed to identify this irregularity, and no notification was made to the facility regarding the missing stop date. The facility's policy required the Consultant Pharmacist to provide written findings and recommendations to the Director of Nursing and Administrator, which was not done in this case. This failure to adhere to the policy placed both residents at risk for unnecessary medication side effects.
Failure to Implement Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications had a 14-day stop date or specified duration, as required by their policy. This deficiency was identified in the cases of three residents, who were at risk for unintended effects related to psychotropic drug medications. The facility's policy mandates that PRN psychotropic medications be time-limited to fourteen days or less and only for specific, clearly documented circumstances. However, the facility did not adhere to this policy, resulting in the absence of stop dates for the PRN antianxiety medications prescribed to the residents. One resident, with diagnoses including protein-calorie malnutrition, hypertension, chronic kidney disease, anxiety, and dementia, was prescribed lorazepam without a stop date. The resident's care plan noted the use of medications with a Black Box Warning and required monitoring for respiratory depression and sedation. Despite these considerations, the PRN lorazepam order lacked a stop date, which was confirmed by the Administrative Nurse. Another resident, diagnosed with conditions such as congestive heart failure, mood disorder, and anxiety, was also prescribed Ativan without a stop date. This resident was under hospice care, and the order for Ativan came from hospice, but the facility failed to ensure compliance with the stop date requirement. A third resident, with a diagnosis of anxiety disorder and severe cognitive impairment, was similarly prescribed Ativan without a stop date. The facility's failure to identify and report the absence of stop dates for these PRN medications placed the residents at risk for unnecessary medication use and related complications. The facility's policy clearly outlined the need for time-limited PRN psychotropic medication orders, yet this was not implemented, leading to the identified deficiencies.
Lack of Coordinated Hospice Care Plans for Residents
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents, R14 and R16, who were receiving hospice services. For R14, the electronic health record indicated diagnoses including protein-calorie malnutrition, hypertension, chronic kidney disease, anxiety, and dementia with behavioral disturbance. Despite being admitted to hospice care, R14's care plan lacked instructions on the services provided by hospice, such as staff visits, supplies, medical equipment, and medications. The facility did not have a hospice care plan that coordinated with the facility's care plan, as confirmed by Administrative Nurse D. Similarly, R16, who had diagnoses including congestive heart failure, edema, mood disorder, dementia, anxiety, and respiratory failure, was also receiving hospice care. R16's care plan documented the need for monitoring signs of pain or distress and notifying hospice staff if interventions were ineffective. However, like R14, the care plan lacked details on hospice services, and there was no evidence of coordination between the facility and hospice provider. Administrative Nurse D confirmed the absence of a coordinated hospice care plan for R16. The facility's Hospice Policy and Procedure policy outlined the responsibilities of both the nursing facility and hospice in coordinating care, but this was not reflected in the care plans for R14 and R16. The lack of coordination placed both residents at risk for inappropriate end-of-life care, as the facility did not have a system in place to ensure that hospice services were integrated into the residents' overall care plans.
Inadequate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently utilize an antibiotic stewardship program, which led to the inappropriate use of antibiotics for a resident, identified as R17. R17's medical history included major depressive disorder, Parkinson's disease, schizoaffective disorder, a personal history of urinary tract infections (UTIs), and diabetes mellitus. The resident's care plan required extensive assistance with daily living activities and included the use of an external urinary catheter. Despite the resident's history of UTIs, there was no documented rationale for the ongoing use of prophylactic antibiotics, specifically cephalexin, which was prescribed without recent confirmation of infection signs or symptoms. The facility's infection preventionists (IPs) explained that the antibiotic stewardship process began with floor nurses identifying changes in a resident's condition. However, the process lacked proper documentation and communication with prescribers, leading to the continued use of antibiotics without meeting the criteria for an infectious process. The IPs acknowledged that the information was brought to the monthly risk/quality assurance meeting but did not result in further action from the facility or prescribers. This lack of action and documentation contributed to the deficiency in the antibiotic stewardship program. The facility's Antibiotic Stewardship Program policy aimed to promote appropriate antibiotic use and reduce adverse events and resistance. However, the facility failed to implement an effective system to assess the appropriateness of antibiotic usage, placing residents at risk of unnecessary treatments. The deficiency was highlighted by the continued prophylactic use of antibiotics for R17 without a documented risk versus benefit statement from the physician, despite suggestions from the pharmacy consultant to consider alternative treatments.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal PCV20 immunizations to three residents, identified as R3, R4, and R19, in accordance with the guidance from the Centers for Disease Control and Prevention (CDC). This oversight was discovered through interviews and record reviews, revealing that the facility did not document whether these residents were offered or refused further pneumococcal vaccinations after receiving an initial Pneumovax dose. Specifically, R3 received a Pneumovax dose on 10/09/18, while R4 and R19 received theirs on 04/12/22, with no subsequent offers or documentation of additional vaccinations. During interviews, Administrative Nurses E and F confirmed that the three residents had not been offered a second pneumonia immunization since their admission, nor had the facility screened them for eligibility for a second dose. Additionally, Administrative Nurse D admitted to being unsure of the pneumococcal vaccination requirements, expecting the Infection Preventionist to manage and provide the necessary immunizations. The facility's policy, last revised in 2010, stated that all residents should be provided with appropriate information to make an informed choice about receiving vaccines, and that pneumococcal immunizations should be offered unless medically contraindicated or previously administered. The failure to adhere to these guidelines placed the residents at risk of acquiring pneumonia.
Kitchen Oven Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that one of two kitchen ovens was in safe and operable condition. During an observation, it was revealed that one oven in the kitchen was not working due to a gas leak, which had been capped off approximately 1.5 years ago. The Dietary Manager confirmed the oven's non-operational status and mentioned it was on a list to be replaced. However, the Administrative Staff was unaware of the oven's condition and the existence of a kitchen repair list. Additionally, the facility did not provide a preventative maintenance policy, indicating a failure to maintain all mechanical, electrical, and resident care equipment in safe operating condition.
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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 Hill City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sheridan County Hospital Ltcu | 17 mi | ★★★★★ | 21 | 0 |
| Trego Co-lemke Memorial Hospital Ltcu | 23.9 mi | ★★★★★ | 1 | 1 |
| Logan Manor Community Health Services | 24.9 mi | ★★★★★ | 19 | 0 |
| Solomon Valley Manor | 30.8 mi | ★★★★★ | 0 | 0 |
| Redbud Village | 30.9 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.