Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Assumption Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a care plan for a mechanical lift with two staff assistance fell during a bed-to-wheelchair transfer when an EZ Way sling strap was not secured to the lift. The resident’s care sheet listed a medium sling, but staff used a small sling, and the resident slid out of the sling and struck the head on the floor. Interviews and records showed the resident had extensive transfer needs, the sling assessment was not documented, and staff later described the need to verify sling size and secure all loops before moving the resident.
A facility failed to provide dignified dining assistance for 5 residents who needed help eating. Staff were observed standing beside or over residents in wheelchairs while feeding them instead of assisting at eye level, including residents with impaired cognition, advanced dementia, weakness, and neurological decline. Interviews showed aides routinely stood during meal assistance, while the RN CM and DON stated eye-level feeding was expected and that standing over residents was not dignified care.
Failure to Offer PCV20 to Eligible Residents: The facility did not offer PCV20 to four residents who had signed consent for pneumococcal vaccination and had medical conditions placing them at increased risk for pneumococcal infection. Record review showed no documentation that PCV20 was administered or offered, and the IP later confirmed through the PneumoRec App that each resident should have been offered the vaccine. The DON stated residents with signed consent were expected to be offered the vaccine unless there was a contraindication or refusal.
Failure to report a mechanical lift fall as potential neglect: A resident with severe cognitive impairment and multiple diagnoses required a mechanical lift with 2-person assist and a medium sling per care plan, but the record lacked evidence of a sling assessment. During a bed-to-wheelchair transfer, the resident slipped from the sling when a shoulder strap was not attached, fell to the floor, and sustained a head abrasion. The facility investigated and determined a small sling had been used, but the ED stated the event was not reported to the SA because it was not viewed as abuse or neglect.
A resident with heart failure, HTN, renal failure, DM, dementia, hemiplegia, seizure disorder, anxiety, bipolar disorder, and an implanted pacemaker had no care plan problem, goal, or intervention related to the pacemaker. The care plan did not address heart rate or rhythm monitoring, signs of pacemaker malfunction, activity precautions, emergency response considerations, or symptoms staff should report. Routine VS were documented, but there was no evidence of pacemaker-specific monitoring, and the ADON and DON confirmed the pacemaker should have been included in the care plan.
Delayed Assistance With Eating: A resident who required total assistance with eating due to impaired cognition was left with breakfast in front of her for an extended period before staff helped her. Her meal became cold and congealed before an unidentified nurse briefly assisted with Jello and an NA later fed her cold oatmeal. The CM and DON stated dependent residents should be assisted as soon as meals are delivered.
A resident with HTN, hydrocephalus, respiratory bronchiolitis interstitial lung disease, and DM had documented consent for the 2025-2026 COVID-19 booster, but the facility did not administer it and had no documentation explaining why it was not given. The immunization record showed the last COVID-19 vaccine was received outside the facility, and the IP and DON both confirmed the booster should have been given after consent.
A resident with intact cognition and requiring assistance with ADLs was injured during a transfer using a Hoyer lift when a strap came undone, resulting in a fall and fractured clavicle. The incident was due to operator error, as staff failed to ensure the sling straps were properly secured under the retainer clip, despite facility policy and manufacturer's guidelines emphasizing this requirement.
A resident with moderate cognitive impairment reported being handled roughly by a staff member, expressing fear of the alleged perpetrator. The incident was reported to the facility's social worker immediately, but the facility delayed reporting to the State Agency, exceeding the required two-hour timeframe. Interviews with staff indicated the incident was initially misclassified as a customer service issue, leading to the reporting delay.
Mechanical lift transfer failure
Penalty
Summary
The facility failed to ensure the correct sling size was used and that the straps on an EZ Way sling were secured to the mechanical EZ Way smart lift during a transfer of a resident who required extensive assistance with two-person transfers and had severely impaired cognition. The resident’s care plan directed use of a mechanical lift with two staff assistance, and the care sheet identified a medium sling. The resident weighed 124.8 lbs, and the EZ Way instructions stated that residents weighing 90-220 lbs should use a medium sling. The resident’s record did not contain evidence that a sling assessment had been completed. During the transfer from bed to wheelchair, staff reported that the straps were connected to the lift hooks and the bottom strap was crossed between the resident’s legs, but once the resident was suspended in the air, they noticed the strap by the resident’s left shoulder was not attached to the lift. The resident then slipped out of the sling and fell to the floor, striking the right posterior side of the head and sustaining an abrasion. The fall investigation stated no unsafe practices occurred in the reenactment, while the ADON determined staff had used a small sling instead of the medium sling listed on the care plan. Staff interviews showed that the facility had trained staff on the mechanical lift and later provided additional retraining after the fall, including review of correct sling size and secure strap placement. Multiple staff described the need to verify that the loops were secured and to pause after lifting a resident slightly to confirm stability. The lift representative also stated staff needed to ensure the straps were connected and the correct sling size was used. The incident was treated as an Immediate Jeopardy event because the resident slid out of the sling and fell during the transfer.
Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure staff assisted residents with eating in a manner that supported dignity for 5 of 5 residents reviewed for dining assistance: R2, R13, R43, R44, and R51. During observations of the evening meal on 11/18/25 and the breakfast meal on 11/19/25, staff were observed standing next to residents seated in wheelchairs in the dining room while helping them eat, rather than assisting at eye level. For R2, an unidentified nurse assisted with Jello while standing beside her, and NA-J later assisted with oatmeal while standing directly over her and leaning down to place the spoon in her mouth. For R13, NA-H assisted with breakfast while standing upright at the side of the wheelchair, and R13 looked upward toward the aide during each bite. For R43, NA-K assisted with eating while standing throughout the interaction. For R44 and R51, NA-I and NA-J were also observed assisting while standing and did not lower themselves to the residents’ level. Record review showed R2 and R13 required extensive assistance with eating due to impaired cognition; R43 required assistance due to physical decline and advanced dementia; R44 required assistance due to left-sided weakness and impaired cognition; and R51 required assistance due to normal pressure hydrocephalus, weakness, and impaired cognition. Staff interviews confirmed that aides routinely stand next to residents when assisting with meals, while the RN Clinical Manager and DON stated staff were expected to assist at eye level and that standing over residents was not dignified care. The facility policy stated residents who cannot feed themselves will be assisted with attention to safety, comfort, and dignity.
Failure to Offer PCV20 to Eligible Residents
Penalty
Summary
The facility failed to ensure the pneumococcal conjugate vaccine (PCV20) was offered to 4 of 5 residents reviewed for pneumococcal immunization. Each of the four residents had signed consent for pneumococcal vaccination, but the facility did not assess eligibility or offer PCV20 in accordance with CDC and facility immunization guidelines. Review of the records for the four residents showed no documentation that PCV20 had been administered and no evidence that it had been offered, despite prior pneumococcal vaccination histories that included PPSV23 or PCV13 and no follow-up vaccination documented. The affected residents had diagnoses that placed them at increased risk for pneumococcal infection, including metabolic encephalopathy, type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease, vascular parkinsonism, hypertension, respiratory bronchiolitis interstitial lung disease, hypertensive chronic kidney disease, acute pyelonephritis, severe sepsis with septic shock, heart failure, and cerebral infarction. During interview, the Infection Preventionist stated she reviewed immunizations quarterly and used the PneumoRec App, but after entering the residents' information confirmed all four should have been offered PCV20. She stated she had not fully read the guidance and acknowledged that residents who signed consent should have been offered the vaccine. The DON stated the expectation was that residents with signed consent must be offered the vaccine unless a contraindication or refusal occurred. The facility policy referenced pneumococcal vaccines according to CDC recommendations, but it only listed PPSV23 and PCV13.
Failure to Report Mechanical Lift Fall as Potential Neglect
Penalty
Summary
The facility failed to report to the State Agency a fall involving a mechanical lift transfer that was identified as an incident that may indicate potential neglect. R13 had severely impaired cognition, required extensive assistance with two staff for transfers, and had diagnoses including progressive supranuclear ophthalmoplegia, unspecified dementia with psychotic disturbance, and type II DM with other circulatory complications. R13’s care plan directed use of a mechanical lift with two staff assistance, and the care sheet indicated a medium sling, but the medical record lacked evidence that a sling assessment had been completed. During the transfer from bed to wheelchair using an EZ Way smart lift, staff reported that the straps were connected and the resident was lifted into the air when the strap by the left shoulder was found not attached to the lift. R13 slipped out of the sling and fell to the floor, striking her head and sustaining an abrasion to the posterior right side of the head. The facility investigated the event and determined staff had used a small sling instead of the medium sling in the care plan, but the executive director stated the incident was not reported to the SA because the facility concluded there was no abuse or neglect concern and the injury did not require treatment.
Pacemaker Not Addressed in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and maintained for a resident with a cardiac condition and an implanted pacemaker. The resident’s quarterly MDS identified moderate cognitive impairment and the need for assistance with ADLs. The resident’s diagnoses included non-traumatic brain dysfunction, heart failure, hypertension, renal failure, diabetes mellitus, non-Alzheimer’s dementia, hemiplegia, seizure disorder, anxiety disorder, and bipolar disorder. The MDS also identified that the resident had a pacemaker. Review of the resident’s individualized care plan, printed on 11/20/25, showed no care plan problem, goal, or intervention related to the pacemaker. There was no documentation addressing monitoring of heart rate or rhythm concerns, signs of pacemaker malfunction, activity precautions, emergency response considerations, or the need for staff to report symptoms such as dizziness, syncope, palpitations, or chest discomfort. Review of the resident’s vital sign flow sheets for June through October 2025 showed routine vital signs were documented, but there was no evidence of monitoring specifically associated with pacemaker function or related cardiac assessments. Provider orders included ongoing amlodipine, but there were no corresponding care plan interventions for enhanced monitoring, reporting parameters, or recognition of complications. The ADON and DON both confirmed during interviews that the pacemaker should have been addressed in the care plan.
Delayed Assistance With Eating
Penalty
Summary
The facility failed to ensure timely and adequate assistance with eating for one dependent resident who required total assistance with ADLs due to impaired cognition. The resident’s quarterly MDS identified impaired cognition, and the care plan directed staff to provide total assistance with eating. The resident’s diagnoses included neurocognitive disorder with Lewy bodies, arthritis, non-Alzheimer’s dementia, and anxiety disorder. During breakfast observation, the resident was seated in the dining room with oatmeal, Jello, and juice placed in front of her at 8:35 a.m., but no staff approached to assist her for nearly 20 minutes. By 8:51 a.m., the food was visibly cooled and congealed. At 8:54 a.m., an unidentified nurse assisted the resident with Jello and then left the oatmeal in front of her. At 8:59 a.m., NA-K began assisting the resident with the bowl of cold oatmeal, which appeared thick and stiff when stirred. NA-K stated the unit was short-staffed and she did not get to the resident in time, and acknowledged the resident needed to be fed immediately after the meal was served. The CM and DON stated dependent residents should be assisted first and as soon as meals were delivered, and the DON stated the resident should not have been waiting that long.
Missed COVID-19 Booster After Documented Consent
Penalty
Summary
The facility failed to ensure a COVID-19 booster vaccination was administered for one resident who had provided written consent for the 2025-2026 booster. Record review showed the resident had diagnoses including hypertension, hydrocephalus, respiratory bronchiolitis interstitial lung disease, and diabetes mellitus. The COVID-19 Vaccine Consent/Declination form dated 9/18/25 showed consent was signed by the resident’s representative, but the form lacked a facility nurse signature. Review of the Immunization Record and Vaccine Administration Log for September, October, and November 2025 showed no documentation that the resident received the booster. The immunization record showed the last COVID-19 vaccine was received on 11/15/22 outside the facility. During interviews, the Infection Preventionist stated the resident should have received the booster and that there was no documentation of any reason it was not given. The DON stated that if a resident consents, the booster must be given unless there is a clear medical reason not to, and acknowledged that the facility missed it. The facility policy stated eligible residents were to be offered the COVID-19 vaccination and booster doses when available.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper use of a full body mechanical lift according to the manufacturer's recommendations, resulting in actual harm to a resident. The resident, who had intact cognition and required assistance with all activities of daily living, was being transferred from bed to wheelchair using a Hoyer lift by two nursing assistants. During the transfer, the right bottom strap of the sling came undone, causing the resident to fall and sustain a fractured clavicle. The incident occurred when one nursing assistant placed the sling under the resident and the other assisted with the transfer. The nursing assistant operating the lift controls did not ensure that the straps were properly secured under the retainer clip, leading to the strap becoming unsecured during the lift. The lift and sling were inspected after the incident, and no defects were found, indicating that the issue was due to operator error. Interviews with the staff involved revealed that the nursing assistants did not double-check the securement of the straps before lifting the resident. The facility's policy and the operator's manual both emphasize the importance of ensuring that all sling loops are properly nested in the hooks and secured with retainer clips before lifting. The failure to adhere to these guidelines directly contributed to the resident's fall and injury.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse immediately to the State Agency (SA) as required. The incident involved a resident with moderate cognitive impairment, who reported being handled roughly by a staff member during a routine care procedure. The resident expressed fear of the alleged perpetrator and reported the incident to the licensed social worker immediately. However, the facility did not report the incident to the SA until three days later, which was beyond the required two-hour timeframe for reporting suspected abuse. Interviews with facility staff, including the social services director, registered nurse manager, and director of nursing, revealed that the incident should have been reported immediately or within two hours. The director of nursing acknowledged that the incident was initially perceived as a customer service issue rather than potential abuse, leading to the delay in reporting. The facility's policy mandates that suspected abuse be reported to the SA within two hours, but this protocol was not followed in this case, resulting in a deficiency.
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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 Cold Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Watkins | 9.5 mi | ★★★★★ | 0 | 0 |
| Sterling Park Health Care Center | 12.5 mi | ★★★★★ | 0 | 0 |
| Benedictine Living Community Mother Of Mercy | 14.2 mi | ★★★★★ | 10 | 1 |
| Cura Of Paynesville | 14.7 mi | ★★★★★ | 4 | 0 |
| St Benedicts Care Center | 16.1 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 August 2026) and official state health department websites.