Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Colonial Manor Nursing Home during CMS and state inspections, most recent first.
RN coverage was not maintained for 8 consecutive hours a day, 7 days a week on multiple reviewed days. Records showed one day with no RN coverage and other days when the RN worked only part of the required shift. The HUC said he managed the schedule and the case manager covered call-offs, while the DON said she or the case manager would provide RN coverage when needed.
Unqualified Dietary Leadership: The facility failed to designate a qualified person to direct food service in the absence of a full-time RD. The DM stated she was not yet certified, had only SERV Safe certification, and had previously worked as the main cook before taking the DM role. The contracted RD came to the facility weekly to complete MDS assessments, review menus, and assist the DM, while the admin and regional director believed the DM's experience met the requirement even though she had not started the required certification coursework.
Unsanitary kitchen surfaces and food equipment were observed throughout the dietary area. Exhaust vents had heavy dust and grease buildup, a milk cooler had dried liquid and food residue, a stand mixer had splattered residue, a plexiglass barrier behind the range had grease and dust, and a table-mounted can opener had black buildup around the blade. The DM and administrator acknowledged that cleaning schedules had not been implemented and that routine cleaning was not being done.
Inaccurate PBJ staffing data was submitted to CMS when the facility’s report showed multiple days without 24-hour licensed nursing coverage, even though timecard punches showed licensed staff were on duty each shift on those days. The regional director of skill operations said the facility had not been without 24 hours of licensed nursing staff, and the business office manager confirmed she was responsible for PBJ submission and found that one full-time LPN was not pulling from the payroll system into the PBJ report, resulting in inaccurate reporting.
QAPI meeting minutes and quality improvement projects lacked measurable goals, action plans, and analysis of the data presented. Dietary concerns, weight variance data, skin concerns, and call light response times were discussed, but the minutes did not document clear goals or review of trends. The QA director, regional administrator, and administrator acknowledged the QAPI documentation was lacking structure and did not reflect the concerns brought to the committee through surveys, grievances, resident council, and staff reports.
QAPI Infection Control Reporting Deficiency: The facility failed to ensure the IP provided a thorough infection control report to QAPI. Quarterly QAPI records contained only sign-in sheets and agendas, with no minutes, and the IDON, who was serving as the IP, stated she did not track, analyze, or report staff illness in QAPI. The regional administrator acknowledged the IDON was not certified for infection control and had taken on IP duties after the prior IP left.
Incomplete staff illness surveillance and return-to-work tracking: The facility did not consistently document staff illness details needed to determine when an LPN, an NA, and the HUC could return to work after symptoms such as sore throat, fever, nausea, vomiting, chills, headache, and body aches. The logs lacked key information including symptom onset and resolution dates, eligible return-to-work dates, and actual return dates, and the IP stated she was not overseeing staff illness to the extent she should have been.
Unqualified Acting Infection Preventionist: The facility designated the IDON as the IP responsible for the infection prevention and control program, but she had not completed specialized IP training and could not provide a certificate of completion for an approved course. The administrator and regional administrator confirmed she was not certified for infection control, and the IP job description did not require IP certification or enrollment in a certification program upon hire.
Failure to Monitor Antibiotic Use and Complete Antibiotic Time-Outs: The facility did not have an effective antibiotic stewardship program with protocols and a system to monitor antibiotic use. Three residents received antibiotics for UTI or aspiration pneumonia, and the IC antibiotic stewardship log did not show antibiotic time-outs for any of them. One resident received Augmentin for longer than ordered, and the infection preventionist stated antibiotic time-outs were not being completed.
A resident was not given timely beneficiary notice before Medicare Part A skilled services ended. The resident signed both the SNF ABN and NOMNC on the same day services ended, leaving no adequate time to appeal or request an independent Medicare review. The regional administrator stated residents were expected to receive 2-day notice before Part A skilled services ended, but no policy was provided.
Missing Discharge Summary Documentation: The facility failed to complete a discharge summary for a resident with moderately impaired cognition who was independent with care and participated in ST, OT, and PT. Staff documented the resident's discharge plans, reviewed discharge information, and faxed orders to the pharmacy, but the recapitulation of stay section on the Transition of Care/Discharge Summary form was left blank and no discharge summary was documented in the progress notes.
Unsecured Areas Accessible to Wandering Resident: A resident with severe cognitive impairment, Alzheimer's disease, dementia with agitation, and a history of falls was observed repeatedly wandering in her wheelchair, attempting to open doors, and moving toward exit areas and other residents' spaces. She was also found near unsecured doors leading to therapy, the kitchen, and a gate with easy reach to basement stairs. Staff confirmed the wander guard only alarmed and did not secure the doors, and the area was not within view of the nursing station or monitored off-hours.
Daily staffing postings failed to include the resident census on every day reviewed. A posted staffing form in the entry area had the facility name, date field, and shift staffing information, but the census section was blank. RN-A was unaware of the current census and asked TMA-A, who checked the EHR and reported the census was 26. The business office manager stated the night nurse completed the form and it was supposed to include the current census, but review of the postings showed the census was left blank each day.
Failure to offer updated pneumococcal vaccinations was identified for two residents. Both had prior PPSV23 and PCV13 immunizations, but their records showed no indication the facility offered PCV20 or PCV21 on admission or during their stay. The IP stated she was not aware the residents were eligible for additional vaccines per CDC guidance, despite the facility policy requiring vaccination review based on CDC recommendations.
The facility failed to ensure the dietary manager was certified to oversee nutrition and food services in the absence of a full-time RD, potentially affecting all 25 residents. The DM, employed since December 2023, was not certified and had not started certification classes. The administrator was aware but believed weekly RD visits were adequate until certification was obtained.
The facility failed to submit accurate staffing data to CMS for Q3 2024, indicating insufficient licensed nursing coverage on multiple days. Despite schedules and timecards showing coverage, the PBJ report triggered a deficiency. Staff responsible for data entry could not identify the cause, and the facility followed CMS policy.
The facility failed to ensure the acting infection preventionist (IP) had completed specialized training, affecting all 25 residents. The DON, who started in July 2024, had only completed one module of the CDC course, while RN-A, the MDS coordinator, had no training. Both were enrolled in the necessary courses, but the facility lacked a trained IP, contrary to its Infection Prevention and Control Program requirements.
The facility failed to implement a process for reviewing antibiotic use, affecting several residents. Infection control logs lacked information on antibiotic dosages and infection resolution. The newly assigned Infection Preventionist had not started training, and the facility's policies on antibiotic stewardship were not adequately enforced.
A resident with moderately impaired cognition reported missing handkerchiefs and shirts, but the facility failed to follow its grievance process. Despite informing staff, no formal report was completed, and confusion among staff about the procedure was evident. The absence of a social worker and a missing belongings binder contributed to the breakdown in handling the grievance.
A facility failed to accurately code a resident's hospice status on the MDS assessment. The resident, with diagnoses of protein-calorie malnutrition and receiving palliative care, was enrolled in hospice care, but this was not reflected in the quarterly MDS. The MDS nurse acknowledged the oversight after reviewing the resident's EMR and admitted to inadvertently missing the hospice status. The facility's policy for MDS accuracy was requested but not provided.
A facility failed to update a resident's care plan to include hospice care, despite the resident being enrolled in hospice services. The resident had diagnoses of protein-calorie malnutrition and was receiving palliative care. Although a provider had ordered hospice admission and the hospice agency confirmed enrollment, the care plan did not reflect these services. The MDS nurse acknowledged the oversight, which was contrary to the facility's care planning policy requiring updates with any changes.
A resident was discharged without a complete recapitulation of stay, as required by facility policy. The resident, with conditions including a pressure ulcer and paraplegia, was discharged home with their spouse. Despite discharge orders being reviewed, the medical record lacked a discharge summary due to staff turnover and lack of awareness by the MDS coordinator.
The facility failed to accurately monitor and document the weights of two residents, leading to a deficiency in providing adequate nutrition. One resident experienced significant weight loss without proper documentation or physician notification, while another had inconsistent weight records that were not addressed. The facility's policy for weight monitoring was not followed, contributing to the deficiency.
A facility failed to follow enhanced barrier precautions (EBP) for a resident with a urinary ostomy. The resident required assistance for daily activities, including toileting. An NA was observed assisting the resident without donning the required PPE, despite an EBP sign on the door. The NA believed PPE was unnecessary as she did not touch the resident directly. The DON confirmed that the facility's policy required PPE during toileting for residents under EBP, and the infection preventionist noted that EBP had been reviewed in a staff meeting attended by the NA.
The facility failed to document and administer pneumococcal and influenza vaccines for residents, despite having policies in place. A resident's record lacked documentation of receiving vaccines or education on risks/benefits, while another resident's record showed consent but no administration of the influenza vaccine. The RN confirmed delays in obtaining consents and that no influenza vaccines had been given, despite availability.
A facility failed to report a verbal abuse allegation involving a resident to the administrator and State Agency (SA) in a timely manner. The incident, where a nursing assistant allegedly threatened a resident, was delayed in reporting due to the absence of key staff and unsuccessful attempts to delegate reporting duties. The facility's policy requires immediate reporting, but the incident was not reported to the SA until the following day.
The facility failed to provide sufficient staffing, resulting in delayed assistance with personal care needs for several residents. Residents reported extended wait times for toileting and other care, leading to incontinence and missed baths. Staff interviews confirmed the shortage, and administration acknowledged the issue but lacked a process to track call light response times.
A resident with severe cognitive impairment and Alzheimer's disease experienced a change in their ADLs, including coughing or choking during meals and weight loss. Despite these changes, the care plan was not updated to include the Speech Language Pathologist's orders for staff assistance with feeding and cues to sit up. Interviews with staff confirmed the resident ate better with assistance, but the care plan remained unchanged, leading to a deficiency.
A resident entered the facility without a pressure ulcer but later developed one due to inadequate assessment and intervention. The facility failed to update the care plan, conduct comprehensive assessments, and follow physician orders for dressing changes. The resident was not placed on the wound clinic list, and the facility's actions did not align with their policy to prevent and treat pressure ulcers.
A resident with severe cognitive impairment experienced a decline in continence due to the facility's failure to implement an effective toileting program. Despite being identified as a good candidate for retraining, the resident's care plan was not consistently followed, and no causal analysis was conducted. The DON acknowledged the decline but lacked a treatment plan, contributing to the deficiency.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to have an RN on duty for 8 consecutive hours a day, 7 days a week for 3 of 18 days reviewed. Record review showed that on 11/15/25 the RN worked only 4.5 hours, on 7/4/25 there was no RN coverage for the day, and on 8/2/25 the RN worked only 6.25 hours. During an interview on 1/28/26, the health unit coordinator stated he was responsible for the schedule and for ensuring an RN worked 8 consecutive hours each day, and that if there was a call-off the case manager was responsible for covering the RN shift; he confirmed no RN worked on 7/4/25. During an interview on 1/29/26, the DON stated the health unit coordinator was responsible for the schedule and would notify her if an RN was not scheduled, and that the case manager or the DON would provide RN coverage when needed. The facility policy reviewed in April 2025 stated that a licensed nurse was to be on duty 24 hours a day, 7 days per week, and that an RN would be scheduled to work 8 consecutive hours in a 24-hour period, 7 days a week.
Unqualified Dietary Leadership
Penalty
Summary
The facility failed to designate a qualified person to serve as the director of food service to oversee the dietary department in the absence of a full-time dietitian. During interview, the dietary manager stated she was not yet certified and was waiting for direction on what courses she needed to complete to obtain certification. She reported that she had SERV Safe certification and had previously worked as the main cook before taking the dietary manager position, but she had not had anyone work alongside her to provide training in her new role. The contracted RD reported that she came to the facility once a week on Tuesdays to complete MDS assessments, review menus, and assist the dietary manager. She stated that the dietary manager completed the initial resident interviews to determine preferences and general information documented in the record. The administrator and regional director stated they believed the dietary manager's years of experience met the requirement for the certified dietary manager position, but they confirmed she had not started the required certification coursework as of the survey date. A policy for management of the dietary department was requested but not provided by the end of the survey.
Unsanitary kitchen surfaces and food equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen and food preparation area. During observation with the dietary manager, two rectangular exhaust vents above the doors on the dining room side of the kitchen were covered with a black, thick, furry appearing substance and were pointed toward the stove and food preparation areas. Vents on the refrigerator and freezer on the same side of the kitchen had a thick layer of dust that was being moved by circulating air. A chest-type milk cooler had dried red liquid on the inside seal along with dirt and food residue, and dried red liquid was also noted on the floor, along the base of the refrigerator, and splattered on the lower portion of the refrigerator. The dietary manager identified the dried liquid as juice that had spilled the day before and had not been cleaned up. Additional observations showed a stand mixer with orange-colored residue splattered on the frame and head, which the dietary manager identified as food residue but could not identify further and did not know when it had last been used. A metal rack behind the electric range and hood, with a plexiglass barrier behind it, contained spatters of grease and dust from the range, and the dietary manager stated the barrier should have been cleaned daily but had not been. Exhaust vents facing the rack behind the range and over the doors on the opposite end of the kitchen also had an accumulation of dust and grease. A table-mounted can opener had black buildup surrounding the blade, which would contact the inner surface of a can, and the dietary manager identified it as food residue and stated it needed to be put in the dishwasher for cleaning. The dietary manager and administrator both acknowledged the need for cleaning schedules, and the dietary manager stated she had begun preparing them but had not implemented them at the time of survey.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to submit accurate PBJ staffing information to CMS for 1 of 4 quarters reviewed, specifically quarter 4. Review of the 2025 quarter 4 PBJ Staffing Data Report 1705D showed multiple dates on which the report indicated the facility did not have licensed nursing coverage 24 hours a day, including several Fridays, Saturdays, and Sundays across July, August, and September 2025. However, review of the facility staff timecard punches for those dates showed that licensed staff were actually on duty each shift on each day identified in the report. During interview, the regional director of skill operations stated there had been PBJ issues at each of the facilities she consulted and said the facility had not been without 24 hours of licensed nursing staff, but she was unsure why the issue had triggered. The business office manager confirmed she was responsible for submitting the PBJ data and said she had not previously reviewed the 1702D report until it was requested during the survey. She found that one full-time LPN was not pulling from the payroll system into the PBJ report and stated that this LPN worked most of the days in question. She also confirmed that inaccurate PBJ reporting had been completed.
QAPI Minutes Lacked Measurable Goals and Data Analysis
Penalty
Summary
The facility failed to ensure that data submitted to the QAPI committee for improvement activities included a developed measurable goal, an action plan to reach the goal, and analysis of the data collected on the improvement activities. Review of quarterly QAPI meeting minutes showed that the committee discussed dietary concerns, including malnutrition, at-risk of malnutrition, supplements, fluid restrictions, modified diets, low BMI, high BMI, and weight loss, along with a weight variance report listing residents’ names, weights, BMI, and weight changes. However, the minutes did not identify any goal, action plan, or analysis of the information presented. Subsequent QAPI meeting minutes again listed dietary-related concerns, including residents with malnutrition, at-risk of malnutrition, supplements, fluid restrictions, modified diets, low BMI, high BMI, and weight loss, but still did not include a measurable goal, action plan, or analysis of the data. Later meeting minutes listed topics such as infection control updates, COVID-19 updates, audits, accident/incident reports, pharmacist consultant reports, medication errors, antibiotic stewardship, quality improvement projects, social service report, dietary report, environmental services, and pressure ulcer, but there was no documentation of new concerns brought forward or any indication that the committee reviewed or analyzed the previously identified concerns. Review of the facility’s 2025 through 2026 quality improvement projects identified goals to decrease call light response times and decrease the number of skin concerns. The project descriptions included collecting data from residents, the call light system, and trends, and implementing wound strategies, staff education, and partnership with an outside wound care company. However, neither project included a measurable goal. During interview, the quality assurance director, regional administrator, and administrator acknowledged that concerns were brought to the QAPI committee through resident surveys, staff reports, grievances, and resident council, but this information was not documented in the QAPI minutes. They also agreed that the QAPI meeting minutes lacked documentation of an identified measurable goal, interventions, and analysis of the data brought forward.
QAPI Infection Control Reporting Deficiency
Penalty
Summary
The facility failed to ensure the infection preventionist brought a thorough report to the Quality Assurance Performance Improvement (QAPI) meetings on the infection control program. Review of the quarterly QAPI information for 2/18/25, 5/15/25, 8/19/25, and 12/16/25 showed only sign-in sheets and agendas, with no minutes provided. The facility’s Infection Prevention Surveillance policy stated the IP was to develop and maintain systems to gather surveillance data for both residents and staff, compile and analyze the data, use the findings to direct infection control activities, and report those findings to the QAPI committee. During interview, the interim DON, who was serving as the facility’s designated infection preventionist, stated that when staff called off for their shift, the manager for that department completed a form that was sent to the HUC, who tracked staff illness. The IDON stated she did not track, analyze, or include staff illness in her QAPI reports, and staff illness was not discussed at QAPI. She also reported she was certified in another state but could not provide any information or certificate to confirm completion of an infection preventionist program. The regional administrator stated the IDON had taken on IP responsibilities after the prior IP abruptly left and acknowledged the IDON was not certified for infection control.
Incomplete staff illness surveillance and return-to-work tracking
Penalty
Summary
The facility failed to ensure employee illnesses were tracked to determine when staff could return to work based on their symptoms. Review of the staff illness surveillance showed that on 10/13/25 an LPN called in with glassy eyes, sore throat, and feeling sick, but the log did not identify the last day worked, the date symptoms resolved, or when the LPN returned to work. On 10/20/25 an NA called in with a sore throat and a temperature of 100.1; the log identified the last day worked as 10/19/25, but did not identify when she was eligible to return to work or her actual return date, and the notes only stated she had been gone a few days and brought in a physician note. The surveillance log also showed that on 11/25/25 the facility's HUC called in with nausea, vomiting, chills, fever, headache, and body aches, but the log did not identify when symptoms resolved, when he was eligible to return to work, or the day he returned. On 12/19/25 the same NA called in with being sick, but the log did not identify any other symptoms, onset date, resolution date, eligible return-to-work date, or actual return date; the notes stated she was out for multiple days until signs and symptoms stopped. The designated infection preventionist stated she was not overseeing staff illness to the extent she should have been, and the administrator and regional administrator stated the infection preventionist was not certified and should have been enrolled in an approved infection prevention certification course when she took over the role.
Unqualified Acting Infection Preventionist
Penalty
Summary
The facility failed to ensure the acting infection preventionist (IP), who was also the interim director of nursing (IDON), had completed specialized training in infection prevention and control. The facility assessment identified the IDON as the designated infection preventionist responsible for the infection prevention and control program, which included preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and others receiving services under contractual arrangements. During interview, the IDON stated she oversaw the infection control program and reported she had completed infection control training while working in another state, but she was unable to provide any information or a certificate showing completion of an approved infection prevention course. The administrator and regional administrator stated the IDON had originally been hired as DON and assumed IP duties after the prior infection preventionist abruptly left. The regional administrator acknowledged the IDON was not certified for infection control, and the facility’s IP job description did not require IP certification or enrollment in an IP certification program upon hire.
Failure to Monitor Antibiotic Use and Complete Antibiotic Time-Outs
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included protocols and a system to monitor antibiotic use for residents who were prescribed antibiotics. Review of the infection control antibiotic stewardship log showed no documentation that an antibiotic time out had been completed for three residents who received antibiotics: one resident received cefdinir for a UTI, another received Augmentin for aspiration pneumonia, and a third received Keflex for a UTI. The report states that the antibiotic stewardship policy identified the facility may consider protocols for evaluating clinical signs and symptoms, optimizing diagnostic testing, and using an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in the facility. The medication records showed that one resident received cefdinir 300 mg by mouth twice daily for 7 days as ordered, another resident received Augmentin 875 mg twice daily for 14 days even though the physician order was for 7 days, and a third resident received Keflex 500 mg by mouth twice daily for 7 days as ordered. During interview, the infection preventionist stated antibiotic time outs were not being completed for residents prescribed antibiotics. The administrator and assistant administrator stated they would have expected the infection preventionist to ensure the facility policy was followed and that antibiotic time outs were completed.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide timely beneficiary notice to 1 of 3 sampled residents, R31, regarding the end of Medicare Part A skilled services. R31's last day of Medicare Part A skilled services ended on 11/18/25, and on that same day the resident was given and signed both the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage and the CMS-10123 Notice of Medicare Non-Coverage. Survey findings stated that R31 was not given adequate time to appeal the decision or request an independent Medicare reviewer before the services ended. During an interview on 1/28/26 at 3:13 p.m., the regional administrator stated that residents were to receive 2-day notice before Medicare Part A skilled services ended and that the facility's expectation was to provide timely notices so residents would have time to appeal if they wanted to. A policy was requested but not received.
Missing Discharge Summary Documentation
Penalty
Summary
The facility failed to have a discharge summary for 1 of 1 sampled residents, R31. R31's accepted discharge MDS assessment dated 12/12/25 identified moderately impaired cognition, independence with care, participation in speech, occupational, and physical therapy, and discharge to home/community. Progress notes dated 11/20/25 stated that R31 was excited to return to the assisted living facility, that staff reviewed the discharge summary with R31, and that discharge orders were faxed to the pharmacy. A progress note dated 11/21/25 documented that R31 was discharged via private vehicle with a caregiver. However, there was no recapitulation of R31's stay documented in the progress notes, and the Transition of Care/Discharge Summary form had a section for recapitulation of stay that was left blank. The DON confirmed that the recapitulation section had not been completed and stated there had not been a discharge summary documented for R31's stay on the discharge form or in the progress notes.
Unsecured Areas Accessible to Wandering Resident
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and adequately supervised for a resident with severe cognitive impairment and wandering behaviors. The resident was admitted on 1/2/26 and had diagnoses including Alzheimer's disease, dementia with agitation, history of falls, and anxiety. Her significant change MDS assessment identified severe cognitive impairment and wandering throughout the facility, including into other residents' spaces. Observations showed her repeatedly wandering in her wheelchair through halls, attempting to open closed doors, and being redirected by staff after going toward exit areas, the dining room area, resident rooms, and the conference room. The resident was also observed going into the area near an exit door with a mural, an unsecured therapy door, an unsecured door to the back of the kitchen, and a wire mesh gate that led to 15 basement steps. The hook-and-eye closure on the gate was mounted on the inside but was within reach of a person in a wheelchair and had no resistance when lifted. Staff and management confirmed there was no locking or security measure in place for these areas, and the wander guard system only sounded an alarm without securing the doors. The long hall and access points were not within view of the nursing station, and no camera or other monitoring was identified during off-hours. Staff reported the resident frequently triggered the alarm and was found near the unsecured therapy and stairway area at least weekly.
Daily Staffing Posting Missing Resident Census
Penalty
Summary
The facility failed to include the resident census in its daily posting of nursing staff for 29 of 29 days reviewed. On 1/27/26 at 6:52 a.m., a daily staff posting was observed in the front entry of the building on a bulletin board titled Colonial Manor Nursing Home. The form included the facility name, a place for the date, the census, and a list of positions for each shift, but the census section was blank. During interview at 6:55 a.m., RN-A, who was working as charge nurse, was unaware of the current facility census and asked TMA-A if she knew it. TMA-A then checked the electronic record and reported the census was 26. Additional observations on 1/28/26 at 2:53 p.m. and 1/29/26 at 12:24 p.m. showed the daily staffing posting still did not document the facility census. During interview on 1/29/26 at 3:00 p.m., the business office manager stated the night nurse completed the daily staffing posting form and that it was supposed to include the facility current census. Review of the daily staff postings from 1/1/26 through 1/29/26 showed the census section was left blank each day. Review of the undated Nurse Staffing Information and Daily Census policy stated the facility must post the facility name, current date, total number and actual hours worked by title and license, and the resident census in a prominent, easy-to-read location.
Failure to Offer Updated Pneumococcal Vaccinations
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after surveyors found the facility did not ensure 2 of 5 sampled residents, R6 and R14, were offered and/or provided updated pneumococcal vaccinations in accordance with CDC guidance. Review of the CDC pneumococcal vaccine recommendations showed that adults 65 years or older have shared clinical decision-making options for receiving PCV20 or PCV21, including those who previously received PCV13 and PPSV23 at the specified ages. The facility’s vaccination policy stated residents would be offered vaccinations per CDC recommendations and that the RN Case Manager and Infection Control Coordinator would research resident records and history to determine whether vaccinations had been given. R6’s MDS identified him as [AGE] years old with renal failure, thyroid disorder, and dementia, and his immunization record showed PPSV23 on 1/4/11 and PCV13 on 3/19/15. His record contained no indication that the facility offered PCV20 or PCV21 on admission or during his stay, and Section O of the MDS indicated his pneumococcal vaccinations were not up to date. R14’s MDS identified her as [AGE] years old with anemia, renal failure, and diabetes mellitus, and her immunization record showed PPSV23 on 7/8/11 and PCV13 on 1/20/16. Her record also had no indication that the facility offered PCV20 or PCV21 on admission or during her stay, despite Section O indicating her pneumococcal vaccinations were up to date. During interview, the designated infection preventionist stated she was not aware the residents were eligible for additional vaccinations per CDC guidance.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to ensure that the dietary manager (DM) was certified to oversee nutrition and food services in the absence of a full-time registered dietician (RD). This deficiency had the potential to affect all 25 residents residing in the facility. During an interview, DM-J, who had been employed since December 2023, admitted she was not a certified dietary manager and had not started any certification classes. Although she held a Food Safety Certificate from 2019, she was only notified on the day of the interview that the administrator would enroll her in the certification class. The administrator acknowledged awareness of DM-J's lack of certification and believed that the RD's weekly visits would suffice until DM-J obtained her certification. However, DM-J had not yet been signed up for the dietary certification classes. The job description for the dietary manager required knowledge of state and federal food regulations, Serv-Safe Certification, and a current certification as a Certified Dietary Manager (CDM) or dietician, or a willingness to obtain such certification.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2024. The CMS payroll-based journal (PBJ) staffing data report indicated that there were four or more days within the quarter where the facility had less than 24 hours per day of licensed nursing coverage. The specific dates identified were 5/25/24, 6/8/24, 6/9/24, 6/16/24, 6/1/24, 6/22/24, 6/23/24, 6/24/24, 6/29/24, and 6/30/24. However, upon review of the nursing staff schedules and daily staffing postings for these dates, it was found that a licensed nurse was scheduled for each shift, and timecards confirmed that all shifts were worked by either an employed nurse or an agency nurse. Interviews with the nursing department coordinator and the business office manager revealed that there was always a licensed nurse working each shift, and all nursing staff, including management and agency staff, were entered into the PBJ report. Despite this, the report still triggered for insufficient coverage. The business office manager, who was responsible for entering the data, and the administrator could not determine why the report indicated a deficiency. The facility stated that they followed the CMS PBJ - LTC policy manual, but the issue with the report remained unresolved.
Lack of Trained Infection Preventionist in Facility
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control, which had the potential to affect all 25 residents residing in the facility. The Director of Nursing (DON), who started her employment in July 2024, assumed the infection control role in October but had only completed one module of the CDC infection preventionist course. The role was intended to be shared with RN-A, the Minimum Data Set (MDS) coordinator, who had no training at the time of the survey. RN-A, who began working at the facility in June 2024, was initially focused on MDS training and had not yet started the CDC infection preventionist course, although she was enrolled. The facility's administrator acknowledged the lack of a trained infection preventionist but noted that both the DON and RN-A were enrolled in the necessary training. The facility's Infection Prevention and Control Program, dated December 2022, outlined the need for effective oversight and training in infection prevention and control practices, which was not being met at the time of the survey.
Failure to Implement Antibiotic Review Process
Penalty
Summary
The facility failed to implement a comprehensive process for reviewing antibiotic use, which affected four out of five residents reviewed for antibiotics. The monthly infection control logs from July to November 2024 identified residents with infections who were administered antibiotics, but these logs lacked critical information such as antibiotic dosages and whether the infections had resolved. For instance, one resident with a urinary tract infection (UTI) was prescribed Macrobid, but the surveillance log did not indicate the dosage or resolution of the infection. Similarly, other residents with UTIs were prescribed antibiotics like ampicillin and cefdinir, yet the logs did not document the resolution of their infections. Interviews revealed that the facility's registered nurse, who was newly assigned as the Infection Preventionist (IP), had not yet started her IP training and was unaware of the existing processes for antibiotic use identification. The facility's administrator expected the nursing team to track and maintain monthly updates on antibiotic use, but this was not consistently enforced. The facility's Antibiotic Stewardship Policy required follow-up on pending cultures and monitoring of antibiotic usage patterns, but these procedures were not adequately implemented, leading to the deficiency in antibiotic management.
Failure to Follow Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to adhere to its grievance process regarding missing personal property for a resident identified as R19, who reported missing handkerchiefs and shirts. R19, who has moderately impaired cognition, stated that multiple packs of handkerchiefs and a couple of shirts have been lost since his admission in January 2024. Despite informing multiple staff members about the missing items, no formal grievance process was initiated. Interviews with nursing assistants and the nursing department coordinator revealed confusion and lack of clarity about the procedure for handling missing belongings, with some staff unsure of the next steps after reporting to the charge nurse. Further investigation showed that the facility's policy required a missing or damaged item report to be completed and submitted to social services, who would maintain a file of such reports. However, the administrator confirmed that no form was completed for R19's missing items, indicating a failure to follow the grievance process. The laundry staff was aware of the missing handkerchiefs but not the shirts, and no resolution was reached. The absence of a social worker further complicated the process, as the missing belongings binder was not maintained, leading to a breakdown in the facility's grievance handling procedure.
Failure to Accurately Code Hospice Status on MDS
Penalty
Summary
The facility failed to accurately code a resident's hospice status on the Minimum Data Set (MDS) assessment. The resident, identified as R15, had diagnoses of protein-calorie malnutrition and was receiving palliative care. Despite being enrolled in hospice care on July 8, 2024, as confirmed by the hospice agency, the quarterly MDS assessment did not reflect this status. The MDS nurse, RN-A, acknowledged during an interview that hospice was not marked in Section O of the MDS assessment, which should indicate special treatments, procedures, and programs. This oversight was identified when RN-A reviewed the resident's electronic medical record and admitted to inadvertently missing the hospice status. The facility's policy for the accuracy of MDS assessments was requested but not provided.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R15, to include hospice care, despite the resident being enrolled in hospice services. R15's facesheet, printed on 11/20/24, listed diagnoses of protein-calorie malnutrition and an encounter for palliative care. The quarterly Minimum Data Set (MDS) assessment indicated that R15 had moderately impaired cognition but could communicate effectively. Progress notes from 7/3/24 showed that a provider had faxed an order for hospice admission, and the hospice agency confirmed R15's enrollment in hospice services on 7/8/24. However, R15's care plan, initiated on 5/1/23, did not reflect the inclusion of hospice or palliative care. During an interview, the MDS nurse acknowledged the omission and stated that the care plan should have been updated to reflect the resident's hospice status. The facility's care planning policy, revised in 8/23, requires care plans to be updated with any changes throughout a resident's stay.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to document a complete recapitulation of stay for a resident reviewed for discharge. The resident, who was admitted to the facility with diagnoses including a pressure ulcer, depression, osteomyelitis, and paraplegia, was discharged to home with their spouse. Although discharge orders were signed by the provider and reviewed with the resident and spouse, the medical record lacked a discharge summary. Interviews with facility staff revealed that there was confusion regarding the responsibility for completing the discharge summary. The regional director of skilled care confirmed the absence of the discharge summary and attributed it to staff turnover. The MDS coordinator, who was handling the discharge process for the first time, was unaware of the requirement to complete a discharge summary, resulting in its omission. The facility's policy required nursing staff to complete the discharge summary in the electronic health record, but this was not adhered to in this instance.
Failure to Accurately Monitor and Document Resident Weights
Penalty
Summary
The facility failed to document and monitor weight loss for a resident, R24, who experienced significant weight loss. R24 had a history of stroke, Parkinsonism, dementia, and dysphagia, which placed her at risk for nutritional compromise. Despite these risks, the facility did not accurately monitor her weight changes, as evidenced by inconsistent weight records and a lack of reweighs when discrepancies were noted. The registered dietician (RD) and licensed practical nurse (LPN) both identified inaccuracies in the weight records, but reweighs were not conducted, and the physician was not notified of the significant weight loss. Additionally, the facility failed to obtain accurate weights for another resident, R4, who had severe protein-calorie malnutrition and dysphagia. R4's weight records showed inconsistencies, with an aberrant weight recorded that was not addressed. The RD noted the inaccuracies in her reports, but there was no communication with the nursing staff or director of nursing (DON) to rectify the issue. The DON was aware of the inaccuracies but relied on verbal communication to address the problem, which did not effectively resolve the issue. The facility's policy required weekly weights to be taken by nursing staff and entered into the electronic medical record, with reweighs requested for significant changes. However, this policy was not followed, as evidenced by the lack of reweighs and physician notification for significant weight changes. The facility's failure to adhere to its policy and ensure accurate weight monitoring contributed to the deficiency in providing adequate nutrition and monitoring for residents at risk of malnutrition.
Failure to Follow Enhanced Barrier Precautions for Resident with Urinary Ostomy
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed for a resident with a urinary ostomy. The resident, who had diagnoses including neuromuscular dysfunction of the bladder and bladder-neck obstruction, required staff assistance for most activities of daily living, including toileting. An observation revealed that a nursing assistant (NA) entered the resident's room and assisted with toileting without donning the required personal protective equipment (PPE), despite an EBP sign on the door indicating the need for gown, gloves, and mask. During interviews, the NA admitted to not wearing PPE while assisting the resident, believing it was unnecessary as she did not touch the resident directly. The director of nursing (DON) was uncertain about the distance requirement for PPE use and later confirmed that the facility's policy required PPE during toileting for residents under EBP. The infection preventionist confirmed that EBP had been reviewed in a staff meeting, and the NA had attended. The facility's policy indicated that EBP should be used for residents with indwelling medical devices during high-contact care activities such as toileting.
Deficiency in Vaccination Documentation and Administration
Penalty
Summary
The facility failed to maintain proper records and documentation for pneumococcal and influenza vaccinations for residents, leading to a deficiency in their immunization protocol. Specifically, one resident's medical record lacked documentation of receiving any pneumococcal or influenza vaccines, as well as documentation of education on the risks and benefits or declination of these vaccines. Additionally, another resident's record showed consent for the influenza vaccine, but there was no documentation of the vaccine being administered, despite the COVID vaccine being given. Furthermore, the facility did not document that the influenza vaccine had been offered or that education on risks and benefits was provided for another resident. The registered nurse (RN) confirmed that the facility had not administered influenza vaccines for the current year, citing delays in receiving consent forms from families. The RN also acknowledged that the influenza vaccines had been available at the facility for several months but had not been administered. The facility's policies on resident vaccinations and infection control outlined the procedures for offering and documenting vaccinations, including providing educational handouts and obtaining consent. However, these procedures were not followed, resulting in the deficiency.
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the administrator and the State Agency (SA) in a timely manner. The incident occurred when a nursing assistant allegedly threatened a resident by saying that her husband would yell at her if she did not cooperate. This event was reported internally by another nursing assistant who witnessed the incident, but the report was delayed due to the absence of the charge nurse, the Director of Nursing (DON), and the administrator. The business office manager was informed later in the day, but the report to the SA was not made until the following day. The facility's Abuse Prevention Plan requires that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made. In this case, the report was delayed beyond the required timeframe, as the administrator was out of the building and the DON was unavailable to report the incident. The delay in reporting was further compounded by unsuccessful attempts to grant another staff member the privileges needed to report to the SA, resulting in a failure to comply with the facility's policy and regulatory requirements.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, resulting in delayed assistance with personal care needs. Seven residents reported concerns about inadequate staffing, leading to extended wait times for assistance with toileting and other personal care tasks. For instance, one resident experienced a 1.5-hour wait for assistance, resulting in incontinence due to diarrhea. Another resident reported sitting on the commode for an hour, causing discomfort and increasing the risk of urinary tract infections due to delayed catheter drainage. The call light logs for the residents indicated numerous instances of prolonged wait times, with some residents experiencing waits of over an hour. Interviews with family members and residents highlighted the impact of these delays, including embarrassment, frustration, and anxiety. Residents expressed concerns about missed baths and the inability to receive timely assistance, which affected their dignity and personal hygiene. The facility's staff also acknowledged the staffing shortages, with some employees stating that they were unable to respond to call lights promptly due to other responsibilities. The facility's administration recognized the staffing challenges but did not have a clear process for tracking and addressing call light response times. The Director of Nursing was unaware of a specific time frame for what constituted a timely response, and the interim case manager noted that staffing was based on census rather than the acuity of residents' needs. Despite efforts to recruit new staff, the facility continued to struggle with providing adequate care, as evidenced by the residents' complaints and the documented call light wait times.
Failure to Revise Care Plan for Resident with ADL Changes
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in their activities of daily living (ADLs). The resident, who had severe cognitive impairment due to Alzheimer's disease and anxiety, initially required partial to substantial assistance with ADLs and showed no signs of a swallowing disorder. However, a significant change in the resident's condition was noted, including coughing or choking during meals and a weight loss from 178 to 160 pounds. Despite these changes, the care plan was not updated to reflect the new needs identified by the Speech Language Pathologist (SLP), which included staff assistance with feeding at every meal and frequent cues to sit up. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Nursing Assistant (NA), revealed that while the resident could feed themselves, they ate better when assisted by staff. The Director of Nursing (DON) acknowledged that the care plan had not been revised to include the SLP's orders and noted the resident's weight loss. The facility's care plan policy requires that care plans be revised as necessary to reflect changes in a resident's condition, but this was not done in this case, leading to the deficiency.
Failure to Prevent and Address Pressure Ulcer Development
Penalty
Summary
The facility failed to comprehensively assess, monitor, and implement person-centered interventions to prevent a pressure ulcer for a resident who entered the facility without a pressure ulcer. Initially, the resident was assessed with a Braden Scale score indicating no risk for pressure ulcers, but later assessments showed an increased risk. Despite this, the care plan did not adequately address the resident's needs, and interventions such as a pressure-reducing device were not effectively implemented. The resident developed a pressure ulcer on the coccyx, which was not promptly or adequately addressed. There was a lack of comprehensive pressure ulcer assessments, including staging, characteristics, and signs of infection. The facility also failed to conduct a tissue tolerance test to determine repositioning frequency and did not perform daily skin monitoring or weekly comprehensive wound assessments. The care plan was not updated to reflect the development of the pressure ulcer or to prevent further occurrences. The facility's policy required individualized repositioning programs and regular monitoring of skin conditions, but these were not followed. The resident's dressing was not changed according to physician orders, and the resident was not placed on the wound clinic list for weekly measurements. The Director of Nursing acknowledged the need for improvement in pressure ulcer care, but the facility's actions did not align with their policy to prevent and treat pressure ulcers effectively.
Failure to Implement Effective Toileting Program
Penalty
Summary
The facility failed to develop an individualized toileting program for a resident with severe cognitive impairment, Alzheimer's disease, and anxiety, leading to a decline in continence. The resident required partial to moderate assistance with toileting and was frequently incontinent of bladder but always continent of bowel upon admission. Despite being identified as a good candidate for a bowel/bladder retraining program, the facility did not implement an effective toileting plan, and the resident's continence declined over time. The resident's care plan included a toileting schedule to prevent bladder incontinence, but the plan was not consistently followed. The resident was supposed to be toileted three times a day, but records showed inconsistencies in adherence to this schedule. Additionally, the facility did not maintain a voiding diary or conduct a causal analysis to understand the resident's baseline toileting routine, which could have informed a more effective care plan. The Director of Nursing (DON) acknowledged the resident's decline in continence but was unable to articulate a treatment plan to address the issue. The facility's policy required a comprehensive assessment and care plan to maintain the highest practicable level of continence, but this was not achieved. The lack of a revised toileting plan and failure to notify the physician of the resident's decline contributed to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lakefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Jackson | 9.4 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Windom | 12.5 mi | ★★★★★ | 23 | 1 |
| Aspire Of Lake Park | 17.4 mi | — | 0 | 0 |
| Accura Healthcare Of Spirit Lake | 18.4 mi | ★★★★★ | 9 | 0 |
| Good Samaritan Society - Mountain Lake | 21.2 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.