Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Cook Community Hospital C&nc during CMS and state inspections, most recent first.
Failure to follow a resident’s fall care plan led to an unwitnessed fall with injury. A resident with dementia, impaired mobility, and a history of falls was supposed to have bed, chair, and Velcro belt alarms on at all times and was not to be left alone in her room while in her wheelchair. Staff reported the resident was left alone in her room, the lap belt alarm may not have been on, and she self-transferred to the bathroom and fell, sustaining a forehead laceration that required sutures.
Nurse staffing posting was not updated daily and was found posted with outdated dates on multiple observations. NA-A confirmed the posting was outdated, SC-B stated she changed staffing hours for the coming week but did not update the posted sheets until later, and the DON verified the posting should be current so families and visitors could see how many residents were in the facility and how many staff were working.
A resident admitted with a cerebral vascular accident did not have a baseline care plan developed within the required 24-48 hours. Instead, the care plan was completed five days after admission, contrary to facility policy and staff expectations, resulting in a delay in addressing the resident's immediate needs.
A resident with dementia and a history of falls was not comprehensively assessed after a fall, and timely interventions were not implemented or documented. Staff interviews revealed inconsistent practices regarding frequent checks, incomplete post-fall investigations, and a lack of new interventions added to the care plan, despite the resident's high fall risk.
A resident with moderate cognitive impairment and high fall risk was injured when a nursing assistant used a mechanical stand lift, contrary to the care plan specifying a stand pivot or ceiling lift transfer. The resident fell asleep during the transfer, resulting in a fall and right clavicle fracture. Staff interviews confirmed the mechanical stand lift was not part of the care plan, and the nursing assistant left the resident on the floor to seek help, violating facility protocol.
An LPN failed to perform appropriate hand hygiene during a blood sugar test by placing her gloved hand into her pocket and then continuing the procedure without changing gloves or washing hands. The infection preventionist and DON confirmed this was against facility policy.
A resident who exhibited wandering behaviors was not assessed or provided with appropriate interventions, despite staff and other residents being aware of the issue for several months. The facility's failure to complete a comprehensive assessment and update the care plan led to ongoing wandering incidents.
The facility failed to label latanoprost eye drops with the open date and expiration date, as required by policy. A nurse confirmed the medication was in use without proper labeling, and the pharmacist noted the drops are only stable for 28 days after opening.
The facility failed to report an injury of unknown origin for a resident with memory impairment within the required two-hour window. The resident was found with a large hematoma and a swollen, bruised eye, and the report was delayed due to staff being busy and shorthanded. The facility's policy mandates immediate reporting within two hours.
A resident with memory impairment was found with significant injuries after staff failed to perform hourly safety checks as required by the care plan. The last check was at 4:00 a.m., and no further checks were done until the resident was found injured at 6:45 a.m. The facility's policy on safety checks was not followed.
Failure to Follow Fall Alarm and Supervision Care Plan
Penalty
Summary
The facility failed to ensure care planned fall interventions were implemented for a resident with significant cognitive impairment, dementia with behaviors, a history of falls, impaired balance, impaired mobility, and psychotropic medication use. The resident’s care plan and care plan summary identified that bed, chair, and Velcro belt alarms were to be on at all times and that she was not to be left alone in her room when in her wheelchair. On the evening of the incident, the resident was having increased behaviors, was trying to get out of the chair, and was refusing to allow staff to reapply the lap belt. Staff reported that the resident was in her wheelchair in her room and was left alone while staff assisted another resident, and it was not known whether the alarm was turned on when the belt was reattached. The resident then self-transferred from the wheelchair to the bathroom in her room and had an unwitnessed fall. She was found lying on the bathroom floor with blood under her forehead and sustained a deep laceration to the right forehead, a scratch on the bridge of the nose, and a skin tear to the left wrist. The injury required emergency room treatment and 10 stitches to the forehead laceration. The facility’s investigation concluded that the alarms were not sounding at the time of the fall and that the resident had refused to let staff place the seatbelt back on.
Nurse Staffing Posting Not Updated Daily
Penalty
Summary
The facility failed to ensure the nurse staff posting was posted daily and updated to reflect current staffing. Surveyors observed the posting on multiple occasions and found it dated 5/26/26 on 5/27/26 at 2:15 p.m. and again on 5/28/26 at 6:58 a.m., dated 5/26/25 on 5/27/26 at 4:10 p.m., and dated 5/28/26 on 5/29/2026 at 8:13 a.m. The deficiency affected all 24 residents residing in the facility. During interview, NA-A verified the posting was dated 5/26/26 and stated it was important for families and visitors to see how many staff were working. SC-B stated she changed the nurse staffing hours on Thursdays for the coming week but did not update the posted sheets, and instead made the changes in the computer after they occurred when she returned on Mondays. A review of the next week's schedules showed the census as 24, and one schedule dated 5/30/26 had zeros for all staff listed with a census of 24. The DON verified the nurse staff posting should be posted daily so anyone could see how many residents were in the facility and how many staff were working, and stated it was important so families could have confidence there was enough staff to take care of their family members.
Failure to Timely Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within the required timeframe for a newly admitted resident with a diagnosis of cerebral vascular accident. Documentation showed that the baseline care plan was completed five days after admission, rather than within the 24-48 hour window specified by facility policy. Interviews with nursing staff confirmed that the initial care plan process was started at admission but not completed promptly, resulting in a delay in identifying and addressing the resident's immediate needs as required.
Failure to Assess and Implement Timely Fall Interventions
Penalty
Summary
The facility failed to comprehensively assess and implement timely interventions following a resident's fall. The resident, who had moderate cognitive impairment and diagnoses including dementia, depression, osteoporosis, and neurogenic bladder, had a documented history of falls and was identified as a high fall risk. Despite this, the care plan only included basic interventions such as bed and chair alarms, and lacked additional measures to protect the resident from further falls. After the resident was found on the floor following an attempted self-transfer, documentation did not include a thorough investigation into contributing factors such as last toileting, footwear, call light availability, or when the resident was last seen. No new interventions were added to the care plan after the fall, and the post-fall documentation and root cause analysis were incomplete. Interviews with staff revealed inconsistent practices regarding frequent checks after falls, with unclear documentation and implementation. The nurse assistant and LPN described procedures for frequent checks, but records showed these were not consistently started or documented for the resident in question. The RN acknowledged missing information in the fall investigation and admitted to copying previous documentation without conducting a comprehensive review or initiating frequent checks. The DON confirmed that a complete investigation and root cause analysis should have been performed, and interventions should have been care planned based on findings, which did not occur in this case.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the care plan interventions for a resident, resulting in a fall and injury. The resident, who had moderate cognitive impairment and was at high risk for falls, was care planned for a stand pivot transfer or a ceiling lift transfer. However, a nursing assistant used a mechanical stand lift, which was not part of the resident's care plan, leading to the resident falling asleep during the transfer and sustaining a right clavicle fracture. Interviews with staff revealed that the nursing assistant believed the mechanical stand lift was appropriate for the resident, despite the care plan specifying otherwise. The nursing assistant attempted to transfer the resident using the mechanical stand lift, but the resident began sliding and eventually fell to the floor. The nursing assistant left the resident on the floor to seek assistance, which was against the facility's protocol of not leaving residents alone on the floor. Further interviews with the director of nursing and other staff confirmed that the resident was not care planned for a mechanical stand lift and that the interdisciplinary team and therapy determine the appropriate transfer methods for residents. The facility's policy required staff to follow the care plan and use the designated transfer methods, which was not done in this case, leading to the resident's injury.
Inappropriate Hand Hygiene During Blood Sugar Test
Penalty
Summary
The facility failed to perform appropriate hand hygiene during a finger stick blood sugar test. An LPN entered a resident's room to perform the test and, after placing gloves on her hands, used a lancet to puncture the resident's finger. The LPN then placed her gloved hand into her pocket, moved items around, and proceeded to push on the opening in the resident's finger without changing gloves or washing her hands. The LPN acknowledged that she should have removed her gloves and washed her hands after putting them in her pocket and before returning to the resident's finger. The infection preventionist and the director of nursing both confirmed that staff should not reach into their pockets while gloved and in the middle of a procedure. Facility policies on glucometer use and hand hygiene, last reviewed in 2023, indicated that aseptic technique and hand hygiene must be observed, and gloves must be worn during the procedure. Hand hygiene should be performed each time direct contact with residents is made and after touching potentially contaminated inanimate objects.
Failure to Assess and Address Resident Wandering Behavior
Penalty
Summary
The facility failed to complete a comprehensive assessment for a resident (R12) who exhibited wandering behaviors. Despite R12 being cognitively intact and using a manual wheelchair with substantial assistance for mobility, the resident's annual Minimum Data Set (MDS) and care plan did not indicate any wandering behavior. However, interviews with another resident (R15) and staff members, as well as direct observations, revealed that R12 frequently wandered into other residents' rooms. This behavior had been ongoing for at least six months, yet no assessment for wandering was conducted, and no interventions were in place to address the issue. Staff members, including a nursing assistant (NA-A), a licensed practical nurse (LPN-A), and a registered nurse (RN-B), confirmed R12's wandering behavior but were unsure of the reasons behind it. The Director of Nursing (DON) was unaware of the wandering behavior and stated that an assessment should have been completed immediately. The RN responsible for MDS assessments and care plan updates acknowledged that mood and behavior charting did not identify wandering behavior, and staff had not reported it until recently. Consequently, R12's care plan was not updated to include interventions for wandering until after the issue was brought to light by the surveyors.
Failure to Properly Label Medicated Eye Drops
Penalty
Summary
The facility failed to ensure that medicated eye drops were properly labeled with the date they were opened and their expiration date. During an observation of the North hallway medication cart, it was found that a bottle of latanoprost 0.005% eye drops had its protective seal removed but lacked the necessary open date and expiration date. A registered nurse confirmed that the medication was in use without the required labeling. The pharmacist stated that such eye drops are only stable for 28 days after opening, and the director of nursing confirmed that the facility's policy required these dates to be recorded. The facility's policy on medication administration, last reviewed in April 2022, indicated that eye drops should be labeled with an open date and are good for 45 days from that date.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an injury of unknown origin was reported immediately to the State Agency (SA) for a resident with memory impairment. The resident required extensive assistance with toilet use and supervision for bed mobility, transfers, and eating. On the morning of 4/7/24, the resident was found with a large hematoma on her right forehead and a swollen and bruised right eye, with no evidence of a fall. The incident was reported to the SA at 11:25 a.m., which was beyond the required two-hour reporting window. The LPN involved stated they were busy and shorthanded, and the Director of Nursing confirmed the expectation to report such incidents within two hours. The facility's Vulnerable Adult Maltreatment Prevention Plan also directed immediate reporting within two hours.
Failure to Implement Hourly Safety Checks
Penalty
Summary
The facility failed to ensure that care-planned interventions for hourly safety checks were consistently implemented for a resident with memory impairment. The resident required extensive assistance with toilet use and supervision for bed mobility, transfers, and eating. The care plan specified that the resident was to be checked on every hour by staff. However, on the morning of 4/7/24, the resident was found with significant injuries, including a bruised face, swollen eye, and a hematoma on the forehead, indicating that the hourly safety checks were not performed as required. Interviews with staff revealed that the last safety check was conducted at 4:00 a.m. by a nursing assistant, and no further checks were done until the resident was found injured at 6:45 a.m. The director of nursing confirmed that the care plan was not followed, as staff were expected to visualize the resident during safety checks. The facility's policy on safety checks was also not adhered to, leading to the resident's injuries of unknown origin.
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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 Cook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Essentia Health Virginia Care Cent | 23.1 mi | ★★★★★ | 4 | 0 |
| The Waterview Pines Llc | 24.1 mi | ★★★★★ | 18 | 1 |
| Cornerstone Villa | 25.6 mi | ★★★★★ | 4 | 0 |
| Heritage Manor | 26.4 mi | ★★★★★ | 0 | 0 |
| The Waterview Woods Llc | 27.6 mi | ★★★★★ | 18 | 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.