Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Franciscan Health Center during CMS and state inspections, most recent first.
Insufficient staffing led to delayed ADL and incontinence care. Surveyors found repeated NA shortages against the facility’s staffing plan, with staff reporting heavy assignments, missed breaks, and delayed basic care when short. A resident who required substantial to max assist and was incontinent was not checked for 4 hours; when care was provided, the brief was soaked with urine and stool was stuck to the skin. Staff confirmed the resident had moisture-related skin concerns and that the gap in checking and changing was too long.
Improper medication labeling, expired supplies, and unsecured resident medications were found in the facility. An RN confirmed an undated insulin pen and opened inhalers in a medication cart, while the medication room contained expired protein supplement boxes, cleaning chemicals stored with consumables, and an IV emergency kit with multiple expired fluids and supplies. A cognitively intact resident approved for SAM had unopened nebulizer ampules and expired vitamin bottles kept at bedside, even though staff confirmed resident-room medications needed to be secured and the resident was no longer taking the vitamins.
Food Safety Practices Not Followed During Chicken Preparation: Raw chicken was observed brining in a covered container in a sink while outside refrigeration, and staff stated it had been out for about 30 minutes before it was to be baked. The brine and chicken temperatures were checked at 36.5°F and 32.9°F, and staff acknowledged it would have been better to brine the chicken in the cooler or refrigerator. The recipe required refrigeration for 4 to 8 hours, and facility policy required perishable foods such as meat and poultry to be kept refrigerated.
EBP was not followed for a resident with chronic pressure ulcers receiving ongoing wound care, as staff provided wound care without gowns and without EBP signage or a PPE station in the room. In a separate observation, staff caring for another resident on EBP entered for transfers, brief changes, dressing changes, and repositioning without proper gown use, hand hygiene between tasks, or sanitizing shared equipment such as a mechanical lift. An LPN also changed gloves during wound care without hand sanitizing between dirty and clean tasks.
A facility failed to code MDS assessments accurately for three residents. One resident with CVA, malnutrition, and pressure ulcers had inconsistent pressure ulcer coding, no skin impairment focus in the care plan, and a RN stated the MDS error would affect reimbursement. Another resident’s MDS contained contradictory antipsychotic coding despite an order for olanzapine and documentation of antipsychotic use. A third resident who used CPAP nightly had no CPAP coding on the annual MDS even though the care plan, orders, TARs, and resident interview all confirmed use.
A resident with vascular dementia, depression, bipolar disorder, and PTSD had a corrected PASRR that identified the need for an OBRA Level II screening for mental illness. The SSD was unsure whether the screening had been completed, the facility could not provide evidence that it was done before or after admission, and the ADON stated she was not familiar with the OBRA Level II process.
A resident’s care plan was not updated to reflect changes in condition after a significant status change assessment identified CVA-related hemiplegia, severe malnutrition, a stage 3 pressure ulcer, an unstageable wound, dependence with ADLs, and daily use of an elopement alarm. The plan also lacked interventions for wandering/elopement and skin impairment, did not include the later fall event, and did not fully reflect current mobility status or individualized pain management, despite staff observations and elopement assessments showing conflicting information about the resident’s wandering risk and wander guard use.
A resident with a stage 4 pressure ulcer on the left buttock and frequent bowel and bladder incontinence was found with no dressing in place during a brief change. The wound had packing, the brief was saturated, and drainage was present where the brief aligned with the wound. Staff did not apply a dressing at the time, and later interviews confirmed the wound was passed between nurses while uncovered and open to the brief.
A resident with CVA-related hemiplegia, severe malnutrition, and hospice status developed facility-acquired pressure ulcers while the record showed repeated gaps in skin checks and wound assessments. The care plan directed q2h turning and repositioning, but it lacked a skin breakdown focus and wound-monitoring interventions. The resident was observed leaning to one side in a Broda chair for an extended period, and an NA later stated the resident should have been repositioned sooner. The DON and PCP both stated they expected at least weekly skin and wound checks with documentation of wound characteristics.
A resident with COPD, chronic respiratory failure with hypoxia, CHF, and OSA had a CPAP that was not properly ordered for cleaning and maintenance. The care plan addressed CPAP settings but not routine cleaning, and the TAR had no cleaning instructions. Staff said nurses were responsible for setting up, monitoring, and cleaning the CPAP, yet observations showed visible water in the humidifier chamber on multiple occasions.
Failure to Offer and Educate on Flu and Pneumococcal Vaccinations: The facility failed to offer influenza and pneumococcal vaccinations and/or provide CDC-required education for 3 of 5 residents reviewed. Two residents received the flu vaccine but had no documentation that education was provided, and one resident who had consented to receive the flu vaccine had no evidence the vaccine was offered during the season. The DON and NC stated residents received VIS and new consents/education during flu season, and the facility policy required vaccination offers, VIS, education, and documentation.
A resident with vascular dementia, depression, bipolar disorder, chronic pain, and PTSD received the COVID-19 vaccine, but the record documented that education was not given. The acting DON stated residents received the VIS in the admission packet, while the NC-B stated new consent and education were provided with each vaccine. The facility policy required a VIS, education, and documentation in the EMR before vaccination.
A resident who was dependent on staff for ADL assistance and was always incontinent of bowel and bladder did not receive timely checking and changing, with staff finding the brief soaked with urine and stool stuck to the skin after several hours without care. The resident had ongoing redness under the breasts, in the groin, and across the abdominal pannus, while weekly skin checks were inconsistently documented and sometimes recorded no skin concerns despite the resident’s continued moisture-related skin issues. Staff confirmed the gap in incontinence care was too long and that weekly skin checks were expected.
The facility failed to report an allegation of sexual assault to the State Agency within the required 2-hour timeframe after a male resident groped a female resident’s breasts without consent in the dining room while approaching his wife. A RN observed the incident, redirected the involved resident, and notified law enforcement and responsible parties, while the affected resident showed no visible distress and later had little recall of the event. The incident was not reported to the State Agency until several hours later, after most of the internal investigation had been completed, and the social worker acknowledged she was unaware that the allegation needed to be reported first and within 2 hours, contrary to facility policy and regulatory requirements.
The facility experienced significant staffing shortages, resulting in delayed medication administration for several residents and inadequate care for a resident with pressure ulcers. Nurses were overwhelmed with responsibilities, leading to late medication passes, while nursing assistants struggled to provide timely repositioning for residents. Interviews and reports confirmed ongoing staffing deficiencies, particularly on weekends and certain shifts, impacting the quality of care.
The facility failed to ensure medications and supplies in the medication storage room were not expired, affecting all 39 residents. Observations revealed expired blood tubes, viral panel swabs, Hibiclens, and Bacitracin ointment. The DON acknowledged the issue, noting the night shift's responsibility to check for expired items, but no check-off sheet was in place to ensure completion.
The facility failed to post ombudsman information at an accessible level for residents, particularly those in wheelchairs. During a resident council meeting, residents expressed difficulty in accessing state inspection postings due to their height. A review confirmed that the ombudsman information was placed too high, approximately six inches from the ceiling, making it inaccessible. The DON verified this issue, which violates resident rights requiring accessible information posting.
A facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate. A resident with multiple diagnoses, including anxiety and dysphagia, received medications late due to a nurse's heavy workload. The nurse was responsible for administering medications to 23-24 residents, including those requiring special precautions, leading to delays in medication delivery.
The facility failed to ensure that call lights in resident bathrooms were accessible from the floor, affecting five residents. Observations showed that cords were either too short or had knots, preventing them from reaching the floor, and one call light was non-functional. Staff interviews revealed a lack of awareness about regulations for call light cord length, and the maintenance director was not informed of the issues.
A facility failed to provide a newly admitted resident with a copy of their baseline care plan, which included essential care needs and interventions. Despite the care plan being developed, neither the resident nor their representative received a copy, as confirmed by interviews with the resident, family, and staff.
A resident with pressure ulcers was not repositioned timely, as required by their care plan, leading to a deficiency in care. The resident, dependent on staff for bed mobility, was left in the same position for over three hours, resulting in an uncovered and actively bleeding wound. The facility's policy required repositioning based on individual assessments, which was not followed in this instance.
A facility failed to establish an effective communication system with an outside dialysis center for a resident with end-stage renal disease and type 2 diabetes mellitus. The resident's care plan required dialysis on specific days and included staff responsibilities for monitoring and communication. However, the dialysis agreement lacked essential information, and the facility's policy on Dialysis Management was not followed, leading to a deficiency in ensuring continuity of care.
A facility failed to investigate and analyze the underlying causes of a resident's delusions, leading to a deficiency in behavioral health care. The resident exhibited hallucinations and delusions, such as seeing people and animals in her room, over several months. Despite staff training on mental health conditions, the facility did not adequately address these symptoms or adjust the care plan, resulting in insufficient behavioral health services.
A facility failed to ensure proper PPE use when staff exited a Covid-19 positive resident's room. Staff removed N-95 masks inside the room and replaced them with surgical masks, contrary to facility policy and CDC guidelines. Interviews revealed staff were misinformed about proper doffing procedures, leading to potential exposure risks.
The facility failed to maintain up-to-date immunization records and provide vaccine education for new admissions. Two residents lacked immunization histories, and another was not offered a pneumococcal vaccine despite eligibility. Additionally, three residents were not educated or offered the influenza vaccine, with no documentation of vaccine declinations. Staff interviews revealed uncertainty about vaccination status and procedures for handling refusals.
The facility failed to educate and offer COVID-19 vaccinations to residents upon admission. A resident with chronic heart failure and other conditions had a record of a past COVID-19 vaccine, but staff were unsure if vaccines were offered upon admission. Another resident with hypertensive heart disease and other conditions had no immunization history, and staff assumed the resident was anti-vaccine without documentation. A third resident with spastic hemiplegia and stroke also lacked an immunization history, and staff were unsure if follow-up occurred. The facility's policy to document and offer vaccines upon admission was not followed.
A resident with severe cognitive impairments and multiple mental health disorders was involved in an inappropriate sexual encounter with a housekeeper, who was unaware of the prohibition against relationships with residents. The incident was documented by a nurse but not reported for investigation, despite the resident's care plan indicating a history of inappropriate behavior. An occupational therapy assistant assessed the resident as not cognitively intact enough to consent, highlighting the facility's failure to protect the resident from potential abuse.
A resident with severe cognitive impairments reported a romantic and physical encounter with a housekeeper, which was documented by an RN but not reported to the State Agency within the required two-hour timeframe. The facility's policy mandates immediate reporting of suspected maltreatment, which was not followed, resulting in a deficiency.
The facility did not ensure that a housekeeper received required training on abuse, neglect, and exploitation. The housekeeper could not recall the last training, and records showed no training since 2021. The DON and administrator confirmed that training should occur upon hire and annually, as per the facility's policy.
Insufficient staffing and delayed incontinence care
Penalty
Summary
The facility failed to provide sufficient staffing per its facility assessment and failed to provide enough staff to complete timely cares and incontinence checks for a resident who was dependent on staff for assistance. The staffing plan dated 10/23/25 identified daily licensed nurse and nursing assistant coverage based on an average daily census of 39, but survey observations and staffing records showed repeated shortages on multiple shifts, including days when the number of nursing assistants scheduled or actually working was below the facility’s identified needs. The PBJ Staffing Data Report for fiscal year 25, quarter 4 also showed multiple instances of actual nursing assistant hours falling below scheduled hours on weekends and other shifts, and staff interviews confirmed the facility was often short-staffed, especially on weekends. During the survey, staff described how shortages affected care delivery. Nursing assistants reported having larger resident assignments when short-staffed and said they sometimes delayed basic care such as washing faces or brushing teeth, or substituted bed baths for showers or tub baths. An RN stated medication and treatment responsibilities for 22 residents were difficult to complete and that one medication pass ran into the next without time between, with medications and treatments being late. A facility scheduler and the acting DON both acknowledged there were times call-ins could not be replaced, and that on weekends there were not extra staff available to help on the floor. For the resident reviewed for ADL care, the record showed diagnoses including vascular dementia, depression, bipolar disorder, chronic pain, recurrent UTIs, and PTSD, and that the resident was cognitively intact but required substantial to maximum assistance with ADLs and was always incontinent of bowel and bladder. The care plan directed toileting every two to three hours and checking every two hours with assistance as needed, and the resident preferred not to be awakened before 9:00 a.m. During a continuous observation, the resident’s room was not entered for four hours, and when care was finally provided the brief was soaked with urine and contained a moderate amount of formed stool stuck to the skin. Staff later confirmed the resident had last been checked and changed at 6:30 a.m., that four hours was too long to go without checking for incontinence and changing a brief, and that the resident had been having moisture-related skin concerns since October 2025. The resident also reported sometimes waiting two hours for the call light to be answered and said one night she was left wet until the next morning.
Improper Medication Labeling, Expired Supplies, and Unsecured Resident Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were properly labeled and expired medications and supplies were removed from use in a medication cart and medication room. During observation of Medication Cart A, an RN confirmed that a resident’s insulin glargine pen was undated after being removed from refrigeration, and three inhalers in the cart had been opened without dates. The RN stated insulin pens should be dated when removed from the refrigerator because the expiration date changes once the medication is at room temperature, and inhalers should also be dated when opened. In the medication room, an RN confirmed multiple expired and improperly stored items. Under a sink cabinet were four boxes of Nestle arginine powder, personal unlabeled electric shavers, four bottles of Clippercide, and cleaning supplies including bleach. Three of the arginine powder boxes had expired, and the RN stated they needed to be discarded. Another cabinet contained an IV emergency kit with expired items, including IV fluids, heparin syringes, and a Continu-Flo solution set. The acting DON stated insulin pens should be dated when removed from the refrigerator and that expired supplies in the IV kit and protein supplements would need to be disposed of. The facility’s inventory of the IV emergency kit also identified additional expired IV fluids, syringes, IV start kits, dressing change kits, catheters, and adapter caps. The facility also failed to ensure proper storage of medications for a resident approved for self-administration. The resident was cognitively intact, had diagnoses including COPD, chronic respiratory failure with hypoxia, CHF, and obstructive sleep apnea, and was approved to self-administer nebulizer treatments after set-up. Observations showed unopened nebulizer ampules on the bedside table and three supplement bottles in a basket beside the recliner on multiple days. The resident stated they no longer took the vitamins. Staff interviews confirmed that medications in a resident room required a SAM assessment and needed to be secured, and the acting DON later confirmed the vitamin bottles were in the room even though the resident was not taking them.
Food Safety Practices Not Followed During Chicken Preparation
Penalty
Summary
The facility failed to ensure food safety practices were followed during meal preparation when raw chicken was observed in a covered plastic container resting in a sink while it was being brined. The Dietary Manager stated the chicken was brining in a solution with lemon and garlic, and a staff member later stated the chicken had been thawed in the refrigerator and that the brine contained salt, sugar, thyme, lemons, and water. The chicken had been brining for about 30 minutes outside of the refrigerator and was expected to be placed on pans and baked about 10 minutes later. When the brine temperature was checked, it was 36.5 degrees Fahrenheit, and a chicken breast temperature was 32.9 degrees Fahrenheit. The staff member stated it would have been better to brine the chicken in the cooler or refrigerator. The recipe for Lemon-Thyme Brined Chicken directed that the chicken be sealed in a bag or container with lid, the liquid added, and then refrigerated for 4 hours, no more than 8 hours. The facility policy stated perishable foods, including meat and poultry, must be appropriately managed and kept refrigerated to prevent bacteria from multiplying or forming toxins.
EBP and Hand Hygiene Failures During Wound Care and Resident Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were in place for a resident with chronic pressure ulcers who was receiving ongoing wound care. The resident had a significant change in status assessment showing decline in cognition, hemiplegia and hemiparesis of the right side, a CVA, severe protein-calorie malnutrition, and pressure ulcers including a stage 3 wound and an unstageable deep tissue injury. The resident’s MAR showed daily wound care to the foot and hip, and provider orders did not identify an order for EBP. The care plan included an undated banner note referencing EBP related to wound, but it did not contain a focus statement for impaired skin integrity or wounds. An integrated wound care note dated 12/3/25 identified a stage 3 pressure ulcer of the right foot fifth interdigital space with heavy serous drainage and a wound bed of 50% slough and 50% granulation. A later wound care note dated 1/5/26 identified an unstageable deep tissue injury to the right lateral hip measuring 2 cm by 2 cm with moderate serosanguineous drainage and 100% slough tissue. During observation on 2/26/26 at 10:47 a.m., the RNCM with hospice and an NA provided wound care to the resident without gowns. There was no PPE station in the room and no sign on the door indicating EBP was in place. The facility also failed to ensure appropriate infection control during personal care for another resident on EBP. That resident’s records identified a stage 4 pressure ulcer of the left buttock, CHF, and venous insufficiency, with care plans and orders for wound care, repositioning, and EBP. During observation, staff entered the room with gloves but no gowns to straighten bedding, adjust a lift sling, and assist with a full sling mechanical lift transfer. Staff later changed the resident’s brief, removed PPE without sanitizing hands, handled personal items and room surfaces, and exited without hand hygiene. The mechanical lift was left outside the room and was not sanitized after use. During another observation, an LPN changed wound dressings on the resident’s right ankle and left heel, changed gloves between wound care tasks without hand sanitizing, and later returned to the room with an NA to reposition the resident while both were gloved but not gowned.
Inaccurate MDS Coding for Pressure Ulcers, Antipsychotic Use, and CPAP
Penalty
Summary
The facility failed to ensure accurate MDS coding for three residents. For one resident with a history of CVA, hemiplegia and hemiparesis of the right side, severe protein-calorie malnutrition, and pressure ulcers, the MDSs contained inconsistent coding related to pressure ulcer status and risk. The resident’s significant change assessment identified a decline in cognition and pressure ulcers present on admission, while a quarterly MDS identified an at-risk and actual stage 3 pressure ulcer not present on admission, and the admission MDS identified no pressure ulcer risk or actual pressure ulcers. The record also showed a Braden Scale score of 17 indicating risk, a CAA that triggered the pressure ulcer care area, and a care plan that did not contain a focus statement for at-risk or actual skin impairment. A wound portal entry documented a new in-house acquired stage 3 pressure ulcer and later an unstageable pressure injury. During interview, the RN stated the MDS information in section M was an error and would affect reimbursement. For another resident with diagnoses including malignant neoplasm of the right renal pelvis, hypothyroidism, dementia, and hypertension, the significant change MDS contained contradictory information in Section N regarding antipsychotic use. The MDS marked antipsychotic use as yes, but also indicated the resident was not on an antipsychotic and that the question about receiving antipsychotic medications since admission was not necessary. The resident’s order summary included an order to observe closely for side effects of antipsychotic medication and an order for olanzapine, and the CAA identified antipsychotic use and routine administration without a gradual dose reduction attempt. For a third resident with COPD, chronic respiratory failure with hypoxia, CHF, and OSA, the annual MDS did not code CPAP use in Section O even though the care plan, provider orders, TARs, and staff documentation showed CPAP was set up nightly and for naps, and the resident stated they used CPAP every night. The RN confirmed the CPAP should have been coded on the MDS.
Failure to Complete Required PASRR Level II Screening
Penalty
Summary
The facility failed to ensure an OBRA Level II evaluation was completed for a resident whose corrected pre-admission screening dated 10/14/25 identified that a Level II screening was required for mental illness. The resident’s quarterly MDS identified diagnoses of vascular dementia, depression, bipolar disorder, and PTSD, and also noted the resident was cognitively intact and required substantial to maximum assistance with activities of daily living. During interview, the social service designee stated she was not sure whether the OBRA Level II had been completed and would check, but the facility was unable to provide evidence that it was completed before admission or after admission. The acting DON stated she was not familiar with the OBRA Level II process and would defer to the SSD. The PASRR guidance in the record stated that when a mental illness or developmental disability is identified, an additional PASRR Level II screening is required.
Care Plan Not Updated for Changing Needs
Penalty
Summary
The facility failed to update R3’s care plan to reflect multiple changes in condition and care needs after a significant change in status assessment completed following hospice admission. R3’s assessment identified a decline in cognition, right-sided hemiplegia/hemiparesis from a CVA, severe protein-calorie malnutrition, a stage 3 pressure ulcer, and an unstageable deep tissue wound. The assessment also showed functional limitations in range of motion, dependence for toilet hygiene, lower body dressing, and transfers, need for maximal assistance with bed mobility, and use of a wander or elopement alarm daily. Despite these findings, the care plan did not contain a focus statement, goals, or interventions for wandering, elopement, or the elopement alarm, and it did not contain a focus statement or interventions for actual skin impairment. The care plan also did not accurately reflect R3’s current mobility status or recent events. Although the plan included revisions related to falls, limited physical mobility, and pain, it did not contain an intervention for the fall that occurred after the listed revisions, and the pain plan was not individualized beyond determining a satisfactory pain level, evaluating mood and behavior, and monitoring for factors that aggravate pain. The record also included elopement assessments showing conflicting findings about wandering risk and the presence or absence of a wander guard, while observations confirmed a non-removable white bracelet on R3’s left wrist that nursing staff identified as a wander guard. The DON stated the care plan was expected to reflect R3’s needs, and the facility policy required a comprehensive person-centered care plan that is updated based on changes in condition.
Uncovered Pressure Ulcer Exposed to Incontinence
Penalty
Summary
The facility failed to ensure a wound bed was protected for a resident with a stage 4 pressure ulcer on the left buttock who was also at risk for cross contamination due to frequent bowel and bladder incontinence. The resident had diagnoses including congestive heart failure and venous insufficiency, was moderately cognitively impaired, and had care plan instructions for wound care, dressing monitoring, skin care, and enhanced barrier precautions. Provider orders required daily wound care to the left buttock pressure ulcer with 1/4 strength Dakins packing and a bordered foam dressing, with additional care as needed if the dressing became soiled or came off during cares or showering. During an observation, nursing staff changed the resident’s brief and found that the left buttock wound had no dressing in place. The wound had packing, the brief was saturated, and there was a baseball-sized amount of light yellow-brown drainage where the brief aligned with the wound. The nursing assistant cleansed the resident’s skin and replaced the brief, but no dressing was applied to the wound. Later interviews confirmed the wound dressing was not in place, that staff were unsure of the current order, and that the uncovered wound was passed between nurses during shift report. The LPN stated the resident often had multiple stool incontinence episodes per shift and confirmed concern for infection prevention with the wound being open to the brief. The DON stated staff were expected to notify the nurse if a wound dressing was missing and confirmed concern for infection control because the resident’s bowel and bladder incontinence put them at risk for contamination of the wound bed.
Failure to Monitor Skin Integrity and Reposition a Resident With Pressure Ulcers
Penalty
Summary
The facility failed to ensure ongoing skin inspections, wound assessments, and timely repositioning for a resident with multiple pressure ulcers. The resident had a significant change in status assessment showing decline in cognition, hemiplegia and hemiparesis on the right side related to a CVA, severe protein-calorie malnutrition, a stage 3 pressure ulcer, and an unstageable deep tissue wound. The resident was dependent for toilet hygiene, lower body dressing, and transfers, needed maximal assistance with bed mobility, and was admitted to hospice on 1/30/26. The resident’s care plan included instructions to turn and reposition every 2 hours and as needed, but it did not include a focus statement for actual or potential skin breakdown or interventions to monitor and assess wounds. The record showed long gaps without documented skin checks or wound assessments, including periods from 9/19/25 to 11/7/25, 11/13/25 to 11/25/25, 11/28/25 to 12/9/25, 12/17/25 to 12/29/25, 1/13/26 to 1/23/26, and 1/27/26 to 2/9/26. The resident developed a wound on the right foot fifth interdigital space that was later diagnosed as a stage 3 pressure ulcer, and later developed an unstageable pressure ulcer on the right lateral hip. The record also showed inconsistent documentation of wound monitoring and repositioning. A wound portal entry identified a new in-house acquired stage 3 pressure ulcer at the right fourth interdigital toe space, and later entries documented the right hip wound, but the facility record did not contain regular wound assessments during multiple intervals. During continuous observation on 2/25/26, the resident was seen asleep and leaning to the right in a Broda chair for an extended period, with the right shoulder and knee lower than the left and the left foot off the footrest. During interview, the NA stated the resident should have been repositioned sooner and should have been repositioned in the chair if he wanted to remain seated. The DON stated her expectation was for skin and wounds to be checked at least weekly with documentation of wound characteristics, and the PCP stated he would expect skin to be looked at every week.
CPAP Cleaning and Maintenance Not Ordered or Documented
Penalty
Summary
The facility failed to ensure that a resident's CPAP machine was properly cleaned and maintained for infection prevention. The resident was cognitively intact and had diagnoses including COPD, chronic respiratory failure with hypoxia, CHF, and obstructive sleep apnea. Although the resident's care plan included CPAP settings, it did not address standard cleaning and maintenance of the CPAP. The provider orders included CPAP use at bedtime and when in bed for naps, but there were no orders for cleaning or maintenance of the CPAP machine, and the TARs for multiple months also had no instructions for cleaning and maintenance. During observations, the resident's CPAP machine had visible water in the chamber on multiple occasions, including 2/23/26, 2/24/26, 2/25/26, and 2/27/26, with one observation on 2/26/26 showing a dry water chamber. Nursing assistants stated nurses started, monitored, and cleaned the CPAP. An RN stated nurses were responsible for placing the CPAP on the resident, monitoring it, and washing it daily and weekly per guidelines, and confirmed CPAP orders, including cleaning, were expected on the TAR or MAR. The acting DON stated residents with CPAPs should have orders for application, water chamber filling, and cleaning of the CPAP machine and tubing/mask, and was concerned that the resident did not have CPAP orders because the TAR is what tells nursing to perform those tasks.
Failure to Offer and Educate on Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccinations and/or provide education according to CDC guidelines for 3 of 5 residents reviewed for vaccinations. R12 had diagnoses including malignant neoplasm of the right renal pelvis, hypothyroidism, dementia, and hypertension; their immunization record showed they received the influenza vaccine on 11/4/25, but education was documented as not given. R8 had diagnoses including vascular dementia, depression, bipolar disorder, chronic pain, and PTSD; their immunization record also showed influenza vaccine administration on 11/4/25 with education documented as not given. R13 had diagnoses including atrial fibrillation, GERD, BPH, hyperlipidemia, arthritis, and depression. Their Vaccination Consent form dated 9/17/25 showed they wanted to receive the influenza vaccine during the influenza season, but there was no evidence they were offered the vaccine during the immunization season. During interviews, the acting DON stated residents received the VIS in their admission packet and that during flu and cold season the facility had a vaccine clinic and re-did consents and VIS. The NC-B stated that when flu season came around, new consents were obtained and new education was given along with a VIS. The facility’s Resident Immunizations policy dated 1/21/25 stated vaccinations would be offered based on CDC recommendations and physician orders, and that VIS and education would be provided and documented before administration.
COVID-19 Vaccine Education Not Documented for a Resident
Penalty
Summary
The facility failed to ensure residents were educated on COVID-19 vaccinations when administered to 1 of 5 residents, R8. R8’s quarterly MDS identified diagnoses including vascular dementia, depression, bipolar disorder, chronic pain, and PTSD. Review of R8’s immunization record showed the COVID-19 vaccine was given on 11/4/25, and the record documented that education was not given. During interview, the acting DON stated residents received the Vaccine Information Statement in their admission packet, while the NC-B stated that when vaccines were given, new consents were obtained and new education was provided along with a VIS. The facility policy stated that residents and/or representatives would be provided a VIS prior to vaccination, education would be provided and questions answered before administration, and the education would be documented in the EMR.
Delayed Incontinence Care and Incomplete Skin Monitoring
Penalty
Summary
The facility failed to provide timely assistance with checking and changing for a resident who was dependent on staff for assistance with ADLs and was always incontinent of bowel and bladder. The resident’s MDS identified diagnoses including vascular dementia, depression, bipolar disorder, chronic pain, history of UTIs, and PTSD, and also noted the resident was cognitively intact and required substantial to maximum assistance with ADLs. The care plan included toileting every two to three hours, checking every two hours and assisting with toileting as needed, and the resident’s preference was not to be awakened before 9:00 a.m. During a four-hour observation, no staff entered the resident’s room until late morning. When the nursing assistant entered, the resident’s brief was later found soaked with urine and contained a moderate amount of formed stool stuck to the resident’s skin. The resident’s skin under the breasts, in the groin, and across the abdominal pannus was bright red, and the resident stated the treatment could sting. The resident also stated she sometimes waited two hours for the call light to be answered and reported being left wet all night on another occasion. The record showed ongoing skin concerns in the breast, groin, and perineal areas dating back to admission, with treatment orders for nystatin powder and later a vinegar-and-water soak with zinc cream after the skin condition was noted not to be improving. Weekly skin assessments were documented, but several entries recorded normal moisture and no skin concerns despite the resident’s ongoing redness, and there were gaps of up to a month without a documented skin assessment. Staff interviews confirmed that four hours was too long to go without checking for incontinence and changing the brief, and the acting DON stated weekly skin checks and checking/changing per the care plan were expected.
Failure to Timely Report Alleged Sexual Assault to State Agency
Penalty
Summary
The facility failed to timely report an allegation of sexual assault to the State Agency within the required 2-hour timeframe after an incident in which one resident groped another resident’s breasts without consent in the dining room. On the morning of 1/20/26 at approximately 9:15 a.m., a registered nurse (RN-A) observed that a male resident (R1) approached the dining room to greet his wife (R3), moved around a table when asked by an aide, and then came behind another resident (R2) and groped her breasts without her consent. R1 was redirected to his room and educated, and he demonstrated little to no remorse for his actions. RN-A reported that R2 was aware the incident occurred but soon closed her eyes and showed no visible negative reaction or distress, and later staff interviews found R2 had slight to no recall of the incident. Police and the responsible parties for R1 and R2 were notified, and RN-A, who had not worked at the facility for long and was unfamiliar with the residents’ plans of care, stated that the plan of care was nonetheless followed. The facility’s incident report shows that the allegation was reported to the State Agency at 4:25 p.m. on 1/20/26, more than 2 hours after the incident. During an interview on 1/29/26, the social worker stated that the decision was made to report to the State Agency after most of the investigation had been completed and acknowledged she was not aware that the report should have been made first. She agreed that the incident was reported late and not within the 2-hour requirement set by regulations and the facility’s “Maltreatment Reporting Guidelines” policy, which requires immediate reporting, but no later than 2 hours after an allegation of abuse, neglect, financial exploitation, injuries of unknown source, or misappropriation of property.
Staffing Shortages Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely completion of resident care, resulting in delayed administration of morning medications for several residents. Specifically, four residents received their medications late, with one resident receiving their morning medications as late as 1:15 p.m. despite being scheduled for administration between 7:00 a.m. and 10:00 a.m. The registered nurse responsible for medication administration was overwhelmed with the task of passing medications to 23-24 residents, including those requiring additional time for medication crushing and enhanced barrier precautions. In addition to medication delays, the facility also failed to provide adequate assistance for a resident with pressure ulcers who required regular turning and repositioning. The resident, who was dependent on staff for bed mobility, was not repositioned for several hours, leading to a worsening of their wound condition. The nursing assistant responsible for the resident's care was unable to attend to the resident in a timely manner due to a busy morning, resulting in the resident's wound being left uncovered and actively bleeding. Interviews with staff revealed ongoing issues with staffing levels, with nurses and nursing assistants frequently unable to complete their duties within their shifts. The facility's staffing levels were consistently below the planned numbers, particularly on weekends and during certain shifts, leading to increased workloads for the remaining staff. The facility's assessment and payroll-based journal report confirmed these staffing deficiencies, highlighting a pattern of insufficient staffing that impacted the quality of care provided to residents.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to ensure that medications and supplies in the medication storage room were not expired, potentially affecting all 39 residents. During an inspection of the locked medication room, it was observed that the lab cart for blood draws contained nine yellow top blood tubes with an expiration date of 10/31/24, all four respiratory viral panel swabs were expired, two bottles of Hibiclens had expiration dates of 8/2024 and 11/2024, and two tubes of Bacitracin ointment had expiration dates of 11/2023. The Director of Nursing (DON) acknowledged that expired medications should not be used due to concerns about potency and efficacy. It was noted that the night shift was responsible for checking for outdated supplies, but there was no check-off sheet to ensure this task was completed. The facility's Night Nurse Weekly Duties document indicated that each Tuesday, the night nurse was to check for dates on opened medications and expired medications on both medication carts, treatment carts, and the medication room, highlighting any dates that expire within the current month.
Inaccessible Posting of Ombudsman Information
Penalty
Summary
The facility failed to ensure that current contact information for all pertinent State Agency and advocacy groups was posted at a level accessible to all residents, particularly those in wheelchairs or with poor eyesight. During a resident council meeting, four residents, all requiring the use of a wheelchair, expressed that they were unaware of where state inspections were posted and noted that some postings were too high to read. A review of the bulletin board in the main dining room revealed that the poster with information regarding the ombudsman was placed approximately six inches from the ceiling, making it inaccessible to residents in wheelchairs. The Director of Nursing confirmed the inaccessibility of the ombudsman information, which is a violation of the Combined Federal and State Resident Rights that require such information to be posted in a form and manner accessible and understandable to residents and their representatives.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 13.79% with four errors out of 29 opportunities. This deficiency involved a resident who was observed during medication passes. The resident, who was moderately cognitively intact, had multiple diagnoses including anxiety, depression, and dysphagia, and required medications to be administered through a gastric tube. The errors were primarily due to the late administration of medications, which were given significantly past their scheduled times. The registered nurse responsible for administering the medications was handling a large workload, passing medications for 23-24 residents, including those requiring crushed medications and enhanced barrier precautions. This workload contributed to the delay in medication administration. The director of nursing confirmed that nurses were responsible for half of the residents in the building and acknowledged the importance of timely medication delivery. The facility's medication delivery schedule was not adhered to, leading to the observed deficiencies.
Inaccessible Call Lights in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call lights were accessible from the bathroom floor in multi-resident bathrooms for five residents. Observations revealed that call light cords in several rooms were either too short or had knots, preventing them from reaching the floor. In one instance, a call light did not function when pulled. Interviews with nursing staff and the maintenance director indicated a lack of awareness regarding the required length of call light cords in bathrooms. Measurements confirmed that the cords were significantly above the floor, with some cords having knots that further reduced their length. The nursing assistant and registered nurses interviewed were not aware of any specific regulations concerning the length of call light cords in resident bathrooms. The maintenance director was not informed of the non-functioning call light and had not received any repair requests. The director of nursing acknowledged the importance of having call lights reach the floor to ensure residents could access them in case of a fall. The facility's call light policy, dated 2017, did not address the required length of call lights in resident bathrooms.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to ensure that a copy of the baseline care plan was provided to a newly admitted resident, identified as R40, or their representative. R40 was admitted with spastic hemiplegia affecting the right dominant side and a nontraumatic intracerebral hemorrhage. The baseline care plan, dated 11/19/24, included short-term goals, health maintenance needs, pain intervention, safety concerns, medication concerns, and designated representative, as well as needs and interventions for eating, toileting, bathing, grooming, dressing, bed mobility, and transfers. However, there was no indication that R40 or their representative had been offered or received a copy of this care plan. Interviews conducted with R40 and their family member revealed that they were not aware of any meetings regarding care plans. The Director of Nursing (DON) stated that the baseline care plan should be reviewed and a copy offered to the resident or their representative. A registered nurse confirmed that while the care plan was developed with the resident, it was not offered to them or their representative. The corporate RN also verified the importance of providing a copy of the baseline care plan to ensure the resident and their family are aware of the plan of care.
Failure to Reposition Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely repositioning for a resident with pressure ulcers, leading to a deficiency in care. The resident, identified as R25, had intact cognition and was diagnosed with Parkinson's with dyskinesia, diabetes mellitus, stage two pressure ulcers in the sacral region and left buttock, dermatitis due to friction or contact with body fluids, and a non-pressure chronic ulcer. R25 was dependent on staff for bed mobility and required repositioning every two to three hours as per the care plan. However, during an observation, R25 was left in the same position from shortly after 7 a.m. until 10:02 a.m., exceeding the recommended repositioning interval. When the nursing assistant (NA-D) finally attended to R25, they discovered the wound was not covered with a dressing and was actively bleeding. The registered nurse (RN-D) was called to clean and dress the wound, noting that it appeared worse than the previous day. RN-D had been conducting weekly wound assessments since the facility's rounding wound provider stopped visiting. Despite the worsening condition of the wound, the resident's provider was aware and visited the facility weekly. The facility's repositioning policy required residents to be repositioned based on individual assessments, but this was not adhered to in R25's case, contributing to the deficiency.
Failure to Implement Effective Dialysis Communication System
Penalty
Summary
The facility failed to establish an effective communication system with an outside dialysis facility, which is crucial for ensuring continuity of care and reducing the risk of complications for a resident requiring dialysis services. The resident, who had intact cognition and was diagnosed with end-stage renal disease and type 2 diabetes mellitus, was receiving dialysis care while residing at the nursing facility. The resident's care plan indicated that dialysis was scheduled for Monday, Wednesday, and Friday, and included staff responsibilities such as assessing the dialysis site for bleeding or drainage, updating the provider or dialysis unit with any concerns, recording weights from the dialysis unit, and observing for signs of infection. During interviews, it was revealed that the health unit coordinator stated that a dialysis communication sheet was supposed to accompany the resident to the dialysis center and be returned to the facility, but the resident did not have a dialysis agreement in their electronic medical record. The director of nursing emphasized the importance of a dialysis agreement for better communication and continuity of care. The dialysis agreement, dated after the deficiency was noted, lacked critical information such as the dialysis contact person and the name and address of the hospital for emergency dialysis. The facility's policy on Dialysis Management required a comprehensive agreement to manage the resident's care, including details on medical and non-medical emergencies and the process for information exchange, which was not adhered to in this case.
Failure to Investigate Resident's Delusions
Penalty
Summary
The facility failed to investigate, review, and analyze the underlying causes of a resident's delusions, leading to a deficiency in providing necessary behavioral health care and services. The resident, identified as R11, exhibited behaviors of hallucinations and delusions, as documented in her quarterly Minimum Data Set (MDS). Despite having no cognitive impairment diagnosis, R11 displayed significant behavioral changes, including hallucinations of people and animals in her room, confusion, and delusional thoughts about children and animals. These behaviors were consistently documented by staff over several months, yet there was no evidence of a thorough investigation or analysis of these symptoms. R11's care plan included interventions such as monitoring for cognitive changes, orienting her to time and place, and providing redirection as needed. However, the progress notes revealed ongoing episodes of delusions and hallucinations, such as seeing babies and cats in her room, believing her teddy bear was a real baby, and expressing a desire to leave the facility due to perceived intrusions. Despite these documented behaviors, the facility did not adequately address the underlying causes or adjust the care plan to better meet R11's needs. Interviews with staff, including registered nurses and nursing assistants, indicated that they received training on dementia and mental health conditions. However, there was uncertainty about R11's diagnoses, and the interventions identified by staff were limited to redirection, reassurance, and reorientation. The director of nursing emphasized the importance of understanding mental health conditions, yet the facility's actions did not reflect a comprehensive approach to managing R11's behavioral health needs. This lack of investigation and analysis contributed to the deficiency in providing necessary behavioral health care and services to R11.
Improper PPE Use in Covid-19 Isolation Room
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) when exiting a resident's room with a Covid-19 positive diagnosis. The resident, identified as R32, was severely cognitively impaired and had a diagnosis of Covid-19. On December 11, 2024, two staff members were observed outside R32's room donning isolation gowns and N-95 masks before entering. However, upon exiting, they were seen wearing surgical masks, having removed their N-95 masks inside the room and replaced them with surgical masks stored inside. This practice was contrary to the facility's policy and the Centers for Disease Control (CDC) guidelines, which state that all PPE except the respirator should be removed before exiting the room. Interviews with staff revealed a misunderstanding of the proper procedure for doffing PPE in an airborne isolation room. Nursing assistants reported being instructed by nurse managers to remove their N-95 masks inside the room, a practice confirmed by RN-B, who stated that staff were educated on PPE procedures during orientation and annually. However, the Director of Nursing (DON) clarified that N-95 masks should not be removed until outside the Covid-19 room to prevent exposure. The facility's policy, dated July 25, 2023, also directed staff to discard disposable respirators after exiting the resident room and performing hand hygiene, which was not followed in this instance.
Failure to Ensure Up-to-Date Immunization Records and Vaccine Education
Penalty
Summary
The facility failed to ensure that immunization records were up to date for two residents who were new admissions. Resident 13, who was over the age of 50 and had multiple diagnoses including hypertensive heart disease and atrial fibrillation, did not have a Minnesota Immunization Information Connection (MIIC) report, and the facility could not provide any immunization history. Similarly, Resident 40, also over the age of 50 with conditions such as spastic hemiplegia and nontraumatic intercerebral hemorrhage, lacked an MIIC report and immunization history. Interviews with registered nurses revealed uncertainty about the residents' vaccination status and whether follow-ups had been conducted. The facility also failed to educate and offer pneumococcal vaccines to residents upon admission. Resident 17, who had a history of cerebrovascular disease and diabetes mellitus, was eligible for a pneumococcal vaccine according to CDC guidelines but was not offered one. The registered nurse was unaware of the CDC's PneumoRecs VaxAdvisor and relied solely on the MIIC for vaccine status, without consulting the resident's provider about vaccine eligibility. The director of nursing expected staff to review CDC guidelines and offer vaccines appropriately, which was not done in this case. Additionally, the facility did not provide education or offer the influenza vaccine to three residents. Resident 11, with chronic heart failure and other conditions, had an outdated influenza vaccine record, and there was no documentation of the vaccine being offered to Residents 13 and 40. The facility could not provide evidence of education about the influenza vaccine or signed declinations from the residents or their representatives. The director of nursing was unsure of the process if a resident declined the vaccine, indicating a lack of clear procedures for handling vaccine refusals.
Failure to Educate and Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that residents were educated on and offered COVID-19 vaccinations upon admission, as evidenced by the cases of three residents. Resident 11, who was admitted with chronic heart failure, hypertension, multidrug-resistant organism, diabetes mellitus, and depression, had a record of a COVID-19 vaccine received on 10/19/23. However, there was uncertainty from the staff regarding whether Resident 11 had been offered any vaccines upon admission. Resident 13, admitted with hypertensive heart disease, anxiety disorder, atrial fibrillation, and adult failure to thrive, had no immunization history available, and the staff assumed the resident was anti-vaccine without documented evidence of education or declination. Resident 40, admitted with spastic hemiplegia and nontraumatic intracerebral hemorrhage, also lacked an immunization history, and the staff was unsure if the resident or their representative had been followed up on regarding vaccination status. Interviews with the nursing staff revealed a lack of clarity and follow-through in documenting and offering COVID-19 vaccinations to these residents. RN-B was unaware of any immunization history for Resident 40 and unsure if any follow-up had occurred. RN-A assumed Resident 13 was anti-vaccine but had no documentation to support this belief. The Director of Nursing expected staff to identify a resident's vaccine status upon admission to ensure proper education and offering of vaccines, but this expectation was not met. The facility's policy required an immunization history to be taken upon admission and documented in the resident's medical record, with any unknown histories shared with the attending physician, but this process was not followed for the residents in question.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by staff, as evidenced by an incident involving a resident with severe cognitive impairments and multiple mental health disorders, including schizoaffective disorder, autism, bipolar disorder, intellectual disabilities, Alzheimer's disease, dementia, and schizophrenia. The resident, who had a court-appointed guardian due to his inability to make decisions, was reported to have engaged in inappropriate sexual contact with a housekeeper. The resident's care plan noted a history of making inappropriate sexual comments and touching others inappropriately, with interventions in place to manage these behaviors. Despite these interventions, the resident reported to a registered nurse that he had a romantic relationship with a housekeeper, which included inappropriate touching. The nurse documented the incident but did not report it for investigation. The housekeeper confirmed the encounter, stating she was unaware of the prohibition against relationships with residents. An occupational therapy assistant assessed that the resident was not cognitively intact enough to consent to a relationship, highlighting the resident's vulnerability and the facility's failure to protect him from potential abuse.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with severe cognitive impairments, including schizoaffective disorder, autism, bipolar disorder, intellectual disabilities, Alzheimer's disease, dementia, and schizophrenia. The resident, who required extensive assistance with daily activities, informed a registered nurse (RN-A) that he had a romantic relationship with a housekeeper and that they had engaged in physical contact. Despite documenting the incident in the resident's medical record, RN-A did not report the allegation to the State Agency within the required two-hour timeframe. The housekeeper confirmed the resident's account, stating that she was unaware of the prohibition against relationships with residents until after the encounter. The facility's policy mandates that any suspected maltreatment be reported within two hours, a guideline reiterated by both RN-B and the director of nursing. The administrator also emphasized the importance of timely reporting. The failure to report the incident promptly constitutes a deficiency in the facility's adherence to its maltreatment reporting guidelines.
Failure to Provide Required Abuse Training
Penalty
Summary
The facility failed to ensure that required training on abuse, neglect, and exploitation was completed for a housekeeper, identified as H-A, whose personnel records were reviewed. During an interview, H-A stated she could not recall the last time she received such training. A review of her personnel file revealed that she had not undergone training on abuse, neglect, and exploitation since June 7, 2021. The Director of Nursing (DON) confirmed that all staff should receive this training upon hire, annually, and as events occur. The facility's Maltreatment Prohibition policy, reviewed on October 18, 2021, also directed that employees be trained on these policies and procedures during orientation and annually. However, the administrator acknowledged that H-A had not received the required education since 2021.
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Illustrative
What surveyors actually found near you
We read the 113 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayshore Residence And Rehabilitation Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Villa Marina Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 9 | 0 |
| Dove Healthcare - Superior | 3.7 mi | ★★★★★ | 3 | 0 |
| Twin Ports Health Services | 3.7 mi | ★★★★★ | 4 | 0 |
| Aftenro Home | 5.2 mi | ★★★★★ | 17 | 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.