Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Good Samaritan Society - Specialty Care Community during CMS and state inspections, most recent first.
Food handling and storage deficiencies were observed during meal service and kitchen checks. A dietary aide and DM were seen preparing and serving food without consistent hair restraints or proper glove hygiene, and food temperatures were found out of range, including egg salad filling and mashed potatoes. In addition, multiple food items in the cooler and freezer were left open or undated, including meats, hot dogs, panko, pizza crust, and carrots.
Infection Surveillance Logs Did Not Track Unresolved Signs and Symptoms: The facility failed to implement routine surveillance of signs and symptoms of illness or infection that were not currently being treated with antibiotics or other treatment. The IP/DON used PCC EMR reports and progress notes to look for fever, respiratory symptoms, GI symptoms, new wounds, MDRO history, and new orders, but the findings were not recorded or compiled for trending, and the surveillance logs did not capture completed testing such as labs or chest x-rays. There were no formal logs for residents being monitored only, and the comment section was not used to document lab results.
Psychotropic Medication Monitoring Failures: The facility did not document side effect monitoring for residents receiving antidepressant and antipsychotic medications, and orthostatic BP monitoring ordered for several residents was incomplete or showed identical readings across positions. Residents with severe cognitive impairment and multiple diagnoses, including dementia, schizophrenia, and cardiovascular conditions, were receiving psychotropic medications, but the EHR lacked evidence of ongoing monitoring for adverse effects. Staff interviews confirmed monthly orthostatic BP checks should include lying, sitting, and standing readings and that side effect monitoring was not yet in place.
Care plans were not updated to reflect changed resident conditions, preferences, and interventions. One resident's plan still showed hospice and wound-based EBP after hospice ended and the wound healed, another still listed Influenza A after the illness had resolved, and a third did not include behavior interventions such as a door chime and bookshelf sticker or updated dining preferences. Two residents with family-requested cameras also had care plans that omitted the camera use, rationale, and related monitoring details.
Medication labels did not match current provider orders for two residents during med passes. An LPN administered quetiapine while the label still showed different directions than the MAR, and an RN gave an inhaler from unlabeled packaging plus insulin doses that differed from the label directions. The CM, RN, and DON all acknowledged the labels should match the MAR or current orders.
Failure to trim a resident’s fingernails during weekly bathing. A resident with cognitive impairment and ADL dependence had very long fingernails on all 10 fingers over several days and stated he could not cut them himself and wanted them trimmed. Staff gave conflicting statements about who could perform nail care, with NAs saying only nurses could cut nails while the RN, CM, and DON stated NAs could trim nails for non-diabetic residents and that nail care should occur with weekly showers when needed or requested.
A resident with severe cognitive impairment and diagnoses including Alzheimer's disease, stroke, and non-Alzheimer's dementia was started on risperidone without documented informed consent from the resident or representative before administration. The EMR did not show consent prior to initiation, and the RN CM later obtained verbal consent from the family after the medication had already been started. The DON stated consent should have been obtained and signed before the psychotropic was given, consistent with the facility's psychotropic medication policy.
A resident with moderate cognitive impairment and dependence for ADLs was observed using a broda chair with multiple cracked cushions, exposed foam, and stuffing visible in the headrest and side areas. Staff said broken equipment should be reported for repair or replacement, but the chair remained in use and hospice had not yet been notified; the DON stated equipment was expected to stay in good repair and that the cracked cushions could not be cleaned appropriately.
Failure to Document Required Involuntary Discharge Notice: The facility transferred a resident to a sister facility without documented written notice of the involuntary discharge, appeal rights, resident or resident rep notification, attempted contact with the resident’s daughter, or Ombudsman notification. The SW and Administrator acknowledged missing discharge documentation, and the Ombudsman confirmed the required discharge process had not been followed.
The facility failed to complete an SCSA in a timely manner after a resident with COPD and chronic respiratory failure was discharged from hospice. Staff interviews and record review showed the EHR continued to list the resident as receiving hospice services after hospice had ended, and the SCSA was not completed until weeks later, after surveyor inquiry.
A resident with severe cognitive impairment, aphasia, dementia, and a history of stroke received clopidogrel, Senexon S, and amlodipine crushed together and mixed with applesauce during med pass before there was an order authorizing crushed meds. The RN said the meds were crushed because it was ordered, while the DON stated meds requiring crushing must have a provider order and that meds should not be crushed without one. The resident's chart lacked authorization to crush meds until later that day, and the facility policy required provider awareness and separate crushing/administering of each medication.
Failure to monitor BP parameters before PRN metoprolol administration: The facility had a PRN order for metoprolol tartrate for BP greater than 150 for a resident with severe cognitive impairment and schizophrenia, but the record did not show BP checks tied to the order or documentation that the threshold was met. Staff interviews reflected confusion about the purpose of the medication, and the RN case manager and DON stated the order lacked clarification on how often BP should be obtained.
A resident admitted with CAD, HTN, and non-Alzheimer's dementia did not have current flu or pneumococcal immunization status reviewed in the EMR, and the record lacked vaccine history, consent, or declination documentation. The IP stated the admission nurse was to review immunizations within 24 hours, verify status through MIIC, and offer needed vaccines, but this had not been done for the resident.
Failure to Offer and Document COVID-19 Immunization: A resident with CAD, HTN, and non-Alzheimer's dementia had no documented review of immunization history, no COVID-19 vaccine status in the EMR, and no evidence that vaccine education, consent, or declination was completed. The IP stated the admission nurse should review immunizations within 24 hours and verify status through MIIC before offering needed vaccines, but the resident's record showed none of this had been done.
A facility failed to ensure the current RBOR was posted for residents, visitors, and staff to review. One RBOR poster in a locked glass case had no print date, and another posted near the therapy room was dated 11/16. The DON stated she was unaware of changes to the RBOR form and did not know the updated version needed to be obtained and posted.
Survey results were not fully posted in the lobby binder for residents, staff, and visitors to review. A review found that several recent complaint investigation survey findings were missing from the binder, and the administrator acknowledged the binder was intended to display survey results from the past 3 years and remain updated at all times per facility policy.
Resident dignity was not maintained when staff were observed speaking disrespectfully to a resident with dementia and severe cognitive impairment during care and transfers. Video showed staff telling the resident she was asking for help for no reason, calling her "grandma" and "momma," and making comments such as "cutting up" and that it was the last time staff would be in the room. The DON and administrator identified the staff in the videos, and staff interviews confirmed residents should be addressed by their preferred names and treated respectfully.
A resident with severe cognitive impairment, dementia, fractures, and multiple traumas was care planned to transfer with a Stand Aid and one staff for toileting. Instead, video footage showed two staff using pivot transfers from the toilet to the wheelchair and from the wheelchair to the bed without the Stand Aid. Interviews confirmed staff knew the resident was supposed to use the Stand Aid, and the DON and CD stated the transfers did not follow the care plan.
A resident with severe cognitive impairment, dementia, and fractures was supposed to be transferred with a Stand Aid, but staff were observed lifting the resident from the floor by the arms without a Hoyer lift and transferring the resident from a wheelchair to standing without a gait belt. Interviews confirmed staff knew a Hoyer lift was to be used after a fall and that a gait belt should be used with the Stand Aid, but the resident was handled manually instead.
The facility failed to complete behavior assessments and implement person-centered care plans for multiple residents with dementia who exhibited wandering, aggression, and other behavioral symptoms. Several residents repeatedly entered others’ rooms, took belongings, and engaged in physical altercations, while staff relied mainly on generic supervision and redirection that they reported as ineffective. Activity and preference assessments documented specific interests such as reading, outdoor time, music, and work-like tasks, but these were not translated into individualized behavioral interventions, and activity staff were rarely present on the unit. Observations showed NAs often seated at the nurse’s station with minimal engagement of residents, and families reported inadequate redirection and lack of meaningful activities, while nurses and NAs described feeling overwhelmed and lacking resident-specific strategies to manage behaviors.
A resident with severe cognitive impairment and dementia-related behaviors was admitted with ample labeled clothing, dentures, a personal radio, and an Army hat. Within about a week, most of the clothing and several personal items were missing from the resident’s room on a locked unit. The family reported the missing items and provided a detailed list to nursing staff and the nurse manager, but a grievance form was not completed, and the required grievance process was not initiated. A NA later reported she had not been informed of the issue, and the RN acknowledged knowing about the missing items for several days without completing a grievance form or involving maintenance. The DON confirmed that, per facility policy, a grievance form and immediate, thorough search should have occurred when the missing items were first reported, but this did not happen.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as evidenced by observations and records showing residents were served meals not aligned with their documented dietary requirements.
The facility failed to ensure residents knew how to file grievances and that grievance forms were accessible in prominent locations. Residents were unaware of the process, and forms were not available in the lobby or nursing stations. The facility's policy outlined the grievance process, but the lack of accessible forms and clear communication led to the deficiency.
The facility failed to monitor and document dishwasher temperatures in four unit kitchenettes, compromising dish sanitation. Logs were incomplete, and dietary staff did not adhere to protocols. Additionally, the coffee machine in the Lakes unit was unsanitary, with mold observed, indicating a lack of daily cleaning. These deficiencies posed potential food-borne illness risks.
A resident with COPD and CHF was found with medications at their bedside without a completed self-administration assessment or physician's order. The facility's policy requires an assessment and a physician's order for self-administration, which were not followed, leading to the deficiency.
The facility failed to maintain clean wheelchairs for two residents with Huntington's disease and dementia, as observed by surveyors. Despite a schedule for cleaning, the wheelchairs had copious amounts of dried food and substances, indicating a lack of regular maintenance. Interviews revealed that the responsibility for cleaning was assigned to overnight staff, but the schedule was not effectively followed, and no specific policy for wheelchair cleaning existed.
A resident with central cord syndrome and obesity experienced an 8.6-pound weight gain in one week, but the facility failed to notify the physician as required. Staff interviews revealed delays in re-weighing and lack of documentation, despite the resident's worsening condition, including edema and shortness of breath, which led to a hospital evaluation recommendation.
A resident at moderate risk for pressure sores did not receive prescribed heel suspension boots as per their care plan. Observations showed the boots were not used, and staff interviews confirmed the care plan was not followed. The resident did not refuse the intervention, indicating a lapse in adherence to pressure ulcer prevention protocols.
A resident with a urinary catheter due to chronic kidney disease and urinary retention had their catheter drainage bag positioned incorrectly at the level of the bladder, contrary to standard practice. The facility's staff failed to document or communicate the resident's preference for using a leg bag, which required deviation from standard catheter care procedures. Observations and interviews revealed a lack of adherence to the facility's catheter care policy, which mandates maintaining a non-obstructed downhill flow of urine.
A resident with severe cognitive impairment and dysphagia was given a regular soda instead of the prescribed thickened liquids, despite orders for a mechanically altered diet. Staff interviews revealed a lack of adherence to dietary requirements, and the facility's policy on documenting refusals and educating on risks was not followed.
A resident with hepatic encephalopathy and alcoholic cirrhosis did not receive rifaximin as ordered due to a delay in cost approval by the facility. The medication was unavailable from the time of the order, and staff failed to notify the medical provider immediately, contrary to facility policy. The delay in communication and action among staff led to the resident not receiving the critical medication for several days.
The facility's assessment failed to specify staffing needs based on resident care requirements, lacking details on staffing levels for different shifts. Interviews with staff revealed uncertainty and insufficient documentation regarding staffing determinations, with the Facility Assessment missing specific staffing requirements.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with complex medical conditions, including stroke-related impairments. The care plan lacked specific goals and interventions for the resident's ADL needs and did not address safety concerns or the need for supervision while eating. Interviews revealed that the care plan was not completed on time, and staff were not adequately informed about the resident's care requirements.
A resident with a swallowing disorder was left unsupervised during meals, leading to aspiration pneumonia. Despite requiring a modified diet and supervision, the care plan was not updated, and staff were unaware of the resident's needs. The resident was found unresponsive and covered in food, resulting in hospitalization. The facility lacked a policy on meal supervision.
The facility failed to ensure call lights were accessible for four residents with cognitive impairments and mobility dependence. Observations showed call lights were not within reach, and staff did not consistently check on the residents. Interviews revealed inconsistencies in staff understanding of residents' abilities and the frequency of checks required, leading to the deficiency.
The facility failed to properly assess, document, and plan the use of physical restraints for several residents, leading to deficiencies in ensuring restraints were used appropriately. Residents with severe cognitive impairments and conditions like Alzheimer's and Huntington's disease were found with restraints without proper documentation or care planning. Interviews with staff revealed a lack of awareness of restraint requirements, contributing to the deficiencies observed.
A nursing assistant in an LTC facility failed to maintain a resident's dignity by speaking in a belittling manner during care. The resident, who has severe cognitive impairment due to Huntington's disease, perceived the comments as verbal abuse. Despite the assistant's claim of joking, the resident expressed discomfort with the communication.
The facility failed to implement and complete person-centered care plans for several residents, leading to deficiencies in meeting their medical and personal care needs. Residents with severe cognitive impairments and various medical conditions were not repositioned or checked on as required by their care plans, resulting in a lack of necessary care and attention. The facility's policy on care plans was not adhered to, and staff interviews revealed a lack of awareness and adherence to the care plans.
A resident with multiple medical conditions, including central cord syndrome, was not provided with adequate personal hygiene care, leading to complaints and a hospitalization for a catheter-related urinary tract infection. Despite being dependent on staff for ADLs, the resident experienced inadequate cleaning, as evidenced by dried blood and feces found during an observation. Staff interviews revealed unresolved complaints and a lack of timely care.
Two residents with cognitive impairments and Huntington's disease were improperly managed by being double briefed, contrary to their care plans. Staff interviews revealed a lack of awareness and adherence to proper incontinence care protocols, and the facility's quality of care policy was not provided.
A resident with dementia and mobility issues developed multiple pressure ulcers due to the facility's failure to implement appropriate preventive measures and interventions. Despite the resident's risk factors, the care plan lacked specific actions to prevent pressure ulcers, and staff did not adequately monitor or report skin changes. This led to the resident's decline and hospital admission with multiple pressure injuries.
The facility failed to serve breakfast at the proper temperature on a unit, affecting 16 residents. Observations revealed scrambled eggs were cold when served, and residents complained about the temperature. A TMA noted challenges in maintaining food temperature due to staggered delivery times and the number of residents needing assistance. The DON was unaware of complaints, and no food temperature policy was obtained.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairments within the required timeframe. A family member's video showed a nursing assistant handling the resident roughly, not using a gait belt, and continuing care despite resistance. The DON acknowledged the mistakes but did not report the incident promptly, believing there was no intent to harm.
Food Handling, Temperature Control, and Storage Deficiencies
Penalty
Summary
The facility failed to ensure dietary staff consistently wore required hair restraints and gloves while serving and preparing food. During evening meal service, a dietary aide was observed with loose strands of hair hanging from a ponytail while setting up the kitchenette, and the dietary manager delivered sherbet without a hair net in place. The dietary aide handled food items, including bread for an egg salad sandwich, wore gloves on one hand and then both hands while preparing the sandwich, and removed gloves without performing hand hygiene in between glove changes. The dietary manager later stated that a ponytail was not adequate as a hair restraint and that staff behind the serving line were expected to wear hairnets, aprons, and gloves on both hands. The facility also failed to maintain food temperatures within the required range during meal preparation. The dietary aide checked the temperature of egg salad filling and found it to be 56.8 degrees Fahrenheit while it sat in a stainless serving container on the counter and was not in an ice bath. The mashed potatoes were also checked and found to be 115.5 degrees Fahrenheit. The dietary aide stated she was unaware of the required food temperatures. The dietary manager later stated cold food should be 40 degrees or less and hot food should be 145 degrees Fahrenheit, and that the potatoes should have been discarded and a fresh batch made when they were found at 116 degrees Fahrenheit. The facility also did not consistently cover, date, and label food items stored in the freezer and cooler. During the kitchen tour, egg rolls, an unidentified meat package, mustard, hot dogs, and panko were observed without dates or with packaging left open to the air. On a follow-up kitchen visit, an opened package of pizza crust and a bag of carrots in the walk-in freezer were also undated. The dietary manager stated items were expected to have an opened date and be placed in appropriate containers, with no items left open to the air.
Infection Surveillance Logs Did Not Track Unresolved Signs and Symptoms
Penalty
Summary
The facility failed to implement routine surveillance of signs and symptoms of illness or infection that were not currently being treated with antibiotic therapy or other treatment. Review of the Infection Surveillance Reports for March, April, and May 2026 showed logs that included the total number of infections, facility or community acquired status, facility acquired infection incidence rates, multidrug resistant organisms, resident name, room number, infection type, signs and symptoms reported, status, and treatment in place. However, the logs did not identify completed testing such as labs or chest x-rays, and the comment section was not used to report completed lab results. During interview, the Infection Preventionist, who was also the DON, stated she used the Point Click Care EMR for surveillance tracking and could run reports and review progress notes using the control-f find feature. She stated she looked for changes in temperatures and vital signs, cough, shortness of breath, altered respiratory status, nausea, vomiting, diarrhea, new admissions, indwelling devices, MDRO history, new wounds, and new orders. Although she reviewed these notes daily Monday through Friday, the information was not recorded or compiled for trending of current symptoms or patterns of illness, and there were no formalized logs for residents being monitored only. The facility policy stated the infection control program and surveillance system were to be implemented to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infections.
Psychotropic Medication Monitoring and Orthostatic BP Documentation Failures
Penalty
Summary
The facility failed to ensure residents receiving psychotropic medications were adequately monitored for side effects and orthostatic blood pressures as ordered. Review of records for 4 of 6 residents identified for psychotropic medication monitoring showed no evidence that side effect monitoring had been implemented for residents receiving antidepressant, antipsychotic, or other psychotropic medications. R7 had moderate cognitive impairment and diagnoses including DVT, hypertension, BPH, renal insufficiency, diabetes mellitus, and CVA. R7 received escitalopram 20 mg daily for depression, but the EHR did not show evidence of side effect monitoring related to the medication. R10 had severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, atrial fibrillation, hypertension, and non-Alzheimer's dementia. R10 received brexpiprazole 1.5 mg twice daily for agitation related to dementia and haloperidol 2 mg daily for delusions related to unspecified dementia, but the EHR did not show evidence of side effect monitoring for these antipsychotics. R41 had severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, hypertension, PVD, hyperlipidemia, arthritis, Alzheimer's disease, stroke, and non-Alzheimer's dementia. R41 received risperidone 0.25 mg three times daily for hallucinations, and the EHR did not show evidence of side effect monitoring. R91 had severe cognitive impairment and schizophrenia and received olanzapine and risperidone for paranoid schizophrenia, but the EHR did not show evidence of side effect monitoring. The record also showed failures to obtain and document orthostatic blood pressures as ordered for R10, R41, and R91. For R10, monthly orthostatic blood pressure documentation contained identical readings across lying, sitting, and standing positions on multiple dates. For R41, some monthly orthostatic blood pressure checks were documented as refused, with no evidence the monitoring was attempted again later, and other entries showed identical readings in all positions. For R91, one monthly entry lacked standing blood pressure and pulse documentation, and another showed identical readings in all positions. Staff interviews confirmed orthostatic blood pressures should be completed monthly in lying, sitting, and standing positions, that identical readings in all positions were not expected, and that side effect monitoring for psychotropic medications was not yet in place.
Care plans not revised for changed conditions, behaviors, and electronic monitoring
Penalty
Summary
The facility failed to revise comprehensive care plans to reflect significant changes in resident status, conditions, preferences, and interventions for three residents reviewed for care plan revision. One resident had a discharge return anticipated MDS showing moderate cognitive impairment, multiple diagnoses including cancer, septicemia, and non-Alzheimer's dementia, and hospice services. The resident's EHR showed hospice services were discontinued, but the care plan continued to identify the resident as receiving hospice care. The same resident's care plan also continued to state that Enhanced Barrier Precautions were required due to a wound, even though the wound had healed and the resident remained on EBP because of a urinary catheter. Another resident's comprehensive MDS identified moderate cognitive impairment, diabetes, CVA, and use of insulin, an anticoagulant, and an antidepressant. The resident's care plan still listed Influenza A as an active respiratory infection with an initiation date from the prior year, but the EHR did not identify ongoing signs, symptoms, treatment, or diagnosis of Influenza A. A third resident had severe cognitive impairment, dementia, PTSD, behavioral symptoms, and wandering behavior. The resident's care plan included dining preference interventions stating the resident preferred to sit alone during meals and liked to sit in the dining room by the television next to the window, but the EHR showed the resident had behavior management interventions in place, including a bookshelf sticker on the door and a door chime to alert staff when the room door opened, and these interventions were not included in the care plan. Observations showed the resident with wandering and behavioral concerns eating and sitting with other residents in the dining room rather than alone, and staff interviews confirmed the resident had become less agitated, spent more time outside the room, and that the door chime and bookshelf sticker had been implemented and were effective. Interviews also confirmed the hospice discharge, the healed wound, the ongoing catheter-related EBP need, and that Influenza A had not been present for quite some time. The DON stated care plans should be updated whenever there was a new diagnosis, condition, intervention, preference change, or other significant change in status, and that care plans served as the primary communication tool for staff. The facility also failed to update care plans for two residents with electronic monitoring in their rooms. One resident's care plan lacked the use of a camera, the rationale for it, and the fact that family had placed it for monitoring and interaction. Another resident's care plan also lacked the use of a video camera with audio capability, the rationale, and related interventions such as signage, staff awareness, and family interaction through audio. Records showed consent forms and progress notes documenting the cameras, staff notification, signage, and family involvement, but these details were not reflected in the care plans. Staff interviews confirmed that the camera use should have been outlined in the care plans and that nursing staff were responsible for updating them.
Medication Labels Did Not Match Current Orders
Penalty
Summary
Medication labels did not properly reflect provider orders for 2 of 7 residents observed during medication administration. During a medication pass, an LPN gave a resident quetiapine fumarate 25 mg 1/2 tablet, while the medication label directed 1/2 tablet daily and also stated to give one tablet at bedtime. The MAR directed staff to give quetiapine fumarate 25 mg 1/2 tablet by mouth one time a day for depression at 4:00 p.m. and 25 mg by mouth one time a day for depression at 8:00 p.m. The LPN stated the MAR directed administration at 4:00 p.m. and was unsure whether the dosing schedule had changed. The LPN stated the medication label should match the MAR and acknowledged there was no label in place to identify a change in orders, although stickers were available for that purpose. A review with the CM found the quetiapine label lacked indication regarding spacing of doses and still directed 1/2 tablet once daily and one tablet at bedtime. During another medication pass, an RN administered Anoro Elipta from a plastic tray that lacked labeling for resident name, date dispensed, expiration date, or directions for use; the inhaler had been opened on 4/29/26. The same resident also received Lantus insulin 38 units sub q even though the label directed 40 units sub q, and Novolog insulin 11 units sub q even though the label directed 9 units sub q. The RN stated insulin labels should have been updated by pharmacy or a sticker should have been placed on the pens to reflect the changed orders and refer staff to the EMR. The DON stated medication labels should include the resident's name, medication name, date dispensed, expiration date, and directions for use, and that labels on the medication card should match the MAR.
Failure to Trim Resident Fingernails During Weekly Bathing
Penalty
Summary
The facility failed to ensure resident grooming needs were met for one resident who had muscle weakness, disorientation, atrial fibrillation, and essential hypertension. The resident’s MDS assessed him as moderately cognitively impaired and needing set-up to maximal assistance with ADLs, and the CAA documented physical limitations including weakness, limited range of motion, poor coordination, poor balance, visual impairment, or pain as factors contributing to dependence. During observation, the resident had very long fingernails on all 10 fingers, estimated at 1/4 inch or longer, and stated he was unable to cut them himself and wanted them trimmed. The resident continued to have long fingernails during daily observation over several days. The record showed weekly baths on Wednesdays, and the care plan documented dependence on staff, including one staff person assisting with bathing. On the day after the scheduled shower, the resident’s fingernails were still long and uncut, and he stated he had received his shower the prior evening. Nursing assistants reviewed the record and stated residents should have nails trimmed with weekly showers, but they believed only nurses could cut fingernails and that NAs were limited to emery boards and nail polish. An RN and the CM stated nails should have been trimmed with the shower and that NAs could trim nails for residents who were not diabetic. The DON stated the expectation was that nails would be trimmed with the weekly bath or shower if needed or requested, and that all NAs could perform nail care except for diabetic residents.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident and/or resident representative was informed of and participated in treatment decisions regarding psychotropic medication use, including failure to obtain informed consent before initiating risperidone for one resident. The resident had severe cognitive impairment and required assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, stroke, and non-Alzheimer's dementia. The resident's MDS also indicated two or more falls since admission. Physician orders showed risperidone was initiated when the resident was admitted to the facility, but the EMR did not contain documentation that informed consent had been obtained before the medication was started. During interview, the RN Case Manager stated psychotropic medication consents were obtained upon admission and reviewed with the resident and/or family member, but she could not locate the consent in the EMR and later contacted the family to obtain verbal consent over the phone. The DON stated consent should have been obtained when the medication order was received, either upon admission if the resident was already on the medication or when a new psychotropic medication was initiated, and that the consent should have been signed by the resident or family member prior to administration. The facility's psychotropic medication policy required residents and/or their family or legal representative to be notified when psychotropic medications were initiated or when residents were admitted on psychotropic medications, and required the Permission for Use of Psychotropic Medications consent form to be completed and signed.
Broda Chair Not Kept in Good Repair
Penalty
Summary
The facility failed to maintain a broda chair in good repair for a resident who used it for daily support and positioning. The resident’s quarterly MDS indicated moderate cognitive impairment and dependence on staff for ADLs, with diagnoses including anemia, dementia, Huntington’s disease, anxiety, depression, and bipolar disorder. On observation, the broda chair had multiple cracked areas on the headrest cushion, including vertical cracks about six inches long with inner foam visible, several cracks on the right side of the head area with foam visible, and a large cracked area on the left side with jagged breaks and exposed foam. The upper corners of the left side cushion also had stuffing and foam sticking out. A follow-up observation showed the resident continued to be placed in the same broda chair with the cracked cushions and exposed foam and stuffing. Staff interviews indicated CNA-C was not aware of the condition and stated broken equipment should be reported through maintenance or hospice if the resident was on hospice. RN-C stated the chair damage may have been caused by the resident’s helmet and that hospice would need to be notified for repair or replacement, but was not aware whether hospice had been informed. CM-B stated several chairs needed repair or replacement but hospice had not yet been notified, and identified infection control as the concern because the cracked cushions could not be cleaned appropriately. The DON stated equipment was expected to remain in good repair and that maintenance requests or hospice updates should be completed in a timely manner to maintain cleanliness and infection control. No facility policy regarding resident equipment was provided.
Failure to Document Required Involuntary Discharge Notice
Penalty
Summary
The facility failed to provide and document written notice of an involuntary transfer/discharge for R100 before the resident was transferred to a sister facility on 8/22/25. The resident’s EHR did not contain documentation of a Notice of Involuntary Discharge, notification of appeal rights, evidence that the resident and/or resident representative were notified, documentation of attempted contact with the resident’s daughter or resident representative, or notification to the Ombudsman program regarding the discharge. During interviews, the Social Worker stated the facility typically issued a NOMNC, discussed appeal rights, reviewed discharge information, coordinated with outside providers, and arranged transportation, but confirmed there was no documentation of attempts to contact the resident’s daughter or of discharge planning for this transfer. The Administrator stated the resident was transferred to the sister facility and that notice had been relayed to the resident, but she could not provide documentation supporting that notification and acknowledged missing pieces in the discharge record. The Ombudsman stated the required discharge process had not been followed, there was no evidence that a Notice of Involuntary Discharge had been issued or that the resident and/or resident representative had been notified, and the Office of Ombudsman for Long-Term Care had not received notification of the discharge.
Delayed SCSA After Hospice Discharge
Penalty
Summary
The facility failed to timely complete a comprehensive assessment after a significant change in status for one resident, including failure to complete a Significant Change in Status Assessment (SCSA) after discharge from hospice services. The resident had diagnoses including COPD and chronic respiratory failure, and the most recent MDS identified that the resident was receiving hospice services. Hospice services were discontinued, but the resident’s electronic health record continued to show hospice status on the resident profile and care plan after hospice had ended. During interviews, staff confirmed the resident had been discharged from hospice and that the record still reflected hospice services. The CM stated the record should have been updated to accurately reflect the resident’s current status and that the SCSA was completed only after surveyor inquiry. The DON stated hospice discharges required updates to the care plan and clinical record and confirmed an SCSA should have been completed following the hospice discharge. Facility MDS history showed the SCSA was not completed until approximately three weeks after the hospice discharge, and the facility’s MDS policy required staff to identify significant changes, notify interdisciplinary team members, and complete the Significant Change MDS according to RAI Manual timelines.
Crushed medications given without prior provider authorization
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during medication administration for a resident with severe cognitive deficits who required assistance with all ADLs and had diagnoses including aphasia, anemia, hypertension, non-Alzheimer's dementia, generalized muscle weakness, and a history of stroke with right-sided weakness. The resident's care plan identified a texture-modified diet and antiplatelet therapy, but it lacked indication prior to 6/3/26 that medications were authorized to be crushed. During a medication observation, the resident was given clopidogrel 75 mg, Senexon S 500 mg/8.6 mg, and amlodipine 10 mg crushed together and mixed with applesauce and administered orally. The RN stated the medications were crushed and mixed with applesauce because it was ordered by the provider. Later the same day, the DON stated all medications requiring crushing were to have an order in place and that this was important to determine whether medications could be crushed based on timed-release status, protective coating, and similar factors. The DON stated she was unaware whether orders were in place for the resident, but affirmed medications were not to be crushed without provider orders. The resident's progress notes showed that an order to crush meds due to history of stroke and seizure was not received until later that day, and the cumulative orders lacked authorization to crush medications before that time. The facility policy stated the attending provider must be aware of the need to crush medications so the appropriate form can be ordered, and that best practice is to separately crush each medication and separately administer each medication with food.
Failure to Monitor BP Parameters Before PRN Metoprolol Administration
Penalty
Summary
The facility failed to ensure physician-ordered parameters were monitored before administering a PRN antihypertensive medication for one resident. The resident had severe cognitive impairment, required assistance with ADLs, and had diagnoses including schizophrenia. The physician order was for metoprolol tartrate 12.5 mg by mouth every 24 hours as needed for blood pressure greater than 150, but the electronic health record did not show that blood pressure readings were obtained to determine whether the ordered parameter was met or whether the PRN dose was indicated. Although the facility obtained the resident’s blood pressure on a weekly basis, the record did not identify blood pressure monitoring tied to the PRN order, documentation that the medication’s ongoing need was evaluated, or evidence that the ordered blood pressure threshold was ever met. During interviews, an LPN stated he believed the medication was intended for symptoms during aggressive episodes, while the RN case manager stated the order should have been clarified with the provider and that staff should have been monitoring blood pressure to determine whether the medication was indicated. The DON also stated blood pressure should have been monitored and the order should have identified how frequently readings were to be obtained.
Failure to Review and Document Immunizations
Penalty
Summary
The facility failed to ensure all residents were offered and up to date on immunizations for 1 of 5 residents reviewed, R29. R29 was admitted on 4/29/26 and had diagnoses including coronary artery disease, hypertension, and non-Alzheimer's dementia. The resident's electronic medical record lacked a review of current immunizations, including vaccines received prior to admission, and did not show the current status of pneumococcal immunizations or influenza vaccinations. The record also lacked documentation that vaccination consent had been reviewed with R29 or the responsible party, including no consent marked refused. During interview, the infection preventionist stated the admission nurse was to review each resident's immunization status within the first 24 hours and then verify it through MIIC before offering needed vaccines. Upon review of R29's immunization tab, the infection preventionist confirmed the immunization status had not been reviewed and the record lacked a vaccination history or evidence that vaccines had been offered. The facility policy required screening for eligibility, providing vaccine education, obtaining consent or declination, and documenting these steps in the medical record.
Failure to Offer and Document COVID-19 Immunization
Penalty
Summary
The facility failed to ensure COVID-19 immunization was offered and/or administered in accordance with current standard of practice for 1 of 5 residents reviewed for immunizations. Resident R29 was admitted on 4/29/26 and had diagnoses including coronary artery disease, hypertension, and non-Alzheimer's dementia. The resident's electronic medical record lacked a review of current immunizations, including any prior vaccination history, and did not show the current status of COVID-19 vaccinations. The record also lacked any consent for vaccination reviewed with R29 or the responsible party, including no documentation that vaccines were offered or refused. During interview, the infection preventionist stated the admission nurse was responsible for reviewing immunization status within the first 24 hours and that the status was then verified through MIIC before needed immunizations were offered. Upon review of R29's immunization tab, the infection preventionist stated the resident's immunization status had not been reviewed and the record lacked vaccination history or evidence that vaccinations were offered. The facility policy required residents to be screened for eligibility, educated on vaccine risks and benefits, and have consent or declination documented before vaccination orders and administration.
Outdated Resident Rights Posting
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident Rights (RBOR) was displayed for residents, visitors, and staff to review. During observation, the RBOR poster was seen in a locked glass case near the main entrance and elevators without a print date, and a combined RBOR posted near the therapy room entrance in the main lobby was dated 11/16. During interview, the administrator stated she was unaware of any changes to the RBOR form and did not know the updated version needed to be obtained and posted. The facility policy, revised 12/23/25, required resident rights and other required information to be posted in a visible, accessible location and kept updated at all times.
Survey Results Not Fully Posted
Penalty
Summary
The facility failed to ensure that all recent survey results were posted in an accessible location for residents, staff, and visitors. During review of the survey binder located on a table on the side wall of the lobby, the binder was found to be missing information from complaint investigation surveys completed on 12/31/25, 4/2/26, 4/8/26, and 5/15/26. The review was completed to verify that surveys from the last recertification completed on 2/14/25 and subsequent follow-up surveys, including complaint investigations and findings, were available for review. On 6/2/26 at 2:16 p.m., the administrator reviewed the binder and acknowledged that the listed survey results were lacking. The administrator stated the binder was intended to reflect survey results from the past three years so the information would be available for residents, visitors, and family members to review if they wished. The facility policy, Posting Information, Social Services-Rehab/Skilled, revised 12/23/25, stated that residents had the right to be aware of certain location information concerning facility operations, as well as their right of appeal and advocacy, and that the required information was to be kept posted in a visible place, accessible to all residents, and updated at all times.
Resident Dignity Not Maintained During Care
Penalty
Summary
The facility failed to promote dignity for 1 of 3 residents reviewed who required assistance with activities of daily living. The resident had an admission MDS indicating severe cognitive impairment, need for staff assistance with transfers, and diagnoses including dementia. A family member stated she had a video of staff yelling at the resident when the resident asked for help and said the resident was upset after being yelled at. The family member also stated it was upsetting to see staff who did not seem like they wanted to help the resident. During interviews, staff stated residents should be treated respectfully and addressed by their preferred names rather than being called "grandma" or "momma." Review of video from the resident's room showed two staff members speaking to the resident in a disrespectful manner, including telling the resident she was asking for help for no reason, saying she was "cutting up," and that it was the last time staff would be in the room. One staff member addressed the resident as "grandma." In another video, two staff transferred the resident with a stand aid, and after the resident sat down, one staff member said, "There you go momma." The DON and administrator identified the staff in the videos and acknowledged the conduct shown. The facility's Resident Dignity policy stated staff would care for residents in a manner that maintained or enhanced dignity and respect and address each resident by their preferred name.
Failure to Follow Care Plan for Safe Transfers
Penalty
Summary
The facility failed to follow R1’s care plan for transfers when staff used two-person pivot transfers instead of the Stand Aid that was specified in the plan. R1’s admission MDS indicated severe cognitive impairment, need for staff assistance with transfers, and diagnoses including fractures, dementia, and multiple traumas. R1’s care plan dated 3/23/26 directed that R1 required assistance of one staff for toileting and transferred with a Stand Aid. During interviews, R1’s family member stated she was concerned that staff transferred R1 without using the machine that staff were supposed to use and said she had videos showing transfers from the toilet to the wheelchair and from the wheelchair to the bed in which the Stand Aid was not used. A nursing assistant stated she did not recall how R1 was supposed to transfer and said staff referred to the therapy book at the nurses’ station for transfer directions. Another nursing assistant stated she was supposed to use the Stand Aid with R1 and said she always used it because R1 could fall using a pivot transfer. Video footage reviewed by the PTA, administrator, and clinical leadership showed two staff pivot transferring R1 from the toilet to the wheelchair and from the wheelchair to the bed without using the Stand Aid. The PTA stated these transfers were not completed according to R1’s care plan. The DON and administrator identified the staff in the videos as NA-C and NA-D. The DON stated R1 was supposed to transfer with a Stand Aid and one staff per the care plan, and the CD stated that if the care plan indicated use of a Stand Aid, staff should have used it for safety. The facility’s policies stated the care plan provided guidance to the interdisciplinary team and that the SRHP provided guidance on equipment and safe lifting practices.
Unsafe resident transfers and floor lift practices
Penalty
Summary
The facility failed to ensure safe transfers for one resident who was severely cognitively impaired, required staff assistance for transfers, and had diagnoses including fractures and dementia. The resident’s care plan indicated the resident required one staff member to assist with toileting and transfers with a Stand Aid. Family reported concern that staff were transferring the resident by manually moving the resident instead of using the Stand Aid and that staff were not using the required belt during transfers, including pulling on the resident’s arms to get the resident out of a chair. Video review and staff interviews showed that after the resident was found on the floor following a fall, two staff lifted the resident from the floor using the resident’s arms without a Hoyer lift and without a gait belt. Staff interviews indicated that after a fall, the resident should have been assessed by nursing staff and then assisted off the floor with a Hoyer lift. The administrator later identified the staff involved in the floor transfer, and the DON acknowledged the facility recommended use of a Hoyer lift to get residents off the floor. The facility’s Safe Resident Handling Program stated that equipment and safe lifting practices were to be used to eliminate manual lifting whenever possible. A separate video review showed staff transferring the resident from a wheelchair to standing with a Stand Aid without using a gait belt and using the resident’s hands to pull the resident up. Staff interviews confirmed that a gait belt should have been used with the Stand Aid and that staff should not pull on a resident’s arms during the transfer. The DON stated that when using a Stand Aid, staff were expected to use a gait belt around the resident’s waist, and the administrator acknowledged the transfer was not done safely. Staff also stated the resident could not make decisions about personal safety due to dementia, and the resident’s transfer needs were known to staff through the therapy book and care plan.
Failure to Provide Person-Centered Dementia Care and Behavior Management
Penalty
Summary
The deficiency involves the facility’s failure to assess, develop, and implement person-centered care plans and behavior management interventions for multiple residents with dementia and behavioral symptoms. Six residents with dementia (R1, R2, R3, R5, R7, and R8) lacked individualized behavior assessments identifying triggers and effective interventions, despite documented wandering, aggression, and resident-to-resident altercations. Care plans for these residents contained only generic directions such as cueing, reorienting, supervising PRN, and redirecting, without specific, individualized strategies based on each resident’s known preferences, histories, or observed behavior patterns. Activity assessments and preference evaluations documented that these residents enjoyed specific activities such as reading, outdoor time, music, work tasks, and social engagement, but these interests were not translated into targeted behavioral interventions. For R1, who had dementia with behavioral disturbances, the record showed repeated episodes of wandering into other residents’ rooms, taking belongings, attempting to tilt another resident from a chair, pushing staff, carrying tables, attempting to climb on tables, and trying to hit windows with a chair. R1 was involved in an altercation where another resident stomped on his face after R1 entered that resident’s room, and later engaged in escalating aggression that led to a 911 call and hospital transfer. Progress notes and staff interviews described ongoing exit-seeking, striking out at staff, unplugging cameras, threatening to damage equipment, and urinating in inappropriate places, while staff primarily responded with close supervision and redirection. Despite this pattern, there was no behavior assessment in the medical record to identify triggers or effective interventions, and staff reported that the care-planned approach of “follow and redirect” did not stop R1’s behaviors. R2, who had dementia with agitation and PTSD, was known not to like others in his room, and his care plan included general interventions to protect the rights and safety of others and redirect him. After an altercation in which another resident entered his room, staff attempted to use a mesh barrier with a stop sign across his doorway, but it was placed inside the closed door where it could not serve as a visible cue to others. R2’s record also lacked a behavior assessment to identify triggers or effective interventions, despite family reporting that staff had been informed of his preference to keep others out of his room. R3, who had dementia and a history of physical behaviors toward others, reported multiple incidents of another resident entering his room, attempting to take his pillow, urinating on his floor, and trying to get into his bed. R3’s care plan referenced a history of altercation when another resident walked into his room and included only broad language to protect rights and safety and divert attention PRN, with no documented behavior assessment to guide more specific preventive strategies. R5, with severe cognitive impairment and frequent physical behaviors and wandering, was observed repeatedly entering other residents’ rooms despite staff attempts to redirect him. The care plan again relied on general redirection, offering snacks or diversional activities, and monitoring whereabouts, but staff interviews confirmed that the primary intervention was to follow and redirect, which they stated did not stop his behaviors and required significant staff time. R7, who had severe cognitive impairment and wandering behavior, had no behavior assessment in the record, and family reported that they rarely saw activity staff on the unit and that R7’s interests in motorcycles, fishing, shopping, and being active were not reflected in activities offered; instead, he was usually observed lying in bed. R8, who had dementia and was dependent for ADLs, also had documented interests in social interaction, outings, music, and games, but family reported that some staff were not good at redirecting residents and allowed them to go where they wanted. During one observation, R1 loudly told R8’s visitors it was time to leave, causing them to move to another area, and staff did not intervene. Unit-wide observations showed that activity staff presence was inconsistent and that residents with dementia and wandering or behavioral symptoms were often minimally engaged. During a prolonged observation period, NAs were frequently seated at the nurse’s station with limited interaction with residents, while residents slept at tables, wandered toward exits, or moved around the kitchen area. Staff interviews confirmed that activities on the secured unit were infrequent, often did not occur as scheduled, and that the unit “almost never had activities” except when surveyors were present. Nursing staff, including NAs and nurses, reported feeling overwhelmed by the behavioral needs of residents, described frequent resident-to-resident conflicts related to wandering into rooms, and stated they needed specific, resident-tailored lists of behavioral interventions, which were not available. The DON and medical director acknowledged behavioral challenges and staffing limitations but there was no evidence in the record of completed behavior assessments or individualized, person-centered behavior management plans for the residents reviewed.
Failure to Address Grievance for Missing Personal Belongings
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances and to make prompt efforts to resolve a grievance regarding missing personal possessions. The resident had severe cognitive impairment with documented physical and verbal behaviors related to dementia, including combative actions and wandering that intruded on others’ privacy. The resident’s preferences indicated that having music was very important, and he had a personal radio in his room. Shortly after admission, the resident’s family member observed that the resident had initially arrived with plenty of labeled clothing and a personal radio, but within about a week most of his clothing, his dentures, personal radio, and Army hat were missing from his locked-unit room. The family member reported the missing items and provided a list of the missing belongings to nursing staff and the nurse manager. Despite this report, staff did not initiate the facility’s grievance process as required by policy. A nursing assistant later stated she had not been informed of the missing items until the family member spoke with her during a subsequent visit. The RN involved acknowledged learning of the missing clothing days earlier and admitted she had not completed a grievance form at that time and had not contacted maintenance to search for the items. The DON stated that when family notice missing items, staff are to notify the nurse manager, who should involve the interdisciplinary or clinical team, and that a grievance form should have been completed when the missing items were reported. The DON further acknowledged that the nurse manager had not completed a grievance form when the missing items were first reported, contrary to the facility’s Missing Items policy, which required immediate completion of a grievance form and an immediate, thorough search when an item was reported missing.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified based on observations and records indicating that residents were not always served meals that met their documented dietary needs and stated preferences.
Grievance Process and Form Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that residents were aware of how to file grievances and that grievance forms were accessible in prominent locations throughout the facility. During a resident council meeting, four residents expressed that they were unaware of the grievance filing process and did not know where to find grievance forms. They mentioned that they previously felt comfortable discussing grievances with a former social worker, but since his departure, they did not feel they could approach the current social services director (SSD). The SSD claimed that the grievance process was covered in meetings and that forms were available in the main lobby, but observations revealed no forms were present. Further interviews and observations indicated that the reception desk personnel acknowledged the absence of grievance forms in the lobby due to time constraints. The administrator stated that forms should be available at the front desk and nursing stations, but there was no provision for anonymous submission within the facility. A registered nurse also confirmed the lack of grievance forms at the nursing station, suggesting residents would need to go to the lobby to obtain one. The facility's policy and pamphlet outlined the grievance process, but the lack of accessible forms and clear communication led to the deficiency.
Dishwasher Temperature Monitoring and Coffee Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that dishwasher temperatures were consistently monitored and documented to guarantee proper sanitation of resident dishes in four of the five unit kitchenettes. Observations revealed incomplete temperature logs for the dishwashers in the Lakes, Woodland, Boundary Waters, and Arrowhead units. Dietary staff were responsible for checking and documenting dishwasher temperatures twice daily, but logs were found to be incomplete or not up to date. Interviews with dietary aides and the kitchen manager confirmed the lack of adherence to the expected protocol for monitoring and documenting dishwasher temperatures. Additionally, the facility did not maintain the coffee machine in a sanitary condition, as observed in the Lakes unit kitchenette. The coffee/hot water dispenser was found to be dirty, with a white foamy substance floating in the overflow basin, which was identified as mold by a dietary aide. The kitchen manager confirmed that the coffee maker had not been cleaned in 7-14 days, despite the expectation for daily cleaning. The cleaning logs were not signed off, indicating a failure to complete the required cleaning tasks. Facility policies required employees to ensure cleanliness and sanitation of food preparation equipment, but these were not followed, leading to potential food-borne illness risks for residents.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medication assessment (SAM) was completed for a resident, identified as R140, who was observed with medications at their bedside. R140's admission Minimum Data Set (MDS) indicated intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), requiring partial assistance with most activities of daily living. Despite this, R140's physician's orders did not include an order to self-administer medication, and the medical record lacked an assessment to allow self-administration. During an observation, R140 was found with three inhalers on their nightstand, including two Breo Ellipta inhalers and one albuterol inhaler. A registered nurse (RN-C) confirmed that R140 was not assessed to self-administer medications and should not have medications at the bedside without a proper assessment and physician's order. The RN-C explained to R140 the importance of not keeping medications in the room without a lock box to prevent other residents from accessing them. The director of nursing (DON) stated that a resident must be assessed for safety and obtain a physician's order to self-administer medications. Medications should not be kept at the bedside, even if the resident is deemed safe to self-administer, and must be stored in a lock box to prevent access by other residents. The facility's policy outlined the procedure for determining if a resident could self-administer medications, which includes completing a Resident Self-Administration of Medications UDA, obtaining a physician's order, and documenting the process in the care plan. However, these steps were not followed for R140, leading to the deficiency.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to maintain a clean and safe environment for two residents who were dependent on wheelchairs for mobility. Both residents had moderately impaired cognition and were diagnosed with Huntington's disease and dementia. During observations, it was noted that the wheelchairs of both residents had copious amounts of dried food and other substances on the wheels, indicating a lack of regular cleaning and maintenance. The care plans for these residents highlighted their dependence on wheelchairs and the need for assistance with mobility, yet their wheelchairs were not kept in a clean condition. Interviews with the nursing staff and the Director of Nursing revealed that the responsibility for cleaning the wheelchairs fell on the overnight shift staff, with a schedule in place to determine which wheelchairs should be cleaned each night. However, the schedule was not effectively followed, as evidenced by the unclean state of the wheelchairs. The facility did not have a specific policy for wheelchair cleaning, and the existing schedule indicated that the wheelchairs were to be cleaned once a week, with additional cleaning by maintenance if needed. Despite these arrangements, the wheelchairs of the two residents remained unclean, demonstrating a failure in maintaining a homelike and safe environment.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who experienced a substantial weight gain. The resident, who had intact cognition and diagnoses including central cord syndrome, spinal stenosis, and chronic pain syndrome, required substantial assistance with activities of daily living and mobility. According to the physician's orders, the resident was to be weighed weekly, and the physician was to be notified if there was a weight gain of more than 5 pounds in a week. On February 5th, the resident weighed 397.5 pounds, and by February 12th, the weight had increased to 406.1 pounds, indicating an 8.6-pound gain. However, there was no documentation of the physician being notified of this change. Interviews with various nursing staff revealed that the resident was not re-weighed immediately due to the unavailability of the appropriate staff and equipment, and the physician was not informed of the weight gain. The resident's progress notes later indicated a change in condition, including edema and shortness of breath, leading to a recommendation for hospital evaluation. Despite the facility's policy on weighing residents, the staff did not adhere to the protocol of re-weighing immediately, notifying the physician, and documenting the incident, which contributed to the deficiency.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure pressure ulcer prevention interventions were in place for a resident identified as R66, who was at moderate risk for developing pressure sores. R66's care plan and physician orders required the use of heel suspension boots to elevate and protect the heels at all times. However, multiple observations revealed that the boots were not being used as prescribed. During several instances, R66 was found with heels resting directly on the mattress or footrest without the protective boots, despite the care plan's instructions and the resident's acknowledgment that she did not refuse the use of the boots. Interviews with staff, including registered nurses and nursing assistants, confirmed that the care plan was not being followed, and the boots were not consistently applied. The staff acknowledged the importance of following care plans and documenting any refusals, which were not evident in this case. The wound doctor and the director of nursing reiterated the necessity of using the boots to prevent further pressure ulcer development, highlighting a lapse in adherence to the facility's policy on pressure ulcer management.
Improper Catheter Care and Positioning for a Resident
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, identified as R68, who had a urinary catheter due to chronic kidney disease and urinary retention. The resident's care plan and physician's orders did not specify that the catheter drainage bag should be positioned below the bladder, which is necessary to facilitate proper urine flow and prevent complications. Observations revealed that the resident's leg catheter bag was attached at the level of the bladder, contrary to standard practice, and was over halfway full of urine. Nursing staff, including nursing assistants and registered nurses, confirmed that the drainage bag was not positioned correctly and acknowledged that the physician should have been notified if the resident's preference for using a leg bag all the time required deviation from standard practice. Interviews with various nursing staff, including registered nurses and the director of nursing, highlighted a lack of communication and documentation regarding the resident's catheter care preferences and the necessity of positioning the drainage bag below the bladder. The facility's policy on catheter care emphasized the importance of maintaining a non-obstructed downhill flow of urine, which was not adhered to in this case. The director of nursing confirmed that any changes in catheter use should be communicated with the provider, especially when deviating from the physician's orders, to ensure proper care and documentation.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to ensure that beverages were served in the appropriate consistency for a resident who required a mechanically altered diet with thickened liquids due to dysphagia. The resident, who had severe cognitive impairment and a history of pneumonitis due to inhalation of food, was observed receiving a can of soda that was not thickened, contrary to her dietary requirements. The resident's care plan and physician orders specified a pureed diet with mildly thick liquids, yet the administrator provided the resident with a regular soda without thickening it, indicating a lapse in following the prescribed dietary orders. Interviews with staff, including registered nurses and the administrator, revealed a lack of adherence to the resident's dietary needs, with staff acknowledging that all liquids should be thickened and that the resident's family was aware of this requirement. The facility's policy required documentation of any refusal of the prescribed diet and education on the risks and benefits, which was not evident in the resident's medical record. The speech-language pathologist confirmed the need for thickened liquids due to silent aspiration risks, and the director of nursing emphasized the expectation for residents to receive diets as ordered.
Failure to Administer Critical Medication Due to Cost Approval Delay
Penalty
Summary
The facility failed to provide medication as ordered by the physician for a resident diagnosed with hepatic encephalopathy and alcoholic cirrhosis of the liver. The physician had ordered rifaximin, a critical medication for preventing liver failure, to be administered twice daily. However, the medication was not available at the facility from the time of the order on January 14th until January 16th. The delay was due to the need for price approval by the facility, which was not promptly addressed. The nursing staff did not notify the medical provider immediately about the unavailability of the medication, contrary to the facility's policy. The delay in medication administration was compounded by a lack of communication and action among the facility staff. The LPN did not call the medical provider because the medication was awaiting management approval due to its cost. The DON was informed of the high-cost medication on January 16th and sought an alternative from the NP, who was not updated about the missed doses until two days later. The consultant pharmacist emphasized the importance of the medication for the resident's condition, and the facility's failure to administer it could have led to an exacerbation of symptoms. The facility's policy required immediate notification to the physician if a medication was unavailable, which was not followed in this case.
Facility Assessment Lacks Specific Staffing Information
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately identified staffing needs based on the care requirements of its resident population. The assessment, which was organized into six parts, was intended to guide staffing and resource decisions, including the operating budget necessary for facility functions. However, it lacked specific information on staffing levels required for different shifts, such as day, evening, and night, and did not adjust for changes in the resident population. Interviews with facility staff revealed a lack of clarity and documentation regarding staffing determinations. A registered nurse indicated that staffing was based on resident care needs and managed by the DON and administrator. The interim DON, temporarily filling the position, stated that staffing was determined by resident acuity levels. The senior director, assisting during the administrator's leave, acknowledged that staffing was based on resident census and needs but was unsure of specific staffing numbers. The Facility Assessment did not include specific staffing requirements, and there were no additional attachments providing this information.
Failure to Develop Timely Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who had multiple complex medical conditions, including hemiplegia, hemiparesis, dysarthria, type 2 diabetes, dysphagia, aphasia, and a history of stroke. The resident was admitted from the hospital following an ischemic cerebrovascular accident and required skilled services such as medication administration, therapy, and assistance with activities of daily living (ADLs). However, the care plan did not include specific goals and interventions for the resident's ADL needs, such as bathing, bed mobility, dressing, eating, oral care, toileting, and transfers. Additionally, the care plan lacked safety concerns and did not address the resident's need for supervision and assistance with eating. Interviews with nursing assistants and the registered nurse responsible for care planning revealed that the care plan was not completed within the required 48-hour timeframe. The interim director of nursing confirmed that the care plan should have been updated within 48 hours, but it was not. The facility's procedure for new admission care plans was not followed, and the unit manager did not review the resident's care plan the day after admission. The director of nursing acknowledged that the care plan was incomplete and that staff were not adequately informed about the resident's care requirements during the resident's stay. The facility was unable to provide a policy related to new admissions and baseline care plans when requested.
Failure to Supervise Resident with Swallowing Disorder During Meals
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with a swallowing disorder, leading to a serious incident. The resident, who had a history of hemiplegia, dysphagia, and other conditions following strokes, required a regular diet with soft and bite-sized textures and moderately thick liquids. Despite these needs, the resident's care plan was not updated to reflect the requirement for supervision during meals, and staff were not adequately informed of the resident's dietary needs and supervision requirements. On one occasion, a family member found the resident slumped over in a chair, unresponsive, and covered in food, indicating a lack of supervision during a meal. The family member reported that staff had left the resident unattended with a meal tray in the room, despite the resident's known swallowing difficulties. This incident resulted in the resident being admitted to the hospital with aspiration pneumonia. Interviews with staff revealed a lack of awareness regarding the resident's dietary modifications and supervision needs, and the care plan did not reflect the necessary supervision during meals. The facility's interim DON confirmed that the resident's functional assessment indicated a need for supervision while eating, but this was not communicated in the care plan. The DON also noted that staff were expected to supervise residents with dysphagia during meals, whether in the dining room or in their rooms, but this expectation was not met. The facility was unable to provide a policy on supervision during meals when requested, highlighting a gap in procedural guidance for staff.
Failure to Ensure Call Lights Accessible for Residents
Penalty
Summary
The facility failed to ensure that call lights or another means to request assistance were accessible for four residents who were dependent on staff for mobility. These residents, identified as R5, R6, R7, and R8, had varying degrees of cognitive impairment and were reliant on staff for activities of daily living. Observations revealed that call lights were not within reach for these residents, and staff did not consistently check on them to ensure their needs were met. R5, who had severe cognitive impairment and was totally dependent on staff, was observed without a call light within reach while in her Broda wheelchair. Despite being checked on by staff, the call light was not placed within her reach. Similarly, R6, who had cognitive impairment and was dependent on staff, was left in her room without a call light accessible, and staff did not check on her for over two hours. R7, with severe cognitive impairment, was also left without a call light within reach, and staff did not check on him for an extended period. R8, who had moderate cognitive impairment, was found in his room with the call light on the floor, out of reach. Staff checked on him but did not ensure the call light was accessible. Interviews with staff revealed inconsistencies in their understanding of the residents' ability to use call lights and the frequency of checks required. The facility's policy required call lights to be within easy reach, but this was not adhered to, leading to the deficiency.
Deficiencies in Restraint Use and Documentation
Penalty
Summary
The facility failed to properly assess, care plan, and re-evaluate the use of physical restraints for five residents, leading to deficiencies in ensuring that restraints were used appropriately and only when necessary for medical treatment. The report highlights that the facility did not document the need for restraints, did not provide interventions for freedom of movement, and did not ensure that the restraints were the least restrictive alternative. For instance, Resident R4, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease and hallucinations, was using a Broda chair with a back latching belt without proper documentation or care planning to address the restraint's use and necessity. The report further details that Resident R5, who had Huntington's disease and severe cognitive impairment, was observed with a thigh belt restraint instead of the pommel cushion as indicated in the physician's orders. The care plan for R5 did not include interventions for freedom of movement or specify the medical symptoms the restraint was intended to treat. Similarly, Residents R6, R7, and R8 were also found to have restraints without proper documentation, care planning, or assessment of the need for such restraints, and there was a lack of documentation of family or resident education regarding the use of these restraints. Interviews with facility staff, including the Medical Director and registered nurses, revealed a lack of awareness and understanding of the requirements for restraint use, including the need for signed physician orders, documentation of symptoms being treated, and regular assessments. The facility's policy on physical restraints and psychotropic medications outlined the risks associated with restraint use but did not provide specific guidance on the use of restraints, contributing to the deficiencies observed during the survey.
Failure to Maintain Resident Dignity and Respectful Communication
Penalty
Summary
The facility failed to uphold the resident's right to dignity and respectful communication, as evidenced by the interaction between a nursing assistant (NA-C) and a resident (R7). During an observation, NA-C was seen speaking to R7 in a belittling manner while providing care. R7, who has severe cognitive impairment due to Huntington's disease, was dependent on staff for various activities of daily living. During the care process, NA-C made inappropriate comments about R7's movements and bodily functions, which R7 perceived as verbal abuse. R7's medical condition includes unclear speech and severe cognitive impairment, making him reliant on staff for communication and care. Despite NA-C's claim that her comments were made in jest, R7 expressed that he did not feel NA-C spoke kindly to him and identified the comments as verbal abuse. The incident highlights a failure in maintaining the resident's dignity and respectful communication, as required by resident rights regulations.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement and complete person-centered care plans for several residents, leading to deficiencies in meeting their medical and personal care needs. Resident R4, who has severe cognitive impairment and multiple diagnoses including Alzheimer's disease and pulmonary fibrosis, did not have a care plan that included necessary assessments and interventions for the use of a Broda chair with a thigh strap. Similarly, Resident R5, who is severely cognitively impaired and diagnosed with Huntington's disease, was not repositioned or checked on as required by her care plan, which included specific instructions for the use of a Broda chair and incontinence care. Resident R6, with cognitive impairment and dependent on staff for daily activities, was not checked on by facility staff for over two hours, contrary to the care plan's requirements for regular checks and repositioning. Additionally, Resident R7, who is severely cognitively impaired and diagnosed with Huntington's disease, was not repositioned or offered a position change as indicated in his care plan, which was designed to prevent pressure ulcers. The care plans for these residents were not followed, resulting in a lack of necessary care and attention. The facility's policy on care plans, which requires comprehensive and measurable objectives to meet residents' needs, was not adhered to. Interviews with staff revealed a lack of awareness and adherence to the care plans, with one nursing assistant stating that the care plan for R7 was not appropriate. The Director of Nursing acknowledged that the care plans should be person-centered and up to date, indicating a gap between policy and practice in the facility.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain proper personal hygiene for a resident who was unable to perform activities of daily living (ADLs) independently. The resident, who had a history of central cord syndrome, post-traumatic stress disorder, and other medical conditions, was dependent on staff for personal hygiene and toileting. Despite physician orders to keep the peri-area clean and dry every shift, the resident experienced inadequate care, as evidenced by multiple complaints about improper cleaning and a recent hospitalization for a catheter-related urinary tract infection. The facility's grievance logs indicated unresolved complaints regarding care, and there was no documentation provided to show how these complaints were addressed. During an observation, it was noted that the resident's peri-care was not completed in the morning, and the catheter bag had not been emptied until the resident requested it. When staff eventually attended to the resident, dried blood and feces were found, indicating a lack of timely and adequate cleaning. Interviews with staff revealed that the resident had made multiple complaints, and there was an acknowledgment that the resident should have been cleaned earlier. However, the staff failed to report the issue or seek assistance, and the facility's policy on ADLs for dependent residents was not provided upon request.
Improper Incontinence Care Management
Penalty
Summary
The facility failed to adhere to professional standards of practice by improperly managing the incontinence care of two residents, identified as R6 and R9. Both residents were observed wearing two incontinence briefs simultaneously, which was not in accordance with their care plans. R6, who has cognitive impairment and is always incontinent of bowel and bladder due to Huntington's disease, was found with two saturated briefs during a bed bath. The hospice nursing assistant noted that double briefing was a common practice on the unit. Similarly, R9, who also suffers from severe cognitive impairment and Huntington's disease, was observed seated in a wheelchair with two briefs. Both residents' care plans specified that their briefs should be checked and changed every two hours, with no mention of double briefing. Interviews with staff, including a hospice RN, a nursing assistant, a trained medication assistant, and the director of nursing, revealed a lack of awareness and adherence to proper incontinence care protocols. The director of nursing confirmed that double briefing was inappropriate and that staff should follow the care plan instructions, which did not include double briefing. Despite the facility's policy on quality of care being requested, it was not provided, indicating a potential gap in policy enforcement or availability.
Failure to Prevent and Address Pressure Ulcers
Penalty
Summary
The facility failed to appropriately assess and initiate interventions to minimize the risk for pressure ulcer development for a resident with dementia, incontinence, and mobility issues. The resident's care plan identified a potential for pressure ulcer development but did not incorporate specific interventions to prevent them. Despite the resident's significant weight loss and inadequate protein intake, which increased the risk for pressure ulcers, the care plan lacked necessary preventive measures. The resident developed a stage 1 pressure ulcer on the right hip, which was not adequately addressed in the care plan. The nursing staff failed to implement frequent turning, maximal remobilization, and other interventions recommended for residents at mild risk for pressure ulcers. The resident's skin assessments and Braden scores indicated a need for more intensive monitoring and care, but these were not provided, leading to the development of additional pressure injuries. Interviews with staff revealed a lack of communication and follow-up regarding the resident's skin condition. Nursing assistants and registered nurses did not consistently report or address skin changes, and there was a delay in obtaining treatment orders from the nurse practitioner. The facility's policy on skin assessment and pressure ulcer prevention was not effectively implemented, resulting in the resident's decline and subsequent hospital admission with multiple pressure injuries.
Failure to Serve Breakfast at Proper Temperature
Penalty
Summary
The facility failed to ensure that breakfast was served at the proper temperature on the 2nd floor WL unit, potentially affecting all 16 residents. During an observation, scrambled eggs were noted to be cold when served to residents. A resident was heard complaining about the cold eggs, and another resident confirmed that their breakfast was cold. The food was not covered while waiting to be served, contributing to the temperature issue. A trained medication assistant acknowledged the difficulty in serving breakfast at the correct temperature due to the staggered delivery times and the number of residents needing assistance. The director of nursing was unaware of any complaints about cold food, and no policy regarding food temperatures was obtained.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the state agency within the required two-hour timeframe after the allegation was made. This deficiency involved a resident with severe cognitive impairments, including dementia and delirium, who required extensive assistance for daily activities. A family member provided a video showing a nursing assistant (NA) handling the resident roughly during care, including exposing the resident, not using a gait belt during transfer, and continuing care despite the resident's resistance. The director of nursing (DON) reviewed the video and acknowledged the NA's mistakes but did not report the incident promptly, believing there was no intent to harm. The resident's care plan indicated the need for two staff members to assist with care and recommended specific dementia care tactics, which were not followed by the NA. The NA's actions included pulling the resident's clothing, leaving the resident in an unsafe position, and failing to communicate effectively. Despite recognizing these issues, the DON did not report the incident to the state agency within the mandated timeframe, as required by the facility's policy on abuse and neglect. The NA was suspended and later terminated, but the delay in reporting the incident constituted a failure to comply with regulatory requirements.
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.
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What surveyors actually found near you
We read the 1,011 citations issued within 25 miles in the last 12 months — including the 33 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 Robbinsdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villas At Robbinsdale | 0.8 mi | ★★★★★ | 5 | 1 |
| The Terrace At Crystal Llc | 0.9 mi | — | 65 | 4 |
| Courage Kenny Rehabilitation Institutes Trp | 1.7 mi | ★★★★★ | 7 | 1 |
| Covenant Living Of Golden Valley Care & Rehab Ctr | 2.2 mi | ★★★★★ | 2 | 0 |
| Victory Health & Rehabilitation Center | 2.6 mi | ★★★★★ | 15 | 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.