Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Windom during CMS and state inspections, most recent first.
Employee health surveillance data were not provided to QAPI during monthly meetings, and the facility’s employee illness tracking lacked clear return-to-work criteria or documentation of who cleared staff to return. RN-A was hired, had a positive TST and IGRA, and was later diagnosed with latent TB, but her file did not contain signed education on active TB symptoms, exclusion requirements, or acknowledgement of instruction. The TB case was noted in IC minutes, but enhanced surveillance and work restriction details were not documented, and multiple staff illness call-ins were recorded without clear RTW oversight.
The facility failed to manage TB surveillance for an employee with a positive TB test, including missing education on active TB symptoms and work restrictions, and failed to document proper employee RTW clearance after multiple illness call-ins. Staff also did not follow the posted disinfectant contact time for whirlpool tubs, and an LPN administered a nebulizer treatment without first cleaning and rinsing the nebulizer parts as required.
Failure to Provide SNF-ABN When Skilled Medicare Services Ended: The DON was responsible for giving beneficiary notices when residents discharged from skilled services, but 3 residents did not receive the CMS-10055 SNF-ABN when their Medicare Part A skilled services ended with days remaining. Although NOMNC forms and handwritten notes showed the residents or their wives were notified that skilled services would end, the facility did not provide the SNF-ABN with the estimated cost for continuing services privately.
Failure to Timely Report Allegations of Potential Abuse: Staff did not promptly report allegations that a CNA/NA was rough during cares, did not respect privacy, and was unorganized with resident care. Residents involved included one with impaired cognition and multiple chronic conditions, another with impaired cognition and dependence on staff, and a third with intact cognition who reported being left exposed during cares. Instead of immediate escalation to the administrator or DON per policy, staff left written statements and notes for management, and one allegation was not reported until days later.
Incomplete Investigation of Alleged Abuse and Neglect: The DON did not thoroughly investigate multiple allegations that a nursing assistant was rough during cares, failed to provide privacy, did not knock before entering rooms, and ignored resident concerns. Residents involved had significant care needs and impaired cognition, and staff had already documented repeated complaints, but the investigation only included limited resident interviews and a phone call with the nursing assistant, without interviewing the reporting staff or other witnesses as required by policy.
Code Status Not Accurately Reflected in EMR: A resident with multiple chronic conditions and intact cognition had an advance directive stating she did not want CPR or a ventilator, yet her EMR banner and paper reference book still listed her as FULL CODE. At a care conference, the resident said she wanted to update her code status and was given a blank POLST, but the record showed no follow-up to reconcile the POLST, physician orders, and advance directive with her stated wishes.
Failure to Identify Target Behaviors for Psychotropic Medications: The facility did not identify target behaviors or symptoms for psychotropic medications for multiple residents receiving antipsychotic, antidepressant, and anti-anxiety medications. Care plans and MARs lacked specific behaviors to monitor for effectiveness, and staff interviews confirmed they could not identify the exact symptoms being tracked for residents with anxiety, depression, PTSD, and other mental health diagnoses.
The facility failed to notify the Ombudsman of unplanned discharges for two residents. One resident discharged home against medical advice, and another was transferred to the hospital after a fall and later discharged to another LTC facility after hip repair surgery. The SSD stated she and the LSW were unsure of the reporting process and had not reported either discharge.
Missed Quarterly MDS Assessment: A resident's quarterly MDS was not completed or submitted on time after the admission/5-day assessment. The RN responsible for MDS completion stated the schedule was not automatically calculated in PCC and acknowledged the quarterly assessment was missed, and the senior clinical reimbursement specialist confirmed the missed quarter assessment.
A resident’s PASARR Level I screen was completed inaccurately when the facility failed to identify PTSD and other mental health diagnoses documented in the resident’s MDS and diagnosis report. The initial PAS submitted to Senior LinkAge stated the resident had no major mental health disorders diagnosable under the DSM, even though the resident had PTSD, anxiety, depression, and related diagnoses. The RNC later confirmed PTSD should have been noted on the PAS.
A resident with severe cognitive impairment and hospice services had a facility care plan that did not clearly delineate which services hospice would provide and which services the facility would provide. Although the hospice care plan listed specific aide tasks and collaboration expectations, facility staff said they were unsure of the hospice aide’s role, the NA stated facility staff completed all cares, and the DON confirmed the facility care plan only listed the hospice provider’s name and phone number rather than the hospice services identified in the hospice plan.
A resident with impaired hearing and cognition was not provided hearing aids daily as ordered. The care plan directed staff to keep the hearing aids in place during the day and remove them at bedtime, but it did not address refusal. The TAR showed repeated refusals, yet the resident was often observed without the hearing aids, reported difficulty hearing and needing his ears cleaned, and said staff did not return with the hearing aids or clean his ears when he asked.
Missing Oxygen Storage Signage Outside Medication Room: The facility failed to post signage outside the South med room identifying that O2 canisters were stored inside. Observation found 3 O2 canisters stored in a cabinet within the room, and an LPN who did not normally work that wing was unaware of the O2 storage. The DON agreed that when O2 is stored in a room, signage should be placed on the outside of the room, and the facility policy and NFPA 99 required precautionary signage on the door or gate of the storage area.
Controlled medications awaiting destruction were stored in a locked cupboard inside the locked South med room, but they were not tracked on any list for easy reconciliation. An LPN and the DON confirmed that discontinued narcotic and controlled meds, including tramadol, lorazepam, pregabalin, and Xanax for multiple residents, were kept in the cabinet and were no longer monitored once placed there, with staff waiting for the DON to destroy them.
Pharmacy recommendation for an AIMS assessment was not completed for a resident receiving an antipsychotic, antidepressant, and anti-anxiety medication. The resident’s record showed the last AIMS had been done months earlier, and the DON confirmed the consultant recommendation was missed even though the facility policy required AIMS monitoring every 6 months for residents on antipsychotic medication.
Medication error rate exceeded the 5% threshold after an LPN left Baclofen and spironolactone unattended in a resident’s room, then documented the meds as administered in PCC. The DON stated staff were not to leave meds unattended in a resident room or chart them as given, and the facility policy required the Six Rights of medication administration.
The facility failed to consistently identify, comprehensively assess, and manage pressure ulcers for a high‑risk, paraplegic resident with diabetes, an indwelling catheter, and an ostomy. An existing heel wound was incompletely documented and not incorporated into the care plan, and later sacral and buttock skin changes, urinary meatus breakdown, and foot wounds were recorded with inconsistent locations, no staging, and missing measurements. Wound clinic records showed detailed staging and treatment recommendations that were not timely or fully reflected in the care plan, including catheter and brief management and measures to prevent recurrent shearing. The resident was not placed on a formal turning/repositioning schedule despite dependence for mobility, and staff documentation of refusals to get out of bed was repetitive and not linked to new interventions, while nursing assistants reported the resident usually accepted care when re‑approached. In late stages, buttock wounds with extensive eschar and slough and a dark lateral foot lesion were present without clear physician notification or evidence‑based treatment orders, and the resident ultimately required hospitalization for advanced, infected pressure ulcers with osteomyelitis and cellulitis.
A resident with paraplegia, diabetes, obesity, and existing right heel skin breakdown was admitted with high risk for pressure ulcers, but the initial care plan did not include a skin integrity focus or the documented heel wound, and the admission wound form lacked required descriptive details. Later, an RN wound assessment identified an unstageable right heel ulcer and subsequent documentation noted a new buttock pressure sore and a stage 3 ulcer at the urinary meatus related to catheter tension and incontinent brief use, yet the care plan was not promptly revised to include these new wounds or the wound clinic’s specific interventions for off-loading boots, catheter device positioning, brief removal, and barrier cream, despite the DON’s expectation that RN leaders update care plans with changes.
Two residents were not afforded appropriate dignity during care. One resident with cognitive impairment and a urinary catheter was twice observed with the catheter bag exposed and improperly placed, once hanging from a trash can and later on the floor in a wash basin, both times without a dignity cover despite staff acknowledging that covers should be used. Another resident who required assistance for bed mobility was left sitting on the edge of the bed in only a brief with pants at the knees, yelling for help, while the room door remained open and the privacy curtain was not drawn as staff provided support. Staff and leadership later confirmed expectations for covered catheter bags and closed doors during care, consistent with the facility’s dignity policy.
A resident with paraplegia and known risk for skin breakdown developed worsening shearing and open areas on the buttocks and impaired skin integrity at the coccyx/sacrum, while documentation of Wound Data Collections lacked measurements and wound type descriptions. Nursing orders and skin observations showed evolving buttock wounds, discoloration, and a left lateral foot issue, but there was no evidence that the physician was notified of new wounds or treatment changes, nor that the care plan was revised to address refusals and repositioning. The resident’s emergency contact reported not being informed of the buttock wounds and learned of their severity from a visitor, despite a facility policy requiring immediate notification of the resident, MD, and representative when treatment must be significantly altered.
A resident with paraplegia and type 2 DM, who was cognitively intact and had no documented dental issues on admission assessments, expressed a desire to pursue dental care, which was noted in the Nursing Admit/Re-admit Data. The resident later reported that no one had assisted in arranging a dental appointment, despite having informed the clinical care leader RN. The CCLRN stated that county case workers and the DON would need to approve dental appointments and described it as a process but could not explain the process or identify who should initiate it. Record review showed no documentation of any attempts to arrange dental services, contrary to facility policy that requires providing or obtaining routine and emergency dental services and assisting residents with making appointments and arranging transportation.
Two residents received wound care, catheter care, and personal care during which staff did not consistently follow infection prevention and control practices. For one resident with paraplegia, multiple pressure ulcers, an indwelling catheter, and an ostomy, nurses performed wound and wound vac care without reliably sanitizing hands between glove changes, placed supplies on undisinfected surfaces, reused gauze from an open package after contact with blood and other contaminated items, and allowed wound vac tubing to fall to the floor and leak secretions. Another nurse then provided IV care wearing gloves but no gown and left the room without hand hygiene. For a second resident with dementia, edema, and a history of pressure ulcers, a nursing assistant performed toileting, perineal care, catheter manipulation, and equipment handling while wearing the same gloves throughout, including into the hallway and bathroom. A nurse conducted leg wound care after dropping gauze on the floor and placing dressings on an uncleaned chair, with inconsistent hand hygiene. Later, a hospice nurse and an LPN performed buttock wound and catheter care without changing gloves or sanitizing hands between contact with the resident’s buttocks and clean supplies, despite staff acknowledging in interviews that such glove use and infection control lapses were problematic.
The facility failed to maintain a comprehensive infection prevention and control program, as the infection preventionist did not conduct formal surveillance or analyze infection data for trends. The DON confirmed the lack of comprehensive infection surveillance, which is crucial for identifying trends and implementing preventive interventions.
A resident with impaired cognition and incontinence was denied timely assistance to use the commode by an NA, leading to embarrassment due to incontinence. Other staff members confirmed that residents should be assisted when requested, and if busy, staff should seek help. The incident highlighted a failure in providing dignified care.
A resident with Parkinson's disease and other conditions experienced a deficiency in care as the facility failed to consistently implement a care plan for maintaining range of motion (ROM). Observations showed the resident's hands were often without the prescribed splint, and staff interviews revealed inconsistencies in applying passive range of motion (PROM) exercises. The occupational therapist confirmed the need for PROM and splinting, but documentation was insufficient to assess changes in the resident's condition.
A facility failed to follow standards of care for a resident with an indwelling catheter. The resident, with a history of UTIs and diagnoses including ulcerative proctitis, had a catheter placed without a clear medical justification. Staff were uncertain about the catheter's necessity, and the facility's policy requiring an order and indication was not met. The catheter was used as a permanent solution for incontinence without further evaluation or a urology consult.
Employee Health Surveillance and TB Monitoring Not Reported to QAPI
Penalty
Summary
The facility failed to ensure the infection preventionist provided employee surveillance and illness data to the QAPI members during monthly meetings. Review of the IC Safety Meeting minutes showed an Employee Health section, but the November 2025 and December 2025 minutes did not include employee surveillance information being brought forward to QAPI from the Infection Control Committee meetings. The facility’s surveillance and employee health documentation also did not identify which nursing staff were trained to determine whether employees were appropriate to return to work, what criteria were used for return-to-work decisions, or how staff were to prevent transmission of infectious disease through employee illness screening. The record for RN-A showed she was hired on 8/13/25 and completed baseline TB screening with a negative first TST. After a second TST was read as positive with induration, the facility planned a blood TB test and later obtained a positive blood test result. RN-A was evaluated by a physician and chest x-ray, which showed latent TB infection. She was not contagious and was able to return to work without restriction, but the employee file did not contain signed education about signs and symptoms of active TB, mitigation measures, exclusion from work if symptoms developed, or acknowledgement that education had been provided. The facility’s TB control documentation identified that employees with untreated latent TB were to receive yearly symptom screening and be re-evaluated on the risks and benefits of treatment, but RN-A was not listed on surveillance documentation. The November 2025 IC Safety Meeting minutes noted one new hire with positive TB and stated symptom screening would be done yearly, but did not identify enhanced surveillance, work exclusion criteria, or annual physician evaluation and chest x-ray requirements. The facility also had numerous employee illness call-ins documented from October 2025 through January 2026, including gastrointestinal and respiratory illnesses, but the absence forms did not show return-to-work dates, who cleared employees, or what criteria were used.
Infection Control Failures in TB Surveillance, Return-to-Work Review, and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an infection prevention and control program related to employee tuberculosis screening and surveillance. RN-A was hired and completed baseline TB screening with a negative first TST, but her second TST was later read as positive with induration. The employee file documented that a blood TB test was planned, but the clinic initially had no record of the test being completed. RN-A was working in the building on floor orientation while the positive result was being clarified, and later documentation showed she was eventually evaluated by a physician and found to have latent TB with a chest x-ray showing no active disease. The record also showed she declined treatment at that time. There was no signed education in her file about signs and symptoms of active TB, reporting requirements, or work restrictions if symptoms developed, and she was not listed on infection control surveillance documentation. The facility also failed to ensure employees were appropriately cleared to return to work after illness and were surveilled for illness over multiple months. The employee absence forms included many call-ins for gastrointestinal, respiratory, flu-like, sore throat, fever, diarrhea, vomiting, and other illnesses, but the forms did not identify the date an employee was allowed to return to work, what criteria were used, or which trained nursing staff verified clearance. The infection control committee and QAPI minutes did not document employee illness surveillance in a way that showed how return-to-work decisions were being made or what standards were being followed. The interim infection preventionist and administrator acknowledged that the forms lacked critical information and that staff were not appropriately screened for return to work. The facility also failed to clean and disinfect whirlpool tubs and a nebulizer device according to the documented instructions. During observation, bath aides used the whirlpool tubs by applying disinfectant, scrubbing, rinsing, and running the jets, but the posted instructions in all three tub rooms did not include the manufacturer’s required 10-minute wet-contact time for the disinfectant. For nebulizer administration, an LPN used a resident’s nebulizer cup that still had residue inside, administered the medication, and did not first disassemble, clean, rinse, and air-dry the cup and mouthpiece as required by policy. The LPN stated the nebulizer parts should have been cleaned or replaced before use, and the DON stated staff were expected to clean and rinse nebulizers after each administration.
Failure to Provide SNF-ABN When Skilled Medicare Services Ended
Penalty
Summary
The facility failed to provide the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to 3 of 3 sampled residents, identified as R13, R24, and R40, when their Medicare Part A skilled services ended with days remaining. For R13, the CMS-10123 Notice of Medicare Non-Coverage (NOMNC) showed skilled services ended on 9/16/25, and a handwritten note on the form dated 9/11/25 documented that the wife had been called and notified that the skilled services would end on that date. However, R13 was not provided the CMS-10055 SNF-ABN that would identify the estimated cost if he chose to continue skilled services on his own. For R24, the CMS-10123 NOMNC showed skilled services ended on 8/22/25, and a handwritten note dated 8/20/25 documented that the resident had been notified that the skilled services would end on that date. R24 was not provided the CMS-10055 SNF-ABN with the estimated cost to continue services privately. For R40, the CMS-10123 NOMNC showed skilled services ended on 12/15/25, and a handwritten note dated 12/10/25 documented that the wife had been called and notified that the skilled services would end on that date. R40 was also not provided the CMS-10055 SNF-ABN with the estimated cost if he chose to continue skilled services on his own. During interview on 2/12/26 at 1:00 p.m., the DON stated she was responsible for providing beneficiary notices when a resident discharged from skilled services and confirmed she had not provided the CMS-10055 form with the estimated cost to continue services.
Failure to Timely Report Allegations of Potential Abuse
Penalty
Summary
The facility failed to timely report allegations of potential abuse to management for three residents. One resident with moderately impaired cognition, vascular disease, renal failure, diabetes, arthritis, asthma, and depression was reported to have said a nursing assistant was too rough during cares and disregarded complaints of discomfort and pain. Another resident with moderately impaired cognition, depression, diabetes, and hemiplegia was reported to have been rough with during cares, unorganized, slow to respond to call lights, not knocking before entering rooms, slamming doors, and continuing to assist residents who did not want help from that nursing assistant. A third resident with intact cognition, anxiety, depression, hypertension, and diabetes was reported to have had privacy concerns during cares and to have been left exposed. Licensed staff and aides described that resident complaints were gathered in writing and placed under the DON's door, but the allegations were not immediately escalated through the facility's reporting process. One LPN stated residents began reporting concerns about the nursing assistant after about a month of employment, and she collected written statements and slid them under the DON's office door. The DON stated she later found the report under her door, interviewed some residents and the staff member involved, and asked whether they felt safe, but did not interview the staff members who made the reports. The administrator stated the report did not point to abuse or neglect, and one allegation signed by a resident had not been reported to the LPN until three days later when the formal complaint was given to the DON. The facility's abuse and neglect policy required allegations of mistreatment, neglect, exploitation, or abuse to be reported immediately to the administrator, and no later than two hours after the allegation was made. The policy also stated that if the administrator was unavailable, staff were to report to the DON or supervisor of social services. Interviews showed that staff instead left notes or statements for management and did not promptly report the allegations through the required chain of command. The reports involved residents who were dependent on staff for care, and the concerns included rough handling, lack of privacy, and failure to respond appropriately to resident complaints.
Incomplete Investigation of Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse involving three residents. Reports submitted to the State Agency described concerns that one resident said a nursing assistant was too rough during care and ignored complaints of pain, another resident reported rough care, poor response to call lights, failure to knock before entering rooms, and slamming doors, and a third resident reported lack of privacy during care and being left exposed. The residents involved had significant care needs and cognitive or behavioral diagnoses, including moderately impaired cognition for two residents and dependence on staff for daily care, with diagnoses such as vascular disease, renal failure, diabetes, arthritis, asthma, depression, hemiplegia, anxiety, and antipsychotic use. Interviews showed that the residents later denied ongoing abuse concerns, but staff had already raised repeated complaints about the nursing assistant’s conduct. An LPN stated that after about a month of the nursing assistant working at the facility, residents reported she was rough during cares, did not knock before entering, and slammed doors, and the LPN gathered written statements and slid them under the DON’s door. The DON stated she interviewed some residents and the nursing assistant, asked residents if they felt safe, and did not interview the staff members who made the reports. She also contacted corporate leadership because she believed the report did not point to abuse or neglect. The investigation documentation did not show that the DON addressed the allegation of rough handling with the nursing assistant, interviewed additional staff, or interviewed other residents not named in the complaint. The record also showed late reporting from the LPN to management after becoming aware of the allegations. Facility policy required interviewing all involved employees, residents, and family individually and documenting the investigation, but the completed investigation did not reflect those steps for the allegations of potential abuse.
Code Status Not Accurately Reflected in EMR
Penalty
Summary
The facility failed to ensure one sampled resident’s code status was accurately reflected in all parts of the medical record. The resident had diagnoses including obstructive sleep apnea, asthma, chronic kidney disease, diabetes, anxiety, edema, arthritis, scoliosis, and a history of multiple back and abdominal surgeries. Her quarterly MDS indicated intact cognition, no behaviors, and dependence on staff for most ADLs, including toileting, dressing, and bathing, with wheelchair use. On observation, the resident’s EMR banner listed her as FULL CODE, even though her Minnesota Health Care Directive stated she did not want CPR, did not want to be on a ventilator, and did not want hemodialysis unless she was coherent and able to decide for herself. She also stated she wanted pain control even if it affected breathing or circulation, and she signed the directive under notary witness. At the care conference, the resident and a family member attended, and staff documented that she had a physician’s order on file for CPR and that she wanted to update her code status. She was given a blank POLST to review, but the progress notes did not show follow-up to obtain an updated POLST or verify the 2024 advance directive against her current wishes. Interviewed staff stated the resident was still listed as FULL CODE in the EMR and that the paper reference book also showed the incorrect status, with no POLSTs or original physician orders in the book. The resident later stated she wanted DNR, did not want CPR, and believed she had given the new POLST to staff, while the DON and corporate consultant agreed the POLST and EMR inconsistencies should have been addressed after the care conference.
Failure to Identify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to identify target behaviors or symptoms for psychotropic medications for 3 of 5 sampled residents, including residents with diagnoses of anxiety, depression, PTSD, and dementia-related conditions. The report states that the expectation was for the facility to identify target behaviors or symptoms for each psychoactive medication and monitor those behaviors for medication effectiveness. For one resident, the quarterly MDS showed intact cognition and the resident was receiving Seroquel, duloxetine, and buspirone for anxiety and depression. The care plan noted that dosage reduction was not clinically appropriate and that non-pharmacological interventions would be attempted, but it did not identify target behaviors or symptoms related to the psychotropic medications. The psychiatry encounter notes listed diagnoses for each medication and documented that the resident denied depression, paranoia, delusions, and mania, but there was no clear identification of the target behaviors or symptoms being treated, and the order summary also lacked target behaviors and monitoring instructions. For two other residents, one had diagnoses of Alzheimer’s disease, anxiety disorder, depression, and PTSD and was receiving citalopram for PTSD, anxiety, and mood disorder with depressive features, while the other had a diagnosis of depression and was receiving citalopram for major depressive disorder. Their care plans listed goals, non-medication interventions, and pharmacy/provider review language, but neither care plan nor MAR identified target behaviors or symptoms to monitor for effectiveness. Staff interviews confirmed they monitored residents generally each shift, but could not identify specific behaviors or symptoms for the resident on multiple psychotropics, and the DON acknowledged that target behaviors should be on the care plan or MAR but was unsure whether this had been completed for all residents taking psychotropic medications.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of unplanned discharges for 2 of 2 sampled residents, R6 and R61. R61’s accepted discharge MDS dated 12/19/25 identified an unplanned discharge return not anticipated, and records showed R61 discharged home with family against medical advice on 12/15/25. During interview on 2/12/26, the social service designee stated she had just clarified discharge reporting with the ombudsman on 2/11/26 because she was unsure of the process, and reported that neither she nor the licensed social worker had notified the ombudsman of R61’s or R6’s unplanned discharge. She also stated they were not aware that all discharges, including unplanned discharges and discharges against medical advice, had to be reported. R6’s records showed a discharge MDS identifying discharge to the hospital, a transfer form documenting transport to the emergency department after a fall, and a hospital discharge summary showing admission for hip repair surgery and discharge to another long-term care facility after 7 days. The facility’s discharge and transfer policy stated that the ombudsman must be notified of a transfer or discharge with the location of the discharge or transfer.
Missed Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete and submit a timely quarterly MDS assessment for one resident, R56. R56 was admitted to the facility at the end of September 2025, and the MDS section in Point Click Care showed the last MDS completed was an admission/5-day assessment with an ARD of 9/26/25. No other MDS assessments had been initiated or started for R56 in the facility's PCC electronic medical record. During interview, the RN responsible for completing and submitting MDS assessments stated that PCC did not automatically calculate R56's MDS schedule and that she had missed completing a quarterly assessment for R56. She confirmed the quarterly MDS should have been completed in December 2025. The senior clinical reimbursement specialist also confirmed that R56 had a missed quarter assessment. The facility policy stated that PCC automatically calculated MDS schedules, and the RAI manual identified that quarterly MDS assessments are conducted every 92 days and submitted within 14 days of completion.
Inaccurate PASARR Level I Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one resident. The resident’s comprehensive MDS assessment showed admission in December 2024 with moderately impaired cognition and diagnoses of anxiety, depression, and PTSD. The resident’s diagnosis report also identified PTSD, insomnia due to another mental illness condition, anxiety disorder, and mood disorder due to a known physiological condition with depressive features upon admission. However, the facility’s initial PAS completed on 12/18/24 and submitted to Senior LinkAge stated that the resident had no major mental health disorders diagnosable as listed in the DSM, and did not identify the PTSD. During interview, the facility’s RNC reviewed the PAS and stated the resident had PTSD that should have been noted on the PAS, and that she would expect a more thorough assessment and correct completion of the pre-admission screen.
Failure to Coordinate Hospice and Facility Care Plans
Penalty
Summary
The facility failed to have an integrated care plan that clearly coordinated and delineated what services hospice would provide and what services the facility would provide for a resident receiving hospice care. The resident had severe cognitive impairment, was dependent on staff for care, and had a condition or chronic disease with a life expectancy of less than 6 months. The hospice care plan stated that hospice staff would provide or assist with care such as applying lotion, incontinent care, dressing, shampooing, hair care, cleaning and tidying the room, and reporting concerns to the RN, and that hospice staff would collaborate with facility staff regarding the plan of care and schedule. The facility care plan identified the resident’s terminal prognosis and noted hospice support, with hospice RN and nursing assistant visits twice weekly or more often as needed, but it did not state what services hospice would provide to ensure coordination of care. Staff interviews showed the TMA was unsure what care the hospice aide provided and had only seen the aide sitting and visiting with the resident, while the nursing assistant stated facility staff completed all cares and she was unaware of the hospice care plan. The DON stated she was unaware the facility care plan needed more information than the hospice provider’s name and phone number, and confirmed the facility care plan did not include the hospice services identified in the hospice care plan. The hospice agreement stated the coordinated plan of care should clearly delineate hospice and facility services based on the resident’s needs.
Failure to Provide Hearing Aids and Address Hearing Needs
Penalty
Summary
The facility failed to ensure a resident with impaired hearing was provided hearing aids daily. The resident’s comprehensive MDS identified moderately impaired hearing and cognition, and the care plan noted impaired thought process and decision making, a need for staff to ask yes-or-no questions, and a communication problem related to the hearing deficit. The care plan also directed staff to ensure the hearing aids were in place during the day and removed at bedtime, but it did not identify refusal of hearing aids or what staff should do if the resident refused them. The resident’s TAR for December 2025 through February 2026 included an order for staff to insert the hearing aids at 7:00 a.m. and remove them at 8:00 p.m., with ears to be irrigated as needed. Staff signed the TAR indicating the resident refused the hearing aids on all but 5 of 73 days, yet the TAR did not show any ear irrigation treatment during that period. During observations and interviews, the resident repeatedly did not have the hearing aids in place, stated he had difficulty hearing, and said his ears needed to be cleaned. He reported that when he asked for his hearing aids or complained about his ears, staff said they would return but did not come back. On one observation, a TMA stated the resident refused the hearing aids every day, then retrieved them, asked if he wanted them in, and inserted them after he said yes and again stated his ears needed cleaning.
Missing Oxygen Storage Signage Outside Medication Room
Penalty
Summary
The facility failed to have signage posted outside the South medication room identifying that oxygen canisters were stored inside. During observation, a cupboard to the far right of the medication room door was found with a pullout drawer containing 3 oxygen canisters secured in individual holders inside the cabinet, but there was no sign on the outside of the room notifying staff that oxygen was being stored there. An LPN who normally did not work on that wing was unaware that oxygen was stored in the room. The DON stated that when oxygen is stored in a room, signage should be placed on the outside of the room identifying that oxygen is being stored within. Review of the facility policy and NFPA 99 section 11.3.4.1 confirmed that precautionary signage should be displayed on each door or gate of an oxygen storage room or enclosure.
Controlled Medications Awaiting Destruction Were Not Tracked
Penalty
Summary
The facility failed to ensure controlled narcotic medications awaiting destruction were easily reconciled in 1 of 3 medication rooms, the South med room, to prevent potential diversion. During observation and interview with an LPN in the South medication room, a locked cupboard was found containing medications awaiting destruction, including discontinued controlled or narcotic blister-pack medications for multiple residents that were not listed on any tracking list. The medications identified included tramadol 50 mg tablets for R26 and R17, lorazepam 0.5 mg tablets for R24 and R17, pregabalin 150 mg for R7, and Xanax 0.5 mg tablets for R2, including one blister pack with 10 tablets remaining. The LPN stated she normally did not work on the South wing and explained that the facility kept all controlled medications awaiting destruction in the locked cabinet inside the locked medication room. Nursing staff had access to the key, and staff would wait for the DON to destroy the medications. The LPN also stated staff did not keep track of the medications once they were placed in the cabinet so they could not be easily reconciled. In interview, the DON confirmed she was aware the narcotics were stored in the cabinet awaiting destruction and verified the medications were no longer tracked for easy reconciliation of potential diversion. A medication storage policy was requested but not provided before the end of the survey.
Pharmacy Recommendation for AIMS Assessment Not Completed
Penalty
Summary
The facility failed to ensure pharmacist consultant recommendations were acted upon for 1 of 5 sampled residents, R26. R26 was admitted on 12/27/25 and had a quarterly MDS assessment that identified cognition as intact and need for moderate to total assistance with ADLs. R26 was receiving psychopharmacological medications, including quetiapine fumarate (Seroquel), duloxetine, and buspirone, and the current care plan identified medication use with warnings of adverse consequences related to major depressive disorder and anxiety. The pharmacist’s 1/28/26 recommendation directed nursing to complete an AIMS assessment, which is used to detect and monitor tardive dyskinesia in residents taking antipsychotic medication. The medical record showed the last AIMS assessment had been completed on 5/9/25. During interview on 2/11/26, the DON confirmed the pharmacy recommendation was not completed and stated the last AIMS assessment was eight months old and should be completed every six months. The facility’s Psychotropic Medication policy required a RN to complete an AIMS assessment for each resident prescribed an antipsychotic medication every 6 months.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure the overall medication error rate remained below 5%, resulting in an 8% medication error rate based on 2 of 25 observations. During an observation on 2/10/26 at 11:54 p.m., an LPN prepared 1 tablet of Baclofen 10 mg and 1 tablet of spironolactone 25 mg for a resident who was reported to be in her room. When the LPN knocked, the resident was not present, so the LPN left the medication cup containing the medications on the resident’s dresser drawer just inside the room and shut the door. The LPN stated the resident was able to self-administer her medications and that she would leave them there for later. The LPN then returned to the medication cart, completed the medication pass, and documented in PCC that the medications had been administered. The DON stated staff were not to leave medications unattended inside a resident room or mark them as administered. Review of the facility policy stated medications were to be administered according to the Six Rights of medication administration, and the self-administration section noted staff were to be aware of medications kept in the room.
Failure to Assess and Manage Pressure Ulcers Leading to Severe Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to identify, comprehensively assess, monitor, and implement effective interventions to prevent and manage pressure ulcers for multiple residents, with Immediate Jeopardy for one resident. One resident with paraplegia, diabetes, obesity, an indwelling catheter, and an ostomy was dependent for lower body care and transfers and was identified as at risk for pressure ulcers. On admission, the resident’s right heel wound was noted but not staged or fully described despite form instructions to document blanchability, size, color, odor, and discharge. The initial care plan did not include a skin integrity problem or the right heel wound, and subsequent skin checks failed to mention the heel wound. For an extended period after admission and readmission, the care plan was not revised to reflect existing and newly identified skin issues, including sacral redness, and pressure-relieving interventions were delayed or incompletely incorporated into the care plan. As time progressed, the resident developed multiple additional areas of impaired skin integrity, including buttocks, coccyx/sacrum, urinary meatus, and foot wounds. Wound clinic records showed comprehensive staging and measurements of the right heel and urinary meatus pressure ulcers and later buttock shearing injuries, while facility documentation (RN wound assessments, skin observations, and progress notes) was inconsistent and often lacked measurements, staging, wound type, and detailed descriptions. New wounds and changes in condition, such as buttock shearing and coccyx pressure areas, were not consistently or comprehensively assessed, and physician notification for new or worsening wounds was not evident for several documented changes. The care plan was not timely updated to include wound clinic recommendations, such as catheter and brief management for the urinary meatus ulcer and interventions to prevent recurrent shearing injuries to the buttocks. In the weeks leading up to the Immediate Jeopardy period, documentation of the resident’s buttock and coccyx wounds remained inconsistent, with alternating descriptions of coccyx versus buttock involvement and characterizations as shearing or pressure sores, without comprehensive wound assessments or clear identification of wound type. Skin observations and wound data collections around the end of the year showed black and blue tissue on the buttocks and new left lateral foot involvement, yet there was no documented physician notification or change in treatment orders for these developments. Wounds were not measured until early January, at which time large buttock wounds with significant eschar and slough, macerated and erythematous margins, and drainage were finally documented. Interviews with nursing staff revealed reliance on a clinical care lead RN to measure wounds and obtain orders, acknowledgment that wounds had not been measured for weeks, and use of treatments such as hydrofera blue and cleansing with soap and water or wet wipes without clear physician authorization or articulated evidence-based rationale. Throughout this period, the resident was not placed on a formal turning and repositioning schedule despite being at risk for pressure ulcers and dependent for repositioning. Staff and interdisciplinary team notes repeatedly referenced the resident’s refusals to get out of bed or reposition, but these notes were often verbatim over multiple entries and did not reflect new assessments or individualized interventions to address refusals. Nursing assistants reported that the resident rarely refused care and would usually accept care when re-approached, while a nurse later stated the resident had not received education on the risks of not repositioning prior to hospitalization. The clinical care lead RN stated that shearing was not a form of pressure, that the resident’s discolored buttocks were “always” monitored, and that larger protective dressings such as Mepilex were sometimes not used due to size or payor concerns, leading to use of ABD pads instead. By the time the resident was evaluated at the wound clinic in January, the buttock and foot wounds were classified as unstageable and stage 3 pressure ulcers, with the gluteal wound described as very advanced and infected, and subsequent hospital records documented sacral decubitus ulcer with osteomyelitis and cellulitis. Additional observations after the resident’s return from the hospital showed ongoing gaps in wound management and monitoring. Nursing staff could not initially locate dressing change orders, and the resident reported that no care had been provided to his heels over the weekend and that wedges for repositioning were only used if he requested them. On examination, facility leadership identified a dark, non-blanching area on the right lateral foot that was questioned as an unstageable pressure ulcer or suspected deep tissue injury, while the clinical care lead RN initially characterized it as a blister and a diabetic wound. Toenails pressing into adjacent toes and causing skin indentations were discovered only during surveyor observation, and improvised measures such as placing gauze between toes were initiated at that time. These documented inactions and inconsistent assessments, monitoring, and interventions for existing and developing wounds contributed to the progression of the resident’s buttock wound to a severe, infected pressure injury requiring hospitalization for osteomyelitis, cellulitis, and soft tissue infection.
Failure to Timely Update Care Plan for Multiple Pressure Ulcers and Catheter-Related Wound
Penalty
Summary
The deficiency involves the facility’s failure to timely and comprehensively update a resident’s care plan to reflect existing and newly developed pressure ulcers and related interventions. The resident was admitted with paraplegia, type 2 diabetes, obesity, and a documented right heel wound on the Nursing Admit/Re-admit Data Collection, but that form lacked required descriptive details such as staging, blanchability, size, color, odor, or discharge. The admission MDS identified the resident as at risk for pressure ulcers, with significant lower extremity impairment, dependence for lower body care and transfers, and use of pressure-reducing devices, but no pressure ulcers were documented at that time. The initial care plan dated the day after admission did not include a skin integrity focus or identify the right heel wound, although it did address assistance needs for turning and transfers. A subsequent care plan identified only potential for pressure ulcer development and general preventive interventions, without specifically addressing the existing right heel wound. As the resident’s condition evolved, the facility did not revise the care plan to reflect new pressure ulcers and specific wound-related interventions in a timely manner. An RN wound assessment later identified an unstageable right heel pressure ulcer, but the assessment did not address a red sacrum noted on the same date, and the care plan was not updated at that time to include off-loading boots, which were only added months later. A progress note documented a new pressure sore on the right buttock and the resident’s refusal to get up in a chair at mealtimes despite education on repositioning, yet there was no indication the care plan was revised to address this new wound. A wound clinic report then identified a stage 3 right heel ulcer and a stage 3 ulcer at the urinary meatus related to catheter tension and incontinent brief use, with specific directions regarding catheter device positioning, removal of the brief, and use of barrier cream. The record showed no corresponding care plan revisions to include the new urinary meatus ulcer or the clinic’s catheter and incontinent garment interventions until a later date, and interventions for prevention/minimization of recurrent buttock shearing injuries were also delayed, contrary to the DON’s stated expectation that RN nurse leaders update care plans with changes.
Failure to Maintain Resident Dignity for Catheter Care and Privacy During Personal Care
Penalty
Summary
The deficiency involves failure to maintain resident dignity related to catheter management and privacy during personal care for two residents. One resident with Alzheimer's disease and dementia, who had a urinary catheter placed by hospice on 1/2/26, was observed on two separate occasions with the catheter collection bag exposed and improperly positioned. On one occasion, the catheter bag was hanging from a garbage can next to the resident's recliner without a dignity cover, despite the resident's care plan identifying self-care deficits and the need for staff assistance. On another occasion, the same resident was observed in bed with the catheter bag placed on the floor in a wash basin, again without a dignity cover, even though a dignity bag was available in the closet. Staff, including an RN and an LPN, acknowledged that urine collection bags should be covered for dignity and should not be hung from garbage cans. The second resident, who had anxiety disorder and required two staff for bed mobility, was left without adequate privacy during care. During morning care, a nursing assistant exited the resident's room without shutting the door, leaving the resident sitting on the edge of the bed wearing only a brief secured at the waist with pants pulled down to the knees, while two other nursing assistants supported the resident in a seated position. The resident was yelling for help while the door remained open and the privacy curtain was not drawn. Staff later stated that the door should have been shut during this care. The DON reported that she expected doors to be shut during cares and that catheter bags should have covers, and the facility's Resident Dignity policy directed staff to maintain the dignity of every resident.
Failure to Notify Physician and Representative of Wound Changes and Inadequate Wound Assessment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and the resident’s representative of changes in a resident’s skin integrity and related treatment orders, and failure to comprehensively assess new and evolving wounds. The resident, who was paraplegic and chair/bedbound, had a care plan identifying shearing on both buttocks and high risk for skin breakdown, with interventions including barrier cream, dressings when areas were open and draining, and monitoring for signs of shearing and infection with reporting of abnormalities to the health care provider. Early faxed communications to the physician noted intermittent shearing on the buttocks and later increased skin breakdown and open sores associated with the resident’s refusal to get out of bed, but there was no evidence that the care plan was revised to address refusals or a repositioning program. Wound Data Collections from mid-December documented impaired skin integrity at the coccyx/sacrum but were not comprehensive, lacking wound measurements and type descriptions, and a physician note during this period did not mention shearing injury. Subsequent nursing orders directed cleansing of the buttocks and application of zinc oxide and ABD pads, and later documentation described shearing on both buttocks, darkened and reddened areas, and black and blue tissue, as well as a dried calloused area on the left lateral foot treated with iodine. However, between early and late December, records did not show that the physician was notified of new wounds or changes in treatment orders, and from late December through the end of the month there was no indication that the buttock wounds and left lateral heel were comprehensively assessed. The resident’s family member, listed as emergency contact, reported not being informed by the facility about the buttock wound and instead learning of its severity from a visitor who assisted with care. A certified wound NP reported that all prior wounds had been healed and that the wound clinic later received a referral for pressure ulcers on the right lateral foot and both buttocks. The DON stated that nurses should notify the physician of any change in condition, and the facility’s Notification of Change policy required immediate notification of the resident, physician, and resident representative when treatment needed to be significantly altered, but the records did not show such notifications occurred for these wound changes.
Failure to Assist Resident in Obtaining Requested Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in obtaining requested dental services, as required by facility policy. The resident, who had paraplegia and type 2 diabetes, was cognitively intact and had no documented dental issues such as cavities, broken teeth, dentures, or bridges on the admission MDS and Nursing Admit/Re-admit Data collection. However, the Nursing Admit/Re-admit Data form included a comment that the resident would like to pursue dental care. Despite this documented request, there was no evidence in the medical record of any attempts to arrange a dental appointment. During interviews, the resident reported that no one at the facility had worked with him to make a dental appointment, although he stated he had informed the clinical care leader RN. The clinical care leader RN confirmed she completed the Nursing Admit/Re-admit Data and acknowledged that county case workers managed the resident and that either they or the DON would have to approve a dental appointment, describing it as a process. She was unable to articulate the process for obtaining a dental appointment when requested by a resident and was unsure who was responsible for initiating it. Review of the resident’s record by the clinical care leader RN did not reveal any documentation of efforts to set up a dental visit, despite the facility’s policy stating that the location provides or obtains routine and 24-hour emergency dental services and assists residents, when necessary, in making appointments and arranging transportation and referrals.
Failure to Follow Infection Control Practices During Wound, Catheter, and Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to follow infection prevention and control practices during wound care and other direct care for two residents. For one resident with paraplegia, multiple pressure ulcers, an indwelling catheter, and an ostomy, staff performed extensive wound and wound vac care without consistently sanitizing hands between glove changes, moved and placed wound supplies on undisinfected surfaces, and handled clean and dirty items interchangeably. During the wound care, staff removed and applied dressings to multiple wounds, manipulated the wound vac, and cleaned blood using gauze taken repeatedly from the same package, sometimes after touching contaminated items, and without always performing hand hygiene between glove changes. The suction tubing from the wound vac fell to the floor and leaked secretions, and the canister was discarded, while staff continued to work in the area. After this care, another nurse entered the room wearing gloves but no gown, removed IV medication, flushed the IV, and left the room without performing hand hygiene. For a second resident with Alzheimer’s, dementia, edema, and a history of pressure ulcers, staff also failed to adhere to infection control practices during toileting, catheter care, and wound care. A nursing assistant performed perineal care, manipulated the mechanical lift, wheelchair, catheter bag and tubing, moved equipment in and out of the room, handled a blanket and pillow, and went into the bathroom and hallway, all while wearing the same pair of gloves and without changing them until the end of the sequence. During wound care to the resident’s legs, a nurse removed heel protectors soaked in bodily fluids, dropped gauze on the floor and picked it up, and placed dressings on a chair that had not been disinfected, while intermittently changing gloves and sometimes sanitizing hands, but not consistently between all clean and dirty contacts. In a subsequent wound assessment of the second resident’s buttocks, a hospice nurse and an LPN initially provided care such as obtaining vital signs and administering medications without gowns or gloves, then donned gowns and gloves to perform wound care and catheter care. During this care, they removed dressings, washed the buttocks with wet wipes obtained from the bathroom sink, applied cream, and handled wound care supplies and the catheter cover without removing gloves or sanitizing hands between touching the resident’s buttocks and clean surfaces. Staff interviews confirmed awareness that gloves should be changed when soiled, between different tasks, and that wearing dirty gloves was an infection control issue. The DON stated that following enhanced barrier precautions and infection control was confusing.
Inadequate Infection Surveillance and Data Analysis
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by the lack of analysis of monthly surveillance data for trends and patterns. The infection preventionist, RN-B, was responsible for overseeing the infection control program and maintaining the surveillance log. However, RN-B admitted that while infections were tracked and documented, there was no formal surveillance or monitoring of trends and breaks in infection practices. The infection data was reviewed informally and not tracked or analyzed comprehensively, which was confirmed by RN-B during an interview. The Director of Nursing (DON) verified that the facility's infection surveillance was not comprehensive, and residents were not tracked or compared for trends or patterns. The DON acknowledged the importance of monthly analysis to identify trends and implement interventions to prevent infections, including staff education and system process review. Despite the facility's policy indicating the need for a robust infection prevention and control program, the facility had not completed the necessary infection surveillance, data collection, analysis, or tracking and trending of infections among residents or staff.
Failure to Provide Dignified Care for Resident's Toileting Needs
Penalty
Summary
The facility failed to provide care in a dignified and respectful manner to a resident with moderately impaired cognition and a history of bowel incontinence. The resident, who was dependent on staff for toilet transfers and hygiene, requested to use the commode but was denied assistance by a nursing assistant (NA-E) who stated she was too busy. NA-E told the resident she should have asked to use the commode earlier and accused the resident of seeking attention out of jealousy. As a result, the resident was taken to the dining room without being assisted to the commode, leading to embarrassment due to incontinence. Interviews with other staff members, including another nursing assistant (NA-D), a registered nurse (RN-C), a licensed practical nurse (LPN-A), and the director of nursing (DON), revealed that the facility's expectation was for residents to be assisted to use the commode when requested. They indicated that if a staff member was too busy, they should seek help from another NA or a nurse. The incident was observed when NA-D later assisted the resident to the commode, where it was noted that the resident had been incontinent of urine in her brief. NA-E's training record showed she had been trained in person-centered care and effective communication.
Failure to Maintain Resident's Range of Motion
Penalty
Summary
The facility failed to provide adequate services to maintain and prevent the loss of range of motion (ROM) for a resident diagnosed with Parkinson's disease, dementia, polyneuropathy, and peripheral vascular disease. The resident, identified as having severely impaired cognition and limited ROM in both upper and lower extremities, was dependent on staff for all activities of daily living. The care plan required passive range of motion (PROM) exercises and the use of a palm splint for the resident's left hand to prevent complications related to immobility. Observations revealed that the resident's left hand was often found without the prescribed splint, and both hands were noted to be in a contracted position. Interviews with nursing assistants and licensed practical nurses indicated a lack of clarity and consistency in the application of the resident's care plan. The nursing assistant responsible for restorative duties reported being frequently pulled from these duties, resulting in inconsistent application of PROM exercises and splinting. Additionally, there was confusion among staff regarding the resident's need for a splint and ROM exercises for the right hand, which was also observed to be contracted. The occupational therapist confirmed that the resident should receive PROM for both hands and wear a splint on the left hand throughout the day. However, the therapist noted a lack of documentation on the progression of the resident's condition, making it difficult to assess changes in the resident's ROM. The facility's failure to consistently implement the care plan and provide necessary interventions contributed to the deficiency in maintaining the resident's ROM.
Failure to Justify Indwelling Catheter Use for Resident
Penalty
Summary
The facility failed to adhere to standards of care and practice for the use of an indwelling catheter for a resident with a history of urinary tract infections (UTIs). The resident, who has diagnoses including ulcerative proctitis, insomnia, and hypothyroidism, was found to have an indwelling catheter without a clear medical diagnosis justifying its use. The resident's care plan indicated the catheter was related to an overactive bladder and hygiene issues, but there was no documentation of post-void residuals or a urology consult to support the necessity of the catheter. Interviews with staff revealed uncertainty about the reason for the catheter, and the resident reported frequent UTIs despite the catheter placement. The facility's urinary catheter policy requires an order and indication for an indwelling Foley insertion, with consideration of alternatives. However, the resident's documentation lacked a specific indication for the catheter, and the director of nursing acknowledged that the resident's diagnosis did not meet the standard of care for a Foley catheter. Despite this, the catheter was placed as a permanent solution to the resident's incontinence, based on a provider's note and order, without further evaluation or consultation with a urologist.
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Illustrative
What surveyors actually found near you
We read the 45 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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Nursing homes near Windom
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Mountain Lake | 10.8 mi | ★★★★★ | 3 | 0 |
| Colonial Manor Nursing Home | 12.5 mi | ★★★★★ | 21 | 0 |
| Good Samaritan Society - Jackson | 17.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Westbrook | 20.1 mi | ★★★★★ | 11 | 0 |
| Seasons Healthcare | 21.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.