Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Hilltop Healthcare Rehabilitation And Skilled Nurs during CMS and state inspections, most recent first.
Delayed Meal Service Due to Insufficient Support Personnel: Residents on multiple units waited well beyond posted meal start times for breakfast, lunch, and dinner. Observations showed food arriving late, trays not being passed promptly, and nursing and culinary staff delaying service while residents waited in dining areas; staff reported kitchen delays, missing equipment, and residents still being assisted out of bed. On several occasions, the last resident was not served until more than 1 hour after mealtime began.
Improper Glove Use and Hand Hygiene During Meal Service. A cook began plating meals and, after leaving the area and touching items and door handles on another unit, returned with the same gloves on and continued handling food without observed hand hygiene. The cook later acknowledged she should have removed her gloves, sanitized her hands, and put on new gloves before plating, and the DON stated staff were expected to do so before food service.
Failure to document PRN AP use and provider review: A resident with intact cognition and diagnoses including dysthymic disorder, anxiety, adjustment insomnia, and delusional disorder received repeated PRN olanzapine orders and administrations for agitation or anxiety, but the EMR lacked correlating behavior documentation and evidence of a face-to-face provider visit before the PRN AP was renewed. Staff and the pharmacy consultant stated the PRN AP should have been limited to 14 days unless the provider evaluated the resident and documented the need for continued use.
A resident with dementia, spinal cord disease, repeated falls, and smoking-related care plan interventions fell from his wheelchair in the smoking area and was sent to the ED after nasal bleeding. The incident record noted the fall and immediate response, but no witness statements, follow-up notes, root cause analysis, or care plan changes were documented. The RN was unsure if an RCA had been done, and the DON confirmed the investigation was not thoroughly documented and that staff had not received education on falls, smoking, or smoking during inclement weather.
Bed hold notification was not provided as required for a resident transferred to the hospital. The resident had intact cognition and chronic pulmonary edema, and the EMR showed staff documented that the resident or POA wanted a bed hold. Staff interviews showed uncertainty about the current process, with some stating a form was used and others describing an EMR template, while the DON said the facility had recently changed to this process. The facility policy required written notification of the bed hold policy, a signed acknowledgment, and a copy sent with the resident at transfer, with emergency-transfer follow-up to the responsible party.
Failure to Update Care Plan After Smoking-Related Wheelchair Fall: A resident with dementia, schizophrenia, nicotine dependence, and repeated falls fell from his wheelchair while smoking in the smoking area. The incident investigation documented no statements, no root cause analysis, and no care plan changes, even though the resident’s POA no longer wanted him to smoke and the DON confirmed the care plan was not updated.
A resident with acute on chronic CHF, respiratory failure, DM2, HTN, morbid obesity, and OSA was ordered daily weights, but the facility did not consistently obtain or document the weights as expected. The resident’s admission weight was not entered at admission, no weight was recorded when the chart was reviewed, and later the record showed a struck-out weight plus a 19.1-pound gain in one day. Staff stated daily weights were required for CHF and that significant weight changes could reflect fluid retention and CHF exacerbation.
Failure to follow aspiration precautions for a resident with dysphagia. The resident’s care plan and swallow eval directed meal setup, wheelchair use for all meals, dining room meals when possible, and upright positioning at 90 degrees during intake and afterward. Instead, staff served meals in bed and the resident was observed eating breakfast and lunch with the HOB at about 45 degrees; an RN confirmed the HOB should have been at 90 degrees to prevent choking.
The facility failed to timely act on a pharmacist recommendation and provider order to discontinue acidophilus for a resident with intact cognition and diagnoses including CHF, COPD, DM, and HTN. The resident had been receiving acidophilus BID for UTI prevention, and the pharmacist identified it as a medication to consider stopping to reduce polypharmacy, pill burden, and unnecessary medication use. An RN manager said pharmacy recommendations were sent to providers, but was unsure what happened with this one, and the pharmacist consultant expected follow-up within 30 days.
Incomplete Daily Nurse Staffing Posting: The facility failed to post the required nurse staffing information daily and the hallway posting remained dated from a prior day over the weekend. The posting listed totals for CNA, LPN, and RN hours, but did not break staffing out by shift and did not include TMA information. The SC and DON stated the posting was supposed to show daily staffing by shift for residents and families to review.
The facility did not consistently offer or provide substantial bedtime snacks to residents, resulting in a prolonged period between dinner and breakfast. Several residents reported that snacks were not delivered or were insufficient, and staff interviews confirmed that snacks were only available upon request, with no routine snack cart service. This practice did not align with the facility's policy and had the potential to affect all residents.
A resident with multiple medical conditions was prescribed duloxetine and pristiq without any documented indication for use. Both an RN and the DON confirmed that these psychotropic medication orders did not include the required indication, which was inconsistent with facility policy.
The facility failed to ensure accurate MDS coding for three residents, including errors in documenting hospice services, colostomy status, and use of mobility devices. Staff interviews and record reviews confirmed that the assessments did not accurately reflect the residents' actual conditions at the time.
A resident with multiple mental health diagnoses was admitted for post-hospital rehabilitation with a Level II PASARR assessment limited to 30 days. When the resident's stay exceeded this period, facility staff failed to conduct or document the required reassessment, as they were unaware of the 30-day limitation and the need for further evaluation, resulting in unmet requirements for addressing the resident's mental health needs.
Two residents with complex pain and wound care needs did not have individualized or comprehensive care plans. One resident's plan lacked specific details on pain assessment, goals, and non-pharmacologic interventions, while another's plan did not address actual wound conditions, individualized positioning, or coordination with outside wound care providers, despite relevant provider orders and staff acknowledgment of these needs.
A resident with COPD, depression, and pressure ulcers did not receive required quarterly care conferences, with documentation showing only two conferences and no further records. The resident recalled only one care conference, and staff confirmed that additional conferences were missed, possibly due to hospitalizations. Facility policy requires quarterly interdisciplinary care plan reviews, which were not completed for this resident.
A resident with heart failure and other chronic conditions did not have daily weights completed as ordered, with only a few weights documented for the month and no record of refusals. Additionally, there was no assessment or documentation prior to the resident being sent to the ER for leg pain and edema, despite staff expectations for such documentation.
A resident with chronic kidney disease and other comorbidities did not have vital signs assessed before or after dialysis sessions. Staff interviews confirmed that vital sign assessments were not routinely performed upon the resident's return from dialysis, and the facility's care plan and policy did not address this requirement.
A nurse administered insulin to a resident with diabetes by drawing doses from insulin pens into a syringe, rather than using the pens as intended, while failing to change gloves or perform hand hygiene and leaving the medication cart and medications unattended. The resident expressed concern about the accuracy of the dose and the method used, and facility policies did not support the nurse's actions.
Two residents were found to have medication orders without proper indications or diagnoses attached, including multiple medications for a resident with severe cognitive impairment and a valacyclovir order for another resident with psychiatric and medical conditions. Both nursing staff and the DON confirmed that all medication orders are expected to have an associated diagnosis or indication, in line with facility policy.
Staff failed to keep medication carts locked and medications secured, leaving narcotics and other prescription drugs unattended and accessible in resident areas. On multiple occasions, medication carts were left unlocked, and medications such as insulin pens were left unattended at the desk, contrary to facility policy requiring locked storage.
A resident with moderate cognitive impairment and a history of falls was injured during a transfer when staff failed to use a gait belt as required by the care plan. The resident fell, resulting in multiple rib fractures, a pneumothorax, and a hemothorax, requiring emergency medical treatment. Staff interviews confirmed awareness of the resident's tendency to lean backwards, which increased fall risk, but the care plan was not followed, leading to the incident.
A resident's POLST indicating full CPR was not followed when the resident was found unresponsive without a pulse. An LPN failed to initiate CPR or verify the resuscitation status promptly, leading to a delay in life-saving measures. The resident was pronounced deceased by EMS upon their arrival.
Two residents requiring 1:1 supervision during meals were left unsupervised, leading to choking risks. One resident with dysphagia experienced multiple coughing episodes and a severe choking incident, while another was found asleep with food in his mouth. Staff failed to follow care plans and therapy recommendations, resulting in immediate jeopardy.
The facility did not ensure that two nursing assistants completed the required 12 hours of annual in-service training. One assistant completed 8.57 hours, and another completed 3.5 hours. Despite daily reminders, one assistant forgot to complete the necessary modules. The DON and administrator expected all assistants to fulfill their training requirements annually.
The facility did not provide mandatory QAPI training to staff, as confirmed by interviews with a nursing assistant, an LPN, and an RN, who were unaware of the QAPI plan. The DON acknowledged the need for staff education, and the administrator admitted the lack of formal training. A review of the Relias training program showed no QAPI training for employees.
Delayed Meal Service Due to Insufficient Support Personnel
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services, resulting in resident meals not being served within 45 minutes of the posted start of mealtimes. Signs throughout the facility showed breakfast, lunch, and dinner start times for Cedar, Elm, and Spruce units, as well as the memory care unit. During observations on Cedar, Spruce, and the memory care unit, residents were waiting in dining areas while food was delayed, trays were not passed promptly, and meal service began well after the scheduled start times. On Cedar unit, breakfast service did not begin until 8:15 a.m. even though the posted start time was 7:45 a.m., and the last resident did not receive a meal until 9:03 a.m. Lunch on Cedar unit was also delayed, with the last resident receiving a tray at 1:02 p.m. after a 12:00 p.m. start time. Dinner service was repeatedly delayed across units. On 3/10/26, an announcement was made that dinner would start 30 minutes late, and observations showed residents waiting in the dining room while food had not yet arrived. On Cedar unit, food arrived at 6:26 p.m., tray carts left at 6:39 p.m., and the last resident was served at 7:12 p.m. On Spruce unit, the first tray was not passed until 6:35 p.m. and the last tray at 7:16 p.m. On the memory care unit, nursing staff were present with residents while no culinary staff had arrived, and meal service did not begin until 6:59 p.m.; the last resident was served at 7:25 p.m. Staff interviews stated delays occurred because food did not arrive on time, there were kitchen issues, equipment was forgotten, and nursing staff were still getting residents up and out of bed. The culinary services manager, administrator, and administrator of record all stated that 45 minutes to an hour was acceptable for all residents to be served, but anything beyond one hour from the start of mealtime was not acceptable.
Improper Glove Use and Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper glove use and hand hygiene during food service on the [NAME] unit, affecting all 26 residents on that unit. During observation, cook C-A began removing plastic coverings from food in the steam table, left the area to another unit to get a cart with cups, then returned and donned gloves without any observed hand sanitization. With the same gloves on, C-A handled a plate and ladle, went to the fridge to retrieve another metal tray for the steam table, and continued plating food. She later went to another unit touching door handles, returned with plate covers, placed them on the counter, and resumed plating with the same gloves. She again opened the fridge and placed another metal container into the steam table with the same gloved hands, then continued plating sandwiches while touching the bread of each sandwich. During interview, C-A stated she should have removed her gloves, sanitized her hands, and put on new gloves before plating food. The DON stated her expectation was that staff would remove gloves, complete hand hygiene, and don new gloves prior to plating food.
Failure to document PRN antipsychotic use and provider review
Penalty
Summary
The facility failed to ensure that a resident prescribed a PRN antipsychotic medication received a face-to-face visit with the provider before the medication was reordered, and it also failed to maintain documentation supporting PRN antipsychotic use for one of five residents reviewed for unnecessary medications. Resident R83’s quarterly MDS identified intact cognition and diagnoses of dysthymic disorder, anxiety, adjustment insomnia, and delusional disorder, and the care plan directed staff to observe, monitor, and document behaviors and mood, notify the supervisor, social worker, and/or physician as needed, and provide psych services as ordered. R83’s EMR showed repeated PRN orders for olanzapine 5 mg by mouth for agitation or anxiety, with multiple MAR entries documenting administration on several dates in 2026. The record did not contain correlating behavior documentation or evidence of a face-to-face provider visit tied to the renewal of the PRN antipsychotic. During interviews, the nurse manager stated she expected the order to be discontinued after 14 days if written that way and expected behavior charting every shift and when the PRN AP was used. The pharmacy consultant stated the order should have stopped after 14 days and that the provider should have seen the resident face to face if renewing the PRN antipsychotic. The facility policy stated PRN psychotropic medications are limited to 14 days unless the physician documents a rationale to extend them, and PRN antipsychotics will not be renewed unless the physician evaluates the resident for appropriateness.
Failure to Thoroughly Investigate Resident Fall in Smoking Area
Penalty
Summary
The facility failed to investigate an accident involving a resident who fell from his wheelchair in the smoking area and sustained injuries. The resident had diagnoses including disease of the spinal cord, dementia, diabetes mellitus, paranoid schizophrenia, insomnia, nicotine dependence, tobacco use, and repeated falls. His MDS identified him as moderately cognitively intact, and his care plan identified him as at risk for falls and as a smoker with interventions related to fall prevention and smoking safety. The incident investigation documented the date and location of the fall, the resident’s inability to explain how he fell, and the immediate actions taken, including lifting him from the ground, bringing him inside, stopping nasal bleeding, and sending him to the ED for evaluation. However, the investigation did not include statements gathered, further follow-up notes, a root cause analysis, or changes to the resident’s care plan. The RN stated he was unsure whether a root cause analysis had been completed and said no smoking assessment was completed after the fall because the resident’s POA no longer wanted him to smoke. The DON verified that a thorough investigation had not been documented and stated there had been no staff education on falls, smoking, or smoking during inclement weather. The facility’s Incident Investigation Procedure required all accidents or incidents to be investigated and reported, with corrective action documented and incident reports reviewed for trends and resident vulnerabilities.
Bed Hold Notification Not Provided in Writing
Penalty
Summary
The facility failed to meet the requirements for bed hold notification for 1 of 2 residents reviewed for hospitalization. Resident R51’s annual MDS identified intact cognition and a diagnosis of chronic pulmonary edema. The resident was transferred to the hospital on 3/7/26 at 11:26 p.m., and the EMR included a transfer charting template with an affirmative response to whether the resident or POA wanted a bed hold. During interviews, RN-F stated bed holds were done on a form and that staff asked the resident if they wanted a bed hold, but he was unsure of the current process because the facility was trying to get rid of paper. RN-B stated staff would note whether the resident wanted a bed hold and thought there was a form the resident would sign and probably get uploaded to the chart. The DON demonstrated the EMR transfer template and stated the facility had just changed to this process, but bed hold information was reviewed with residents on admission and annually. The facility policy stated the resident or responsible party must be notified in writing of the bed hold policy, sign the policy as evidence of notification before being charged, and receive a copy of the policy when transferred to the hospital; for emergency transfers, staff were to attempt to provide the resident a copy and notify the responsible party within 24 hours.
Failure to Update Care Plan After Smoking-Related Wheelchair Fall
Penalty
Summary
The facility failed to update a resident’s care plan after an accident involving the resident falling from a wheelchair while smoking. The resident, R106, had diagnoses including disease of the spinal cord, dementia, diabetes mellitus, paranoid schizophrenia, insomnia, nicotine dependence, tobacco use, and repeated falls. His quarterly MDS identified him as moderately cognitively intact, and his care plan identified him as at risk for falls and as a smoker with interventions related to safe smoking practices, smoking policy education, and storage of smoking materials. The incident investigation for the 1/26/26 fall documented that R106 fell off his wheelchair outside in the smoking area, could not explain the incident, and was assisted from the ground, brought inside, had nasal bleeding stopped, and was sent to the emergency department for evaluation. The investigation noted no statements gathered, no further follow-up notes, no root cause analysis, and no changes made to the resident’s care plan. During interviews, RN-D stated the resident’s POA no longer wanted him to smoke and verified the care plan had not been updated, and the DON confirmed there were no updates made after the incident.
Failure to Monitor Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to monitor weights to identify a possible CHF exacerbation for a resident with acute on chronic CHF, acute respiratory failure with hypercapnia, DM2, HTN, morbid obesity, and OSA. The resident’s care plan and provider orders included daily weights related to acute diastolic CHF, and the facility’s standing orders indicated daily weights for residents with heart failure unless otherwise directed. However, the resident’s weight record showed an admission weight was not entered at the time of admission, and on 3/9/26 the record still showed no weights entered despite the daily weight order being in place. The resident’s weight record later showed a struck-out weight on 3/10/26 and two weights on 3/11/26, including a recorded increase of 19.1 pounds in one day. Staff interviews confirmed that daily weights were expected for residents with CHF, that a significant weight change in a CHF resident could indicate fluid retention, and that the resident’s admission weight had been found later in handwritten notes and entered historically into the medical record. The DON stated that weight discrepancies should prompt reweighing, assessment, and provider notification, and that significant weight gain in CHF residents was concerning for fluid retention, shortness of breath, edema, and CHF exacerbation.
Failure to Follow Aspiration Precautions During Meals
Penalty
Summary
The facility failed to follow R99’s care plan to prevent aspiration. R99’s MDS identified diagnoses including recurrent C. difficile enterocolitis, urinary retention, pressure ulcer, dysphagia, and long-term opiate use, and noted she required set up for meals. Her orders included a cardiac mechanical soft diet with regular/thin consistency, and her care plan directed that she be set up for eating, placed in a wheelchair for all meals, encouraged to eat in the dining room, and kept upright at 90 degrees during oral intake and for 30 minutes afterward. A swallow evaluation also recommended alternating liquids and solids, using general swallow precautions, modifying bolus size, and maintaining an upright posture during meals and for more than 30 minutes afterward. During observation, R99 was served breakfast in bed and was seen seated in bed with the head of the bed elevated to about 45 degrees while eating. She remained in bed at about 45 degrees later that morning, with her tray on the overbed table, and was later observed eating lunch in bed with the bed again elevated to about 45 degrees. During interview, RN-B verified the bed was elevated at about 45 degrees and stated the bed should be at 90 degrees when R99 declined to get out of bed and come to the dining room for meals. RN-B stated that having the head of the bed at 90 degrees was important to prevent choking. A dysphagia policy was requested but not provided.
Delayed Action on Pharmacist Recommendation for Unnecessary Medication
Penalty
Summary
The facility failed to ensure timely implementation of a pharmacist recommendation and subsequent provider order for one resident with intact cognition and diagnoses of CHF, COPD, diabetes mellitus, and hypertension. The resident’s orders included acidophilus twice daily for prevention of UTI. A pharmacist recommendation dated 9/12/25 identified acidophilus as a medication to consider discontinuing to help prevent polypharmacy, excessive pill burden, and unnecessary medication use. The provider responded on 10/3/25 to discontinue lactobacillus (acidophilus) due to therapy completed, but the record review and interviews indicated the recommendation and order were not acted on in a timely manner. An RN manager stated pharmacy recommendations were sent to providers when received by nurse managers and was unsure what happened with this one, while the pharmacist consultant stated follow-up on pharmacy recommendations would be expected within 30 days.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the required nurse staffing information was posted daily and included all required details. During observation on 3/9/26 at 7:27 a.m., the staffing posting in the main hallway was dated 3/6/26 and showed the facility name, date, day of the week, census, nursing hours, and hours per patient day, with totals listed for CNAs, LPNs, and RNs. The posting was for Friday and was still displayed on the weekend. It also did not separate staffing by shifts and did not include any information on trained medication aides. During interview, the staffing coordinator stated the posting was supposed to be posted daily, including weekends, and should show staff working by shift rather than only total hours in a 24-hour period. The DON stated the posting was intended for families and residents to see how many staff were working on each shift. The facility’s Daily Staff Posting form stated the posting must include the number of nursing staff on duty per shift, total number and actual hours worked, current resident census, and that it would be posted daily.
Failure to Routinely Offer and Provide Substantive Bedtime Snacks
Penalty
Summary
The facility failed to consistently offer and provide a substantive, nutrient- and calorie-rich snack to residents after the dinner meal and before bedtime, resulting in a gap of up to 15 hours between the evening and morning meals. Multiple residents with intact cognition reported during interviews and a resident council meeting that staff did not deliver bedtime snacks, snacks were not substantial, and there was insufficient variety or quantity. Staff interviews revealed that snacks were available on the unit, but residents had to request them, and there was no routine snack cart service. Some staff were unaware of the existence of snack carts, and the DON stated that the expectation was for snacks to be offered before bedtime. Meal delivery times for each unit were documented, showing dinner was served in the early evening and breakfast the following morning, confirming the extended period without food. The facility's Snack Availability policy stated that residents should have access to nourishing snacks, defined as verbal offerings from basic food groups, but the practice did not align with this policy. The deficiency had the potential to affect all 107 residents in the facility.
Psychotropic Medication Orders Lacked Indication for Use
Penalty
Summary
The facility failed to ensure that psychotropic medication orders included an indication for use for one resident. Record review showed that a cognitively intact resident with multiple diagnoses, including depression, anxiety, polyneuropathy, hypertension, and amputation, had active orders for duloxetine and pristiq without any listed indication for use. During interviews, both a registered nurse and the director of nursing confirmed that these medication orders lacked an indication, which was contrary to facility policy requiring every medication order to have an associated indication or diagnosis. The facility's medication administration policy also specified that staff should be able to state the indication for each medication administered.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, resulting in assessments that did not reflect the residents' actual status at the time of completion. For one resident, the admission MDS was incorrectly coded to indicate the resident was not receiving hospice services, despite census documentation and the care plan confirming hospice care at admission. Both the RN and DON acknowledged that the MDS should have reflected hospice services. Another resident's quarterly MDS was marked as having a colostomy in Section H, but interviews with nursing staff confirmed the resident did not have a colostomy, and the MDS nurse admitted this was an error. A third resident's quarterly MDS indicated no use of mobility devices, despite the resident having a history of lower limb amputation and being observed with a wheelchair and prosthetic leg in the room. The resident confirmed using these devices when out of bed, and the MDS coordinator acknowledged the MDS was inaccurate. The DON confirmed the expectation that MDS reports should accurately reflect the resident's status and that the MDS in question was not accurate regarding mobility devices. These findings were based on record review, staff interviews, and direct observation.
Failure to Complete Required PASARR Reassessment After 30 Days
Penalty
Summary
A deficiency occurred when the facility failed to ensure a required Level II Pre-Admission Screening and Resident Review (PASARR) reassessment was conducted, documented, and retained for a resident with multiple mental health diagnoses. The resident, who had severely impaired cognition and required substantial assistance with most activities of daily living, was admitted with diagnoses including dementia with agitation, delusional disorder, bipolar disorder, depression, and schizophrenia. The initial PASARR Level II assessment approved admission for post-hospital rehabilitative services for 30 days, with instructions that further assessment and service plan changes must be documented if the resident's stay exceeded 30 days or if there was a change in condition. Despite these requirements, the facility did not complete or document a PASARR reassessment after the resident remained in the facility beyond the approved 30-day period. Interviews with the admissions clerk, social services director, and director of nursing revealed that none were aware of the 30-day limitation on the Level II assessment or the need to notify the appropriate agency for reassessment. As a result, the resident's mental health needs may not have been appropriately addressed or provided for during their extended stay.
Failure to Develop Individualized and Comprehensive Care Plans for Pain and Wound Management
Penalty
Summary
The facility failed to develop individualized and comprehensive care plans for two residents with needs related to pain and wound management. For one resident with diagnoses including malignant neoplasm of the prostate, chronic pain syndrome, and anxiety, the care plan did not clearly identify the presence of pain, lacked individualized details on pain assessment, did not specify a goal for pain tolerance, and omitted how pain impacted sleep, activities of daily living, leisure activities, mood, or behavior. Provider orders included scheduled and as-needed morphine, but there were no documented non-pharmacologic interventions. Interviews revealed that non-pharmacologic strategies were not consistently implemented or documented, and the care plan was not updated to reflect the resident's specific pain symptoms and interventions. For another resident with bilateral lower extremity cellulitis, thoracic spine pain, and chronic pulmonary edema, the care plan identified a general problem with skin integrity but did not specify the presence of venous stasis or pressure ulcers. The interventions listed were generic and did not include individualized instructions for positioning, a turning and repositioning program, or coordination with the outside wound care provider, despite provider orders and documentation indicating the need for these measures. Interviews with nursing staff confirmed the importance of individualized positioning and turning for this resident, but the care plan did not reflect these needs.
Missed Quarterly Care Conferences for Resident
Penalty
Summary
The facility failed to ensure that quarterly care conferences were completed for a resident with diagnoses of COPD, depression, and pressure ulcers. Documentation showed that the resident had care conferences on two occasions, but no further conferences were documented as required. The resident reported only recalling one care conference since admission. The social services director confirmed that the last care conference occurred several months prior and acknowledged that subsequent conferences were missed, possibly due to the resident's hospitalizations. The director of nursing stated that care conferences should occur quarterly and after a change in condition, emphasizing their importance in developing individualized care plans. Facility policy requires quarterly interdisciplinary care plan reviews and conferences, but this was not followed for the resident in question.
Failure to Complete Ordered Weights and Document Assessment Prior to ER Transfer
Penalty
Summary
The facility failed to ensure that a resident with multiple chronic conditions, including congestive heart failure, chronic obstructive pulmonary disease, morbid obesity, obstructive sleep apnea, hypertension, and chronic kidney disease, received care and treatment according to physician orders and care plan interventions. Specifically, the resident had provider orders for daily weights and fluid restriction, as well as multiple diuretic medications. However, the electronic medical record for April did not show that weights were taken as ordered, with only three weights documented for the entire month. There was no documentation of the resident refusing weights or any progress notes explaining missed weights. Additionally, prior to the resident being sent to the emergency department for leg pain and edema, there was no assessment or documentation in the medical record regarding the resident's symptoms or the decision to transfer. Observations noted the resident had significant lower extremity edema and pain, and interviews with staff confirmed that documentation and assessment were expected but not completed. The director of nursing and registered nurse both acknowledged that daily weights and documentation of refusals or assessments prior to ER transfer should have occurred.
Failure to Assess Pre- and Post-Dialysis Vital Signs
Penalty
Summary
The facility failed to ensure that vital signs were assessed before and after dialysis for a resident with multiple chronic conditions, including chronic kidney disease, atrial fibrillation, coronary artery disease, diabetes mellitus, and hypertension. The resident's care plan included interventions for monitoring the dialysis access site but did not address the need for pre- and post-dialysis vital sign assessments. Documentation for April 2025 did not show any record of vital sign assessments before or after dialysis sessions. Interviews with the resident and staff revealed that vital signs were not routinely taken upon the resident's return from dialysis, and staff were unaware of any requirement to do so. The trained medication aide confirmed that no assessment was performed after dialysis, and the registered nurse stated that only the dialysis site was checked, with vital signs being taken at the dialysis facility. The director of nursing acknowledged that pre- and post-dialysis vital signs should be taken to monitor for complications, but this was not reflected in practice or in the facility's dialysis policy, which did not address vital sign assessments.
Improper Insulin Administration and Infection Control Lapses
Penalty
Summary
A nurse failed to competently administer insulin to a resident with diabetes, as evidenced by video footage and interviews. The nurse, while wearing the same pair of gloves throughout the process, handled multiple surfaces, medication drawers, and insulin pens without changing gloves or performing hand hygiene. The nurse drew insulin from two different insulin pens into a syringe and administered two injections to the resident, rather than using the insulin pens as intended. The medication cart and insulin pens were left open and unattended during the process, contrary to facility policy. The resident, who was cognitively intact and had a diagnosis of type II diabetes, expressed concern about the insulin administration, specifically suspecting that the nurse may have miscalculated the dose and administered too much insulin. The resident reported experiencing a low blood sugar episode that night, although this was not documented in the vitals summary. The resident also noted that the nurse appeared unsure during the administration and that the method used—drawing insulin from pens into a syringe—was not appropriate. Interviews with the nurse, the DON, and the consulting pharmacist confirmed that drawing insulin from an insulin pen with a syringe is not an acceptable practice and is not included in the facility's competency checklist or policy. The nurse acknowledged the improper technique and infection control lapses, and the DON confirmed that the medication cart and medications should not be left unlocked or unattended. Facility policies reviewed did not support the actions taken by the nurse during the insulin administration.
Failure to Document Indications for Medication Orders
Penalty
Summary
The facility failed to ensure that all medication orders for two residents included a proper indication or diagnosis for use, as required. For one resident with severe cognitive impairment and multiple diagnoses including cerebrovascular disease, dementia, hypertension, depression, hyperlipidemia, and a history of transient ischemic attack, provider orders for several medications such as aspirin, atorvastatin, clopidogrel, losartan, and pantoprazole did not have an associated indication or diagnosis. This was confirmed during a review of the resident's chart by a registered nurse, who acknowledged the absence of proper indications for these medications. For another resident with diagnoses of bipolar disorder, PTSD, and chronic pancreatitis, a provider order for valacyclovir also lacked a documented diagnosis or indication for use. The DON confirmed the expectation that all medication orders should have a diagnosis or indication attached. The facility's medication administration policy requires staff to be able to state the indication for all medications, but this was not followed in these cases.
Medications Left Unsecured and Medication Carts Unlocked
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were securely stored in accordance with professional standards and facility policy. On multiple occasions, medication carts containing narcotics and other prescription medications were observed to be left unlocked and unattended in resident-accessible areas. Specifically, a medication cart was found unlocked and unattended by the DON, who confirmed the incident with the trained medication administrator (TMA). The TMA acknowledged leaving the cart unsecured, which contained medications such as gabapentin and muscle relaxants. Additionally, video footage reviewed by the DON showed a nurse leaving the medication cart open and unlocked while administering insulin to a resident, and also leaving insulin pens unattended at the desk. The facility's policy required all medications to be stored in locked compartments, with controlled substances requiring two locks. These observations and interviews confirmed that staff did not consistently follow procedures for securing medications, resulting in medications being left accessible to unauthorized individuals.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement care plan interventions for a resident who required the use of a transfer belt during transfers, resulting in a fall and significant injuries. The resident, who had moderate cognitive impairment and required assistance with various activities of daily living, was being assisted to the bathroom by a nursing assistant. During the transfer, the nursing assistant held onto the resident's pants instead of using a gait belt, as specified in the care plan. This led to the resident falling backwards and sustaining multiple rib fractures, a pneumothorax, and a hemothorax, necessitating emergency medical treatment. The resident's care plan clearly indicated the need for a gait belt during transfers due to the resident's tendency to lean backwards, which increased the risk of falls. Despite this, the nursing assistant did not use the gait belt, resulting in the resident's fall. The physical therapy assistant and registered nurse confirmed that the resident's backward lean was a known issue, and the use of a gait belt was emphasized to provide better control during transfers. Interviews with staff revealed that the nursing assistant was aware of the resident's tendency to lean backwards but failed to follow the care plan by not using the gait belt. The director of nursing confirmed that the care plan was not followed, which contributed to the fall and subsequent injuries. The facility's gait belt and care plan policies were requested but not provided, indicating a lack of documentation to support proper procedures.
Failure to Follow POLST and Initiate CPR
Penalty
Summary
The facility failed to follow a Physician Orders for Life-Sustaining Treatment (POLST) for a resident who wished to have cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The resident was found unresponsive, without a pulse or respirations, by an LPN who did not initiate CPR as per the resident's POLST. The LPN left the room multiple times and communicated with other staff members but did not take action to start CPR or call for emergency assistance. The resident was eventually pronounced deceased by emergency medical services. The incident was further compounded by the LPN's failure to verify the resident's resuscitation status promptly, despite being advised by other staff members to do so. The Director of Nursing was informed of the situation and upon arrival, confirmed the resident's full code status and initiated CPR with the assistance of another RN. However, by the time CPR was started, the resident was already deceased. The facility's CPR procedure was not followed, leading to a delay in providing life-saving measures to the resident.
Removal Plan
- Reviewed their policy and procedure on CPR, and re-educated all staff on the CPR policy and procedure.
- Assessed all residents to ensure their POLST were completed and accurate.
- Conducted a mock CPR drill during morning and evening shift to ensure staff respond correctly.
- Reviewed the daily schedule to ensure each shift had at least three staff of nurses or TMAs who were CPR certified.
- Completed audits to ensure all crash carts had all essential equipment and supplies, and the AED was functional and will bring the results of the audits to the Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Provide 1:1 Supervision During Meals
Penalty
Summary
The facility failed to provide proper supervision during meals for two residents who required 1:1 supervision to prevent choking. Resident 1 had a history of dysphagia and required close supervision during meals to prevent choking. Despite this, there were multiple instances where Resident 1 was left unsupervised during meals, leading to coughing episodes and a severe choking incident on medications. The staff failed to adhere to the care plan and therapy recommendations, which required 1:1 supervision and cues to ensure safe eating practices. Resident 2, who had aphasia and required 1:1 supervision during meals, was also left unsupervised. On one occasion, Resident 2 was found asleep at the dining table with food in his mouth, unresponsive to initial attempts to wake him. Despite therapy recommendations for 1:1 supervision, staff did not consistently provide the necessary oversight, leaving Resident 2 at risk of choking and aspiration. The facility's failure to provide adequate supervision during meals for these residents resulted in immediate jeopardy. Staff were aware of the supervision requirements but did not consistently implement them, leading to potentially dangerous situations for both residents. The lack of documentation and communication among staff further contributed to the deficiency, as incidents were not properly recorded or addressed in a timely manner.
Removal Plan
- The facility reviewed and revised their current policy on meal assistance.
- The facility reviewed all resident care plans/Kardex to reflect current ST recommendations.
- The facility implemented a new system for therapy recommendations.
- The facility completed staff education on the meal assistance policy with post quiz.
- The facility completed audits on all residents who needed assistance or supervision with meals to ensure they were being assisted or supervised.
Deficiency in Annual Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure the completion of 12 hours of annual in-service training for two of the five nursing assistants reviewed. NA-A had completed only 8.57 hours, while NA-D had completed 3.5 hours of the required training within the last 12 months. Despite being reminded almost daily by the facility, NA-A forgot to complete the necessary modules, resulting in overdue training. The Director of Nursing and the administrator both stated that all nursing assistants were expected to complete their 12 hours of training each year by the due date.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to all staff. During interviews, a nursing assistant, a licensed practical nurse, and a registered nurse all stated they did not recall receiving any QAPI training and were unaware of the facility's QAPI plan or how to communicate concerns related to it. The director of nursing acknowledged that all staff should be educated on QAPI, while the administrator admitted that although QAPI is often discussed, there has been no formal education provided to staff. A review of the facility's Relias training program confirmed the absence of QAPI training for employees.
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 116 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Health Center | 1.3 mi | ★★★★★ | 23 | 2 |
| Aftenro Home | 1.7 mi | ★★★★★ | 17 | 0 |
| Viewcrest Health Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Bayshore Residence And Rehabilitation Center | 4 mi | ★★★★★ | 2 | 0 |
| Ecumen Lakeshore | 4 mi | ★★★★★ | 8 | 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.