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 Hopkins Restorative Care Center during CMS and state inspections, most recent first.
Insufficient RN coverage was identified when staffing records showed only 7.5 hours of RN coverage and no consecutive 8-hour RN presence in the building. The interim DON was on site for only 2 hours, and the DON later confirmed there had been only 2 hours of RN coverage. The facility policy required an RN for at least 8 consecutive hours per day, 7 days per week.
Arbitration Agreements Not Clearly Explained: The facility did not ensure binding arbitration agreements were clearly communicated in a way residents understood before signing or waiving them. Three residents, including one with moderate cognitive impairment, one with severe cognitive impairment and dementia, and one who was cognitively intact, later denied memory of being told about arbitration. The SS said she used a brief version of the explanation, did not fully understand arbitration herself, and did not tell residents they had 30 days to rescind the agreement.
Arbitration Agreement Lacked Neutral Arbitrator Selection: The facility's binding arbitration agreement did not ensure that both the resident and/or resident rep and the facility agreed on a neutral arbitrator. The agreement only addressed where arbitration would occur if the parties could not agree on a location, and the owner acknowledged that neutral arbitrator selection was not addressed. Records showed 12 residents were admitted after the agreement was implemented, with most agreeing to arbitration and others waiving or pending.
Failure to Offer and Document Flu and Pneumococcal Vaccines: The facility did not ensure multiple residents were offered or received annual influenza immunizations, and several residents also lacked evidence of being offered, educated on, and provided indicated pneumococcal vaccines per CDC guidance. Records showed missing immunization histories, consent without documented administration, and incomplete documentation for residents with diagnoses including encephalopathy, dementia, diabetes, sepsis, pneumonia, atrial fibrillation, and seizure disorder.
A ceiling tile in a second-floor east wing common area had a large yellow water stain and grey mold growth, and the condition remained unchanged on re-observation. The area was used by residents, families, and physicians for activities, visits, charting, and dictation. An LPN manager, the activities director, and the director of maintenance all observed the area, and maintenance identified the issue as likely related to a water leak and confirmed the grey growth was mold.
A resident with cognitive impairment, a seizure disorder, and multiple psychotropic medication orders had target behaviors of calling out, screaming, and attention-seeking that were supposed to be documented every shift. ACP notes said staff should record the time, triggers, interventions, and response, but the TAR and progress notes did not accurately reflect the resident’s repeated yelling and calling out, even though an LPN and the DON both heard the behaviors. The facility’s policy required psychotropic use to be supported by monitoring and documentation of the resident’s response.
Hand hygiene was not performed appropriately during a wound dressing change for a resident. An RN wore two pairs of gloves, completed the dressing change, removed gloves and gown at different points, left the room to find a marker, returned to label the dressing, and only washed hands after disposing of garbage. The RN and DON stated hand hygiene was expected before and after the task, when gloves were removed, and when entering and exiting the room; the facility policy stated gloves do not replace hand hygiene.
Failure to offer and document COVID-19 vaccination for 4 of 5 residents reviewed. Records for residents with diagnoses including Wernicke’s encephalopathy, encephalitis/encephalomyelitis, seizure disorder, vascular dementia, sepsis, and pneumonia lacked evidence of immunization histories and/or that the resident or RP was offered the COVID vaccine; one resident had consented, but the chart lacked evidence the vaccine was provided. The IP acknowledged the missing documentation and stated nurses were expected to offer vaccines per CDC guidance on admission and annually.
Failure to Provide Transfer, Bed Hold, and Ombudsman Notifications: The facility did not provide written transfer notices for three residents who had hospital transfers, and two residents did not have written bed hold information in the record. One resident with severe cognitive impairment and another with dementia-related diagnoses were transferred to the hospital without the required documentation, and the DON confirmed the missing notices. The facility also did not report one resident's transfer to the Ombudsman as required.
A resident with moderate cognitive impairment and diagnoses including encephalitis, encephalomyelitis, and a seizure disorder did not receive needed nail care as part of ADL assistance. Staff were expected to provide weekly nail care during regular bathing, but the resident’s fingernails were observed long, jagged, and with a brown-colored substance under several nails, and the DON stated staff were expected to check residents’ nails daily.
Staffing Posting Not Accessible or Posted Daily: The facility failed to post the required nurse staffing information daily and in an area accessible to residents and visitors. Surveyors observed the posting only on the 1st floor, across from offices, while all residents lived on the 2nd floor and the elevator required a code to use. The BOM confirmed the posting was only in that location, was too high for residents in wheelchairs, and had not been posted on weekends because the BOM was the only staff responsible and worked Monday through Friday.
The facility failed to complete annual performance reviews for five nursing assistants, potentially affecting all 37 residents. Employee records lacked documentation of these reviews, and interviews revealed that the previous DON was believed to have completed them, but no documentation was found. The facility's assessment indicated that annual reviews were part of the training program to meet regulatory requirements, but no policy was provided.
The facility failed to ensure proper hand hygiene during medication administration, implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, and develop a Legionella risk assessment and mitigation plan. An LPN did not perform hand hygiene between handling medications for different residents, and the facility lacked signage and PPE for EBP. Additionally, the facility could not provide documentation of a Legionella water management plan.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. Observations showed call lights going unanswered for extended periods, with residents left unattended. Staff interviews confirmed understaffing, with some working double shifts and being interrupted during critical tasks. The facility's assessment noted a high need for two-person assistance, yet staffing levels were insufficient to meet these demands.
The facility failed to maintain a clean and safe environment, with structural issues and disrepair noted throughout. Residents and staff reported poor conditions, including unclean kitchen areas, a tired memory care dining area, and a malfunctioning ice machine. The facility lacked a maintenance director, leading to inadequate upkeep and cleanliness.
The facility failed to act on pharmacist recommendations for four residents, leading to deficiencies in medication management. One resident lacked side effect monitoring for psychotropic medications, while another had no follow-up on pharmacy recommendations for psychotropic orders. Two residents had incomplete lab tests and unaddressed medication clarifications. Staff interviews revealed inconsistent follow-up on pharmacist recommendations.
The facility failed to complete required in-service training based on annual performance reviews for five nursing assistants, potentially affecting all 37 residents. Employee records lacked documentation of completed reviews and training addressing identified weaknesses. Interviews revealed an assumption that the previous DON completed these tasks, but no documentation was found. The facility plans to restart reviews, as indicated by the DON.
A facility failed to document a resident's resuscitation wishes clearly in both the EMR and paper chart. The resident, with cognitive impairments and multiple medical conditions, had no clear code status documented, leading staff to potentially initiate CPR contrary to the resident's wishes. Interviews revealed inconsistencies in verifying and documenting code status, and the facility lacked a POLST policy, relying on state guidance.
A facility failed to notify healthcare providers about a resident's weight status while on a diuretic for edema. The resident, with severe cognitive impairment and multiple diagnoses, was on hospice care. Despite significant weight loss and refusals to be weighed, there was no documentation of provider notification. Staff interviews confirmed the lack of communication, and the facility's policy required immediate notification of changes in treatment needs.
A facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) within the required timeframe for a resident with moderate cognitive impairment and dementia. The resident's POA discussed discharge plans with the facility two days prior, but the NOMNC was not presented to the POA. Instead, the resident signed the NOMNC on the day of discharge. A nurse confirmed she sometimes allowed residents to sign if she believed they were cognitively intact, based on observation. The facility lacked a specific policy on NOMNC and stated they follow Medicare regulations.
A facility failed to complete a Level II PASARR for a resident with mental health needs, including schizophrenia and other disorders. Despite a preadmission screening indicating the need for a Level II assessment, the social services staff did not recognize this requirement. The oversight was confirmed during interviews, highlighting the importance of identifying mental health disorders for appropriate care. The facility's policy was requested but not provided.
A resident with cognitive impairments and a need for substantial assistance was not offered or documented as having received a shower for over 30 days, despite his care plan indicating the importance of bathing preferences. Staff interviews revealed inconsistencies in documentation and communication regarding his shower schedule and refusals. The facility's policies on resident rights and ADLs were not followed, leading to a deficiency in care.
A resident with severely impaired cognition and a preference for outdoor activities was not offered opportunities to go outside, despite this being documented as important in her care plan. Observations showed the resident spent most of her time in bed, and staff did not consistently facilitate or document attempts to meet her preferences. The facility's activities policy was not followed, and there was a lack of communication and documentation regarding the resident's requests and refusals.
A facility failed to comprehensively assess and provide appropriate treatment to prevent UTIs and restore continence for a resident. The resident, dependent on staff for toileting and transfers, experienced frequent incontinence and significant delays in receiving assistance after activating her call light. Despite a history of UTIs and risk for skin breakdown, the facility did not implement a toileting program, and staffing levels were insufficient to meet resident needs. The DON acknowledged the staffing issues and the potential benefits of a toileting program, but the facility lacked an occupational therapist to guide such a program.
A facility failed to ensure proper administration and documentation of prescription topical medications for a resident with impaired cognition. The resident's MAR lacked documentation for Nystatin powder application, which was observed being applied by a nursing assistant instead of a nurse. Facility policy requires medications to be administered by authorized personnel and documented immediately, but the Nystatin powder was kept at the resident's bedside and applied without proper oversight.
A facility failed to monitor side effects and obtain informed consent for a resident's psychotropic medication use. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed several psychotropic medications without proper monitoring of vital signs and orthostatic blood pressure. The care plan lacked necessary monitoring, and there was no consent for gabapentin use. PRN trazodone was administered without an end date, contrary to policy. Interviews revealed inconsistencies in monitoring practices and documentation, confirmed by the DON and consulting pharmacist.
A resident with severe cognitive impairment was found using a bed remote control with exposed wires, posing a risk of electrical shock. Despite staff awareness of reporting protocols, no maintenance request was recorded. Maintenance records showed a history of inadequate bed conditions and inconsistent oversight, contributing to the deficiency.
The facility failed to maintain a safe and homelike environment, with issues such as missing baseboards, gouged walls, and unstable cabinetry in resident rooms and dining areas. Residents reported unsanitary conditions and environmental hazards, but the facility's understaffed maintenance department did not address these concerns. Staff confirmed the lack of a dedicated maintenance team, leading to delays in resolving safety issues.
The facility failed to provide Ombudsman contact information to residents, as confirmed by interviews and observations. Residents were unaware of the Ombudsman and their services, with one resident having to search online for the information. Staff confirmed the information was not accessible to residents, contrary to the facility's policy on Resident Rights.
The facility did not ensure that State survey results were accessible to residents, particularly those on the second floor. The results were only available in a binder on the first floor, and residents were unaware of their right to view them. An LPN confirmed the lack of accessibility, contrary to the facility's policy requiring survey results to be posted in an accessible location.
A resident with dementia reported being pinched and having her hair grabbed by a nursing assistant. The incident was not reported to the State Agency within the required two-hour timeframe due to delays in communication among staff and a busy schedule. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to, resulting in a deficiency.
A resident with dementia and personality disorder reported being physically abused by a nursing assistant (NA) during care. The facility failed to immediately remove the NA from the building after the allegation, as she completed her shift before being suspended. The resident felt unsafe until assured of the NA's suspension, highlighting a delay in protective measures as per facility policy.
Insufficient RN Coverage
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for at least 8 consecutive hours a day, seven days a week. Document review showed the Daily Staffing Report dated 2/28/26 indicated 7.5 hours of RN coverage, and the Daily Schedule Report dated 2/28/26 confirmed there was no consecutive eight hours of RN coverage in the facility on that date. The Pathway Health Invoice dated 2/28/26 indicated the interim director of nursing (DON) had been on site for 2 hours on 2/28/26, which did not meet the requirement for eight consecutive hours of RN coverage. On 3/12/26 at 2:01 p.m., the DON confirmed there had only been 2 hours of RN coverage on 2/28/26 and stated the importance of having an RN in the building to provide triage assessments and meet federal and state requirements. The facility Nursing Services-Registered Nurse Policy, last reviewed 3/5/25, stated the facility would utilize the services of an RN for at least eight consecutive hours per day, 7 days per week.
Arbitration Agreements Not Clearly Explained to Residents
Penalty
Summary
The facility failed to ensure binding arbitration agreements were clearly communicated in a form and manner residents understood before they signed. For 3 of 3 residents reviewed (R13, R26, and R38), the records showed arbitration agreements were signed or waived, but each resident later denied memory of someone from the facility explaining binding arbitration or the agreement itself. R13’s quarterly MDS indicated moderate cognitive impairment and a diagnosis of cerebral infarction (stroke); R26’s comprehensive MDS indicated severe cognitive impairment and dementia; and R38’s comprehensive MDS indicated cognitive intactness and a diagnosis of displaced fracture of the left tibial spine. The facility’s records included an untitled, undated list of 12 residents admitted after 10/1/25 showing whether each agreed, waived, or had a pending decision regarding arbitration. The social service director stated she reviewed a “cliff notes version” of binding arbitration with each resident upon admission, but she had not been provided education on arbitration and did not fully understand it. She stated she told residents they could seek legal advice and that the facility’s legal department would step in, and she acknowledged she did not explain that residents and/or representatives had 30 days to rescind the agreement. The owner stated the facility began offering binding arbitration after the purchase in September 2025 and expected the social worker to explain it as part of admission, but facility policy on arbitration was requested and not received.
Arbitration Agreement Lacked Neutral Arbitrator Selection
Penalty
Summary
The facility's binding Arbitration Agreement failed to provide a neutral and fair arbitration process because it did not ensure that both the resident and/or resident representative and the facility agreed on the selection of a neutral arbitrator. Review of the undated Resident and Facility Arbitration Agreement showed that binding arbitration would be conducted at a place agreed upon by the parties, or if no agreement was reached, at the facility, but it did not address how a neutral arbitrator would be selected by both parties. The facility's Resident Listing Report dated 3/12/26 showed 12 residents were admitted after 10/1/25, and an undated listing of those residents indicated whether each agreed or declined the arbitration agreement, with 9 agreeing, 3 waiving, and 1 decision pending. On 3/12/26 at 1:57 p.m., the facility owner stated the facility was purchased in September 2025 and binding arbitration agreements were implemented, and acknowledged that the selection of a neutral arbitrator was not addressed in the agreement.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure 5 of 5 residents reviewed were offered an annual influenza immunization from October 1 through March 31. The record review showed that R3, R9, R11, R24, and R25 all had documentation gaps related to influenza vaccination, including missing evidence that the vaccine had been offered and/or provided as indicated by the CDC Adult Immunization Schedule. The regional nurse manager/infection preventionist acknowledged on 3/12/26 that the residents’ medical records lacked evidence that annual influenza and/or pneumococcal vaccines had been offered and/or provided as indicated. R3’s record showed diagnoses of Wernicke’s encephalopathy and bipolar disorder, but lacked evidence that an immunization history had been obtained or that R3 and/or the resident representative had been offered, educated on, and provided an annual influenza vaccine or a PCV immunization. R24’s record, for a resident with sepsis and pneumonia, also lacked evidence that an immunization history had been obtained and lacked evidence that the resident and/or resident representative had been offered, educated on, and provided an annual influenza vaccine or a PCV immunization. R25’s record showed dementia and diabetes, and although consent for influenza vaccination was documented, the record lacked evidence that the vaccine had been administered after consent was given. The facility also failed to ensure 4 of 5 residents reviewed were offered, educated on, and provided the pneumococcal vaccination series as recommended by the CDC. R9’s MIIC report showed prior PPSV23 and PCV13 immunizations, making R9 eligible for PCV20 or PCV21 after 2/18/25, but the record lacked evidence that this vaccine was provided. R11’s MIIC report showed no influenza vaccination history and prior PCV13 on 10/26/22, yet the record lacked evidence that R11 had been offered, educated on, and provided PCV20 or PCV21. The facility’s influenza and pneumococcal vaccine policies stated that residents were to be offered immunization in accordance with CDC guidance.
Ceiling Tile in Common Area Had Water Stain and Mold Growth
Penalty
Summary
The facility failed to ensure the second-floor east wing common area was kept clean, sanitary, and in good repair. During observation on 3/11/26, a ceiling tile near a large window in the common area had a large yellow stain or substance covering the entire tile, measuring approximately 1.5 feet by 1.5 feet, with a grey growth-type matter in the center measuring about 8 inches by 6 inches. The same discoloration and grey growth were still present on 3/12/26 during a follow-up observation. The second-floor east wing common area was identified by staff as a space used for resident activities and family visits. The LPN manager stated the area was used for resident activities and family visits and that there was a piano available for visitors or residents. The activities director stated the area was no longer used for activities, but families still used it to meet with loved ones and physicians used it to chart or dictate. The director of maintenance observed the tile, described it as a yellowing water stain likely from a water leak, and confirmed the grey growth in the center was mold. The director of maintenance stated they were unaware of the tile and its condition but would have it replaced as soon as possible. The facility policy on Preventative Maintenance stated the maintenance program shall ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Inaccurate monitoring of target behaviors for a resident receiving psychotropic medications
Penalty
Summary
The facility failed to ensure target behaviors were adequately monitored for a resident with moderate cognitive impairment and diagnoses including encephalitis, encephalomyelitis, and a seizure disorder. The resident’s quarterly MDS indicated physical and verbal behavioral symptoms directed toward others and rejection of evaluation or care less than daily. The resident’s order summary included multiple psychotropic medications: escitalopram for depression, haloperidol for anxiety, divalproex for anxiety, and trazodone for insomnia. The care plan identified target behaviors of calling out loudly multiple times per shift, attention-seeking, and self-limiting with cares/independence, with behaviors to be monitored and documented every shift. ACP visit notes stated the resident continued to display attention-seeking behaviors such as calling out and screaming, and staff were instructed to document the time of occurrence, possible triggers, interventions, and the resident’s response. On 3/11/26, the resident was heard loudly screaming and calling out help numerous times from another unit, but the TAR documented no screaming or yelling during the day shift and the progress notes lacked documentation of the observed behavior. The LPN unit manager and the DON both stated the charting for the day shifts on 3/10/26 and 3/11/26 was inaccurate because they personally heard the resident yelling out repeatedly, and they confirmed that accurate documentation was needed so providers could monitor and direct care appropriately. The facility policy stated psychotropic medications are to be used only when appropriate for a specific, diagnosed, and documented condition and when benefit is demonstrated through monitoring and documentation of response.
Hand Hygiene Not Performed Appropriately During Dressing Change
Penalty
Summary
The facility failed to conduct appropriate hand hygiene during a dressing change for 1 resident reviewed for wound care. During the dressing change, the RN entered the room, put on a gown and two pairs of gloves, removed the old dressing, poured saline onto gauze, and dabbed the wound. The RN then removed the second pair of gloves, put cream onto a finger, and applied it to the wound, then removed the first layer of gloves and gown and put on a new pair of gloves. The RN left the room to find a Sharpie to date and label the dressing, returned to complete that task, gathered the garbage, exited the room again, deposited the garbage in the soiled utility room, and washed hands afterward. The RN stated that during a dressing change, hand hygiene was expected before and after the event, when gloves were soiled, and when placing the new dressing. The RN confirmed hand hygiene was performed before starting the dressing change and after everything was finished, but not after removing gloves or when entering and exiting the room. The RN also stated the second layer of gloves was used for convenience and did not meet the facility expectation. The DON stated staff were expected to wash hands upon entering and exiting the room and when taking off gowns and gloves, according to facility policy and regulations. The facility policy on Hand Hygiene, last revised 1/1/26, stated that gloves do not replace hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure 4 of 5 residents reviewed for immunizations were offered and/or provided the COVID-19 vaccine after education. The report states the facility was expected to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff after education, and document each resident and staff member’s vaccination status, but records for R3, R9, R11, and R24 did not show that this occurred. R3’s record lacked evidence that an immunization history had been obtained and also lacked evidence that the resident and/or resident representative had been offered a COVID-19 vaccination. R9’s record showed a prior COVID immunization and a vaccine consent form, but lacked evidence that the facility provided the requested COVID-19 vaccination. R11’s record showed no COVID-19 vaccinations and lacked evidence that the resident and/or resident representative had been offered vaccination. R24’s record also lacked evidence that an immunization history had been obtained and lacked evidence that the resident and/or resident representative had been offered a COVID-19 vaccine. The regional nurse manager/infection preventionist acknowledged these records lacked evidence that a COVID vaccine had been offered and/or provided, and stated nurses were expected to offer vaccinations per CDC guidelines upon admission and at least annually.
Failure to Provide Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to ensure written notice of transfer was provided to the resident and/or legal representative for 3 of 3 residents reviewed for hospital transfers: R3, R22, and R46. R3 had severe cognitive impairment and diagnoses including Wernicke's encephalopathy and bipolar disorder; after a fall with right lower extremity pain, R3 was sent to the hospital and later readmitted, but the medical record lacked evidence of a written transfer notice. R22 had diagnoses including encephalopathy, dementia, unilateral osteoarthritis, generalized muscle weakness, and difficulty walking; after an unplanned discharge to a short-term acute hospital with return anticipated, the record lacked evidence of a written notice of transfer. R46 was moderately cognitively impaired and had diagnoses including anemia, heart failure, hypertension, diabetes, arthritis, and Alzheimer's disease; after a discharge to a short-term hospital stay with return anticipated, the record lacked evidence that a written notice of transfer was provided to the resident or representative. The facility also failed to provide a written bed hold notice for 2 of 3 residents reviewed for bed hold, R3 and R22. R3's record lacked evidence of a written bed hold notice after the hospital transfer, and R22's bed hold agreement was requested but not provided. In addition, the facility failed to notify the Ombudsman of R3's hospital transfer; the 11/2025 Ombudsman Report listed admissions and discharges but did not include R3's transfer, and subsequent reports also did not reflect it. The DON confirmed the missing transfer notice, bed hold notice, and Ombudsman notification during interviews and stated the importance of completing the transfer notice to notify the resident or next of kin of the reason for transfer to a higher level of care.
Failure to Provide Nail Care and ADL Assistance
Penalty
Summary
The facility failed to provide ADL care for one resident who was unable to perform the care independently. The resident’s quarterly MDS indicated moderate cognitive impairment and diagnoses of encephalitis, encephalomyelitis, and a seizure disorder. The care plan showed the resident required partial to moderate assistance with personal hygiene, bed mobility, and upper body dressing, and substantial to maximal assistance with bathing, toileting, and lower body dressing. Weekly skin assessments showed the resident’s fingernails were last trimmed on 2/3/26. During observation, the resident stated staff were supposed to cut her fingernails but had not done so, and the nails were too long. The fingernails were observed to be various lengths, jagged, and with a brown-colored substance under several nails. The regional nurse manager/infection preventionist verified the nails were long and jagged with brown-colored substance under them and stated staff were expected to provide weekly nail care as part of regular bathing. The IP stated the resident’s nails should have been cleaned and clipped with the last weekly skin assessment, and the DON stated staff were expected to look at residents’ nails every day since they assist residents daily.
Staffing Posting Not Accessible or Posted Daily
Penalty
Summary
The facility failed to ensure the required nurse staffing information was posted daily and in an area accessible to residents and visitors. On 3/9/26 at approximately 2:00 p.m., surveyors observed the staffing posting on the wall of the 1st floor hallway across from the business office and other offices. All residents lived on the 2nd floor, and the 1st floor was only accessible by an elevator that required a code to use. The posting was about 6 feet off the ground and, while it contained the required information, it was not accessible or at a height easy to read for residents in wheelchairs, ambulatory residents, or visitors. The posting remained in the same location throughout the survey. On 3/11/26, NA-A confirmed the staffing posting was only on the 1st floor and nowhere else in the building. The BOM stated they were responsible for the posting and confirmed it was only on the 1st floor, that all residents lived on the 2nd floor, and that it was not at a height accessible for residents in wheelchairs. The BOM also stated the posting had not been posted on weekends because they were the only staff responsible and were in the building Monday through Friday. The DON stated the expectation was that staff would be posted according to nursing home regulations and that the staffing information should be available to residents, staff, and visitors who wished to view it. The facility policy stated the nurse staffing sheet would be posted daily and available for the public to review.
Failure to Complete Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance reviews for five nursing assistants, which had the potential to affect all 37 residents residing at the facility. During a review of employee records, it was found that there was a lack of documentation for completed annual performance reviews for these nursing assistants, all of whom had been employed at the facility for more than a year. Interviews with the administrator and the Director of Nursing (DON) revealed that the previous DON was believed to have completed these reviews, but no documentation could be found to confirm this. The facility's assessment, last reviewed in August, indicated that the training program was based on the resident population and included ongoing training for all staff. This assessment also identified that annual reviews were part of the training sessions and were necessary to meet regulatory requirements. The assessment further stated that skills and competencies were to be completed upon hire and annually to ensure continued competence in various areas such as assessment, safe patient handling, and infection control. Despite these requirements, the facility was unable to provide a policy pertaining to annual reviews when requested.
Deficiencies in Hand Hygiene, EBP, and Legionella Management
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during medication administration for two residents. An LPN was observed not performing hand hygiene between handling medications for different residents, despite the facility's policy requiring hand hygiene before preparing or handling medications. This lapse in protocol was confirmed by both the LPN and the Director of Nursing (DON), who acknowledged the importance of hand hygiene in preventing the spread of germs between residents. The facility also failed to implement Enhanced Barrier Precautions (EBP) for six residents who had either open wounds or indwelling medical devices. Observations revealed a lack of signage or personal protective equipment in the rooms of these residents, and their care plans did not include necessary interventions for EBP. Interviews with staff, including a nursing assistant and the DON, indicated a lack of understanding and implementation of EBP, despite the facility's policy and CDC guidelines requiring such precautions for residents with wounds or indwelling devices. Additionally, the facility did not have a Legionella risk assessment or a plan to mitigate the growth of Legionella, which is required to prevent potential infections. Despite multiple requests, the facility's administrator and DON were unable to provide documentation of a Legionella water management plan or a schematic of the water system. The facility's policy stated the need for strategies to prevent and control Legionella infections, but no evidence of such a plan was provided.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews. Residents were left unattended for extended periods, with call lights going unanswered for significant lengths of time. For instance, one resident's call light was activated at 10:48 a.m., but assistance did not arrive until 11:42 a.m., nearly an hour later. This delay in care was observed repeatedly, with staff being unavailable or occupied with other tasks, leaving residents without necessary assistance. The report highlights specific instances where residents were not provided timely care, such as a resident who was left wet for 2.5 hours and another who was not changed after a bowel movement for three hours. These incidents were compounded by grievances from residents about long wait times for call lights to be answered, particularly during evening and night shifts. Interviews with staff revealed that the facility was understaffed, with some staff members working double shifts and others being interrupted during critical tasks like medication passes and meal services. The facility's assessment indicated that a significant portion of the resident population required two-person assistance for transfers and other care needs, yet staffing levels were insufficient to meet these demands. The Director of Nursing and other staff members acknowledged the staffing shortages and the impact on resident care, noting that the facility did not utilize agency or pool staff to fill gaps. The lack of adequate staffing was further exacerbated by the absence of a maintenance director, leading to additional operational challenges within the facility.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a functional, sanitary, and safe environment, as evidenced by structural issues and items in disrepair throughout the facility. Residents reported during a council meeting that the facility was in poor condition, with no maintenance staff available to address problems in resident rooms, dining rooms, and hallways. Observations revealed multiple areas with blackish-brownish speckles, crumbs, and streaks of tannish substances in the main kitchen, indicating a lack of cleanliness and maintenance. In the memory care dining area, family members and staff noted missing appliances, mismatched items, and a generally tired appearance. Observations confirmed the presence of orange-yellow splotches, grayish-blackish fuzzy substances on air vents, and brownish-black speckles on walls and valances. Missing cabinet pieces and scuff marks on walls further highlighted the disrepair. Staff confirmed these conditions, acknowledging that the dining area had not been maintained to a homelike standard for an extended period. The ice and water dispensing machine in the second-floor dining room was also found to be malfunctioning and unclean, with excess mineral buildup and sediment around the spout. Family members and staff reported issues with the machine spraying water erratically, and the dietary manager confirmed the need for a deep cleaning due to hard water. The facility had been without a maintenance director since September, and the administrator admitted to being unsure about the comprehensiveness of maintenance reports, relying on corporate assistance every two weeks.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely action on consultant pharmacist recommendations for four residents reviewed for unnecessary medications. For one resident, the facility did not implement side effect monitoring for psychotropic medications and failed to establish an end date for trazodone, despite repeated recommendations from the consulting pharmacist. The resident had severe cognitive impairment and was on multiple medications, including antipsychotics and antidepressants, without proper monitoring or documentation of follow-up on pharmacy recommendations. Another resident, who was receiving hospice care, had multiple medication orders, including psychotropic medications, without proper documentation of medication regimen review (MRR) follow-up. The facility did not provide a signed order summary or documentation of follow-up on pharmacy recommendations, which included concerns about duplicative therapy and the need for clinical rationale for PRN psychotropic orders. The consulting pharmacist's recommendations were not acted upon, and there was no evidence of provider or nursing staff follow-up. For two other residents, the facility failed to complete recommended lab tests and did not document follow-up on pharmacy recommendations. One resident had a history of schizophrenia and other mental health disorders, and the facility did not complete labs ordered months prior. The other resident, with multiple chronic conditions, had recommendations for medication clarifications and adjustments that were not documented as followed up by the facility. Interviews with staff revealed a lack of consistent follow-up on pharmacist recommendations, contributing to the deficiencies identified.
Deficiency in Annual Performance Reviews and In-Service Training
Penalty
Summary
The facility failed to ensure that required in-service training based on annual performance reviews was completed for five nursing assistants whose employee files were reviewed. This deficiency had the potential to affect all 37 residents residing at the facility. During a review of employee records, it was found that there was a lack of documentation for completed annual performance reviews and in-service training addressing areas of weakness identified by these reviews. All five sampled employees had been employed at the facility for more than one year. Interviews with the administrator and the Director of Nursing (DON) revealed that there was an assumption that the previous DON had completed the competencies with annual reviews, but no documentation could be found to support this. The DON confirmed that the facility would restart these reviews at the beginning of the next year, emphasizing the importance of staff being aware of their strengths and areas for improvement. The facility's assessment indicated that annual reviews were part of the training sessions to meet regulatory requirements, but no policy regarding annual reviews or in-service training was provided upon request.
Failure to Document Resident's Resuscitation Wishes
Penalty
Summary
The facility failed to ensure that a resident's resuscitation wishes were clearly documented and accessible in both the electronic medical record (EMR) and physical paper chart. The resident, identified as R22, had significant cognitive impairments and multiple medical conditions, including Alzheimer's disease and dementia. Despite these conditions, there was no clear documentation of R22's code status in the EMR or paper chart, and the POLST (Physician Orders for Life-Sustaining Treatment) was not uploaded or available. Interviews with various staff members, including nursing assistants, licensed practical nurses (LPNs), and the director of nursing (DON), revealed inconsistencies in the process of verifying and documenting code status. Staff members indicated they would initiate CPR if a resident's code status was unclear or not documented, as was the case with R22. The facility's process for confirming and entering code status during admission was not followed for R22, and there was no admission checklist in place to ensure all necessary documentation was completed. The facility's social worker and DON acknowledged the lack of a POLST policy and procedure, relying instead on state guidance. The absence of a clear and consistent process for documenting and verifying code status led to confusion among staff and the potential for actions contrary to the resident's wishes. The facility's CPR policy directed staff to provide life support in accordance with advance directives, but the failure to have these directives clearly documented for R22 highlighted a significant deficiency in the facility's procedures.
Failure to Notify Providers of Resident's Weight Status
Penalty
Summary
The facility failed to notify healthcare providers about a resident's weight status while the resident was on a prescribed diuretic for edema management. The resident, who had severe cognitive impairment and multiple diagnoses including heart failure, kidney failure, and lymphedema, was receiving hospice care. The care plan required staff to report signs of dehydration, hypotension, and weight changes, but there was a lack of documentation regarding the resident's weight and refusals to be weighed. The resident's treatment administration record showed inconsistent documentation of weights, with several instances where weights were not recorded or the resident refused to be weighed. Despite a significant weight loss over several months, there was no documentation of provider notification about these refusals or the weight loss. Interviews with staff, including the registered dietitian and hospice nurse, confirmed the lack of communication with the primary care provider regarding the resident's weight status and refusals. The facility's policy required immediate notification of the resident's physician and representative when there was a need to alter treatment significantly. However, interviews with the primary care provider and nursing staff revealed that the provider was not informed about the resident's weight refusals and lack of documentation. The director of nursing expected staff to report such refusals to the interdisciplinary team and the resident's care providers, but this was not done, leading to a deficiency in care management.
Failure to Provide Timely NOMNC to POA
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) within the required timeframe for a resident with moderate cognitive impairment and a diagnosis of dementia. The resident's power of attorney (POA) discussed discharge plans with the facility two days prior to the resident's discharge, but the NOMNC was not presented to the POA at that time. Instead, the NOMNC was signed by the resident on the day of discharge, despite the presence of a POA. A registered nurse confirmed that she sometimes allowed residents to sign the form if she believed they were cognitively intact, based on her observation rather than a formal assessment. The facility administrator acknowledged that there are no exceptions to the requirement for the NOMNC to be given two days prior to discharge and that the POA should have been given the notice to sign. The facility did not have a specific policy on NOMNC and stated they follow Medicare regulations.
Failure to Complete Level II PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) was completed for a resident with mental health needs. The resident, identified as R8, had a documented diagnosis of schizophrenia and other mental health disorders, including schizoaffective disorder, depression, bipolar disorder, and hoarding disorder. The preadmission screening results indicated that a Level II assessment was necessary for mental illness. However, the social services staff member, SS-A, did not realize the requirement for a Level II assessment despite conducting an audit of PAS results. This oversight was confirmed during interviews, where SS-A acknowledged the importance of identifying mental health or developmental disorders to provide appropriate care. The facility's policy was requested but not provided, indicating a lack of documentation to support compliance with PASARR requirements.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was offered or provided a shower as per his care plan and preferences. R30, who had moderately impaired cognition, memory deficits, and required substantial assistance for activities of daily living (ADLs), was not documented as having received a shower for the past 30 days. His care plan indicated that bathing preferences were very important to him, and he was scheduled for showers on Tuesday mornings. However, there was no documentation of showers or refusals in the PointOfCare (POC) system or progress notes. Interviews with staff, including nursing assistants and licensed practical nurses, revealed inconsistencies in documentation and communication regarding R30's shower schedule and refusals. Staff members were unable to find records of R30's last shower, and there was no documentation of any refusals. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that staff might not be diligent in documenting when a bed bath was performed. The DON emphasized the importance of offering showers to residents to promote dignity and overall health. The facility's policies on resident rights and activities of daily living (ADLs) were not adhered to, as they require that residents be treated with respect and dignity, and that their abilities in ADLs do not deteriorate unless unavoidable. The policies also mandate that care and services for ADLs, including bathing, be provided based on the resident's comprehensive assessment and consistent with their needs and choices. The failure to offer or document showers for R30 represents a deficiency in meeting these standards.
Failure to Provide Preferred Activities for Resident
Penalty
Summary
The facility failed to ensure that a resident's preferred activities for individual entertainment were offered, specifically for a resident with severely impaired cognition and a primary language of Russian. The resident's care plan and activity participation review indicated a preference for 1:1 activities, reading Russian books, watching Russian television, and going outside for fresh air. However, the care plan and documentation lacked evidence of the resident being offered the opportunity to go outside, despite this being identified as important in the resident's significant change Minimum Data Set (MDS). Observations and interviews revealed that the resident spent much of her time in bed, with limited engagement in activities. The resident expressed a desire to go outside more often, but staff did not consistently offer or document attempts to facilitate this preference. The activities staff, who was the only one in the facility, acknowledged the challenge of meeting all residents' preferences and noted that the language barrier could be an issue. The staff also mentioned that the resident's family sometimes took her outside, but there was no consistent effort from the facility to ensure this preference was met. The facility's policy on activities emphasized the importance of supporting residents' choices based on their assessments and care plans, including indoor and outdoor activities. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and effort to accommodate the resident's preference for outdoor activities. Interviews with the nursing assistant and the Director of Nursing (DON) highlighted a lack of awareness and documentation regarding the resident's requests and refusals, indicating a gap in communication and implementation of the care plan.
Failure to Provide Comprehensive Assessment and Timely Care for Resident
Penalty
Summary
The facility failed to comprehensively assess and provide appropriate treatment and services to prevent urinary tract infections (UTIs) and restore continence for a resident. The resident, who had intact cognition and was dependent on staff for toileting and transfers, was frequently incontinent of urine and bowel. Despite having a history of UTIs and being at risk for skin breakdown, the facility did not implement a urinary or bowel toileting training program. The resident's care plan lacked interventions to promote continence or improve her current level of function, and the facility did not conduct a thorough bladder/incontinence evaluation. Observations and interviews revealed that the resident experienced significant delays in receiving assistance after activating her call light. On one occasion, the resident waited nearly an hour for assistance, during which time no staff were present on the unit to address her needs. The resident's family member expressed concerns about understaffing and long wait times for assistance, particularly during evenings and mealtimes. The resident herself reported that call light wait times were particularly bad on weekends, and she was not aware of her urge to void. Interviews with facility staff, including the Director of Nursing (DON) and a nurse practitioner, highlighted issues with staffing levels and the lack of a toileting program for the resident. The DON acknowledged that the facility's staffing was not meeting the needs of the residents and that the resident could potentially benefit from a toileting program. However, the facility did not have an occupational therapist to guide such a program, and the resident's cognitive issues and unawareness of her urge to void were cited as reasons for not initiating a toileting program. The facility's assessment tool indicated that it provided bowel and bladder care, but the lack of a toileting program and delayed response to call lights contributed to the resident's risk of UTIs and skin breakdown.
Failure to Properly Administer and Document Topical Medications
Penalty
Summary
The facility failed to ensure that prescription topical medications were applied and documented according to professional standards of practice for a resident with severely impaired cognition and a self-care deficit. The resident, identified as R26, had active physician orders for Nystatin powder to be applied to skin folds and the groin area as needed. However, the medication administration records (MAR) for October, November, and December 2024 lacked documentation of the administration of the Nystatin powder, indicating a failure to record the use of the medication as required. During an observation, a nursing assistant (NA) was seen applying the Nystatin powder to the resident's skin without proper documentation or oversight from a licensed nurse. The NA stated that they applied the powder for the resident's dry skin and monitored the skin condition, reporting any changes to the nurses. However, the licensed practical nurse (LPN) and director of nursing (DON) interviews revealed that prescription medications, including topical powders, should be applied by nurses, who are responsible for assessing the resident's condition and ensuring proper medication administration. The facility's policy on medication administration requires that medications be administered by authorized personnel and documented immediately after administration. The policy also mandates that prescription medications be kept in a locked medication cart. The failure to adhere to these protocols resulted in the Nystatin powder being kept at the resident's bedside and applied by an unauthorized staff member, leading to a deficiency in the facility's pharmaceutical services.
Inadequate Monitoring and Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide appropriate side effect monitoring and obtain informed consent for psychotropic medication use for a resident with severe cognitive impairment and multiple diagnoses, including heart failure and adjustment disorder with mixed anxiety and depressed mood. The resident was prescribed several psychotropic medications, including Depakote, trazodone, Seroquel, and Neurontin, without proper monitoring of vital signs and orthostatic blood pressure. The care plan did not include necessary monitoring, and there was no evidence of informed consent for the use of gabapentin. The facility's medication administration records indicated that the resident received trazodone PRN on multiple occasions without an end date, contrary to the facility's policy requiring a 14-day limit for PRN psychotropic medications. Interviews with nursing staff revealed inconsistencies in monitoring practices and a lack of documentation for vital signs and orthostatic blood pressure. The staff also failed to obtain consent for gabapentin, which was used for anxiety and pain, and did not adequately monitor for side effects of psychotropic medications. The Director of Nursing and consulting pharmacist confirmed the deficiencies, emphasizing the importance of obtaining informed consent and monitoring for side effects. The facility's policy required education on the risks and benefits of psychotropic drugs and limited PRN orders to a specific duration. However, the facility did not adhere to these guidelines, resulting in inadequate monitoring and documentation for the resident's psychotropic medication use.
Failure to Maintain Safe Bed Remote Control
Penalty
Summary
The facility failed to ensure the safety and proper maintenance of a bed remote control for a resident with severely impaired cognition and multiple diagnoses, including heart failure and dementia. The resident was observed using a bed controller with exposed wires, although the wires were not frayed. Despite the resident's ability to use the controller independently, the potential risk of electrical shock was present. Interviews with staff revealed that while the nursing assistant and LPNs were aware of the protocol to report such issues through the TELS system, no maintenance request had been recorded for the resident's bed controller. The facility's maintenance records indicated a history of inadequate bed conditions and a lack of consistent maintenance oversight, as evidenced by skipped tasks and unrecorded actions in the TELS system. The absence of a maintenance director during certain periods contributed to the failure to address the bed controller's condition. The facility's policy required routine inspection and maintenance of electrical equipment, but this was not effectively implemented, leading to the deficiency observed in the resident's bed controller.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple maintenance issues that were not addressed. Observations revealed significant environmental concerns in the dining areas and resident rooms, including missing baseboards, gouged walls, stained ceiling tiles, and web-like material on blinds. These issues were reported by residents and staff, but there was a lack of timely response from the facility's maintenance department, which was noted to be understaffed. Resident R30, who had been admitted to the facility, reported several complaints about the unsanitary conditions and environmental hazards, including fire and electrical hazards. Despite these complaints, the facility did not take adequate action to rectify the issues. Observations confirmed the presence of gouge marks, missing baseboards, and scuff marks in the dining room, as well as an electrical outlet coming out of the wall in R30's room. Interviews with staff and residents indicated that these conditions had persisted for some time without resolution. Resident R36 also experienced a lack of a homelike environment, with issues such as unstable cabinetry, a lack of heat in the bathroom, and a privacy curtain that could not fully close. The resident expressed dissatisfaction with the living conditions, describing the facility as "falling down." Staff interviews confirmed that there was no dedicated maintenance department, and concerns were to be reported to the administrator. However, the absence of a maintenance team led to delays in addressing these safety and environmental concerns.
Failure to Provide Ombudsman Contact Information
Penalty
Summary
The facility failed to provide contact information for the Ombudsman to three residents who attended a resident council group meeting. During the meeting, two residents stated they were unaware of the Ombudsman, their telephone number, or the advocacy services provided. Another resident mentioned that they had to search the Internet to obtain this information, as it was not posted in the facility. An observation confirmed that the Ombudsman information was not visible in the facility. Interviews with facility staff revealed that the Ombudsman contact information was not accessible to residents. An LPN mentioned that the information was located in the copier room, which residents could not access. Another LPN confirmed that the information was not posted in the facility. The Director of Nursing stated that the Ombudsman contact information was in the administrator's office and confirmed it was not posted in a place accessible to residents and families. The facility's policy on Resident Rights emphasized the importance of informing residents of their rights and providing an environment where they can exercise them, which includes providing a list of pertinent contact information.
Inaccessible State Survey Results for Residents
Penalty
Summary
The facility failed to ensure that the most recent State agency survey results were accessible for review by residents, particularly those residing on the second floor. During an observation, it was noted that the survey results were placed in a red three-ring binder attached to the wall near the main entrance on the first floor. However, there was no indication or posting of these results on the second floor, where all 37 residents resided, nor any signage to inform them that the results were available elsewhere in the building. During a resident group meeting, three residents expressed that they were unaware of the location of the State Survey results and did not know they had the right to view them. An LPN confirmed that the survey results were not easily accessible to all residents, as they were only available on the first floor by the business office. The facility's policy stated that survey results should be posted in an accessible location where individuals do not have to ask to see them, which was not adhered to in this case.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with dementia and personality disorder in a timely manner, as required by regulations. The resident, who had unimpaired cognition, reported that a nursing assistant became angry during care, pinched her leg, and grabbed her hair with wet hands. The incident was reported to the State Agency (SA) and the administrator later than the mandated two-hour timeframe. The report was submitted to the SA at 5:41 p.m., despite the incident being known to staff earlier in the day. Interviews with staff revealed that the allegation was first reported to an LPN at approximately 11:30 a.m., but was not escalated to the administrator until 2:00 p.m. due to other duties such as medication administration and meal service. The administrator acknowledged the delay in reporting to the SA, citing a busy schedule and lack of immediate follow-up. The facility's policy required immediate reporting of abuse allegations to the administrator and the SA within two hours, but this protocol was not followed, leading to the deficiency.
Failure to Immediately Protect Resident After Abuse Allegation
Penalty
Summary
The facility failed to immediately implement an intervention to protect a resident following an allegation of physical abuse by a staff member. The resident, who had diagnoses of dementia and personality disorder but whose cognition was not impaired, reported that a nursing assistant (NA) became angry during care, pinched her leg, and grabbed her hair with wet hands. The incident was reported to social services and the administrator at approximately 2:00 p.m. on the day of the alleged abuse, but the NA was not immediately removed from the building, as she had already completed her shift. The facility's policy on abuse, neglect, and exploitation requires immediate action to protect residents from harm during and after an investigation, including removing the alleged perpetrator from direct care. However, the NA continued to work her shift until its completion, and the resident expressed feeling unsafe until assured that the NA would be suspended. Interviews with staff confirmed that the NA was suspended for three days during the investigation, but there was a delay in implementing protective measures immediately after the allegation was made.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,035 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hopkins
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Augustana Chapel View Care Center | 1.3 mi | ★★★★★ | 6 | 0 |
| Sholom Home West | 1.9 mi | ★★★★★ | 7 | 0 |
| The Estates At St Louis Park Llc | 2.5 mi | ★★★★★ | 0 | 0 |
| The Villas At The Cedars | 3 mi | ★★★★★ | 15 | 1 |
| The Villas At St Louis Park | 3.7 mi | ★★★★★ | 18 | 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.