Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kittson Healthcare during CMS and state inspections, most recent first.
A resident slipped and fell on a freshly mopped wet floor in her room after no wet floor sign was in place, striking her head on the concrete floor and sustaining a laceration that required ER evaluation and staples. The record also showed a separate failure involving another resident with severe cognitive impairment and dependence for transfers, when an NA completed a transfer without the two-person assist specified in the care plan.
Failure to Use EBP and Track Infection Symptoms: Staff did not consistently use gowns and gloves during high-contact care for a resident with a Foley catheter and a resident with a pressure ulcer, and the resident care plan did not identify EBP for the wound. Staff observations showed aides, an RN, and a lab tech providing care without the expected PPE, and interviews showed confusion about when gowns were required. The facility also failed to maintain complete infection surveillance, as a resident’s diarrheal illness was not captured on the infection control log and the logs did not consistently track all signs and symptoms of infection.
A resident with moderate cognitive impairment and significant care needs had ongoing difficulty using the standard call light, but the record had no formal assessment of call light ability and no adaptive call light was tried. The resident and family reported delayed responses and confusion about whether the call light had been activated, while an NA said the resident complained almost daily that staff did not answer. The DON confirmed the resident did not like a pancake call light, but no formal assessment had been completed.
A resident with dementia, Parkinson’s disease, and behavioral symptoms had PRN olanzapine ordered for severe agitation with an open-ended end date and no documented 14-day prescriber evaluation. The med had been discontinued for nonuse after the resident remained stable, then later restarted at the family’s request despite no recent anger outbursts and without adequate clinical justification documented for the renewed PRN antipsychotic use.
A resident with intact cognition and a history of falls slipped on a freshly mopped floor in her room after staff failed to place a wet-floor sign, struck the back of her head, and required emergency treatment with sutures/staples. Facility records and the DON’s interview confirmed the floor was wet and the sign was not posted, but the incident was not reported to the SA as alleged neglect, despite the facility policy requiring reporting within 24 hours when caregiver neglect results in injury.
A resident with moderate cognitive impairment and late-onset Alzheimer’s disease had a care plan that did not accurately reflect current function with toileting, transfers, and ambulation. Therapy notes and staff observations showed the resident was independent and stable with walking, toileting, and transfers, but the care plan still contained conflicting interventions about needing assistance and unsteady balance. The DON stated the care plan should have been updated to show the resident was independent so staff would know the current care needs.
A resident who was cognitively intact and needed substantial to maximal help with transfers and toileting, with a hx of stroke and IBS with diarrhea, repeatedly waited 24 to 35 minutes for call light response. The resident reported waiting about 30 minutes for bathroom help and soiling themselves multiple times, while an NA confirmed the resident had soiled their brief after waiting more than 30 minutes. The DON stated the facility expectation was to answer call lights within 10 minutes.
Failure to provide timely incontinence care for a resident dependent on staff for ADLs. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, and was incontinent of bowel and bladder. A NA transferred the resident to a wheelchair for lunch without checking or changing her first, and her jeans were visibly wet with a saturated brief. The NA stated he had forgotten to check her, while the RN said the resident should be checked every 2 hours and changed when needed.
A resident with severe cognitive impairment, dependence for transfers and bed mobility, and diagnoses including Alzheimer's disease, dementia, and prior TIA/stroke was on an every-two-hour turn and reposition schedule for pressure ulcer prevention. During observation, the resident remained lying on her back in bed for over two and a half hours without staff repositioning, and a NA stated he had not returned to the room after placing her in bed after breakfast and was unsure whether she needed to be turned. An RN confirmed the resident was on the two-hour turning list, and the DON stated staff had communicated her increased care needs.
A resident with PTSD and moderate cognitive impairment had a documented history of abuse, but the facility did not complete the trauma symptoms and triggers portion of the trauma-informed assessment and did not include PTSD or trigger-based interventions in the care plan. Staff interviews showed the resident preferred that staff knock, introduce themselves, and use a suggested approach rather than telling her what to do, yet staff did not know her triggers and the SWD stated the assessment section was not completed because PTSD was not present at admission.
A resident with severe cognitive impairment, dementia, and chronic lymphocytic leukemia returned from the ED with an order to recheck a WBC the next day, but nursing staff failed to arrange the lab draw. The AVS was reviewed later, the missed order was discovered, and staff stated the charge nurse was responsible for checking post-visit orders and that the lab order had been overlooked.
A resident with severe cognitive impairment, incontinence, and multiple chronic conditions received repeated antibiotic courses for suspected UTI/cystitis, including cephalexin, Rocephin, and nitrofurantoin. The facility used a UTI SBAR process and had an antibiotic stewardship policy requiring Loeb criteria review, a 72-hour reassessment, and documentation of the antibiotic time-out, but the record lacked the required reassessments and further urine testing/culture results. Staff described the process as informal, and the DON could not provide the SBAR forms sent to the PCP.
A resident with blindness and multiple comorbidities, identified as a fall risk and care planned for contact guard assist, was ambulating with a cane and staff supervision when she lost balance and fell, resulting in a left arm fracture. Staff did not use a gait belt or maintain close proximity as required by the care plan, and interviews confirmed confusion about assistance levels. The facility's policy did not explicitly require gait belt use for all transfers or ambulation, contributing to the incident.
A resident identified as DNR in facility records and who verbally confirmed their DNR preference did not have a signed advanced directive in their medical record. The DON confirmed the required documentation was missing and could not provide the facility's policy on advanced directives.
A resident who was independent with bed mobility and transfers was observed using half bed rails, but the facility did not complete a comprehensive assessment or obtain informed consent for their use. Staff interviews confirmed that no assessment was performed, as the rails were considered adaptive equipment rather than restraints, despite facility policy requiring documentation and assessment.
A resident with diabetes did not receive insulin according to manufacturer instructions when an LPN failed to prime the insulin pen with 2 units before administration. The LPN attached a new needle but did not perform the required priming step, contrary to facility policy and manufacturer guidelines. This was confirmed through observation, staff interviews, and review of the facility's insulin administration policy.
The facility did not provide the latest CDC education on vaccine risks and benefits or offer the most recent pneumococcal vaccines to several residents. Documentation was lacking regarding whether residents received required vaccine information or were offered the newer PCV20 or PCV21 vaccines, and staff interviews confirmed there was no process to re-evaluate vaccination status outside of annual reviews.
The facility did not include the daily resident census on the nurse staffing posting, despite displaying other required staffing information. The census was omitted on nearly all reviewed days, and staff confirmed they were not trained or instructed to include it. The census was only recorded in a non-public area, making it inaccessible to residents and visitors.
The facility failed to implement timely transmission-based precautions and confirmatory testing for COVID-19 for residents displaying symptoms, as per CDC guidelines. Additionally, enhanced barrier precautions were not used for a resident with an indwelling catheter. The facility's infection control log lacked details on test types and isolation measures, and staff were not instructed on proper PPE use for catheter care.
The facility failed to ensure unlicensed personnel did not administer injectable medications, violating state requirements, and omitted medications during medication pass for several residents. A CCMA administered insulin injections, which should have been done by licensed professionals. Additionally, medications were not administered as ordered, with some remaining in the medication cart despite being signed off. The DON acknowledged these as medication errors and was attempting to improve medication tracking.
The facility failed to date opened prescription eye drops, risking the use of expired products for three residents. During a review, it was found that the open vials of latanoprost on a medication cart lacked recorded open dates. The RN acknowledged that staff often forget to date medications, and the DON confirmed that not all staff were following the policy. The facility's policy required discarding latanoprost 42 days after opening, but without open dates, compliance was not possible.
A facility failed to implement antibiotic stewardship protocols for a resident with a UTI. The infection control log did not specify the organism identified in urine cultures, and the resident's medical record lacked evidence of culture results to ensure the correct antibiotic was prescribed. Staff interviews revealed gaps in processes, including lack of orientation for an RN and inadequate documentation of culture results. The facility's Antibiotic Stewardship Policy was not followed in this case.
A resident with severe cognitive impairment was left exposed in their room, visible from the hallway, due to staff inaction. Despite multiple staff members passing by, the resident remained uncovered for several minutes. The facility's policy emphasizes maintaining resident dignity and privacy, which was not upheld in this instance.
A resident with severe cognitive impairment was improperly restrained in a recliner by a nursing assistant to prevent wandering. The resident's wheelchair was moved out of reach, restricting self-transfer, which violated the facility's restraint-free policy. Video evidence and staff interviews confirmed the incident, revealing a misunderstanding of restraint use among staff.
The facility failed to report an incident where a resident with cognitive impairment was handled roughly and restrained by a nursing assistant. Additionally, an injury of unknown origin on another resident was not reported, despite being in a suspicious location. The facility's policy requires immediate reporting of such incidents, but these were not reported to the appropriate authorities.
A facility failed to investigate allegations of rough treatment and the use of a recliner as a restraint for a resident with severe cognitive impairment. Additionally, the facility did not report or investigate an injury of unknown origin for another resident, violating its own policies on abuse and injury investigation.
A resident with severe cognitive impairment and bladder cancer experienced a skin tear on the scrotum, which the facility failed to properly assess and address. Despite being at risk for pressure ulcers and frequently incontinent, the resident's care plan was not updated, and staff were unaware of the injury. Observations showed improper handling during transfers, and interviews revealed a lack of communication and follow-through in wound care, leading to inadequate interventions and oversight of the resident's condition.
A resident with severe cognitive impairment and hemiplegia was at risk for pressure ulcers, yet the facility failed to consistently implement prescribed interventions. Observations showed the resident wearing fuzzy slippers instead of heel protectors, and their heels were not properly offloaded. Staff interviews confirmed the care plan was not followed, and a policy on pressure ulcer care was not provided.
A nursing assistant improperly transferred a resident with severe cognitive impairment, using a recliner as a restraint and failing to use a gait belt, leading to unsafe conditions. Additionally, another resident with severe cognitive impairment was not adequately supervised, resulting in aimless wandering and potential safety risks. Staff failed to intervene appropriately in both cases, highlighting deficiencies in the facility's transfer and supervision practices.
A resident with dementia became agitated and aggressive when a nursing assistant attempted to remove a banana from his wheelchair, contrary to his care plan directives. The incident, captured on video, showed the assistant's approach escalated the situation, leading to physical aggression from the resident. The facility lacked a policy on dementia care.
A resident with multiple diagnoses, including cancer and Parkinson's disease, did not have a physician-prescribed Tramadol taper order implemented, leading to continued urinary retention issues. Despite a pharmacy consultant's recommendation and the physician's signed order, the medication dosage was not reduced due to communication and system issues within the facility.
Wet Floor Fall and Failure to Follow Transfer Care Plan
Penalty
Summary
The facility failed to maintain a safe environment when a freshly mopped floor was left wet without appropriate precautions in place for a resident who was ambulating in her room. R25 had intact cognition and was documented as independent with transfers and ambulation on her annual MDS, with diagnoses including repeated falls, osteoporosis, gait and mobility abnormalities, weakness, urinary incontinence, seizures, and disorientation. Her care plan identified that she believed herself capable of increased independence, while also noting supervision with shower transfer and that she was to walk with staff when out of her room. R25 stated that she was trying to go to the bathroom when the housekeeper had just mopped the floor and she slipped on the wet floor and fell. She reported that no wet floor sign had been placed and that she was not aware the floor was wet. The event report documented that she had an unwitnessed fall in her room, that the floor was wet, and that she slipped and struck the back of her head on the concrete floor. Staff observed a 1-to-2-centimeter laceration and an egg-like bruise on the back of her head, and she was sent to the emergency room for evaluation. The record also noted that she later returned with 8 staples to the back of her head. The facility also failed to provide transfer assistance in accordance with the resident’s care-planned interventions for R9. R9’s MDS identified severe cognitive impairment, dependence with transfers and bed mobility, inability to ambulate, and diagnoses including Alzheimer’s disease, abnormal gait and mobility, TIA/stroke history, heart disease, and dementia. Her care plan identified her as a two-person stand-and-pivot transfer. During observation, NA-C assisted R9 with a transfer from bed to wheelchair, then back to bed for incontinence care, and later transferred her back to the wheelchair without another staff member assisting, despite the resident having difficulty standing and despite the care plan calling for two-person assistance. Staff interviews confirmed that R9 was to be transferred with two-person assistance per the care plan.
Failure to Use EBP and Track Infection Symptoms
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Foley catheter and for a resident receiving wound care. One resident had moderate cognitive impairment, was incontinent of bowel and bladder, and had diagnoses including chronic kidney disease stage 3 and chronic urinary retention. After returning from the hospital with a Foley catheter, the resident was observed during morning care while staff assisted with dressing, repositioning, and transfer activities. A registered nurse completed a dressing change and assisted the resident in bed without wearing a gown. Nursing assistants later assisted the resident with dressing, handling the Foley catheter tubing, and transferring him with a total lift while wearing gloves but not consistently using gowns. A hospital lab tech drew blood from the resident and stated he did not know the resident was on EBP and had not received an update from staff; he said he would have worn a gown and gloves if he had known. A second resident had moderate cognitive impairment, diagnoses including chronic heart failure, pressure ulcer, peripheral vascular disease, and chronic kidney disease, and used a pressure-reducing device and a nonsurgical dressing. The resident’s care plan did not identify the need for EBP related to the pressure ulcer. During observation, nursing assistants entered the room without disposable gowns, assisted the resident with use of the bedpan, transferred the resident with a full-body mechanical lift, and later returned the resident to bed after the wound dressing had been removed and the wound was exposed. A registered nurse later entered to assist with the resident’s stockinette and assess the wound without wearing a disposable gown. Staff interviews reflected differing understandings of when gowns were required, with some stating gowns were only needed during wound dressing changes or when drainage was present. The facility also failed to conduct ongoing infection surveillance to identify and track residents with signs and symptoms of potential infection. One resident’s record included a nursing note stating the resident refused breakfast, drank an Ensure with medications, and said she had been sick with diarrhea. However, the facility’s infection control logs for May, June, and July did not identify this diarrheal illness, and the logs also failed to capture infectious symptoms that were not treated with antibiotics. The logs listed multiple infections such as UTIs, cellulitis, pneumonia, and other infections, but did not consistently include cultures, organism information, or all symptomatic cases. The infection preventionist stated she received the log monthly from the DON and used it for QAPI reporting, while the DON stated nursing entered notes and she reviewed them for the log, but also said she was unable to keep track of everything and that viral infections were not added to the log.
Failure to Assess Call Light Use and Provide Adaptive Call Light
Penalty
Summary
The facility failed to assess a resident’s ability to independently activate the call light and did not provide a reasonable accommodation, such as an adaptive call light, after staff became aware of ongoing difficulty using the standard call system. The resident had a quarterly MDS identifying moderate cognitive impairment and diagnoses including chronic kidney disease, a sacral pressure ulcer, atrial fibrillation, and hypertension. The resident required substantial to maximal assistance with bathing and was dependent on staff for all other care areas, with a care plan directing staff to respond promptly to toileting requests, provide a bedpan when safely possible, and keep the call light in reach. During interview, the resident stated she could push the call button but staff did not come for over two hours, while a family member said the resident had difficulty pushing the call light at times and sometimes believed it had been activated when it had not. The resident’s record contained no assessment of call light ability. A nursing assistant reported the resident complained almost daily that she had turned on the call light and staff did not answer, and said this had been reported to nursing without change. The DON stated the resident had complained of long wait times, but call light logs showed the resident had not turned on the call light; the DON also stated the resident did not like a pancake call light, yet no formal call light assessment had been completed and no different adaptive call light had been tried.
PRN Antipsychotic Not Limited to 14 Days and Restarted Without Adequate Evaluation
Penalty
Summary
The facility failed to ensure an as-needed (PRN) antipsychotic medication order for a resident with Parkinson’s disease, Alzheimer’s disease, dementia with agitation, and mild neurocognitive disorder with behavioral disturbances was limited to 14 days, and failed to ensure the resident was evaluated by the prescribing practitioner before the PRN antipsychotic was renewed. The resident’s quarterly MDS identified moderately impaired cognition and behaviors such as rummaging, pacing, disrobing, disruptive sounds, rejection of care, and wandering, but no physical or verbal symptoms toward others during the observation period. The care plan referenced behavioral symptoms directed toward others and approaches such as avoiding power struggles and maintaining a calm, slow approach during care. The resident’s medication record showed olanzapine 2.5 mg PRN daily for severe agitation with an open-ended end date, and the medication remained available beyond 14 days. Provider notes showed the resident’s behaviors had improved, the PRN olanzapine had not been used for weeks, and psychiatry documented on 6/12/26 that the medication would be discontinued due to lack of use. Later, psychiatry documented that the resident had been stable with minimal behavioral or psychological disturbances and that the olanzapine had previously been discontinued due to nonuse. When the PRN olanzapine was restarted, the psychiatric note stated the resident had not had anger outbursts similar to prior episodes and that the family requested the medication be available after a refusal to return indoors following an outing. The record did not show adequate clinical justification for restarting the PRN antipsychotic after it had been discontinued for nonuse, and it did not show the resident was directly examined and evaluated every 14 days to determine whether the PRN antipsychotic remained appropriate. During interviews, the DON and RN stated the medication had continued or been restarted, that a 14-day assessment was needed, and that more justification should have been documented for the PRN use.
Failure to Report Alleged Neglect After Resident Fell on Wet Floor
Penalty
Summary
The facility failed to identify and report an alleged neglect incident to the State Agency for one resident who slipped and fell in her room after staff had mopped the floor and did not place a wet-floor warning sign. The resident had intact cognition and was independent with ADLs, transfers, and ambulation, with diagnoses including repeated falls, osteoporosis, gait and mobility abnormalities, weakness, urinary incontinence, seizures, and disorientation. She stated she was walking to the bathroom when she slipped on the wet floor, fell, and struck the back of her head, requiring emergency care and sutures/staples for a head laceration. Facility records documented that the resident was found on the bedroom floor with blood and a posterior head injury after reporting that the floor had just been mopped and was slippery. The incident report noted the floor was wet, and the resident was sent to the emergency room, where she received staples to the back of her head. The DON stated the facility investigated the fall and confirmed the floor was wet and that a wet-floor sign had not been placed, but the facility did not report the incident to the SA. The facility policy stated that if caregiver neglect occurred, meaning care plan not followed and resulting in resident injury, a report must be made to the Minnesota Department of Health within 24 hours of the initial findings.
Care Plan Not Updated to Reflect Resident’s Independence
Penalty
Summary
The facility failed to revise the comprehensive care plan to accurately reflect a resident’s current level of independence with toileting, transfers, and ambulation. The resident had a quarterly MDS identifying moderate cognitive impairment, a diagnosis of late-onset Alzheimer’s disease, and a need for supervision to touch assist with toileting, transfers, and walking. The care plan dated 5/21/26 identified a history of falls and included two therapy-based interventions, one stating the resident was unsteady and needed human assistance for toileting and surface-to-surface transfers while being independent with standing, walking, and turning, and a second stating the resident was unsteady but able to stabilize without human assistance for those same activities. During observations on 7/29/26 and 7/30/26, the resident was seen standing, ambulating, using the bathroom, and going to the dining room without assistance and was stable on their feet. A nursing assistant stated the resident was vastly independent and only needed slight help getting up and washed up in the morning, otherwise being independent with transfers, toileting, and ambulation. The RN clinical care coordinator stated care plans are reviewed regularly during IDT meetings, and the DON stated the care plan should have been updated to reflect the resident’s current status so staff would be aware of the care needed. The DON also stated there was a mistake with updating the care plan and that it should have stated the resident was independent.
Delayed Toileting Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance for one resident who was cognitively intact and required substantial to maximal assistance with transfers and toileting. The resident’s MDS identified the resident as continent of bowel and bladder, with diagnoses including stroke and irritable bowel syndrome with diarrhea. The care plan stated the resident needed assistance with toileting related to impaired mobility after a stroke and that staff would respond promptly to toileting requests, provide one-person pivot transfers as indicated, and assist with toileting hygiene. The resident’s call light log showed four instances in which the resident waited 24 to 35 minutes before the call light was answered. During interview, the resident stated they sometimes had to wait 30 minutes for bathroom assistance and, because of the delay, soiled themselves numerous times and became embarrassed. A nursing assistant stated the resident had soiled their brief after waiting more than 30 minutes and that when staff were busy, residents might have to wait longer than 30 minutes for assistance. An RN stated there were times when there were not enough staff to help residents quickly and that nursing would assist NAs in answering call lights, while the DON stated the facility expectation was to answer all call lights within 10 minutes and that it would be unacceptable for residents to wait longer than 20 minutes.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for activities of daily living. The resident’s annual MDS identified severe cognitive impairment and need for maximal assistance with dressing, grooming, and toileting hygiene, along with dependence for transfers and bed mobility and inability to ambulate. Diagnoses included Alzheimer’s disease, abnormal gait and mobility, history of TIA and stroke, heart disease, and dementia. The care plan identified substantial assistance with toileting hygiene, bathing, and dressing, and the resident was noted to be incontinent of bowel and bladder. During observation, a nursing assistant assisted the resident from bed to wheelchair for lunch without checking or changing her first. The resident’s jeans were visibly wet, and after the transfer the nursing assistant confirmed the brief was saturated and the resident had been incontinent of bowel. He then returned the resident to bed, removed the soiled brief, washed her peri area, and changed her brief and clothing before transferring her back to the wheelchair for the meal. The nursing assistant stated he had not checked or changed the resident since after breakfast and had forgotten to check her before taking her to lunch. The RN stated the resident should be checked every two hours and changed when needed, and the DON stated the resident should not be left in soiled briefs.
Failure to Reposition Resident on Turn Schedule
Penalty
Summary
The facility failed to reposition a resident according to the established every-two-hour turn and reposition schedule for one resident reviewed for pressure ulcer prevention. The resident had severe cognitive impairment, required maximal assistance with dressing, grooming, and toileting hygiene, was dependent for transfers and bed mobility, and was unable to ambulate. Diagnoses included Alzheimer's disease, abnormal gait and mobility, history of TIA and stroke, and dementia. The care plan identified the resident as at risk for pressure ulcers and included a goal that the resident's skin would remain intact, with approaches including daily skin observation with care, weekly head-to-toe nursing assessments, and a standard pressure reduction mattress. During continuous observation, the resident was seen lying on her back in bed from 9:30 a.m. to 12:06 p.m. without moving on her own, and no nursing staff entered the room to offer repositioning during that period. At 12:07 p.m., a nursing assistant entered the room to get the resident up for lunch and stated he had not been in the room since he assisted her to lie down after breakfast. The nursing assistant said the resident sometimes could turn herself unless she was tired, and he could not identify whether she should have been repositioned after two hours in bed. An RN stated the nursing assistants had a clipboard list of residents requiring turning and repositioning every two hours, and the DON stated the resident was on a turn and reposition schedule because staff had communicated her care needs had increased.
Failure to Complete Trauma-Informed Assessment and Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to complete a comprehensive trauma-informed assessment for a resident with a diagnosis of PTSD to identify and address potential triggers. The resident’s CAA documented a history of abuse from past boyfriends/husbands, emotional abuse from parents, dyslexia, and prior counseling that helped with self-worth and assertiveness. The resident also reported wanting contact with a childhood friend in Mexico City and stated things had been going well, but the CAM/PHQ-2 to 9/PHQ-9-OV/Trauma observation did not include the trauma symptoms and triggers section. The resident’s quarterly MDS identified moderate cognitive impairment and PTSD, but the care plan revision did not identify PTSD or interventions for known triggers. Nursing documentation and interviews showed the resident preferred staff to knock, introduce themselves, and make suggestions rather than tell her what to do; she also preferred to stay in her room and became upset when approached in a way she perceived as bossy. Staff interviews confirmed the resident had a history of abuse, but they did not know her triggers, and the DON stated the social work designee was responsible for the trauma-informed assessment and care planning. The social work designee stated the trauma-informed care assessments were done annually and did not complete the trauma symptoms and triggers section because the resident did not have PTSD when admitted, although the resident later had been diagnosed with PTSD.
Failure to Arrange Ordered WBC Lab Draw After ED Return
Penalty
Summary
The facility failed to obtain laboratory services as ordered for one resident when staff did not arrange a WBC lab draw after the resident returned from the ED. The resident had severe cognitive impairment and required maximal assistance with ADLs. Diagnoses included Alzheimer's disease, a history of TIA and stroke, heart disease, dementia, and chronic lymphocytic leukemia. The resident's care plan identified an alteration in health care status related to dementia, unstable gait, hypertension, chronic lymphocytic leukemia, osteoarthritis, and history of TIA, with goals including vital signs in acceptable range, pain controlled to mild range, and ordered labs in acceptable range. The ED provider notes stated the resident was to return to the facility and have the WBC rechecked the next day. The resident's progress notes showed the AVS from the ED visit was reviewed several days later, and the instructions to check a WBC were noted at that time. When the laboratory department was contacted, it reported that no lab draw had been performed on the ordered date. Interviews with nursing staff indicated the charge nurse on the resident's unit was responsible for checking orders after return from an appointment, hospital, or ED, and another nurse was to recheck completed orders. Staff stated the nurse who reviewed the AVS missed the lab order and did not call it into the lab.
Failure to Follow Antibiotic Stewardship and UTI Reassessment Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocols for a resident with severe cognitive impairment, frequent bowel and bladder incontinence, and diagnoses including Alzheimer’s disease, dementia, abnormal gait and mobility, history of TIA/stroke, and heart disease. The resident’s care plan identified substantial assistance needs for toileting hygiene, bathing, dressing, and other functional abilities, with dependence for most activities and assistance with peri care due to incontinence. The resident received repeated antibiotic treatment for suspected urinary tract infections, including cephalexin, Rocephin, and nitrofurantoin, with one antibiotic later changed because the resident required medications to be crushed and nitrofurantoin could not be crushed. Progress notes documented lethargy, a low-grade temperature, elevated pulse, rhonchi, and an ED return with acute cystitis, followed by additional treatment for cystitis/UTI. The record also noted completion of antibiotic courses and denial of pain or burning, but the medical record lacked further urinalysis or culture results despite three courses of antibiotics during the reviewed period. The facility’s UTI SBAR process required nurses to document vital signs and urinary symptoms, and the antibiotic stewardship policy required use of Loeb criteria, reassessment at 72 hours after antibiotic initiation, and documentation of the antibiotic time-out in the resident record. During interview, the DON stated the consultant pharmacist was responsible for the antibiotic stewardship program, but the pharmacist was unavailable. Staff described an informal process of pushing fluids, monitoring, and notifying the physician quickly, and the RN stated the provider did not feel additional labs were needed and did not want a urinalysis or culture. The DON could not provide the SBAR communication forms sent to the PCP, and the record lacked documented 72-hour reassessments evaluating the continued need, duration, and selection of antibiotic therapy.
Failure to Use Gait Belt During Ambulation Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to use a transfer (gait) belt during ambulation for a resident identified as being at risk for falls. The resident, who was blind and had diagnoses including type 2 diabetes and hypertension, required partial to moderate assistance for walking and was care planned for contact guard assist (CGA) or stand by assist (SBA) with one staff for all mobility. Documentation and care plans indicated that a gait belt was to be used during ambulation, particularly when walking to dine. On the day of the incident, the resident was ambulating in a hallway with a cane and a nursing assistant providing SBA. The resident lost balance and fell, landing on her left side and sustaining a left arm fracture. Multiple staff interviews and a review of surveillance video confirmed that the resident was not wearing a gait belt and the nursing assistant was not in close proximity at the time of the fall, contrary to care plan directives and facility expectations. Staff interviews revealed confusion regarding the meaning of CGA and SBA, and it was acknowledged that a gait belt should have been used for safety. The facility's fall prevention policy outlined universal fall precautions and the need for individualized care plans for residents at risk of falls, but did not specifically direct staff to use a gait belt with all transfers or ambulation. The lack of adherence to the care plan and failure to use a gait belt directly contributed to the resident's fall and subsequent injury.
Failure to Maintain Signed Advanced Directive for DNR Status
Penalty
Summary
The facility failed to ensure that a signed copy of an advanced directive, specifically indicating whether to perform cardiopulmonary resuscitation (CPR) or to implement a do not resuscitate (DNR) order, was present in the medical record for one resident. Documentation including the resident's face sheet, care plan, and admission checklist identified the resident as DNR, and the resident verbally confirmed their wish for DNR status during an interview. However, the medical record did not contain a signed advanced directive by the resident or their representative and the provider. The DON confirmed that the process required a signed provider order and advanced directive upon admission, and that the resident was not listed as wanting CPR, but was unable to locate the required signed document. Additionally, a policy related to advanced directives was requested but not provided.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident with attached bed rails was comprehensively assessed for their use. The resident in question had no cognitive impairment and was independent with bed mobility and transfers, according to the quarterly Minimum Data Set (MDS), which also indicated that bed rails were not used. However, observations on two separate occasions showed that the resident had half bed rails up and locked on both sides of the upper half of the bed. The resident reported using the rails to reposition and assist with getting out of bed, and stated that the rails did not restrain movement. A review of the resident's medical record revealed a lack of assessment regarding entrapment risk, risk versus benefits, informed consent, bed dimensions in relation to the resident's height and weight, and documentation of alternatives attempted or contraindicated before installation. Interviews with facility staff, including the MDS coordinator and the DON, confirmed that no assessment was performed because the bed rails were considered adaptive equipment for mobility and transfers, not restraints. The facility's policy required documentation and assessment for bed rail use, but this was not completed in this case.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to administer insulin according to the manufacturer's instructions for a resident with diabetes. The resident, who was cognitively intact and had a diagnosis of diabetes, was prescribed Lantus and Novolog insulin at specific times throughout the day. During an observation of medication administration, the LPN prepared the Novolog insulin pen by attaching a new sterile needle but did not prime the pen with 2 units of insulin before administering the dose, as required by the manufacturer's instructions. The LPN stated she had been instructed that priming was only necessary on the initial use and had never primed the pen before subsequent injections. Further review revealed that the facility's policy, as well as the manufacturer's instructions for the insulin pen, required priming with 2 units before each injection to ensure accurate dosing. Another nurse confirmed that she always primed the pen by wasting 2 units before drawing up the prescribed dose. The director of nursing also stated that staff are instructed to always prime insulin pens prior to administration. The failure to follow these procedures resulted in the resident not receiving insulin in accordance with the manufacturer's instructions.
Failure to Provide Updated Pneumococcal Vaccine Education and Offer New Vaccines
Penalty
Summary
The facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the risks and benefits of vaccinations and did not offer the most recent pneumococcal vaccines to three out of five residents reviewed for immunizations. Specifically, the medical records for these residents did not document whether they received the Vaccine Information Statements (VIS) or education about the risks and benefits of the pneumococcal vaccine. Additionally, there was no documentation indicating that these residents were offered or had accepted or declined the newer pneumococcal vaccines (PCV20 or PCV21), despite having received earlier versions of the vaccine in previous years. Interviews with nursing staff and the Director of Nursing revealed that while vaccination status is reviewed upon admission and annually during care conferences, there was no established process to re-evaluate current residents' pneumococcal vaccination status outside of these times. The facility's standing orders and policies referenced the use of older pneumococcal vaccines and did not address the newer recommendations. As a result, the facility did not ensure that current residents were consistently offered the most up-to-date pneumococcal vaccines or provided with the latest CDC educational materials as required.
Failure to Post Daily Resident Census on Nurse Staffing Information
Penalty
Summary
The facility failed to include the daily resident census on the nurse staffing posting, as required. Observations on multiple days showed that the nurse staff posting, displayed across from the nurse's station, included the date, shift hours, and the number of RNs, LPNs, and NAs with their total and actual hours worked, but consistently omitted the daily census. Review of postings from over a month revealed that the census was missing on 37 out of 38 days. Interviews with the health unit coordinator (HUC) and the director of nursing (DON) confirmed that neither had been documenting the census on the posting, as the HUC was not trained to do so and the DON had not enforced this requirement. The census was only recorded on a white board in the nurse's area, which was not visible to residents or visitors. No nurse staff posting policy was provided upon request.
Inadequate Infection Control and Precautions in LTC Facility
Penalty
Summary
The facility failed to implement timely transmission-based precautions and testing for COVID-19 according to CDC guidelines for four residents who were displaying COVID-19 symptoms. These residents exhibited symptoms such as cough, shortness of breath, and fever, yet were not placed in isolation after initial negative antigen tests. The facility's infection control log did not specify the type of COVID-19 test used, whether confirmatory tests were conducted, or if isolation was implemented. The Director of Nursing (DON) confirmed that symptomatic residents were not placed in isolation, as the facility did not want to isolate residents based on initial negative antigen tests. Additionally, the facility failed to implement enhanced barrier precautions for a resident with an indwelling catheter. The care plan for this resident did not include instructions for using personal protective equipment (PPE) during catheter care. A nursing assistant was observed performing catheter care without wearing a gown, and the DON admitted that staff had not been instructed on enhanced barrier precautions related to catheter care. The facility's policy on catheter care did not provide specific guidance on PPE use. The facility's policies and procedures were not aligned with CDC guidelines, which recommend confirmatory testing following a negative antigen test for symptomatic individuals and the use of enhanced barrier precautions for residents with indwelling medical devices. The DON and staff were unaware of these guidelines, leading to inadequate infection prevention and control measures for both COVID-19 and catheter care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that unlicensed personnel did not administer injectable medications, which is inconsistent with state requirements. This deficiency was identified for four residents who received insulin injections. The certified clinical medical assistant (CCMA) administered insulin to these residents, despite state statutes requiring that injectable medications be administered only by licensed professionals such as physicians, physician's assistants, registered nurses, nurse practitioners, or licensed practical nurses. The CCMA believed that administering injections was within her scope of practice, as she was supervised by a registered nurse who was available in the building. Additionally, the facility failed to ensure medications were administered as ordered for three residents whose medications were omitted during medication pass. For instance, one resident's levothyroxine tablets were found in the medication cart, indicating they were not administered as signed off by the licensed practical nurse. Another resident's medication card was missing a tablet without any documentation of wastage, and a third resident's medication was not administered despite being signed off by the CCMA. These omissions were identified during observations of the medication cart and interviews with nursing staff. The facility's director of nursing acknowledged that extra or missing medications from resident medication cards constituted medication errors. The facility was aware of the issues with medication administration and was attempting to improve tracking of resident medications. The director of nursing had implemented a policy for nurses to initial and date each bubble on the medication cards when administering medications, but inconsistencies remained. The facility's policy on medication pass delivery emphasized the importance of following the six rights of medication administration, yet these standards were not consistently met.
Failure to Date Opened Eye Drops Leads to Potential Expired Medication Use
Penalty
Summary
The facility failed to ensure that prescription eye drops were dated when opened, which could lead to the administration of expired products. During an observation of the medication carts, it was found that the open vials of latanoprost for three residents did not have the date of opening recorded. This oversight was noted on one of the two medication carts reviewed. The registered nurse (RN-A) acknowledged that staff often forget to date the medications when opened, and was unsure when the eye drops had been opened, suggesting that new vials should be ordered. The director of nursing (DON) confirmed that the expectation was for staff to record open dates on medication bottles, but acknowledged that not all staff were complying with this policy. The facility had a significant number of new staff members, and efforts were being made to ensure they were properly trained. The facility's policy stated that latanoprost eye drops should be discarded 42 days after opening, and the manufacturer's guidelines indicated that once opened, the drops could be stored at room temperature for six weeks. However, the lack of recorded open dates on the medication vials meant that these guidelines could not be followed accurately.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic stewardship protocols for a resident identified as R4, who was taking an antibiotic for a urinary tract infection (UTI). The Nursing Home Infection Control Log, updated in April 2022, identified three residents diagnosed with UTIs in May 2024, including R4. However, the log did not specify the organism identified in the urine cultures. R4's medical record lacked evidence of the urine culture results to ensure the correct antibiotic was prescribed, and the facility was unable to provide a copy of these results. R4, who had a history of bladder cancer and chronic kidney disease, experienced recurring blood and blood clots in his urine. On May 3, 2024, R4 complained of pain, and a registered nurse (RN) obtained a verbal order for a urinalysis. The following day, R4 was confirmed to have a UTI, and an antibiotic, Augmentin, was prescribed and administered. However, the culture and sensitivity results, which confirmed sensitivity to Augmentin, were not documented in R4's medical record. Interviews with staff revealed gaps in the facility's processes. RN-A, who did not receive proper orientation, learned the facility's processes from travel nurses. The Director of Nursing (DON) stated that the infection control log did not include organisms due to lack of access to the clinic's electronic medical record system. The campus-wide Infection Preventionist (IP) followed the urine culture results but did not share them with the DON. The facility's Antibiotic Stewardship Policy, reviewed in February 2023, outlined the need for tracking and documenting antibiotic use, but these procedures were not followed in R4's case.
Resident Privacy Violation Due to Staff Inaction
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident, identified as R19, who was observed exposed from the hallway. R19, who had severe cognitive impairment and diagnoses including Alzheimer's disease and anxiety, was dependent on staff for all abilities. The care plan for R19 did not include measures to maintain his privacy. During an observation, R19 was seen lying in bed with his room door wide open, and his back, legs, and incontinent brief were visible due to bunched-up blankets and gown. Multiple staff members, including nursing assistants, walked past R19's room without addressing his exposure, although one eventually covered him after a delay. Interviews with staff revealed that it was expected for staff to check on residents and ensure their privacy by covering them if exposed. However, staff admitted to being preoccupied with other tasks or not noticing R19's condition. The Director of Nursing acknowledged the importance of care planning interventions to prevent such exposure and stated that staff had been educated on maintaining resident privacy. The facility's Quality of Life policy emphasized the importance of maintaining resident dignity and privacy, including keeping residents covered when outside their rooms.
Inappropriate Use of Recliner as Restraint for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was free from physical restraints. R13, who had severe cognitive impairment and exhibited wandering behaviors, was observed being placed into a recliner by a nursing assistant (NA-C) without consent. NA-C removed R13's wheelchair out of reach, effectively using the recliner as a restraint to prevent R13 from wandering. This action was witnessed by a registered nurse (RN-A) and was reported to the director of nursing (DON). The incident was corroborated by video surveillance, which showed NA-C placing R13 in a recliner and moving the wheelchair away, preventing R13 from self-transferring. Despite the facility's policy to keep residents restraint-free, staff, including NA-C, admitted to routinely placing wandering residents in recliners to prevent them from entering other residents' rooms. The DON acknowledged that moving the wheelchair out of reach constituted a restraint. Interviews with staff revealed a misunderstanding or disregard for the facility's restraint policy. The DON initially did not consider the recliner as a restraint and did not review the surveillance footage until later. The facility's policy defined physical restraints as any item that confined a person, including recliners, if the resident could not remove themselves independently. This incident highlighted a failure to adhere to the policy, resulting in the inappropriate use of a recliner as a restraint for R13.
Failure to Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of rough treatment and the use of a recliner as a restraint for a resident identified as R13. R13, who had severe cognitive impairment and exhibited wandering behaviors, was reportedly handled roughly by nursing assistant NA-C. NA-C was observed grabbing R13 by the underarms and placing her into a recliner against her will, with the intent to prevent her from wandering. Despite witnessing the incident, RN-A did not ensure the incident was reported to the appropriate authorities, and the Director of Nursing (DON) did not investigate further, believing it to be a personal issue between staff members. Additionally, the facility failed to report an injury of unknown origin for another resident, R4, who had severe cognitive impairment and was at risk for pressure ulcers. R4 was found to have a skin tear in a sensitive area, which was not documented thoroughly in the medical record. The DON acknowledged that the injury should have been reported as it was in a suspicious location and the resident could not explain how it occurred. However, the injury was not reported to the State Agency as required by the facility's policy. The facility's policy on abuse, neglect, and injuries of unknown origin mandates immediate reporting of such incidents to the administrator and the Minnesota Department of Health. Despite this policy, the incidents involving R13 and R4 were not reported in a timely manner, highlighting a failure in the facility's adherence to its own procedures for ensuring resident safety and compliance with federal and state laws.
Failure to Investigate Allegations of Rough Treatment and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of rough treatment and the use of a recliner as a restraint for a resident with severe cognitive impairment. The incident involved a nursing assistant (NA-C) who was observed placing the resident into a recliner against her will to prevent wandering, which was witnessed by a registered nurse (RN-A). Despite RN-A's concerns and communication with the Director of Nursing (DON), no immediate investigation was initiated, and NA-C continued to work without any intervention. The facility did not review available video surveillance that captured the incident, which showed NA-C handling the resident roughly and not using proper transfer techniques. Additionally, the facility failed to report and investigate an injury of unknown origin for another resident who had a severe cognitive impairment. The resident was found to have a significant skin tear in a sensitive area, which was not documented or explained in the medical records. The injury was discovered during routine care, and staff were unable to determine how or when it occurred. The facility's policy required such injuries to be reported and investigated, but this was not done. The facility's lack of action in both cases violated its own policies on abuse and injury investigation. There was no evidence of staff interviews or protective measures taken for the residents involved. The DON acknowledged the oversight and the need for an investigation but failed to act promptly, leaving the residents without the necessary protection and care.
Failure to Address Skin Tear in Resident with Cognitive Impairment
Penalty
Summary
The facility failed to properly identify, assess, and implement interventions to promote skin integrity and healing for a resident with a skin tear on the scrotum. The resident, who had severe cognitive impairment and a diagnosis of bladder cancer, was at risk for pressure ulcers and frequently incontinent. Despite these risks, the care plan and interventions were not adequately followed or updated to address the resident's skin condition. Observations revealed that the resident was transferred using a standing lift, during which the removal of a soaked incontinent brief caused discomfort and potentially contributed to the skin tear. The brief was soaked with bloody urine and blood clots, which may have obscured the presence of the skin tear. Staff members, including nursing assistants and a licensed practical nurse, were unaware of the skin tear's existence or its cause, and the resident's medical record lacked comprehensive documentation of the injury. Interviews with staff indicated a lack of communication and follow-through regarding the resident's wound care. The Director of Nursing acknowledged that the incident slipped through the cracks, and the resident was not added to wound rounds or provided with appropriate interventions. The facility's Skin Breakdown Prevention Protocol was not adhered to, as weekly skin checks and documentation were not consistently performed, leading to the oversight of the resident's skin tear and inadequate care planning.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement appropriate interventions for preventing pressure ulcers for a resident identified as being at risk. The resident, who had severe cognitive impairment and conditions including hemiplegia and Alzheimer's disease, was noted to have a healing unstageable pressure injury on the left heel. Despite the care plan directing staff to use heel protectors while the resident was in bed, observations revealed that the resident was wearing fuzzy slippers instead of the prescribed heel protectors. Additionally, the resident's heels were observed resting on the mattress rather than being offloaded with a pillow as required. Staff interviews confirmed that the fuzzy slippers were incorrectly used as heel protectors, and the resident's care plan was not consistently followed. The LPN acknowledged that the resident should always wear heel protectors in bed to maintain skin integrity, especially given the resident's limited mobility. The director of nursing emphasized the importance of adhering to the care plan to prevent the recurrence of pressure injuries. A policy on pressure ulcer care and interventions was requested but not provided, indicating a potential gap in the facility's documentation and adherence to care protocols.
Deficiencies in Resident Transfer and Supervision Practices
Penalty
Summary
The facility failed to ensure safe resident transfer practices for a resident with severe cognitive impairment, identified as R13. The incident involved a nursing assistant, NA-C, who improperly transferred R13 by lifting her under the arms and placing her into a recliner against her will. This action was taken to prevent R13 from wandering in her wheelchair, which was used as a restraint. The transfer was conducted without the use of a gait belt, and the wheelchair brakes were not locked, posing a risk of falls. The incident was witnessed by RN-A, who intervened by asking another nursing assistant, NA-D, to transfer R13 back to her wheelchair. However, NA-C, visibly upset, proceeded to transfer R13 back to her wheelchair without proper technique, dragging R13's feet on the floor. The facility also failed to provide a safe environment and adequate supervision for a resident identified as R19, who had severe cognitive impairment and a history of wandering. R19 was observed moving aimlessly in his wheelchair in the common area, coming into close contact with a family member, FM-A, who had to push R19 away multiple times. Staff did not intervene during these interactions, and R19's movements were not redirected to prevent potential harm. Observations showed that R19's wheelchair bumped into furniture and other residents, yet staff did not take action to ensure R19's safety or the safety of others. The facility's policies on safe lifting and movement of residents, as well as elopement and wandering, were not adequately followed. The policy on safe lifting did not specify when gait belts should be used, and the wandering policy did not address maintaining safety for wandering residents within the facility. The Director of Nursing acknowledged the deficiencies, noting that staff failed to communicate effectively and did not intervene appropriately to safeguard the residents involved.
Failure to Follow Dementia Care Plan Leads to Resident Agitation
Penalty
Summary
The facility failed to provide appropriate dementia care interventions for a resident diagnosed with Alzheimer's disease and dementia with behavioral disturbances. The resident, identified as having moderate cognitive impairment, required assistance with daily activities and had a history of agitation and aggression, particularly when personal items were removed from his sight. The care plan for the resident included specific interventions to manage these behaviors, such as keeping the resident in line of sight when out of his room and removing items only when he was not present to prevent agitation. However, these interventions were not followed during an incident where a nursing assistant attempted to remove a banana from the resident's wheelchair, leading to the resident becoming agitated and physically aggressive. The incident was captured on video surveillance, showing the nursing assistant's inappropriate approach, which escalated the situation. The nursing assistant attempted to take the banana, which the resident perceived as a threat to his personal belongings, resulting in the resident grabbing and squeezing the assistant's arm. The assistant's response, including loud verbal exchanges, further aggravated the resident. The director of nursing acknowledged that the approach was not appropriate and that the care plan's directives were not followed. The facility did not provide a policy on caring for residents with dementia when requested.
Failure to Implement Physician-Prescribed Medication Taper Order
Penalty
Summary
The facility failed to ensure that a resident's physician-prescribed medication taper order was implemented, which did not meet professional standards of quality. The resident, who was moderately cognitively impaired and had multiple diagnoses including cancer, Parkinson's disease, and diabetes mellitus, was prescribed Tramadol for chronic back pain. Despite a pharmacy consultant's recommendation to taper the Tramadol dosage to address urinary retention issues, the order was not executed. The resident's pain was identified as mild and rarely impacted his daily activities, yet the medication taper was not implemented as prescribed by the physician. The pharmacy consultant recommended a reduction in Tramadol from three times a day (TID) to twice a day (BID) to potentially alleviate urinary retention, a side effect of the medication. This recommendation was documented and signed by the physician but was not acted upon. The physician expected the order to be processed, but it was not, leading to the resident continuing on the higher dosage of Tramadol. The Director of Nursing (DON) confirmed that the signed order was not processed and attributed the delay to a system glitch and communication issues between the medical staff. Interviews with the pharmacy consultant, the physicians involved, and the DON revealed that there was a lack of follow-through on the medication taper order. The DON acknowledged that the pharmacy review forms should have been returned and acted upon more promptly. The facility's policy on medication and treatment review was not adhered to, resulting in the resident continuing to receive a medication dosage that potentially contributed to his urinary retention issues.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hallock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Karlstad Healthcare Center Inc | 23.3 mi | ★★★★★ | 7 | 0 |
| Wedgewood Manor | 31.5 mi | ★★★★★ | 9 | 0 |
| Lutheran Sunset Home | 31.7 mi | ★★★★★ | 8 | 0 |
| Lifecare Greenbush Manor | 34.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.