Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Minnewaska Community Health Services during CMS and state inspections, most recent first.
The facility failed to ensure that 13 single resident rooms on the A-wing met the required 100 sq ft of usable floor space, and 6 occupied rooms were identified as noncompliant. The DON confirmed the rooms did not meet the standard, while an RN reported no resident complaints about room size and the Administrators stated they had no requests for room moves or complaints from current residents. One resident said staff care was not inhibited by the room size, and the facility reported it had previously moved a resident to a larger room for family visiting needs.
Failure to use EBP PPE and perform hand hygiene during wound care. A resident with severe cognitive impairment, dementia, and a venous ulcer was on EBP for wounds, but RN-A did not wear a gown during wound care, the room lacked EBP signage, and hand hygiene was not performed after glove removal and before putting on new gloves. RN-A said he was unaware the resident was on EBP, and the DON confirmed gowns, gloves, signage, and hand hygiene were expected.
A resident with multiple health conditions and moderate risk for pressure ulcers developed a deep tissue injury on the sacrum. Facility staff failed to consistently monitor and document the wound daily, with incomplete records and unclear communication among nursing staff. The facility's policy required only weekly wound assessments, and there were no clear orders for daily observation or treatment, resulting in the wound being identified as severe upon hospital transfer.
Several residents with significant mobility and cognitive impairments reported being handled roughly and rushed during transfers and personal care by a nursing assistant, leading to discomfort, pain, and emotional distress. Staff interviews confirmed that the emergency button on the lift was used inappropriately to lower residents quickly, and some staff failed to report concerns about rough handling and disrespectful comments. Management was unaware of these issues until they were raised during the survey, despite facility policy requiring dignified and respectful treatment.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy between the resident's DNR wishes and the EHR indicating CPR. Staff interviews confirmed they would have followed the incorrect documentation, potentially administering unwanted CPR. The facility's policy required the POLST to be documented and reviewed, but this was not followed.
The facility was cited for deficiencies in food service and sanitation practices, including improper handling of beverages by an activities aide, unsanitary conditions of the ice and coffee machines, and failure to maintain proper food temperatures. These practices could lead to contamination and potential illness among residents.
The facility failed to submit complete and accurate staffing information to CMS for Quarter 4 due to not including contracted staff hours in their PBJ submissions. The administrator and CFO confirmed that invoices for contracted staff were received after the submission deadline, leading to inaccuracies in reported staffing levels. This affected all 30 residents in the facility.
The facility failed to maintain an effective infection control program, lacking comprehensive surveillance of resident infections and proper hand hygiene practices. The infection control log did not track necessary data such as signs, symptoms, and antibiotic usage. Additionally, nursing assistants did not sanitize their hands during water pitcher delivery, increasing the risk of infection spread.
The facility failed to provide single resident rooms with at least 100 square feet of usable floor space for 10 residents on the A-wing. The administrator confirmed the deficiency, and room measurements were provided by the maintenance director, showing rooms were less than the required size. Some residents expressed satisfaction with their room size, while others were unable to respond. No complaints were reported by staff, and the administrator planned to apply for a waiver.
A facility failed to secure cleaning chemicals, leaving them accessible to residents on the B-wing. Observations showed open doors to rooms with unsecured chemicals, including Vindicator+ and QT-TB, with no staff present. Two residents with cognitive impairments and wandering behaviors were seen near these areas. Staff interviews confirmed the expectation for doors to be closed, but the chemicals were not properly stored, posing a potential risk.
A resident with cognitive impairment and high fall risk had a call light out of reach, contrary to the care plan and facility policy. Observations and staff interviews confirmed the deficiency, highlighting a failure to ensure call light accessibility for the resident.
A resident with a history of atrial fibrillation experienced a significant medication error when Warfarin doses were missed due to a transcription error in the electronic medical record. This error led to subtherapeutic INR levels, increasing the resident's risk for blood clots. The issue was identified after several days, highlighting a lapse in medication management and monitoring.
Insufficient Room Size in A-Wing Single Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 single resident rooms on the A-wing had at least 100 square feet of usable floor space for 6 residents who were occupying those rooms, including A24, A25, A27, A33, A35, and A36. During the entrance conference, the DON confirmed the rooms in hallway A did not meet the required square footage. During the initial screening on the A-wing, those rooms were observed to be occupied by residents. In interviews, one resident stated that staff care was not inhibited by the room size, and an RN reported she was not aware of any resident complaints related to room size. The Administrators stated they had no requests for room moves or complaints that rooms were too small from current residents, and they reported they would accommodate any resident request for more space as allowed. The facility also reported that it had previously moved a resident to a larger room at family request so a large family could visit together. A policy on room size was requested but not received.
Failure to Use EBP PPE and Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure appropriate PPE was worn for enhanced barrier precautions and failed to ensure proper hand hygiene during wound care for a resident with severe cognitive impairment, dementia, arthritis, and a psychotic disorder. The resident required assistance with ADLs and had a venous ulcer with non-surgical dressings and ointments or medications other than to feet. The care plan revised 11/10/25 identified the resident required enhanced barrier precautions related to wounds, with gowns and gloves to be worn during high-contact care activities and signage posted to notify staff of the need for EBP. During observation, the resident was seated in a wheelchair outside the room, and the room did not have signage indicating EBP. PPE supplies were stored in a dresser at the end of the hallway, and there was no trash can placed by the doorway. During wound care, RN-A entered the room, washed hands, applied a mask and gloves, removed the dressings from the resident’s left foot, and cleaned the wounds. RN-A removed and reapplied gloves multiple times while continuing wound care, but did not apply a gown for EBP and did not perform hand hygiene after removing gloves and before putting on new gloves. RN-A later stated he was unaware the resident was on EBP and said he should have checked the care plan before wound care. He also verified he had not completed hand hygiene after removing gloves and before applying new gloves. The DON confirmed the resident was on EBP, stated gowns and gloves were expected during personal cares and wound cares, confirmed the resident did not have a purple star posted until later that day, and stated hand hygiene was expected after glove removal and before donning new gloves. Facility policies for EBP, hand hygiene, and clean dressing changes also required hand hygiene, glove use, gown availability near the room, and signage to identify residents on EBP.
Failure to Provide Daily Monitoring and Assessment of Pressure Ulcer
Penalty
Summary
The facility failed to implement daily monitoring and assessment of a deep tissue injury for a resident who was at moderate risk for pressure ulcers. The resident had multiple diagnoses, including diabetes mellitus and a history of stroke, and required significant assistance with activities of daily living. Upon admission, the resident had no unhealed pressure ulcers, and care plans identified interventions such as regular repositioning, use of pressure-relieving devices, and weekly skin assessments. However, after a pressure wound was identified on the sacrum, documentation showed inconsistent and incomplete monitoring, with several entries lacking details on the wound's condition, such as pain, size, drainage, and tissue description. Nursing staff interviews revealed confusion and lack of clarity regarding the assessment and documentation of the pressure ulcer. Some staff were unaware of the wound, while others could not recall or describe its characteristics. There were no clear orders for daily wound observation or treatment, and the wound was not consistently evaluated or documented each day. The facility's policy required weekly wound assessments but did not specify daily monitoring for existing pressure ulcers, contributing to the lack of consistent care. The resident's medical record lacked evidence of daily monitoring of the pressure ulcer, and the wound was ultimately described as a severe decubitus ulcer upon transfer to the emergency room. The deficiency was further highlighted by the absence of clear documentation and communication among staff regarding the wound's status and the lack of a specific treatment plan or daily assessment orders in the resident's records.
Failure to Ensure Dignified and Respectful Care During Transfers and Personal Care
Penalty
Summary
Multiple residents with significant physical and cognitive impairments reported being treated in a manner that lacked dignity and respect by a specific nursing assistant (NA-A) and, at times, other staff. Residents described being rushed during transfers and personal care, handled roughly, and not given adequate time to participate in their own care. Several residents recounted incidents where their bodies were bumped, pinched, or positioned improperly during transfers with mechanical lifts, resulting in discomfort, pain, and emotional distress. One resident with a history of polio and severe mobility limitations described being left alone in a lift harness, feeling like a 'horse with a harness,' and being lowered too quickly, sometimes resulting in her head being struck by the lift bar. Another resident reported embarrassment and discomfort due to improper application of incontinence briefs and insensitive comments from staff about the odor in her room. Staff interviews corroborated resident accounts, with several nursing assistants and LPNs acknowledging that NA-A worked quickly, used the emergency button on the lift inappropriately to lower residents rapidly, and sometimes failed to ensure residents' safety and comfort during transfers. Some staff admitted to witnessing or being told about rough handling, improper positioning, and lack of attention to residents' needs, but did not always report these concerns to management. There were also reports of staff making inappropriate comments about the time required to care for certain residents and expressing annoyance in front of residents. Despite multiple complaints from residents and some staff, management, including the DON and administrator, stated they were unaware of any concerns regarding inappropriate treatment by staff until the issues were brought to their attention during the survey. The facility's policy required staff to treat residents with dignity and respect, explain procedures before care, and maintain residents' quality of life, but these expectations were not consistently met, as evidenced by the repeated resident and staff reports of undignified and disrespectful care.
Discrepancy in Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately documented in the clinical record, leading to a discrepancy between the resident's wishes and the documented orders. The resident, who was cognitively impaired and had diagnoses including dementia, asthma, and hypertension, had a Physician's Order for Life-Sustaining Treatment (POLST) indicating a Do Not Resuscitate (DNR) status. However, the electronic health record (EHR) and other documentation inaccurately reflected that the resident wanted cardiopulmonary resuscitation (CPR). This discrepancy was identified through observations, interviews, and document reviews, revealing that the facility's records did not align with the resident's current wishes. Interviews with facility staff, including licensed practical nurses and registered nurses, confirmed that they would have followed the incorrect documentation in the event of an emergency, potentially administering CPR against the resident's wishes. The assistant director of nursing and director of nursing acknowledged the discrepancy and confirmed that the facility's policy was not followed, as the POLST should have been the guiding document for the resident's care preferences. The facility's policy required that the POLST be documented in the EHR and reviewed quarterly, but this was not adhered to, resulting in the potential for the resident to receive unwanted medical intervention.
Removal Plan
- All residents' records were reviewed to ensure the POLST form, the electronic medical records were updated to ensure resident's wishes for advance directives, were accurate.
- R9's EHR record was updated to match the current POLST.
- All current licensed staff were educated on the policy for advance directives, updating the POLST and the EHR to reflect the resident's wishes, as evidenced by the education sign in sheet and interviews.
- A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift, by notification of required education via phone/text. All staff would sign off once education had been completed.
- The advance directive policy was reviewed and determined no changes were required.
Deficiencies in Food Service and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food service and sanitation practices. During an observation, an activities aide was seen serving beverages without washing her hands or wearing gloves, and she handled the top rims of glasses and cups, which could lead to contamination. The aide also served uncovered desserts from a food cart, which were exposed to potential contamination as staff walked by. The assistant director of nursing confirmed that staff were expected to handle glasses by the bottom and that desserts should be covered to prevent contamination. The facility also failed to maintain the ice and coffee machines in a sanitary manner. Observations revealed a white powdery substance on the coffee machine's hot water spout and a white scaley buildup inside the ice machine's spout. The dietary manager confirmed these findings and acknowledged that there were no cleaning logs for these machines, which could lead to bacterial contamination and illness among residents. The maintenance director was unaware of the buildup and stated that dietary staff were responsible for cleaning the machines. Additionally, the facility did not maintain proper food temperatures, as evidenced by a large bin of cole slaw that was found to be at 49.5 degrees Fahrenheit, above the safe cold holding temperature. The dietary aide was unaware of the correct temperature range, and the dietary manager confirmed the lack of a policy for keeping foods cold. The Food and Drug Administration food code specifies that food should be kept out of the danger zone, which is between 40 and 140 degrees Fahrenheit, to prevent bacterial growth and foodborne illness.
Incomplete Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for Quarter 4. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Report, which showed excessively low weekend staffing. The issue arose because the facility did not include contracted staff hours in their submissions to CMS. The administrator confirmed that the contracted staff hours were not calculated into the system before submission, leading to inaccuracies in the reported staffing levels. During interviews, the administrator and chief financial officer (CFO) explained that the contracted staff hours were obtained from invoices received from the contract company. However, these invoices were received after the required submission date for the facility's PBJ information to CMS. As a result, the facility's PBJ submissions continued to be incomplete and inaccurate, as they did not include the necessary contracted staff hours. This practice had the potential to affect all 30 residents residing in the facility.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish an ongoing infection control program that included comprehensive surveillance of resident infections. The infection control surveillance log, titled Peerlytics, used by the facility from October 2024 to March 2025, was found lacking in necessary data tracking. The log only highlighted rooms with diagnosed infections but did not track signs and symptoms, culture results, or antibiotic usage. During interviews, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) admitted that the mapping document only included diagnosed illnesses and did not track other critical data. They were unaware that all signs and symptoms needed to be tracked for every resident, and the facility had not implemented a process for tracking and trending infections. Additionally, the facility failed to ensure proper hand hygiene during the delivery of water pitchers to residents. Nursing assistants were observed delivering water pitchers without sanitizing their hands before entering resident rooms or after handling used water pitchers. This practice was confirmed by the nursing assistants and verified by the ADON, who acknowledged that staff were expected to sanitize their hands to prevent the spread of germs. The facility's policy on infection control surveillance was requested but not provided, and the existing hand hygiene policy was undated, indicating a lack of proper procedural documentation.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that the 13 single resident rooms on the A-wing had at least 100 square feet of usable floor space, as required by regulations. This deficiency affected 10 residents who were currently residing in those rooms. During the entrance conference, the administrator confirmed that the rooms in hallway A did not meet the required size. Observations during the initial screening of residents on the A-wing confirmed that the rooms for the identified residents did not have the required floor space. Interviews with residents revealed mixed responses; some residents expressed satisfaction with their room size, while others were unable to respond due to their condition. Further interviews with staff, including a nursing assistant and the director of nursing, indicated that no complaints had been received regarding room sizes. The maintenance director provided room measurements, confirming that the rooms were less than 100 square feet. The administrator acknowledged the deficiency and mentioned plans to apply for a waiver. Despite the deficiency, no facility policy regarding room size was provided upon request.
Unsecured Chemicals Pose Risk to Residents
Penalty
Summary
The facility failed to ensure that cleaning chemicals were secured in a locked cabinet or cart, posing a potential risk to all residents residing on the B-wing. Observations revealed that the tub/shower room door was propped open with a trash can, and various cleaning chemicals, including Vindicator+, QT-TB, and Barrier II, were left unsecured on the floor and on carts. The storage room B-50's door was also open, with a bottle of pine liquid odor control sitting on the floor. These chemicals were accessible to residents, as no staff were present in the hallway or at the nurses' station during multiple observations. Two residents, identified as R22 and R10, were observed walking down the hallway past the open doors where the chemicals were stored. Both residents were severely cognitively impaired, with diagnoses including dementia and other conditions. Their care plans noted wandering behaviors, and they were independent with transfers and mobility, increasing the risk of them accessing the unsecured chemicals. Interviews with staff, including a nursing assistant and the director of nursing, confirmed that the doors to the rooms with chemicals were supposed to be closed at all times. However, the doors did not have locks, and the chemicals were not stored properly even when the doors were closed. The director of nursing acknowledged that having chemicals sitting out could lead to a harmful situation. The facility's policy on hazard communication emphasized the importance of securing hazardous substances to protect health and safety, but this was not adhered to in practice.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident identified as R9, who was cognitively impaired and had diagnoses including dementia, asthma, and hypertension. R9 was dependent on staff for activities of daily living such as bed mobility, toileting, and transfers. The care plan for R9, dated 1/28/25, indicated that R9 was at high risk for falls due to weakness and age-related osteoporosis, with an intervention to ensure the call light was within reach and to encourage the resident to use it for assistance as needed. During observations on 3/23/25 and 3/24/25, R9 was seated in a stationary chair about five feet from the bed, with the call light attached to the bedrail and out of reach. Interviews with a nursing assistant and an LPN confirmed that the call light was not within R9's reach, although R9 was able to use it. The Director of Nursing also verified that the expectation was for call lights to be within reach at all times. The facility's policy on call light accessibility, revised on 10/1/24, required staff to ensure call lights were within reach during each interaction in the resident's room or bathroom.
Significant Medication Error with Warfarin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Warfarin, a blood thinner. The resident, who had a history of atrial fibrillation and other cardiovascular issues, was supposed to transition from Eliquis to Warfarin as per the cardiologist's orders. However, the orders for Warfarin were not correctly transcribed into the electronic medical record, resulting in the resident missing six doses of Warfarin 5 mg. The resident's INR levels, which are critical for monitoring the effectiveness of Warfarin, were not maintained within the therapeutic range due to these missed doses. The INR levels dropped from 2.9 to 1.2, indicating a subtherapeutic level, which increased the resident's risk for blood clots. The error was discovered when the INR clinic nurse noted the discrepancy in the medication administration record and communicated it to the facility staff. Interviews with facility staff, including the medical director, registered nurse, and director of nursing, revealed that the transcription error was not identified until several days after it occurred. The staff acknowledged that the missed doses of Warfarin were due to a transcription error in the electronic medical record, which was not corrected in a timely manner. This oversight placed the resident at an increased risk for adverse health outcomes, as the therapeutic management of their condition was compromised.
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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.
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Nursing homes near Starbuck
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenwood Village Care Center | 7.3 mi | ★★★★★ | 2 | 1 |
| West Wind Village | 19.3 mi | ★★★★★ | 4 | 0 |
| Bethany On The Lake Llc | 19.7 mi | ★★★★★ | 14 | 0 |
| Knute Nelson Care Center | 19.9 mi | ★★★★★ | 7 | 0 |
| Galeon | 25.1 mi | ★★★★★ | 7 | 0 |
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