Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Neilson Place during CMS and state inspections, most recent first.
Unclean stove and griddle surfaces were observed in 3 unit kitchenettes, with greasy buildup, charred food debris, and spattered residue on burners, splash guards, and backsplashes. In addition, an open freezer on one unit contained unlabeled frozen pasta and meat links with no dates or identifying information. The DM stated there was no cleaning schedule for the stove equipment and that opened foods should be labeled and dated.
Staff failed to use required gowns and gloves during high-contact care for residents on EBP, including G-tube medication administration, transfers, and catheter care. An RN, NAs, and an NA all performed direct care without the required gown, and staff gave conflicting accounts about whether one resident was still on EBP. The facility also delayed airborne/contact precautions for a resident with COVID-19 symptoms, and the resident was later seen eating in the dining room with two other residents before isolation was started.
A resident with severe cognitive impairment and total ADL dependence was given Seroquel for dementia-related behaviors and sleep without evidence of a comprehensive assessment or documented non-pharmacological interventions before initiation. The chart showed limited behavior incidents, and staff interviews indicated the resident was no longer wandering, had declined significantly, and did not appear to have the behaviors listed as the reason for the antipsychotic. The DON stated other interventions for sleep should have been tried before starting the medication.
A resident with Alzheimer's disease and heart disease had documented changes in ADL status, including new dependence with dressing and toileting and ambulation no longer attempted. The RN and DON stated a SCSA should have been completed when the resident declined in ADLs, but the quarterly MDS was not completed as a significant change assessment despite the new functional decline.
A resident with severe cognitive impairment, dementia, and fall risk had a care plan directing that wheelchair footrests be used only for transport. Staff repeatedly left the footrests attached while the resident sat at the dining table, and one NA stated she always left them on unless the resident was transferred. An RN stated the footrests should have been removed and placed in the bag on the back of the wheelchair, and the DON stated staff were expected to follow care plans.
Failure to provide toileting assistance and nail care for dependent residents. One resident with dementia and incontinence was not toileted during morning cares despite a care plan directing toileting before and after meals and at bedtime, and the resident later voided immediately after being placed on the toilet. Another resident with dementia, diabetes, and neurogenic bladder had long fingernails extending beyond the fingertips; the resident said the nails were too long, preferred them short, and had asked staff to trim them, but the request was not completed and the care plan lacked guidance for nail care.
A resident with Alzheimer's disease and heart disease had a care plan directing staff to ambulate her with a walker and assist of one to meals and the bathroom, but ambulation was not assigned on aide task sheets and was not documented as attempted or completed. Staff observed the resident wheeling herself to breakfast without offering ambulation assistance, and interviews showed confusion about whether she was being walked. When later offered, she was able to ambulate with a walker, gait belt, and assistance, requiring frequent verbal prompts and moderate physical assistance.
Incomplete assessment and reassessment of bed rail use: The facility failed to comprehensively assess and reassess side rail use for two residents. One resident with severe cognitive impairment and total ADL dependence had side rails in place without a documented consent or resident-specific assessment, and staff did not use the rails during care. Another resident’s side rail form listed boundary limitations and family request, but did not document alternatives tried or resident-specific factors, and staff observed the resident not using the rails for bed mobility.
A resident with dementia and a history of falls was left unsupervised in a wheelchair with foot pedals attached, contrary to her care plan. Staff interviews and documentation confirmed that the foot pedals should have been removed when not transporting her, as she was prone to attempting to stand independently. The resident fell and sustained a right femoral fracture requiring surgery.
A deficiency was cited when a resident was not protected from separation from others, their room, or confinement to their room, as required by regulations. The report does not provide further details about the circumstances or the individuals involved.
A nurse used shared glucometers to check blood sugar for multiple residents with diabetes without cleaning the devices between uses, despite facility policy and training requiring disinfection after each use. Disinfectant wipes were not available on the medication cart, and the nurse reported not being instructed to clean the glucometers. The infection preventionist confirmed that each resident should have an assigned glucometer and that cleaning is required after every use.
A resident with multiple health issues, including mild cognitive impairment, experienced a deteriorating skin condition due to the facility's failure to implement care plan interventions for refusal of care. Despite directives to document refusals and re-approach the resident, staff inconsistently followed these guidelines, and the resident's POA was not contacted as instructed. This led to the resident remaining in soiled briefs for extended periods, exacerbating skin issues.
A resident with multiple health issues, including mild cognitive impairment, experienced worsening skin conditions due to inadequate toileting and hygiene care. Despite a care plan requiring substantial assistance, the resident was often left in soiled briefs, leading to significant skin issues. Staff interviews revealed inconsistent care and failure to follow facility policy on refusal of treatment, resulting in the need for physician-ordered treatment.
A resident with impaired mobility and a care plan requiring a gait belt for ambulation fell and sustained bilateral sacral fractures when staff failed to use the gait belt. The incident occurred as the resident reached for a pen, causing the walker to fall forward. Staff interviews confirmed the care plan was not followed, and the facility's policy on gait belt use was not adhered to.
The facility failed to maintain sanitary conditions in the kitchen, affecting all residents receiving food. An industrial mixer was found with food debris, and the ice and water dispenser had a black substance in the spout. Staff were unclear about cleaning procedures, and dietary aides were observed not wearing hairnets while preparing food, violating facility policy and FDA guidelines.
The facility failed to implement an effective infection control plan, as evidenced by inadequate tracking of residents with diarrhea and lack of infection analysis. Staff did not adhere to enhanced barrier precautions for residents with medical devices, and during a COVID-19 outbreak, a dietary aide was observed not wearing a mask properly while serving food. These deficiencies highlight lapses in infection prevention and control measures.
A resident with a history of stroke and hemiplegia, dependent on staff for care, did not receive routine oral care and shaving assistance as required. Observations revealed the resident was unshaven, and staff failed to offer necessary grooming services during morning care. Interviews with staff confirmed that these services should have been provided according to facility policy.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss over several months without comprehensive dietary assessments or interventions. The facility's staff failed to consistently monitor and evaluate the resident's weight, and there was a lack of communication with the medical provider regarding significant weight changes. The facility's policy required dietary assessments on admission and quarterly, but these were not completed, contributing to the deficiency in care.
The facility did not consistently post daily nurse staffing information, affecting transparency for residents, staff, and visitors. An outdated staffing document was observed, and the responsible staff member acknowledged the oversight. The DON and Administrator confirmed the expectation for daily updates, but a policy was not provided.
A facility failed to ensure a consulting pharmacist identified the need for a gradual dose reduction (GDR) or provided medical justification for a resident's continued use of antipsychotic medication. The resident, with severe cognitive impairment and multiple diagnoses, received daily olanzapine without documented GDR attempts or contraindications. Despite monthly pharmacy reviews, no irregularities were noted, and staff interviews revealed an expectation for the pharmacist to recommend a GDR, which was not done.
A facility failed to attempt a gradual dose reduction (GDR) or provide medical justification for a resident receiving daily olanzapine for bipolar disorder. Despite severe cognitive impairment and multiple diagnoses, there was no documentation of GDR attempts or justification. Staff interviews revealed reliance on pharmacist recommendations, which were not made, and a lack of communication regarding GDR. The facility's policy required annual GDR consideration, which was not followed.
Two residents in an LTC facility experienced medication administration errors, resulting in a 6.9% error rate. One resident received an incorrect dose of Voltaren gel due to a lack of dosing instructions, while another resident was initially given only one vitamin D3 tablet instead of two. The facility's policy did not specify how to administer topical medications per manufacturer's instructions.
The facility failed to serve the correct diet texture to a resident with Alzheimer's, risking choking, and did not accommodate another resident's vegetarian diet preferences, leading to inadequate protein intake. Staff did not consistently follow dietary orders, as confirmed by interviews with facility personnel.
A facility failed to offer and educate a resident with severe cognitive impairment on the risks and benefits of immunizations, as per CDC guidance. The resident's medical record lacked evidence of being offered the most recent COVID-19 booster, annual influenza, and pneumococcal vaccinations. The LPN responsible for infection prevention admitted to missing the opportunity to provide these immunizations and the necessary education and consent documentation, contrary to the facility's policy.
A resident with a documented DNR status was subjected to CPR due to a failure in verifying code status. Despite multiple staff members questioning the decision, the DON relied on an outdated paper chart indicating full code, leading to unwanted medical interventions. The incident highlights a deficiency in the facility's handling of advance directives and emergency response protocols.
A resident with dementia and diabetes exhibited food-seeking behaviors, such as taking snacks from the kitchen, which were not addressed in their care plan. Despite staff and family concerns about the impact on the resident's health, the facility failed to implement effective interventions. The care plan lacked specific strategies to manage these behaviors, and attempts to secure the kitchen were insufficient.
The facility failed to administer insulin and perform blood sugar checks timely for three diabetic residents, leading to significant medication errors. Staff interviews revealed a lack of adherence to protocols, with blood sugar checks and insulin doses often administered late. The Director of Nursing confirmed the expectation for timely administration, but staff did not complete medication error reports, contributing to the issue.
Unclean kitchenette cooking equipment and improperly stored frozen foods
Penalty
Summary
Food service equipment in 3 of 4 facility kitchenettes was not kept in a clean and sanitary condition. On 3/3/26, lunch service was observed on one unit while a dietary aide served residents. The unit’s stove and attached griddle appeared dirty, with greasy buildup, charred food bits around the burners and base, and a thick dark substance on the griddle splash guard. During a later tour of the facility kitchenettes, similar conditions were observed on the stoves and griddles in the Strawberry, [NAME], and Elderberry units, including black and greasy buildup on the stove tops, between burners, on the splash guards, and on the backsplashes. The dietary manager stated there was no cleaning schedule for maintenance cleaning of the equipment such as the stove and that the current daily cleaning schedule did not include the stove top, griddle, and splash guards. The Strawberry unit freezer also contained improperly stored frozen food items. An opened bag of cooked frozen pasta was found on the bottom shelf with ice coating many of the noodles, and the bag was clear, unmarked, and had no expiration date or date opened. Another clear bag contained half-used open meat links and also lacked identifying information, expiration date, or date opened. The dietary manager stated the food should be labeled and dated so staff would know what it was and when it could no longer be used, and removed both bags from the freezer and discarded them. The facility policy General Sanitation-Food and Nutrition dated 6/27/25 stated food contact surfaces were to be washed, rinsed, and sanitized after each use and when moving between foods, and that non-removable parts of fixed equipment were to be cleaned with detergent and hot water, rinsed, air dried, and sanitized. The Food Supply Storage policy dated 3/7/25 stated opened or prepared foods were to be placed in an enclosed container, dated, labeled, and stored properly.
Failure to Use Required PPE and Delay in Isolation Precautions
Penalty
Summary
The facility failed to ensure staff used the required PPE during enhanced barrier precautions for three residents. One resident had severe cognitive impairment, traumatic brain dysfunction, quadriplegia, seizure disorder, and a feeding tube. The resident’s care plan required enhanced barrier precautions because of the G-tube, and PPE was available outside the room. During an observation, an RN entered the room to administer G-tube medications wearing gloves but no gown while touching the resident, the bed, and belongings. The RN later stated a gown should have been worn, and the IP stated gowns and gloves were expected for high-contact care, including contact with the resident or belongings. A second resident had diagnoses including heart failure, COPD, morbid obesity, and a history of C. diff. The resident’s care sheet did not identify enhanced barrier precautions, and the care plan did not identify them either. During an observation, an EBP sign and PPE cart were outside the room, but two nursing assistants transferred the resident from a recliner to bed and provided morning care without gowns or gloves. One assistant later stated the resident was no longer on EBP, while another stated staff should have worn gowns and gloves and that she did not know the resident was on EBP. An LPN stated the resident was on EBP due to a history of C. diff and staff were expected to wear gowns, gloves, and a mask if needed during personal care. A third resident had cognitive impairment, diabetes, urinary retention, and an indwelling Foley catheter. The care plan required staff assistance for catheter care and required PPE, including gowns and gloves, for high-contact care such as transferring and urinary catheter care. During an observation, an NA wore gloves but no gown while transferring the resident from a wheelchair to bed and while emptying the catheter bag. The NA stated the resident was on EBP because of the catheter and acknowledged failing to wear a gown. An RN, an LPN, and the DON stated residents with catheters were placed on EBP and staff were to wear gowns and gloves during transfers and catheter care. The facility also failed to implement timely airborne precautions for a resident with COVID-19. The resident had moderate cognition and diagnoses including chronic kidney disease, adult failure to thrive, and dementia. The care plan identified airborne with contact precautions and required gown, gloves, N95 respirator, and eye protection. The resident had nasal congestion, a respiratory panel was ordered, and airborne/contact precautions were noted as initiated in a progress note. However, staff interviews indicated the resident was not immediately placed in isolation after symptoms were identified, and the resident was later observed eating in the dining room with two other residents before precautions were implemented. Staff stated the resident should have been placed in airborne and contact precautions immediately after symptoms were identified.
Failure to justify and document antipsychotic use before initiation
Penalty
Summary
The facility failed to ensure clinical justification and non-pharmacological interventions were used before starting an antipsychotic medication for one resident. The resident had severe cognitive impairment, was dependent on staff for all ADLs, and had diagnoses including Alzheimer's disease, failure to thrive, pneumonia, diabetes, and CHF. The resident's MDS and care plan identified psychotropic medication use and referenced behaviors such as wandering, exit seeking, and inappropriate comments, but the record lacked evidence of a comprehensive assessment documenting medical justification for Seroquel before it was initiated. The resident's medication record showed Seroquel 25 mg at bedtime was started for dementia, psychotic disturbance, mood disturbance, and anxiety, while physician notes also described the medication as being started for sleep. Review of behavior documentation from the prior three months showed only limited incidents, including two wandering episodes, two physical behavioral incidents toward others, three verbal behavioral incidents toward others, and one rejection of care. On observation, the resident was lying in bed in a hospital gown, unable to participate in dressing, transferred with a mechanical lift, made no attempt to resist care, and was unable to propel the wheelchair. Staff interviews indicated the resident was no longer wandering and had declined significantly, with several staff stating they had not seen the resident exhibit the behaviors that were listed as reasons for the medication. One RN stated the resident was not wandering now and questioned whether Seroquel was helping with lethargy and decline, while another RN stated the medication was definitely not appropriate for the resident now. The DON stated targeted behaviors and other interventions for sleep should have been implemented before starting the antipsychotic, and the facility policy required documentation of mood, symptoms, behaviors, and non-pharmacological interventions before non-emergency psychotropic medication use.
Failure to Complete Significant Change MDS for New ADL Decline
Penalty
Summary
The facility failed to ensure a significant change in status assessment (SCSA) was completed within the required timeframe for one resident, R21, to support timely person-centered care planning. R21 had diagnoses including Alzheimer's disease and heart disease. Her quarterly MDS identified setup or supervision with dressing and grooming and indicated ambulation was not attempted due to safety. An interdisciplinary assessment later noted walking was not attempted due to safety concerns, and a progress note reviewing the quarterly MDS stated R21 was coded as not applicable because she was non-ambulatory at the time. Her annual MDS identified her as independent with upper and lower extremity dressing and grooming, with ambulation listed as not applicable. Subsequent documentation showed a change in R21's condition. An interdisciplinary assessment again noted walking was not attempted, and the care plan identified a self-care deficit related to Alzheimer's disease with a goal to maintain ambulation ability. The care plan directed staff to ambulate R21 to and from meals and the bathroom with a full wheeled walker and assist of one, and to provide assist of one with dressing in the morning and evening. A later quarterly MDS identified R21 as requiring moderate assistance with upper extremity dressing and grooming, dependent with lower extremity dressing, and ambulation not applicable. During interview, the RN and DON stated a significant change MDS should have been completed when there was a decline in ADL abilities, and the RN reviewed R21's MDS and felt the quarterly should have been a significant change MDS due to the new dependence with dressing and toileting.
Wheelchair Footrests Left On Against Care Plan
Penalty
Summary
The nursing facility failed to ensure foot pedals were removed from a resident’s wheelchair as directed by the care plan for 2 of 3 residents reviewed for falls. One resident had severe cognitive impairment, dementia, and was identified on the MDS and care plan as being at risk for falls due to weakness, cognition, and a history of falls. The care plan directed that the wheelchair footrests be used only when transporting the resident, and the nurse aide care sheet also identified footrests on the wheelchair when transporting. During observation, a nursing assistant wheeled the resident to the dining room and left the footrests on while the resident remained seated at the table. The resident’s feet were up against the table pedestal, and the footrests were still attached later in the morning. One nursing assistant stated she always left the footrests on and only removed them when the resident was transferred out of the wheelchair, while an RN stated the footrests should have been removed and placed in the bag on the back of the wheelchair because the resident was more likely to try to climb over them and potentially fall. A second nursing assistant later observed the resident in the dining room with the footrests still on and stated she was unaware the footrests were to be used only for transportation; she then turned them away from the front of the resident but left them attached. The DON stated staff were expected to follow resident care plans for the safety of all residents.
Failure to Provide Toileting Assistance and Nail Care
Penalty
Summary
The facility failed to ensure routine personal hygiene cares were offered and completed for residents who were dependent on staff for those cares. One resident had severe cognitive impairment, dementia, and was dependent on staff for all care areas except eating, upper body dressing, oral hygiene, and personal hygiene. The resident’s care plan directed toileting before and after meals and at bedtime, and the nurse aide care sheet directed toileting when the resident got up, after meals, and before bed. During observation, the resident was incontinent of urine during morning cares, was not offered toileting, and was taken to breakfast. The resident remained in the dining room without toileting until later, when the nurse aide brought the resident to the bathroom and the resident immediately voided on the toilet. The nurse aide stated toileting should have been provided during morning cares, and nursing staff stated the resident was supposed to be toileted every 2 to 3 hours and that staff were expected to follow the care plan. Another resident had moderate cognitive impairment, dementia, diabetes, neurogenic bladder, and was dependent with dressing and toileting and required setup and supervision with grooming. The resident’s care plan addressed bathing but did not include guidance for fingernail care, including resident preference or how often nails should be checked or clipped. The resident’s fingernails were observed to be long, extending a centimeter or more beyond the fingertips, and the resident stated the nails were very long, preferred them short, and had asked staff days earlier to trim them. Staff had agreed but did not return to do so. A nurse aide stated aides were not allowed to trim fingernails of diabetic residents and would check whether a nurse could do it, while an LPN later stated diabetic residents’ nails were done by nurses and that staff should have trimmed the nails when requested or as soon as reasonably possible.
Failure to Provide Ordered Ambulation Assistance
Penalty
Summary
The facility failed to provide appropriate ambulation care for a resident with Alzheimer's disease and heart disease who had a care plan goal to maintain ambulation ability. The resident's quarterly MDS identified severe cognitive impairment and listed ambulation as not applicable, while interdisciplinary assessments noted walking was not attempted due to safety concerns or was not attempted. The medical record did not contain a comprehensive assessment to determine whether there were safety concerns or whether new interventions were needed, even though the care plan directed staff to ambulate the resident with a full wheeled walker and assist of one to and from meals and the bathroom. The resident's aide care plan sheet directed staff to assist with ambulation to meals and the bathroom each day, but the point of care task sheets for February and March 2026 did not include an ambulation task and no ambulation was documented as attempted or completed. During observation, the resident wheeled herself to breakfast in her wheelchair while staff present in the dining room made no attempt to stop her and offer assistance to ambulate. Staff interviews showed confusion about the resident's mobility status and whether ambulation was actually being carried out, and the DON stated the task should have been completed or at least offered to the resident. When the resident was later offered assistance, she ambulated with a wheeled walker, gait belt, and assist of one, with a wheelchair following behind, and required frequent verbal prompts and moderate physical assistance.
Incomplete assessment and reassessment of bed rail use
Penalty
Summary
The facility failed to ensure residents with side rails were comprehensively assessed before use and/or reassessed for continued use for 2 of 3 residents reviewed. R6 had a significant change MDS identifying severe cognitive impairment, total dependence for ADLs, and diagnoses including Alzheimer’s disease, failure to thrive, pneumonia, diabetes, and CHF. Although R6’s care plan directed staff to assist with turning and repositioning and to use bilateral upper bed rails, the medical record lacked a consent for bed rails and lacked an assessment addressing alternatives tried before installation, resident-specific factors, and whether the side rails remained appropriate after the resident’s condition changed. On observation, R6 was in bed with 1/4 length side rails on both sides, but staff did not prompt or assist R6 to use the rails during care. Nursing assistants stated R6 did not use the rails to turn and often pushed against them when staff rolled him, and one aide believed the rails were there for safety and to keep him from falling out of bed. An LPN stated a side rail assessment would not be completed if a patient did not have, want, or need side rails, while an RN stated the facility had stopped doing side rail assessments at one point and did not use an actual assessment form to determine whether rails were being used as a restraint. The RN and DON both stated R6 should have been reassessed when the significant change MDS was completed. R63’s admission MDS identified severe cognitive impairment, dementia, and dependence for most care, and it did not identify bed rails or restraints in use. However, a side rail assessment and consent identified R63 as using side rails for boundary limitations and family request, with top half rails on both sides used all the time. The assessment did not identify alternatives tried and failed before installation and did not include resident-specific information. During observation, staff rolled R63 for morning care without encouraging use of the side rails or placing R63’s hands on them, and staff stated R63 did not really participate. Interviews showed staff believed the rails were used because the family wanted them and to keep R63 in bed, while the DON stated side rails should not be used for boundary limitations and that R63 should have been reassessed because the resident was not using the rails for bed mobility.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned fall interventions for a resident with a history of falls, cognitive deficits, and diminished safety awareness. The resident, who had diagnoses including Alzheimer's disease, dementia, and a prior sacral fracture, was identified as high risk for falls and required specific interventions such as keeping the bed at transfer height, hourly purposeful rounding, and removal of wheelchair footrests except during transport. Despite these interventions being documented in the care plan, they were not followed on the day of the incident. On the day of the fall, the resident was found seated in her wheelchair with foot pedals attached and a blanket wrapped around her, placed there by overnight staff. Staff interviews confirmed that the foot pedals should have been removed when the resident was not being transported, as she was known to attempt to stand up independently and was not directable due to her cognitive condition. The resident was left unsupervised in a common area, and staff were occupied in other rooms when a yell and crash were heard. The resident was found on the floor against a plastic barrier, exhibiting signs of a right femoral fracture. Documentation and staff interviews indicated that the presence of the foot pedals may have contributed to the resident's fall. The care plan was not followed, as the foot pedals were not removed and adequate supervision was not provided. As a result, the resident sustained a hip fracture that required surgical intervention.
Failure to Protect Residents from Unwarranted Separation or Confinement
Penalty
Summary
A deficiency was identified regarding the protection of residents from being separated from other residents, their rooms, or being confined to their rooms. The report notes that the facility failed to ensure that each resident was protected from such separation or confinement, as required by regulations. Specific actions or inactions by staff or facility policies that led to this deficiency are not detailed in the report. No additional information about the residents involved, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Clean Shared Glucometers Between Uses
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of shared glucometers between patient use for three residents with diabetes mellitus who required regular blood glucose monitoring. Observations showed that a registered nurse used a glucometer to check blood sugar levels for multiple residents without cleaning the device between uses. Disinfectant wipes were not present on the medication cart, and the nurse confirmed during an interview that he had not been instructed to clean the glucometers between uses. The infection preventionist stated that nurses were trained to clean glucometers during orientation and that each resident should have their own assigned glucometer, but this was not being followed in practice. Facility policy required that blood glucose meters be cleaned and disinfected after each use, regardless of whether the meter was shared or assigned to a single resident. Documentation confirmed that the residents involved had orders for frequent blood glucose monitoring and that the glucometers were shared among them without proper cleaning. The failure to follow established infection control protocols was identified through observation, interview, and document review.
Failure to Implement Care Plan for Resident Refusal of Care
Penalty
Summary
The facility failed to develop and implement care planned interventions to address a resident's refusal of care, which contributed to a deteriorating skin condition. The resident, who had diagnoses including congestive heart failure, hypertension, cellulitis, and mild cognitive impairment, was identified as being at risk for skin breakdown. Despite the care plan directing staff to document refusals and re-approach the resident, staff interviews revealed inconsistencies in following these directives. The resident's power of attorney (POA) had instructed staff to call if the resident refused care, but this was not consistently done, leading to the resident sitting in soiled briefs for extended periods. The resident's condition worsened, as noted in a physician's progress note, which documented significant skin issues due to prolonged incontinence. Staff interviews indicated a lack of awareness and implementation of the care plan updates regarding the resident's refusal of care. The interim director of nursing acknowledged that interventions should have been implemented when refusals put the resident at risk. The facility's policy required individualized, comprehensive care plans, but this was not effectively executed for the resident in question.
Failure to Provide Adequate Toileting and Hygiene Care
Penalty
Summary
The facility failed to ensure proper toileting and hygiene care for a resident, resulting in a worsening skin condition that required physician-ordered treatment. The resident, who was admitted with diagnoses including congestive heart failure, hypertension, cellulitis, and mild cognitive impairment, was identified as being at risk for skin breakdown. Despite a care plan that required substantial assistance for grooming and toileting, the resident was frequently found in soiled briefs, leading to significant skin issues. Interviews with the resident's power of attorney and staff revealed that the resident often sat in soiled briefs for extended periods, sometimes up to 48 hours, without receiving necessary care. The resident's care plan directed staff to check for incontinence and reposition the resident at night, but these directives were not consistently followed. Staff interviews indicated a lack of consistent care, with some staff members marking the resident as refusing care without attempting to re-approach or notify a nurse. The resident's physician noted a rash and significant maceration in the groin area, requiring antibiotic treatment. Despite the resident's occasional refusal of care, staff failed to implement interventions or notify the physician as required by facility policy. The facility's policy on refusal of treatment was not adequately followed, as staff did not consistently document refusals or discuss the health consequences with the resident. The interim director of nursing acknowledged that interventions should have been implemented when refusals put the resident at risk.
Failure to Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to the care plan intervention for a resident who required the use of a gait belt while ambulating. The resident, who had a history of osteoarthritis, osteoporosis, and impaired mobility, was being assisted by a nursing assistant and a licensed nurse when the incident occurred. The care plan specified that the resident required assistance from one staff member using a gait belt and a walker, with a wheelchair following behind. However, during the incident, the staff did not use a gait belt, which was a critical component of the resident's care plan. The incident occurred when the resident was ambulating with staff assistance and reached for a pen at the nurse's station. The walker fell forward, causing the resident to fall on top of it, resulting in bilateral sacral fractures. Interviews with staff revealed that the nursing assistant did not use a gait belt during the ambulation, and the registered nurse confirmed that the care plan intervention was not followed. The facility's policy required the use of a gait belt for residents needing assistance with ambulation, which was not adhered to in this case. The resident's fall and subsequent injury were attributed to the staff's failure to follow the care plan, specifically the omission of the gait belt. The physical therapist highlighted the importance of the gait belt in providing stability and preventing falls. The nursing assistant involved in the incident acknowledged the oversight and received education on the proper use of gait belts and the importance of following care plans. The facility's policy clearly stated the necessity of using a gait belt for residents requiring assistance, which was not implemented during the incident.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the kitchen, which had the potential to affect all 69 residents receiving food from the kitchen. During an initial tour, a large industrial mixer was found with tan-colored food debris on the underside of the mixer head and white dust on the mixing bowl arms. This condition persisted over several days, indicating a lack of proper cleaning after each use. The administrator confirmed that staff were expected to clean kitchen equipment after every use to prevent food contamination and foodborne illness. Additionally, the facility did not ensure proper cleaning of the ice and water dispenser, as observed in the kitchenette. A black tar-like substance was found inside the spout, and there was confusion among staff about the cleaning responsibilities and procedures. The facility's policy did not specify the cleaning procedure for the mixer or the ice and water dispenser. Furthermore, dietary aides were observed not wearing hairnets while preparing food, which is against the facility's policy and the FDA Food Code. These deficiencies highlight lapses in maintaining sanitary conditions and adherence to hygiene protocols.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to develop and implement an effective infection control surveillance plan, as evidenced by the lack of documentation and monitoring of residents with potential infection symptoms. Two residents, identified as having diarrhea, were not properly tracked or reported to the infection control nurse, leading to a lack of awareness and monitoring by the infection preventionist. The facility's monthly infection control logs also failed to provide an analysis of infection patterns or interventions to reduce further incidences, particularly concerning COVID-19, pneumonia, and urinary tract infections. Additionally, the facility did not adhere to enhanced barrier precautions (EBP) for residents with wound care and indwelling medical devices. Observations revealed that staff members entered rooms of residents requiring EBP without donning the necessary personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities. This non-compliance with EBP guidelines was acknowledged by staff members, who admitted to forgetting or misunderstanding the requirements. Furthermore, during a COVID-19 outbreak, the facility failed to ensure that staff utilized masks appropriately. A dietary aide was observed not wearing a mask properly while preparing and serving food to residents, despite the facility being in outbreak status and requiring masks to be worn at all times. This lapse in mask usage was acknowledged by the staff member, who only adjusted the mask upon the approach of a state surveyor. The facility's policy on mask use during an outbreak was requested but not provided.
Failure to Provide Routine Oral Care and Shaving Assistance
Penalty
Summary
The facility failed to provide routine oral care and shaving assistance to a resident who was dependent on staff for all care activities. The resident, who was cognitively intact and had a history of stroke resulting in hemiplegia, was observed to have a self-care deficit due to left-sided hemiparesis. The care plan for the resident, revised on December 3, 2024, directed staff to assist with grooming but did not specify the frequency of shaving or oral care. During observations, the resident was found unshaven with significant beard growth, and staff did not offer shaving or oral care assistance during morning care. Interviews with nursing assistants, a registered nurse, the director of nursing, and the administrator confirmed that shaving and oral care should have been offered during care activities. The facility's policy on Activities of Daily Living, revised on December 4, 2023, stated that residents unable to perform activities of daily living should receive necessary services to maintain grooming and personal hygiene. Despite this policy, the resident did not receive the required assistance, leading to the identified deficiency.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to comprehensively assess and develop interventions to prevent continued weight loss for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's and congestive heart failure. The resident's weight was not consistently monitored or evaluated, as evidenced by the lack of completed dietary assessments at admission, quarterly, or when significant weight loss was identified. The resident experienced a notable weight loss over several months, yet there was no evidence of dietary assessments or interventions being implemented to address this issue. Staff interviews revealed that the facility had a dietician who was shared with other facilities, and documentation was often incomplete or missing. The dietician had recently been hired and was in the process of reviewing resident charts. Nursing staff were responsible for entering resident weights into the medication administration record (MAR) but failed to recognize significant weight discrepancies. The facility's policy required licensed nurses to notify the director of food and nutrition and the medical provider of any significant weight changes, but this was not consistently done. The director of nursing and other staff members acknowledged that dietary assessments should have been completed on admission and during quarterly reassessments. The facility's policy outlined the need for comprehensive assessments to ensure residents maintained acceptable nutritional status, but this was not adhered to in the case of the resident in question. The lack of timely dietary assessments and communication with the medical provider contributed to the deficiency in care for the resident experiencing weight loss.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required nurse staffing information was consistently posted on a daily basis, which had the potential to affect all 72 residents, staff, and visitors who might wish to review this information. On December 3, 2024, it was observed that the staffing information posted near the front doors was outdated, displaying information from November 26, 2024, which was seven days prior. Medical Records staff member, MR-I, who was responsible for the daily staffing posting, acknowledged the oversight and mentioned working on a system to prevent future lapses. The Director of Nursing and the Administrator both confirmed the expectation for daily updates to the staffing information to ensure transparency with staff, family, and state officials. A policy regarding the nurse staff posting was requested but not provided.
Failure to Ensure Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified the need for a gradual dose reduction (GDR) or provided medical justification for the continued use of antipsychotic medication for one resident. The resident, who had severe cognitive impairment and was receiving daily antipsychotic medication, did not have a documented attempt at GDR, nor was there any indication from the physician that a GDR was contraindicated. The resident's diagnoses included Alzheimer's, bipolar disorder, drug-induced subacute dyskinesia, heart disease, and kidney failure. Despite monthly pharmacy reviews from December 2023 to November 2024, no irregularities were identified, and there was no evidence of a GDR attempt or medical justification for the continued use of olanzapine. Interviews with facility staff revealed that the registered nurse and the director of nursing expected the consulting pharmacist to recommend a GDR for the resident's medication. The consulting pharmacist acknowledged that he should have asked the physician to review the resident's dose of olanzapine to ensure it was the minimal effective dose. The facility's policy on psychotropic medications required a GDR to be addressed annually, but this was not done for the resident in question. The administrator also expressed that he expected the consulting pharmacist to have reviewed and requested a GDR for the resident's medication.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or medically justified for a resident receiving antipsychotic medication. The resident, who had severe cognitive impairment and was diagnosed with Alzheimer's, bipolar disorder, and other health issues, was receiving olanzapine daily for bipolar disorder. Despite the requirement for GDR, there was no documentation of an attempt to reduce the dose or any medical justification for the continued use of the medication. The resident's care plan included goals for medication effectiveness and reduction in targeted behaviors, but the necessary steps for GDR were not taken. Interviews with facility staff revealed a lack of communication and follow-up regarding the GDR process. The registered nurse responsible for reviewing psychotropic medication use relied on pharmacist recommendations, which were not made in this case. The consultant pharmacist acknowledged the oversight in not recommending a GDR. The director of nursing and the facility administrator both expressed expectations that the provider should have been notified to consider a GDR. The facility's policy required annual consideration of GDR for psychotropic medications, but this was not adhered to for the resident in question.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines, resulting in a medication administration error rate of 6.9%. For one resident, who was cognitively intact and had a history of hemiplegia due to a stroke, a registered nurse applied an incorrect dose of Voltaren gel to the resident's thigh/knee, contrary to the physician's order to apply it to the back. The nurse was unaware of how to measure the correct dose and did not have access to the manufacturer's dosing chart, which had been removed from the packaging. The Director of Nursing stated that staff were expected to measure the gel per the manufacturer's instructions. Another resident, who had severe cognitive impairment and diagnoses including high blood pressure and hypokalemia, was prescribed vitamin D3 tablets. During a medication pass, a registered nurse initially dispensed only one tablet instead of the ordered two tablets. The nurse failed to cross-check the medication label with the resident's Medication Administration Record (MAR), which led to the error. The Director of Nursing and the facility's administrator both stated that they expected nurses to follow the six rights of medication administration and perform three checks to ensure accuracy, but the facility's policy did not specify how to administer topical medications per manufacturer's instructions.
Dietary Deficiencies in Meeting Resident Needs
Penalty
Summary
The facility failed to ensure the correct diet texture was served to a resident with severe cognitive impairment and Alzheimer's disease, who required a mechanically altered diet due to chewing and swallowing difficulties. The resident's dietary order specified a minced and moist texture, but during a meal service observation, the dietary aide served pork that was not minced and moist, and no sauce or gravy was added to the meal. The dietary aide admitted to relying on the kitchen for sauce availability and did not follow the dietary orders correctly, which could potentially increase the risk of choking or aspiration. Another resident, who was an ovo pescetarian with severe cognitive impairment and Type 2 diabetes, did not have their dietary preferences adequately accommodated. The resident's care plan and physician orders specified a regular vegetarian diet with specific food preferences, but during meal service, the dietary aide did not consult the dietary orders and served the resident vegetables without protein. The family member expressed concerns about the resident not receiving adequate protein, and the registered dietitian confirmed that the resident's food choices should be followed to ensure adequate nutrition. Interviews with facility staff, including the registered dietitian, director of nursing, and administrator, revealed expectations for staff to follow dietary orders and menus to prevent risks such as choking and aspiration. However, the dietary staff did not consistently adhere to these expectations, leading to deficiencies in meeting the nutritional needs and preferences of the residents.
Failure to Offer and Educate on Immunizations
Penalty
Summary
The facility failed to offer and provide education on the risks versus benefits of receiving or declining immunizations, as per CDC guidance, for one resident reviewed for immunizations. The resident, who was 38 years old with severe cognitive impairment and a diagnosis of malignant neoplasm of the prostate, had an immunization record indicating previous COVID-19 and pneumococcal vaccinations. However, the medical record lacked evidence that the most recent COVID-19 booster, annual influenza, and pneumococcal vaccinations were offered or that the resident or their representative was educated on the risks and benefits of these vaccinations. During an interview, the LPN responsible for infection prevention acknowledged missing the opportunity to offer these immunizations and provide the necessary education and consent documentation. The facility's policy required that immunizations be reviewed upon admission and regularly, with education and consent documented. The Director of Nursing expected adherence to this policy, but the deficiency occurred due to the failure to follow these procedures, resulting in the resident not being offered the necessary immunizations and education.
Failure to Honor Resident's DNR Status
Penalty
Summary
The facility failed to immediately identify and act on a resident's code status, resulting in the initiation of cardiopulmonary resuscitation (CPR) against the resident's wishes. The incident involved a resident who was found in distress in the common area, exhibiting symptoms such as pale skin, blue lips, and difficulty speaking. Despite the resident's documented Do Not Resuscitate (DNR) status, CPR was initiated, leading to the resident being sent to the hospital and requiring mechanical ventilation. The deficiency arose from a lack of clear communication and verification of the resident's code status. The resident's advance directive indicated a DNR status, which was also reflected in the electronic medical record and discussed during a care conference attended by the Director of Nursing (DON). However, during the emergency, the DON relied on an outdated paper chart that incorrectly indicated a full code status, leading to the initiation of CPR despite multiple staff members questioning the decision and the availability of correct information in the electronic record. Interviews with staff revealed confusion and inconsistency in accessing and verifying code status information. The DON, despite being aware of the resident's DNR status from previous discussions, failed to verify the information in the electronic record and insisted on CPR based on the incorrect paper chart. This miscommunication and failure to follow proper procedures resulted in the resident undergoing unwanted medical interventions, highlighting a significant deficiency in the facility's handling of advance directives and emergency response protocols.
Removal Plan
- Reviewed policy for advance directives
- Educated staff to the policy and procedure for verification of advance directives
- Initiated use of a binder for verification of code status
- Implemented an audit process to ensure accuracy
Failure to Address Food-Seeking Behaviors in Resident with Diabetes
Penalty
Summary
The facility failed to develop a comprehensive care plan with person-centered interventions for a resident with food-seeking behaviors, despite the resident's diagnosis of dementia and type 2 diabetes mellitus with hyperglycemia. The resident exhibited behaviors such as taking food and beverages from the kitchen without permission, which were not addressed in the care plan. The care plan only included monitoring blood glucose levels and signs of hyperglycemia but lacked specific interventions to manage the resident's food-seeking behaviors. The resident's behaviors were documented multiple times, including taking milk, Boost shakes, and other snacks from the kitchen. Staff and family members expressed concerns about the impact of these behaviors on the resident's blood sugar and potassium levels. Despite these concerns being raised at care conferences and with facility management, the care plan was not updated to include interventions to address the resident's behaviors. Interviews with staff revealed that the resident's behaviors had been ongoing since admission, and various attempts to secure the kitchen and restrict access to snacks were made. However, these measures were not effective, and the resident continued to access food and beverages. The facility's policy on behavioral causes and interventions was not effectively implemented, as there was no evidence of staff guidance or communication of appropriate interventions to prevent or decrease the resident's behaviors.
Failure in Timely Insulin Administration for Diabetic Residents
Penalty
Summary
The facility failed to ensure timely blood sugar checks and insulin administration for three residents diagnosed with diabetes. Resident 1, who also had dementia, experienced late blood glucose monitoring and insulin administration multiple times throughout June 2024. Similarly, Resident 2 and Resident 3 had their blood glucose checks and insulin doses administered late on numerous occasions during the same period. These delays were not in accordance with the physician's orders, which specified specific times for these procedures. Interviews with staff revealed a lack of adherence to the expected protocol for blood sugar monitoring and insulin administration. A family member of Resident 1 noticed the discrepancies in insulin administration timing, and staff members, including registered nurses and a nurse practitioner, acknowledged the issue. They expressed concerns about the accuracy of blood sugar readings and the subsequent insulin administration when not performed as ordered. The staff admitted to not completing medication error reports, which would have helped track and address these issues. The Director of Nursing confirmed that staff were expected to perform blood sugar checks and administer insulin before meals or within a short time frame after meals. The facility's policy on medication errors required prompt reporting and documentation of any deviations from prescribed orders. However, the staff's failure to follow these procedures resulted in significant medication errors, as defined by the facility's policy, due to the late administration of insulin and blood sugar checks.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 39 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 Bemidji
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Havenwood Care Center | 1.4 mi | ★★★★★ | 18 | 0 |
| Good Samaritan Society - Blackduck | 22.3 mi | ★★★★★ | 20 | 0 |
| Cornerstone Nsg & Rehab Center | 23.3 mi | ★★★★★ | 1 | 0 |
| Jourdain Perpich Ext Care Fac | 26.5 mi | ★★★★★ | 9 | 0 |
| First Care Living Center | 39.7 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.