Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Redeemer Health Care Center during CMS and state inspections, most recent first.
The facility did not follow infection control protocols in three key areas: a resident's wheelchair had damaged armrests that could not be properly cleaned, personal laundry was transported in an uncovered cart, and transmission-based precautions were not promptly implemented for a resident with gastrointestinal symptoms. Staff interviews confirmed awareness of these lapses and the inability to maintain proper infection prevention practices.
Two residents had inaccurate medication information coded in their MDS assessments. One was incorrectly documented as receiving insulin when only Ozempic was administered, and another was coded as receiving both an antiplatelet and an anticoagulant when only aspirin was given. MDS coordinators and the DON confirmed these errors, and a facility policy on MDS was not provided when requested.
The facility did not ensure that final PASARR determinations were obtained and documented for two residents with schizoaffective disorder, despite policy requiring these approvals to be uploaded into the medical record. The process for receiving these determinations had changed, and the facility had not adapted, resulting in missing documentation.
A resident with a history of pressure ulcers and heart failure developed persistent dry, flaky skin that was not consistently treated according to physician orders. Although a topical cream was prescribed, it was often unavailable and not substituted as directed, with staff inconsistently applying alternative products and failing to document treatments or notify providers. This resulted in the resident's dry skin condition remaining unimproved over several weeks.
A resident with severe cognitive impairment and multiple complex diagnoses did not have a required quarterly care conference completed, resulting in a lack of participation by the resident and their guardian in the care planning process. The social services department did not follow up after unsuccessful attempts to contact the guardian, and the care conference was not documented as required by facility policy.
A resident with a history of DVT, PE, stroke, diabetes, and other conditions experienced an unresponsive episode that was assessed by an LPN, but the provider was not notified as required by facility policy. Staff interviews confirmed that notification and documentation should have occurred following this significant change in condition.
A resident with impaired cognition and partial natural teeth, dependent on staff for ADLs, did not receive routine oral hygiene as required by their care plan. Staff failed to document or provide oral care, with one nursing assistant incorrectly assuming the resident had no real teeth. Observation revealed poor oral condition, and the nurse manager confirmed oral care should have been provided and documented.
Staff failed to consistently perform hand hygiene and use appropriate PPE when caring for residents on Enhanced Barrier Precautions, including instances where a nursing assistant wore the same mask all day, a physical therapist did not sanitize hands or don a gown before assisting a resident, and another assistant did not perform hand hygiene when delivering a meal tray, despite clear facility policies and posted instructions.
The facility failed to ensure the QAPI committee was effective in maintaining action plans to correct a deficiency related to self-administration of medications, resulting in a recurrence of the issue. The QAPI minutes lacked consistent documentation and follow-up on medication administration audits, leading to the deficiency being identified again during the current survey.
The facility failed to ensure proper hand hygiene during medication administration and catheter care, and did not ensure proper use of PPE for a resident on enhanced barrier precautions. An LPN and a nursing assistant did not follow infection control protocols, as confirmed by the DON.
The facility failed to ensure proper SAM assessments for residents, leading to medications being left at the bedside without appropriate orders or supervision. One resident with multiple diagnoses had medications at his bedside without a current SAM assessment or order. Another resident with cognitive loss had medications left on the dining table without supervision. A third resident with intact cognition had medications at his bedside despite SAM assessments indicating he was not safe to self-administer.
A resident with moderate cognitive impairment and a history of falls was found with an inaccessible call light, despite care plans and facility policies requiring it to be within reach. Staff confirmed the oversight, and a missing clip was later attached to the call light cord.
A resident with Alzheimer's and dementia was administered Tamiflu without notifying or gaining consent from the designated healthcare POA. The facility's staff failed to document the notification, leading to dissatisfaction from the family member.
A resident was left uncovered and undressed with the privacy curtain and room door open during personal care, leading to exposure and embarrassment. Staff interviews and observations confirmed the failure to follow privacy protocols, despite the facility's Resident Rights policy emphasizing the need for privacy.
The facility failed to ensure a baseline care plan was reviewed and provided timely for a resident with multiple diagnoses, including end-stage renal disease and diabetes mellitus. The resident was not included in any planning or informed about the expectations for her stay or discharge planning. The Licensed Social Worker confirmed that an initial care conference was not held as required by the facility's policy.
A resident with significant medical conditions and chronic skin issues was not properly assessed or monitored for multiple non-healing and bleeding skin lesions. Despite being dependent on staff for care, the resident's care plan did not identify their recurrent skin lesions, and staff failed to document and treat these conditions adequately, leading to inadequate treatment and monitoring.
The facility failed to ensure that pressure-reducing air mattresses were operational for two residents at risk for pressure ulcers. One resident was found lying on a deflated mattress, while another was observed on a non-functional mattress with a significant indentation. Nursing staff confirmed the necessity of these mattresses for preventing skin breakdown, but they were not properly maintained.
A facility failed to ensure post-dialysis assessment and monitoring for a resident with multiple diagnoses, including kidney failure. Despite having physician orders and a care plan, the medical records lacked documentation of post-dialysis monitoring on several dates. Staff interviews revealed inconsistencies in performing and documenting these assessments, particularly during evening shifts. The Director of Nursing confirmed the deficiency, highlighting the importance of monitoring for complications post-dialysis.
A facility failed to provide medically related social services and obtain mental health counseling for a resident with major depressive disorder and inappropriate tendencies towards staff. Despite a care plan and provider note recommending psychiatric services, the resident did not receive the necessary support due to a breakdown in the referral process and misfiled documents in the electronic health record.
The facility failed to conduct comprehensive trauma assessments for six residents with a history of traumatic events, resulting in care plans that did not address trauma-related goals and interventions. Despite documented histories of abuse and trauma, the facility did not identify potential triggers or provide appropriate interventions, leaving residents vulnerable to retraumatization and inadequate care.
Infection Control Failures in Environmental Cleaning, Linen Handling, and Precaution Implementation
Penalty
Summary
The facility failed to adhere to infection control standards in several areas, as observed and confirmed through staff interviews. In one instance, a resident with multiple diagnoses including traumatic brain injury, diabetes, aphasia, dementia, and other conditions was found to have a wheelchair with cracked and peeling vinyl armrests, exposing foam and metal. Multiple staff members, including a nursing assistant, medication aide, nurse manager, DON, infection control preventionist, and housekeeper, all acknowledged that the damaged armrests could not be properly cleaned and posed an infection control concern due to their inability to be disinfected effectively. Additionally, the facility did not ensure that personal laundry was transported in a manner that prevented contamination. A laundry aide was observed leaving a laundry cart uncovered and unattended in a hallway, with personal laundry visible and accessible. The aide later acknowledged that the cart should have been covered to prevent contamination, as per facility policy, which requires linen to be handled and transported in a way that avoids exposure and contamination. The facility also failed to implement timely transmission-based precautions (TBP) for a resident who exhibited symptoms of a possible gastrointestinal illness, including multiple episodes of nausea and vomiting. Despite these symptoms being documented in the resident's progress notes, staff did not initiate TBP or use additional personal protective equipment beyond gloves until the infection control preventionist reviewed the case the following day. The facility's policy and CDC guidelines require TBP to be implemented for residents with suspected communicable diseases, but this was not done promptly.
Inaccurate MDS Coding of Medications for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in incorrect documentation of medications received. For one resident, the admission MDS indicated receipt of an insulin injection, but the physician order report showed the resident was only receiving Ozempic, a GLP-1 receptor agonist, which should not be classified as insulin or a high-risk hypoglycemic medication according to the Resident Assessment Instrument (RAI) Manual. The MDS coordinator confirmed the resident was not receiving insulin and expressed uncertainty about how to code Ozempic, indicating a lack of reference to the RAI Manual at the time of coding. For another resident, the admission MDS documented receipt of both an antiplatelet and an anticoagulant medication, but the physician order report only listed aspirin, which should be coded solely as an antiplatelet. The MDS coordinator acknowledged the error, confirming the resident was not on an anticoagulant. The director of nursing agreed that the MDS coding for both residents was inaccurate. Additionally, a facility policy on MDS was requested but not provided.
Failure to Obtain and Document Final PASARR Determinations
Penalty
Summary
The facility failed to ensure that a Level I Pre-admission Screening (PAS) and, when indicated, a Level II Pre-admission Screening and Resident Review (PASARR) were completed for two residents with mental health diagnoses. Both residents had intact cognition and were diagnosed with schizoaffective disorder, one with auditory hallucinations and the other with an acute exacerbation. Documentation in their medical records showed that while a PAS notice was present, there was no evidence that a final PASARR determination had been received from the lead agency for either resident. The director of nursing confirmed during an interview that the final PASARR determinations could not be found in the medical records for these residents. The facility's policy required that copies of PASARR approvals be uploaded into each resident's medical record, but this was not done. The process for obtaining final determinations had recently changed from fax to electronic requests, and the facility had not been following the new procedure, resulting in the missing documentation.
Failure to Consistently Treat and Document Dry Skin Condition
Penalty
Summary
A deficiency occurred when a resident with a history of pressure ulcers, heart failure, and hemiparesis developed dry, itchy, and visibly flaky skin on his arms and legs. The resident's care plan included interventions to moisturize dry skin, and a physician's order directed the application of CeraVe cream twice daily. However, observations and interviews revealed that the prescribed cream was not consistently applied, and the resident reported that staff were not regularly treating his dry skin as ordered. Review of the Medication Administration Record (MAR) showed that the CeraVe cream was frequently not administered, with staff documenting 'Drug/Item Unavailable' on multiple occasions. Despite the lack of CeraVe, there was no documentation of an alternative cream being used, even though the physician's order allowed for an alternative topical cream. Staff interviews confirmed inconsistent application of lotion, uncertainty about which products were being used, and a lack of communication regarding the unavailability of the prescribed product. The medical record lacked evidence of provider notification, order clarification, or attempts to obtain the prescribed cream after insurance denial. Nursing leadership confirmed that the CeraVe was not available and that staff had been using A&D ointment instead, without updating the provider or the MAR to reflect this substitution. There was no documentation of what products were actually applied, and the facility's policy did not provide clear guidance for treating non-wound skin concerns like dry skin. The lack of consistent treatment and documentation resulted in the resident's ongoing dry skin condition, with no evidence of improvement over several weeks.
Failure to Ensure Resident and Guardian Participation in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their guardian participated in the development and implementation of the resident's person-centered plan of care. According to the report, the resident had severely impaired cognition and multiple diagnoses, including traumatic brain injury, diabetes, aphasia, dementia, seizures, depression, bipolar disorder, and psychotic disorder. The resident was dependent on staff for several activities of daily living. The resident's family member was identified as the emergency contact, guardian, and primary financial contact. Review of the electronic medical record showed that the required quarterly care conference, which should coincide with the Minimum Data Set (MDS) assessment, was not completed for the resident in March. The last documented care conference was in January, and attempts to contact the guardian were made but not followed up. Interviews with the DON and social services staff confirmed that care conferences are expected to be held in conjunction with MDS assessments and that documentation should be present in the resident's record. The social services staff acknowledged responsibility for scheduling and documenting care conferences and stated that the March care conference was missed, likely due to a lack of follow-up after an initial attempt to contact the guardian. Facility policy requires quarterly care conferences and assigns responsibility for coordination and documentation to the social services department.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician of a significant change in condition for a resident with a complex medical history, including deep vein thrombosis, pulmonary embolism, stroke, diabetes, schizoaffective disorder, and cancer. The resident experienced an unresponsive episode observed by a nursing assistant, after which an LPN conducted an assessment. The assessment documented that the resident regained responsiveness within seconds, was able to answer questions, follow commands, and denied headache. However, there was no documentation that the provider was notified of this unresponsive episode, and the resident's care plan did not include a history of such episodes. Interviews with facility staff confirmed that the nurse in charge and the nurse practitioner were not informed of the incident, and both indicated that provider notification would have been expected according to facility procedures. The facility's policy required staff to notify the provider of significant changes in a resident's condition and to document this communication. The lack of provider notification and documentation following the unresponsive episode constituted a failure to follow established protocols for change of condition.
Failure to Provide Routine Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that routine oral hygiene was provided for a resident who was dependent on staff for activities of daily living. The resident had moderately impaired cognition, required substantial assistance with oral care, and had a care plan indicating the need for extensive staff assistance due to having full upper dentures and natural lower teeth with some missing. Review of documentation showed no record of oral care being provided over a one-month period. The resident reported that staff were supposed to help with brushing teeth twice daily but had not been doing so, and that previously staff would leave a basin and toothbrush but no longer did even that. A nursing assistant assigned to the resident stated she did not provide oral care because she believed the resident had no real teeth, despite the resident having remaining lower teeth. Observation confirmed the resident had yellowed lower teeth with visible white/yellow matter around the edges. The unit nurse manager confirmed that oral hygiene was the standard of care and should be performed preferably twice daily, and that documentation should be present in the point of care charting, which was not found. A policy on oral care was requested but not provided.
Failure to Ensure Proper Hand Hygiene and PPE Use Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) for multiple residents under Enhanced Barrier Precautions (EBP). For one resident with an indwelling catheter and pressure ulcers, a nursing assistant donned gloves and a gown but continued to wear the same surgical mask throughout the day, contrary to posted EBP instructions. The signage on the resident's door clearly outlined the required sequence for donning and doffing PPE and emphasized the need for hand hygiene before entering and after leaving the room. Another resident with an ostomy and kidney insufficiency was assisted by a physical therapist who did not perform hand hygiene or don a gown before entering the room, despite EBP signage. The therapist only donned gloves after entering and failed to perform hand hygiene upon exit. The therapist later acknowledged not following the required procedures and recognized the importance of these measures in preventing infection spread. A third resident with a suprapubic catheter and a wound was served a meal tray by a nursing assistant who did not perform hand hygiene before or after entering the room, despite EBP signage and recent training. The assistant believed hand hygiene was unnecessary since no direct care was provided. Interviews with the infection preventionist, director of nursing, and registered nurse confirmed that staff were expected to follow EBP protocols, including hand hygiene and appropriate PPE use, as outlined in facility policies.
Failure to Maintain Effective QAPI Committee
Penalty
Summary
The facility failed to ensure the Quality Assurance Process Improvement (QAPI) committee was effective in maintaining appropriate action plans to correct a quality deficiency identified during a previous survey related to self-administration of medications (SAM). This resulted in a deficiency identified during the current survey. Specifically, the facility did not complete SAM assessments to allow residents to safely administer their own medications for three residents observed with medications at their bedside. During the review of the QAPI minutes for the first quarter of 2023, it was noted that the facility had been cited for F755 related to a resident not being monitored for medication administration. The minutes indicated that education was completed, a whole house sweep was conducted to check for medications in rooms, and medication administration audits were performed. However, the subsequent QAPI minutes for the second, third, and fourth quarters of 2023 lacked consistent documentation and follow-up on medication administration audits, which were crucial for addressing the identified deficiency. In an interview, the administrator acknowledged that QAPI meetings were held quarterly and would transition to monthly. The administrator also mentioned that performance improvement projects (PIPs) were ongoing, but there was a lack of consistent monitoring and documentation in the QAPI minutes regarding the SAM assessments. This inconsistency in maintaining and following through with action plans led to the recurrence of the deficiency related to self-administration of medications during the current survey.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration for two residents. An LPN administered medications to two residents without sanitizing hands between each administration. The LPN also handled medication cups and other items without performing hand hygiene. The Director of Nursing (DON) confirmed that staff are expected to sanitize hands between medication administrations to prevent the spread of infection. The facility also failed to ensure proper hand hygiene during suprapubic catheter care for one resident. An LPN did not change gloves or sanitize hands between removing a dirty dressing and cleaning the catheter site. The DON confirmed that staff are expected to change gloves and sanitize hands to prevent infection at the catheter site. Additionally, the facility failed to ensure proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions. A nursing assistant did not don a gown or gloves when entering the resident's room and assisting with care. The DON and infection preventionist confirmed that staff are expected to follow enhanced barrier precautions, including wearing gowns and gloves for high-contact care activities.
Failure to Ensure Proper Self-Administration of Medications Assessment
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for residents to safely administer their own medications. Resident 66, who had multiple diagnoses including traumatic brain injury and major depressive disorder, was observed with medications at his bedside without a current SAM assessment or order. The resident's care plan did not address SAM, and staff confirmed that medications should not be left at the bedside without the appropriate order and assessment in place. Additionally, the resident's inhaler and capsules were found at the bedside without supervision, contrary to facility policy and staff statements that an order and assessment were required for SAM. Resident 6, who was cognitively intact but had a care plan indicating cognitive loss and dementia, was observed with medications left on the dining table in front of her without supervision. The resident's SAM assessment indicated she did not want to self-administer medications, and her physician orders lacked SAM documentation. The director of nursing verified that the resident should be supervised during medication pass and that medications should not be left with the resident on the dining table. Resident 73, who had intact cognition and multiple diagnoses including diabetes and high blood pressure, was observed with medications at his bedside without staff present. Although the resident had a care plan indicating he wished to self-administer certain medications, his SAM assessments indicated he was not safe to administer his own medications. Staff were unaware of the resident's SAM status and left medications at the bedside, contrary to the facility's policy requiring both an assessment and a provider's order for SAM.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure the call light was accessible for a resident (R39) who had moderate cognitive impairment and required substantial assistance with most activities of daily living. R39's care plan and falls risk assessment both indicated that the call light should be within reach to prevent falls. However, during an observation, the call light was found on the floor under R39's bed, making it inaccessible. R39 attempted to reach the call light but was unable to do so, which posed a risk given his history of falls and cognitive impairment. Interviews with staff confirmed that the call light should have been within R39's reach. A nursing assistant noted that the call light cord was missing a clip, which was later retrieved and attached. The registered nurse and director of nursing both stated that the expectation was for call lights to be accessible to residents who could use them. The facility's policy also indicated that call lights should be placed within reach at all times. Despite these guidelines, the call light was not accessible to R39, leading to a deficiency in accommodating the resident's needs and preferences.
Failure to Notify and Gain Consent for Medical Treatment
Penalty
Summary
The facility failed to contact the designated representative and gain consent for medical treatment for a resident with Alzheimer's disease and dementia. The resident, who had altered levels of consciousness and was rarely or never understood, was administered Tamiflu prophylactically due to an influenza outbreak in the facility. The resident's care plan indicated that staff should notify the provider and representative of any changes, but the electronic health record lacked documentation that the family member was informed about the administration of Tamiflu. Interviews with the family member and staff revealed that the family member, who was the healthcare power of attorney (POA), was not notified or asked for consent before the administration of Tamiflu. The family member expressed dissatisfaction with the lack of communication and decision-making by the staff. The director of nursing acknowledged the mistake, stating that the facility did not have the POA paperwork at the time, which led to the oversight in notifying the family member.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care activities. The resident, who was cognitively intact and dependent on staff for various activities, reported feeling exposed and embarrassed when a nursing assistant left them uncovered and undressed with the privacy curtain open. The resident's roommate's family entered the room during this time, further compromising their privacy. Observations confirmed that the resident was left visible from the hallway, uncovered, and with the privacy curtain and room door open, despite a sign requesting the door to be closed completely. Interviews with staff revealed inconsistencies in following privacy protocols. Nursing assistants stated that privacy curtains should be pulled during care and residents should be covered if staff needed to leave the room. However, the incident showed a failure to adhere to these practices. The registered nurse confirmed the oversight, and the director of nursing emphasized that residents should not be left exposed unless it was their personal preference. The facility's Resident Rights policy supports the need for privacy in treatment and personal care, which was not upheld in this case.
Failure to Provide Timely Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan was reviewed and provided timely for a resident who was admitted and readmitted multiple times. The resident, who had diagnoses including end-stage renal disease, diabetes mellitus, and bipolar disorder, was not included in any planning or informed about the expectations for her stay or discharge planning. The resident denied having a care conference or being invited to one, and was not provided with any information regarding her care verbally or in writing. During an interview, the Licensed Social Worker (LSW) and Social Service Director confirmed that an initial care conference should be held by day 7, but this was not done for the resident. The LSW verified that a 48-hour care plan was not given to the resident and no care conference was held. The facility's policy indicated that care conferences should be held within 21 days of admission and quarterly thereafter, but this was not adhered to in this case.
Failure to Accurately Assess and Monitor Skin Lesions
Penalty
Summary
The facility failed to accurately assess and monitor multiple non-healing and bleeding skin lesions, lacerations, and scabs for a resident (R40) who was cognitively intact and had significant medical conditions including heart failure, peripheral vascular disease, kidney failure, diabetes, and a lower limb amputation. Despite being dependent on staff for showers, dressing, personal hygiene, and transfers, and being at risk for pressure ulcers, R40's care plan did not identify their recurrent skin lesions on their arms, legs, and chest, nor did it include appropriate interventions for these conditions. The care plan instructed licensed staff to complete visual body observations weekly and notify the provider and family of any new areas of concern, but this was not effectively carried out as evidenced by the lack of documentation and monitoring of R40's numerous current open areas and scabs on their arms and chest. Observations and interviews revealed that R40 had multiple small, circular superficial lesions on both upper extremities, which were not properly assessed or treated. On several occasions, R40 was found with soiled and improperly applied dressings, and numerous sores and scabs in various states of healing on their arms and chest. R40 reported that staff only applied regular moisturizing lotion to their sores and did not assess or treat them adequately. Nursing assistants and registered nurses confirmed that they observed R40's skin issues but did not consistently document or monitor them, and there was confusion about whether R40 had any special creams or lotions for their sores. The facility's director of nursing (DON) and other nursing staff acknowledged that weekly head-to-toe skin assessments were supposed to be completed and documented, and any new concerns should have been added to the wound management form. However, R40's chronic skin issues were not consistently recorded or monitored, and their care plan did not reflect these ongoing concerns. The facility's Skin Integrity policy required licensed nurses to complete visual head-to-toe skin inspections and document any skin alterations, but this was not effectively implemented for R40, leading to inadequate treatment and monitoring of their skin conditions.
Failure to Ensure Operational Pressure-Reducing Air Mattresses
Penalty
Summary
The facility failed to ensure that pressure-reducing air mattresses were properly operational for two residents, leading to a deficiency in pressure ulcer care. Resident R39, who had moderate cognitive impairment and was at risk for developing pressure ulcers, was observed lying on a deflated air mattress that was not plugged in. Nursing staff confirmed that the air mattress was required but was not operational due to the bed's position, which prevented the pump from reaching the outlet. This oversight was noted during multiple observations and interviews with nursing staff, who acknowledged the necessity of the air mattress for preventing skin breakdown. Similarly, Resident R87, who also had moderate cognitive impairment and was at risk for pressure ulcers, was observed multiple times lying on an air mattress that was not turned on. The mattress had a significant indentation, indicating it was not functioning correctly. Nursing staff confirmed that the air mattress should be operational whenever the resident was in bed to prevent skin breakdown. The facility's policy on skin integrity emphasized the importance of appropriate treatment plans and interventions to prevent skin injuries, which were not followed in these cases.
Failure to Ensure Post-Dialysis Monitoring
Penalty
Summary
The facility failed to ensure post-dialysis assessment and monitoring for a resident who required hemodialysis. The resident, who had diagnoses including kidney failure, high blood pressure, diabetes, heart failure, and peripheral vascular disease, did not receive the necessary post-dialysis monitoring of their access site, shunt bruit and thrill, and vital signs. Despite having physician orders and a care plan in place, the medical records lacked documentation of these assessments on multiple dates when the resident returned from dialysis treatments. Interviews with staff revealed that while pre-dialysis assessments were conducted, post-dialysis assessments were not consistently performed or documented, particularly when the resident returned to the facility in the evening shift. The Director of Nursing confirmed that the facility's policy required ongoing assessment and monitoring for complications before and after each dialysis treatment. However, a review of the resident's medical record indicated that staff were not completing the necessary post-dialysis assessments. This oversight was acknowledged by the Director of Nursing, who emphasized the importance of ensuring the shunt was functioning properly and monitoring for excessive bleeding or other complications. The lack of post-dialysis monitoring represents a significant deficiency in the care provided to the resident.
Failure to Provide Mental Health Counseling
Penalty
Summary
The facility failed to provide medically related social services and/or obtain mental health counseling for a resident diagnosed with major depressive disorder and inappropriate tendencies towards staff. The resident's quarterly MDS indicated moderate cognitive impairment and a need for assistance with most ADLs. Despite a care plan identifying the resident's risk for mood and behavioral disturbances and a provider note recommending a referral to in-house psychiatric services, the resident did not receive the necessary mental health support. The resident expressed feelings of sadness due to the loss of his wife and reported not being offered any psychological or grief support, which he felt would be helpful. Interviews with facility staff revealed a breakdown in the referral process. The registered nurse and health unit coordinator indicated that referrals to psychiatric services were typically made by the social worker based on nursing communication or provider orders. However, the social worker admitted to incorrectly assuming the resident was already receiving psychiatric services based on misfiled documents in the electronic health record. The social worker and other staff members acknowledged that the resident should have had a psychiatric referral and that all offers and refusals should be documented. The facility's policy on ancillary services was not followed, leading to the resident not receiving the necessary mental health support.
Failure to Conduct Comprehensive Trauma Assessments
Penalty
Summary
The facility failed to ensure comprehensive trauma assessments were completed for six residents with a history of traumatic events. These residents included individuals with diagnoses such as cerebral palsy, mood disorder, anxiety, traumatic brain injury, dementia, and major depressive disorder. Despite the presence of documented histories of abuse and trauma, the facility did not conduct thorough trauma assessments to identify potential triggers and appropriate interventions to maintain the residents' mental and psychosocial well-being. For instance, one resident reported a history of abuse by her father and an incident involving a staff member making inappropriate sexual requests, yet no comprehensive trauma assessment was completed following the allegation. Another resident with a history of traumatic brain injury and recent rape expressed discomfort with male caregivers, but the facility did not complete a trauma assessment to address her needs. Similarly, other residents with documented histories of abuse and trauma, including childhood and spousal abuse, were not provided with comprehensive trauma assessments. This lack of assessment resulted in care plans that did not address trauma-related goals and interventions, leaving residents vulnerable to retraumatization and inadequate care. Interviews with staff and family members revealed a lack of awareness and training regarding trauma-informed care. Direct care staff were not informed about residents' trauma histories, and care plans did not include specific interventions to mitigate the risks of retraumatization. The facility's policy on trauma-informed care emphasized the importance of identifying trauma histories and developing appropriate care plans, but this was not consistently implemented, leading to deficiencies in the care provided to residents with a history of trauma.
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What surveyors actually found near you
We read the 1,057 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Care Home | 0 mi | ★★★★★ | 3 | 0 |
| Southside Care Center | 0.6 mi | ★★★★★ | 28 | 1 |
| Lakehouse Healthcare & Rehabilitation Center | 0.8 mi | ★★★★★ | 37 | 1 |
| The Estates At Chateau Llc | 1.2 mi | ★★★★★ | 14 | 1 |
| Grand Avenue Rest Home | 1.3 mi | ★★★★★ | 9 | 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.