Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 Renville Health Services during CMS and state inspections, most recent first.
A resident admitted for skilled nursing services did not have documented TB testing completed on admission. A T-spot was later drawn, but there was no record that the specimen was sent to the lab or that results were obtained. The DON stated the facility missed the resident during TB audit checks and that the sample was not processed because the lab form was not sent with it, despite the facility policy requiring TB screening and testing within 72 hours of admission.
A resident with multiple complex medical conditions was admitted with several wounds, including a blister on the right fourth toe that was not included in the physician's wound care orders. Nursing staff observed worsening conditions of the toes, such as maceration, drainage, and discoloration, but did not notify the physician or update treatment orders. The primary care physician was not informed about these wounds, and facility policy requiring physician notification for new skin issues was not followed.
Two residents with significant skin integrity issues did not have all necessary wound care and preventive interventions incorporated into their care plans. One resident with multiple wounds and complex medical conditions had no wound care interventions documented in the care plan, while another resident's care plan did not consistently reflect physician orders for heel protectors, and heel boots were not always in place as required.
A resident with multiple comorbidities and numerous wounds was admitted without specific wound care orders or clear documentation in the care plan. Nursing staff provided wound care to the resident's toes without physician orders and failed to notify the physician of worsening wound conditions, despite observations of drainage, discoloration, and foul odor. The lack of timely physician notification and incomplete documentation led to the resident's wounds deteriorating, requiring hospitalization and surgical intervention.
A resident with multiple risk factors for skin breakdown developed an open area on the coccyx that was not promptly identified or comprehensively assessed by staff. Nursing assistants discovered the wound, but the nurse was not called at the time, and a subsequent assessment by an LPN revealed the open area had not been previously documented or treated according to facility policy.
Failure to update a resident's care plan for changed nutritional status. A resident with severely impaired cognition, malnutrition, DM2, and dependence for all ADLs was observed slouched in his wheelchair while his meal sat nearby. Staff reported they had begun offering oral food and prompting him when he stopped eating, and ST documented a soft and bite sized diet with added moisture, thin liquids, and complete assist with all oral intakes. However, the care plan still reflected continuous G-tube feeding and did not include oral intake assistance or the resident's ability to take food by mouth.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 39 residents. Expired and unlabeled food items were found, and the walk-in freezer had significant frost buildup. Interviews revealed a lack of adherence to food safety protocols due to staff turnover and absence of a structured system for checking expired foods and completing cleaning tasks. The facility's policies lacked specific systems to ensure compliance, leading to these deficiencies.
The facility failed to implement a comprehensive assessment protocol to ensure staff competencies and solicit input from residents and representatives. The assessment document highlighted changes that were not executed, and competencies for dietary staff were incomplete. Interviews revealed gaps in implementation, with the administrator acknowledging the lack of required input and incomplete competencies.
The facility's QAPI program lacked documentation of measurable goals and data analysis for various initiatives, including bowel incontinence management and employee recruitment. Despite data submission from departments, there was no evidence of goal-setting or analysis in QAPI meeting minutes from February, March, and July 2024. Issues such as falls and dementia care also lacked documented goals and action plans, as confirmed by the administrator.
A resident's lisinopril dosage was not properly reconciled, leading to the administration of an incorrect dose. The TMA used a medication card with 10 mg tablets, despite the EMR showing a 5 mg order. The facility's procedures for handling medication changes were not followed, as the incorrect card was not removed, and the pharmacy was not notified.
The facility failed to ensure accurate medication labeling and dosage for two residents, leading to potential medication errors. One resident received an incorrect dosage of Lisinopril due to a lack of communication about a dosage change. Another resident had discrepancies in Gabapentin and Lidoderm patch orders and labels. The facility's policies for medication order transcription and communication were not followed.
Incomplete TB Testing on Admission
Penalty
Summary
The facility failed to ensure that 1 of 5 sampled residents, R12, had completed TB testing upon admission. R12’s admission record showed admission to the facility in March 2026 for skilled nursing services. A progress note dated 5/11/26 documented that an interferon-gamma release assay (T-spot) test was drawn, but there was no further documentation showing that the specimen was sent to the laboratory or that results were obtained. There was also no documentation showing that TB testing had been completed at admission in March 2026 rather than as a delayed test in May 2026. During interview, the DON stated the facility had been auditing for missing TB testing and had missed R12 during that process; she explained that blood had been drawn for the T-spot, but the facility forgot to send the form with the sample to the lab, so the process ended there. Review of the facility’s Resident Tuberculosis Prevention and Control policy showed that all new resident admissions were to have TB screening and testing completed within 72 hours of admission.
Failure to Notify Physician of New and Worsening Wounds
Penalty
Summary
The facility failed to notify the physician of new wounds for a resident with multiple complex medical conditions, including heart disease, diabetes, chronic kidney disease, and a left below-knee amputation. Upon admission, the resident was found to have fourteen wounds, including a blister on the right fourth toe that was not included in the physician's orders for wound care. Nursing staff observed maceration, drainage, and discoloration of the toes during dressing changes, but did not notify the physician about these wounds or their changes in appearance. Documentation shows that wound care orders were only in place for four of the fourteen wounds, and the remaining wounds, including those on the toes, were not addressed with new physician orders. Interviews with nursing staff revealed that they assumed the physician was already aware of the wounds or that wound care was being managed by others, leading to a lack of direct communication with the physician regarding the new or worsening wounds. The resident's primary care physician confirmed not being informed about the wounds since admission and did not assess the toes during a visit, as they were wrapped. Facility policy required staff to notify the physician and responsible party of new skin integrity issues, but this protocol was not followed in this case.
Failure to Incorporate Skin Integrity Interventions into Care Plans
Penalty
Summary
The facility failed to incorporate appropriate skin integrity interventions into the care plans for two residents who were reviewed for skin conditions. One resident was admitted with multiple complex medical diagnoses, including a history of myocardial infarction, chronic atrial fibrillation, diabetes, stage 5 chronic kidney disease, and a left below-knee amputation. This resident required maximum assistance with activities of daily living and had a stage two pressure ulcer on admission, as well as a total of fourteen wounds identified during the facility's skin/wound assessment. Despite these findings, the resident's care plan did not include documentation of wounds, wound care, or interventions aimed at preventing further deterioration of skin integrity. Another resident was admitted with diagnoses including non-pressure chronic ulcers on both lower legs, varicose veins with ulceration, a stage 3 pressure ulcer on the left heel, and localized edema. The care plan for this resident did identify some skin integrity issues and listed interventions such as use of an air mattress, encouragement of nutrition and hydration, heel protection, and regular repositioning. However, physician orders for heel protectors were not consistently reflected in the care plan, and documentation indicated that heel boots were not in place at times due to drainage and odor, with pillows being used instead. Interviews with staff and administration confirmed that not all interventions for prevention and management of skin breakdown were included in the care plans, as required by facility policy.
Failure to Initiate, Monitor, and Notify Physician of Resident Wounds
Penalty
Summary
The facility failed to initiate, monitor, and notify the physician regarding multiple wounds for a resident who was admitted with significant comorbidities and impaired skin integrity. Upon admission, the resident had numerous wounds, including a blister on the right 4th toe, abrasions, a stage 2 pressure ulcer, and a left below-knee amputation site. The initial wound assessment documented these wounds, but there was no corresponding physician order for wound care to the right 4th digit toe, and the care plan did not specify wound locations, treatments, or interventions for the identified wounds. Throughout the resident's stay, nursing staff provided wound care to the toes without physician orders, and documentation was inconsistent or incomplete. Several nurses and nursing assistants described the wounds as macerated, draining, and discolored, with some noting foul odor and difficulty separating the toes due to drainage. Despite these observations, staff did not notify the physician of the wounds' condition or deterioration, assuming the physician was already aware or that orders were not needed for all treatments. Progress notes indicated worsening wound conditions, including purulent drainage and discoloration, but lacked details on treatments applied or physician notification. The lack of timely physician notification and absence of specific wound care orders resulted in the resident's wounds worsening, ultimately leading to hospitalization and surgical intervention for wet gangrene and peripheral vascular disease. Interviews with staff and the resident's primary care physician confirmed that the physician was not informed about the wounds, and wound care orders were not entered into the medication administration record. Facility policy required notification of the provider and initiation of treatment orders for new or worsening wounds, but these steps were not followed for this resident.
Failure to Identify and Assess Pressure Ulcer
Penalty
Summary
The facility failed to identify and comprehensively assess a pressure ulcer for one resident with multiple risk factors, including a recent femur fracture, type 2 diabetes, incontinence, and substantial assistance required for activities of daily living. The resident's care plan noted skin integrity impairment and interventions such as encouraging nutrition, hydration, and prompt treatment of skin breaks. Despite a Braden scale score indicating risk, a skin and wound evaluation did not identify an open area on the coccyx the day before the deficiency was observed. During care, nursing assistants discovered an open spot with fresh blood on the resident's coccyx, but the nurse was not called to assess the area at that time, as the resident was leaving for an appointment and declined further evaluation. The following day, an LPN was unaware of the wound until informed and then measured the area as 0.5 cm x 0.5 cm, confirming it was open. The LPN stated that wounds should be photographed, covered, and have a dressing order entered, with ongoing assessment on bath days and daily checks by nursing assistants. However, the wound had not been properly identified, assessed, or documented prior to this, and a nursing assistant reported that a nurse had previously been dismissive when informed of the wound. The facility's policy required prompt monitoring and addressing of skin integrity issues, but this was not followed in the resident's case.
Failure to Update Care Plan for Changed Nutritional Status
Penalty
Summary
The facility failed to revise 1 resident's care plan when his nutritional status changed. The resident had a 9/8/25 admission MDS that identified severely impaired cognition and diagnoses including malnutrition, encephalitis and encephalomyelitis, meningitis, type II diabetes, disorientation, and anxiety. He was dependent on staff for all ADLs and required total assist with meals. On 9/15/25, he was observed in the dining room slouched over in his wheelchair with his eyes closed and appearing to be sleeping while his meal sat about 2 feet away from him. Staff woke him and moved him and his food to another table to assist with the meal. During interview, a nursing assistant stated staff let the resident feed himself, prompted him when he tapped his fork on the table, and offered help if he stopped eating; staff had been told a couple weeks earlier they could start offering him food orally. The resident would not finish eating if staff did not assist him. A 9/15/25 Speech Therapy Treatment Encounter Note identified a soft and bite sized texture with added moisture, thin liquids, straws okay, and complete assistance needed by staff with all oral intakes, with the resident to sit upright at 90 degrees for eating and drinking and remain upright for 20-30 minutes after meals. The current undated care plan still described continuous G-tube feeding and did not mention oral intake assistance or that he could take food by mouth. The DON agreed nursing should have used the speech therapy communication to update the care plan, noting nursing was notified of the diet change on 8/28/25 and the care plan should have been updated then.
Deficiencies in Kitchen Sanitation and Food Safety Protocols
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 39 residents. During an inspection, several expired food items were found, including Parmesan Pepper Corn Pasta Salad, mustard, sun-dried raisins, minced garlic, dressing, smoothie mix, cheese, and pepperoni. Additionally, there were multiple unlabeled and undated food items in the walk-in cooler, such as a bowl with a white creamy substance, a plastic squeeze bottle with a solid white substance, and a glass jar with a yellow creamy consistency. The walk-in freezer had significant frost buildup, and the stove and surrounding areas were observed to be unclean. Interviews with kitchen staff revealed a lack of awareness and adherence to food safety protocols. Cook-A admitted uncertainty about the contents of unlabeled bottles and acknowledged that the kitchen had experienced significant staff turnover, which impacted their ability to maintain cleanliness and check for expired foods. The dietary manager confirmed the findings and admitted that there was no system in place to ensure staff were checking for expired foods or completing necessary cleaning tasks. The director of dietary services, who oversees multiple facilities, had previously discussed the need for audits and competencies with the dietary manager but had not followed up on their implementation. The facility's policies on labeling foods and using sanitary practices were reviewed and found to lack specific systems to ensure compliance. The administrator expected the dietary manager to have a system in place to ensure all kitchen duties were completed, including cleaning, removal of expired foods, and appropriate labeling. However, the absence of a structured system led to the observed deficiencies, as evidenced by the incomplete cleaning sign-off sheets and the lack of audits or competencies to verify adherence to food safety protocols.
Failure to Implement Comprehensive Facility Assessment Protocol
Penalty
Summary
The facility failed to implement a comprehensive facility-wide assessment protocol to ensure staff competencies were identified and completed according to their respective duties. The assessment did not solicit input from staff, residents, representatives, or family members, which is a requirement. The facility assessment document, dated 8/8/24, highlighted changes that were supposed to be implemented, including feedback solicitation through questionnaires, suggestion boxes, and meetings. However, these changes had not been executed at the time of the survey. The assessment also failed to include competencies for all staff, as evidenced by the lack of completed competencies for two dietary staff members. Interviews with the dietary manager and the administrator revealed gaps in the implementation of the assessment protocol. The dietary manager admitted that competencies for the dietary staff were only completed annually and were not available for the two staff members in question. The administrator acknowledged that the facility had not yet implemented the required input from residents or representatives, as the regulation had just come into effect. The facility had discussed these changes internally but had not taken steps to gather input or complete the necessary competencies, as highlighted in the assessment document.
Lack of Measurable Goals and Data Analysis in QAPI Program
Penalty
Summary
The facility failed to provide evidence of measurable goals and documentation of analysis and evaluation of data submitted to the Quality Assurance Performance Improvement (QAPI) committee. During the review of the QAPI meeting minutes from February, March, and July 2024, it was identified that the facility departments were submitting data to the committee. However, there was a lack of documentation of measurable goals and analysis of the data. For instance, the Quality Improvement Incentive Program (QIIP) for bowel incontinence did not have documented measurable goals or evidence of data analysis by the QAPI committee. Similarly, the Performance-Based Incentive Payment Program (PIIP) for employee recruitment and retention lacked an action plan and data analysis. In the QAPI meeting minutes from March 2024, the same issues persisted. The QIIP for bowel incontinence continued without measurable goals or data analysis documentation. The PIIP for employee recruitment and retention also lacked an action plan and data analysis. Additionally, new tasks such as performance reviews in the UKG system were introduced, but there was no documentation of how the facility would achieve compliance or if revisions were needed. By July 2024, the facility still had not documented measurable goals or analyzed data for identified problems such as falls and dementia care. For example, the problem of falls in April was identified, but there was no documentation of measurable goals or data analysis. Similarly, tasks related to dementia care education lacked an assigned person, completion date, and follow-up action plan. An interview with the administrator confirmed the lack of measurable goals and analysis of information during the QAPI meetings.
Medication Administration and Reconciliation Deficiency
Penalty
Summary
The facility failed to appropriately administer and accurately reconcile a resident's medication, specifically lisinopril, which is used for high blood pressure. During an observation, a trained medication aid (TMA) was preparing to administer morning medications and was found to be using a medication card that contained 10 mg tablets of lisinopril, despite the electronic medical record (EMR) displaying a current order for 5 mg. The TMA admitted to administering 10 mg of lisinopril daily and was unaware of any change in the dosage. The medication card had no label indicating a change in order and was improperly stored with other current medications. Interviews with the TMA, a licensed practical nurse (LPN), and the director of nursing (DON) revealed that the procedure for handling medication order changes was not followed. The order for lisinopril had changed the day before, but the medication card with the incorrect dose was not removed from the cart, and the pharmacy was not notified to provide the correct dose. The facility's policy required that medication orders be entered into the EMR, the pharmacy be notified of changes, and the medication card be updated or removed as necessary. However, these steps were not completed, leading to the potential for medication errors.
Medication Labeling and Dosage Errors
Penalty
Summary
The facility failed to ensure accurate labeling of medications for two residents, leading to potential medication errors. For one resident, the physician's order for Lisinopril was for 5 mg daily, but the medication card contained 10 mg tablets without any label indicating a change in dosage. The trained medication aid confirmed administering the incorrect dosage due to a lack of notification about the change. Similarly, the licensed practical nurse was unaware of the dosage change, indicating a failure in communication and process adherence. Another resident had a physician order for Gabapentin 100 mg capsules, but the medication card contained 300 mg capsules with incorrect administration instructions. Additionally, there was a discrepancy in the order and pharmacy label for a Lidoderm patch. The director of nursing confirmed that the medication card should have been updated, and the pharmacy notified, but this process was not followed. The facility's policies required proper transcription and communication of medication orders, which were not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Renville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Olivia Restorative Care Center | 10.8 mi | ★★★★★ | 2 | 0 |
| Clara City Care Center | 14.6 mi | ★★★★★ | 9 | 1 |
| Avera Granite Falls Care Center | 15.4 mi | ★★★★★ | 5 | 0 |
| Parkview Home | 16.4 mi | ★★★★★ | 8 | 0 |
| River Valley Health And Rehabilitation Center Llc | 17.8 mi | ★★★★★ | 8 | 0 |
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