Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Saint Therese At Oxbow Lake during CMS and state inspections, most recent first.
The facility failed to keep several residents’ care plans current with their actual needs. A resident with severe cognitive impairment had outdated transfer instructions, another resident’s plan still listed wandering and Lorazepam despite those no longer applying, and a resident using a motorized wheelchair had no related care plan guidance. Other residents’ plans also remained inaccurate for ADLs, medication references, transfers, and equipment use, while staff observations and interviews confirmed the documented care needs had changed.
A facility failed to provide an ongoing program of activities that matched residents’ assessed needs and preferences. Several residents with cognitive impairment, stroke-related deficits, depression, dementia, pain, and sensory loss were repeatedly observed sitting alone in their rooms or beds with no activity materials or staff interaction, despite documented interests in one-to-one visits, escorted activities, religious services, music, games, reading, and other activities. Activity records showed no documented participation and no evidence that individualized or in-room activities were offered, while staff said activities had been limited during COVID but were still expected to continue on a smaller scale.
Visible Catheter Drainage Bag Exposed Resident's Privacy: A resident with severe cognitive impairment, multiple chronic diagnoses, and a Foley catheter was observed in a wheelchair with the drainage bag hanging uncovered from the side of the chair. The straw-colored urine in the bag was visible from the hallway and to people passing by on multiple observations. NA-D confirmed the bag was visible and that the resident did not have a dignity bag available, while CC-B and the DON stated catheter drainage bags should be covered to maintain privacy and dignity.
Missed Timely Care Conferences and Resident Participation in Care Planning: The facility failed to ensure two residents with cognitive impairment were given the opportunity to participate in timely care plan conferences. EMR review showed each resident’s most recent care conference had occurred months earlier, with later quarterly conferences due but not scheduled, conducted, or documented as attempted. SS-B confirmed the conferences were not completed within the expected timeframe and there was no documentation of attempts to contact the family or representative, while the DON stated quarterly care conferences and documentation of contact attempts were expected.
Failure to Document AMA Discharge: A resident with a recent hospital admission and diagnoses including compression fracture, depression, hallucinations, and PVD became agitated, physically aggressive, and attempted unsafe self-transfers before leaving AMA. The EMR did not show a discharge note, notification of the provider or family, or documentation that the resident received education or signed an AMA form, despite staff stating these steps were required and the facility policy calling for notification and documentation.
The facility failed to send the required transfer/discharge notice to the Ombudsman for a resident who discharged AMA. The resident had diagnoses including lumbar vertebra compression fracture, depression, hallucinations, and peripheral vascular disease, and the EMR showed evening meds were not given because the resident left AMA. The SW said Ombudsman notices were not sent for AMA discharges, while the NHA was unaware the Ombudsman needed to be notified and the DON stated all hospitalizations and discharges, including AMA, were to be reported.
A resident with moderate cognitive impairment and multiple diagnoses, including Alzheimer’s disease, anxiety, depression, and alcohol abuse, had a care plan with generic Substance Use and Trauma focus areas. The plan did not identify the resident’s specific substance use history, triggers, risks, trauma history, or individualized interventions, and the CC-F and DON acknowledged the templated plan was not person-centered.
Failure to provide needed ADL assistance for bathing, nail care, and shaving. One resident with severe cognitive impairment and dependence for personal hygiene had long fingernails with dark debris under the nails on repeated observations, and staff did not consistently provide full partial bathing or proper oral care during morning care. A second resident who was dependent for grooming had persistent facial hair over several days, while staff gave mixed accounts about shaving responsibility and the care plan did not reflect the resident’s grooming preference.
A resident with dementia, diabetes, and total ADL dependence had a dark, raised area on the thumb that was seen during observation but was not documented on the skin assessment, monitored in the TAR, or noted in nurse documentation as being reported to the provider or NP. In a separate issue, staff pushed another resident with cognitive impairment and reduced mobility in a wheelchair without foot pedals in place, and the resident’s feet were observed sliding or bouncing on the floor; the care plan did not address foot pedal use.
Failure to Follow Heel Offloading Interventions: A resident with DM, diabetic neuropathy, and a healed stage 3 heel pressure ulcer remained at risk for skin breakdown, and the care plan required heel offloading in bed and floating the heels on two pillows in a recliner. Observations showed the resident repeatedly reclined with the heels resting directly on the recliner foot rest, including when only one pillow was in place and while breakfast was being served. Staff and the DON confirmed the resident’s heels were supposed to be kept floating to prevent recurrence of pressure ulcers.
Failure to follow a therapy-recommended ambulation program for a resident with intact cognition who needed supervision/touch assist for ambulation. The resident’s care plan directed staff to assist him to walk to meals with a FWW and provide walking help with restroom use, but observations showed him propelling himself in a wheelchair to the dining room while staff made no attempt to encourage ambulation. The resident said he wanted to walk more and that staff did not offer as often as they used to; interviews with NA and RN leadership confirmed the ambulation assistance was expected and no refusal documentation was found.
Failure to Complete Fall Analysis and Neuro Checks After Resident Falls: A resident with severe cognitive impairment, Alzheimer’s disease, and dependence for transfers experienced multiple falls, including an unwitnessed fall with head injury and later another fall with injury and fracture. Staff documented the events and hospital transfers, but the record did not include a root cause analysis after the fall or ongoing neuro assessments after the head injury, and interviews confirmed the expected fall interventions and neuro monitoring were not completed.
An LPN administered a nebulizer treatment to a resident with COVID-19 while the room door was left fully open. The resident was not assessed to self-administer, and the facility did not have AIIR rooms. The CC and DON stated the door should have been kept closed during the aerosol treatment and for at least 15 minutes afterward, but the facility policy did not give specific direction for managing nebulizer use in this situation.
Failure to Offer or Document Pneumococcal Vaccination: A resident’s EMR showed signed consent for pneumococcal vaccination, but there was no documentation that the vaccine was offered or administered, and no MIIC review was found to verify prior immunization status. The DON stated MIIC is reviewed on admission and vaccines are then consented for and obtained if due, but the record for this resident did not show any pneumococcal doses.
A facility failed to ensure the most up to date RBOR was provided to each resident and displayed for residents, visitors, and staff to review. During observation, the RBOR posted by the memory care entrance was the 2009 revised version, and the campus executive director stated she was aware of changes to the [NAME] for assisted living but was not aware of the changes made to the RBOR.
Survey Results Not Accessible to Residents: A binder labeled "Survey Results" was observed in a wall-mounted holder near the front desk, but it was placed about five feet from the floor. The administrator stated that a resident in a wheelchair or a shorter resident would not be able to access it without assistance.
A facility failed to ensure a resident's resuscitation wishes, as indicated on a signed POLST, were accurately reflected in the EMR. The resident's POLST indicated a wish for CPR, but a verbal order in the physician's orders indicated a DNR/DNI status, leading to confusion and inconsistency. Staff interviews revealed a lack of clarity and consistency in verifying and documenting the resident's wishes, and there was no documentation of discussions or updates regarding changes in resuscitation wishes.
The facility failed to cool meat properly, maintain cleanliness of the ice and water machine, and ensure the dish machine reached proper temperatures. A turkey was improperly cooled, risking bacterial growth. The ice machine had mineral buildup, and the dish machine did not reach correct temperatures, with staff not following infection control techniques.
A resident with multiple diagnoses, including diabetes and arthritis, was found with medications at their bedside without a completed self-administration assessment. The facility failed to document consistent medication usage and lacked a physician's order for one of the medications. Nursing staff were unaware of the medications at the bedside, and the assessment was only initiated after the observation.
The facility failed to follow proper infection control protocols for a resident with C. diff, as staff did not consistently adhere to contact precautions and hand hygiene requirements. Additionally, improper glove use and hand hygiene were observed during personal care for another resident. The facility's infection control policies were outdated, and staff interviews revealed a lack of adherence to expected protocols, posing potential risks of infection spread.
The facility failed to ensure that three residents were offered and/or provided updated pneumococcal vaccinations and one resident was not offered an influenza vaccine, as per CDC recommendations. The medical records lacked documentation of consent, declination, and shared clinical decision-making for additional vaccinations. The infection preventionist confirmed the use of CDC guidelines but could not locate necessary documentation. The facility's policy required offering vaccines and documenting education, but these were not followed, leading to the noted deficiencies.
A resident recovering from joint replacement surgery was unable to reach their call light, which had fallen to the floor, leading to a delay in receiving assistance for knee pain. Staff interviews revealed that the call light was not secured as required by facility policy, and the oversight was acknowledged by the nursing staff.
A resident with a known cinnamon allergy was served food containing cinnamon on multiple occasions, including a snickerdoodle cookie and cinnamon raisin bread. The facility's meal ticket system failed to prevent the selection of allergenic foods, and there was no policy in place regarding food allergies. The resident experienced tongue swelling after consuming the cookie, and staff were unaware of the allergy when preparing and serving meals.
The facility failed to develop person-centered baseline care plans and implement individualized fall interventions for three residents admitted with fall risks. The care plans lacked specific interventions for cognitive impairments, cardiovascular diagnoses, and other medical conditions, leading to falls shortly after admission.
The facility failed to assess fall risk and implement individualized interventions for three residents, leading to multiple falls. One resident with a femur fracture and history of falls was not properly assessed, resulting in a fall shortly after admission. Another resident with a traumatic brain injury fell twice due to inadequate supervision and assistance. A third resident with a urinary tract infection and fall history fell after attempting to self-transfer, lacking necessary adaptive devices and supervision.
Care Plans Not Kept Accurate for Multiple Residents
Penalty
Summary
The facility failed to keep comprehensive care plans accurate and revised for multiple residents whose conditions and care needs had changed. For R5, the admission and quarterly MDSs identified severe cognitive impairment, dependence with all ADLs, and a history of falls with major injury. However, the care plan still listed a stand lift with 2 staff for transfers and also included toileting transfer instructions using a walker and gait belt. Staff interviews showed inconsistent understanding of R5’s transfer needs, with one RN and two NAs describing one-staff assistance and noting that R5 sometimes attempted to transfer independently. For R8, the quarterly MDS identified severe cognitive impairment and dependence with ADLs. The care plan continued to list wandering behaviors and interventions related to Lorazepam even though staff and the CC confirmed R8 no longer wandered and was no longer receiving Lorazepam. The order summary showed Haloperidol had been started for agitation, hallucinations, and delusions, but the care plan did not include interventions, monitoring, or revisions related to the newly initiated antipsychotic medication. Staff interviews confirmed the wandering information was outdated and that the care plan required revision. For R10, the annual MDS identified severe cognitive impairment and extensive assistance with ADLs, and the EMR showed the resident used a motorized wheelchair throughout the facility and in the room. The comprehensive care plan did not address the motorized wheelchair or related safety considerations and staff interventions. For R40, the care plan still listed assistance with bathing, grooming, repositioning every two hours, and antiplatelet-related monitoring, while the quarterly MDS and physician orders showed the resident was cognitively intact, independent with transfers and several ADLs, and not taking an anticoagulant; staff also stated R40 was independent with toileting, bathing, hygiene, transfers, and repositioning. For R47, the annual MDS showed dependence for eating, oral hygiene, and all other ADLs, but the care plan listed only set-up assistance for eating and oral care and still referenced trazodone for insomnia even though physician orders did not include it. Observation and staff interview showed R47 required full assistance to eat and drink and did not use adaptive equipment. For R7, the quarterly MDS showed moderate cognitive impairment and dependence or partial assistance with several ADLs, but the care plan contained conflicting and inaccurate instructions for eating, toileting, transfers, wheelchair foot pedals, and sling padding. Observation showed R7 was transferred with a ceiling lift and two staff, had no sling padding observed, had feet sliding on the floor because foot pedals were not in place, and was eating independently after set-up despite the care plan listing different levels of assistance.
Failure to Provide Ongoing Resident Activities
Penalty
Summary
The facility failed to ensure an ongoing program of activities was provided to meet residents’ assessed needs, interests, and abilities for 4 of 5 residents reviewed for activities. Record review and observations showed that residents with varying cognitive levels and multiple diagnoses were repeatedly observed sitting alone in their rooms or beds with no activity materials or staff interaction present, despite documented preferences for one-to-one visits, escorted activities, religious services, music, reading, games, and other individualized or group activities. R6 had intact cognition and diagnoses including arthritis, macular degeneration, overactive bladder, cervicalgia, and bilateral sensorineural hearing loss. R6 was observed multiple times sitting in a recliner or bed with no activity materials or staff interaction. During one observation, R6 asked the surveyor to visit because it broke up her day and later stated she was going crazy just sitting in her room all day and liked to talk to people. R6’s activity interests assessment listed preferences such as one-to-one visits, being invited or escorted to activities, pastoral care, pet visits, Protestant worship services, and watching television or movies, but the activity documentation from 2/12/26 through 2/25/26 did not show participation in any activity and did not show individualized or in-room activities being offered. R10 had severe cognitive impairment and diagnoses including stroke, aphasia, hemiplegia, and depression. R10 was repeatedly observed in her room in a motorized wheelchair or bed watching television, looking outside, or eating breakfast, with no activity materials or staff interaction present. Her activity interests assessment listed many preferences, including adult coloring, bingo, crafts, devotions, exercise, music, parties, pet visits, resident council, singing, table games, trivia, walking, and watching television or movies, but the activity documentation from 2/12/26 through 2/25/26 did not show participation in any activity or evidence that individualized or in-room activities were offered. R13 had moderate cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, anemia, and non-Alzheimer’s dementia. R13 was observed repeatedly sitting in her recliner or chair with her eyes closed and no activity materials or staff interaction present. She stated she was going stir crazy because she was not able to leave her room. Her activity interests assessment listed preferences such as baking, being outdoors, Bible study, bingo, card games, Catholic communion, devotions, escorted activities, Eucharistic ministry visits, happy hour, Mass, music, reading, reminiscing, resident council, singing, table games, and watching television or movies, but the activity documentation from 2/12/26 through 2/25/26 did not show participation in any activity or evidence of individualized or in-room activities being offered. R42 had severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, arthritis, non-Alzheimer’s dementia, depression, and chronic pain. R42 was observed multiple times sitting in a wheelchair or lying in bed with eyes closed, and at one point staff assisted her with eating breakfast while remaining in the room. Her activity interests assessment listed one-to-one visits, being outdoors, escorted activities, Methodist services, newspapers, reading, and watching television or movies, but the activity documentation from 2/12/26 through 2/25/26 showed no participation in any activity and no documented evidence that individualized or in-room activities were offered. Staff interviews indicated activities had not been occurring for several weeks due to COVID, although activity staff and nursing leadership stated activities were still expected to occur on a smaller scale and be documented.
Visible Catheter Drainage Bag Exposed Resident's Privacy
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect by maintaining privacy of a urinary catheter drainage bag. R10’s annual MDS identified severe cognitive impairment and a need for assistance with ADLs. R10’s diagnoses included stroke, atrial fibrillation, heart failure, hypertension, peripheral vascular disease, GERD, diabetes mellitus, aphasia, hemiplegia, depression, COPD, aphasia following cerebral infarction, dysphasia, edema, acquired absence of the right leg above the knee, and a cardiac pacemaker. A physician order dated 2/24/26 indicated R10 had a Foley catheter, the collection bag was to be kept below the bladder, not rest on the floor, and a dignity bag was to be in use at all times. Observations on 2/24/26, 2/25/26, and 2/26/26 showed R10 sitting in a wheelchair with the catheter drainage bag hanging from the side of the wheelchair without a dignity cover. The bag contained straw-colored liquid and was visible from the hallway and to individuals walking past the room. During interviews, NA-D confirmed the bag was visible and stated it should typically be placed in a privacy or dignity cover when the resident was in areas visible to others, but R10 did not have a dignity bag available. CC-B confirmed catheter drainage bags should be covered or positioned to maintain dignity and prevent unnecessary exposure, and the DON stated catheter drainage bags were expected to be covered at all times to maintain resident privacy and dignity.
Missed Timely Care Conferences and Resident Participation in Care Planning
Penalty
Summary
The facility failed to ensure residents were given the opportunity to participate in the development and review of their person-centered plans of care through timely care conferences for 2 of 7 residents reviewed, R8 and R19. R8’s quarterly MDS identified severe cognitive impairment and need for assistance with ADLs, and R19’s quarterly MDS identified moderate cognitive impairment and need for assistance with ADLs. Both residents had multiple chronic diagnoses, including dementia-related conditions and other significant medical problems. Review of the EMR showed R8’s most recent care conference was completed on 4/10/25, with subsequent conferences due in July 2025, September 2025, and December 2025 per facility practice, but there was no documented evidence that the facility scheduled, conducted, or attempted to schedule those conferences or provided R8 and/or the resident representative the opportunity to participate at the time of survey. For R19, the EMR showed the most recent care conference was completed on 7/29/25, with subsequent conferences due in November 2025 and February 2026 per facility practice, but there was no documented evidence that the facility scheduled, conducted, or attempted to schedule those conferences or provided R19 and/or the resident representative the opportunity to participate at the time of survey. During interview, SS-B confirmed the care conferences had not been completed within the expected timeframe and acknowledged there was no documentation of attempts to contact the family to schedule them. The DON stated care conferences were expected quarterly or with a significant change in condition and that attempts to contact the resident’s family or representative should be documented in the progress notes. The facility policy stated the plan of care would be discussed with the resident and/or representative at regularly scheduled care plan conferences and that the facility would make an effort to schedule the conference at the best time of day for the resident or representative.
Failure to Document AMA Discharge
Penalty
Summary
The facility failed to document an AMA discharge for one resident who left the facility after an unplanned discharge. The resident, R76, was admitted following a hospital stay and had diagnoses including lumbar vertebra compression fracture, depression, hallucinations, and peripheral vascular disease. Progress notes showed the resident became agitated and physically aggressive toward staff, and staff attempted to redirect the resident unsuccessfully. The resident was also noted attempting unsafe self-transfers, and an EMR medication administration note documented that the resident left AMA. Review of the EMR failed to show that the resident was discharged from the facility, and there was no documentation that the medical provider and/or family were notified of the AMA discharge. The record also did not show that the resident received education or was presented with an AMA form for signature. Staff interviews stated that when a resident discharged AMA, the resident or representative was to sign an AMA form, the provider and family/resident representative were to be updated, and all of this was to be documented in the EMR. The facility policy stated that the resident and family/legal representative should be informed of the risks, benefits, and alternatives, the physician should be notified of the intended AMA discharge, and documentation of the notification should be entered into the nurses notes.
Failure to Notify Ombudsman of AMA Discharge
Penalty
Summary
The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for 1 of 2 residents reviewed for discharge, R76. R76’s MDS indicated admission to the facility from a hospital stay and a later discharge MDS indicated an unplanned discharge. R76 had diagnoses including lumbar vertebra compression fracture, depression, hallucinations, and peripheral vascular disease. Review of the December 2025 and January 2026 Ombudsman notifications sent by the facility did not show that the Ombudsman office was notified of R76’s discharge. The EMR showed R76 did not receive evening medications on 12/18/25 because the resident discharged against medical advice (AMA). During interviews, the SW stated Ombudsman notifications were sent for residents who discharged or were hospitalized, but not for residents who discharged AMA. The NHA stated she knew R76 discharged AMA but was not aware the Ombudsman office needed to be informed of an AMA discharge. The DON stated the Ombudsman was to be notified of any resident who was hospitalized or discharged, including residents who discharged AMA, for resident safety. The facility’s Transfer and Discharge (including AMA) policy dated 2/2025 indicated the facility would provide transfer/discharge notice to the ombudsman.
Individualized Care Plan Not Developed for Substance Use and Trauma History
Penalty
Summary
The facility failed to ensure that R19’s comprehensive care plan was individualized and resident-specific. R19’s quarterly MDS identified moderate cognitive impairment and a need for assistance with ADLs. R19’s diagnoses included non-traumatic brain dysfunction, Alzheimer’s disease, heart failure, hypertension, obstructive uropathy, diabetes mellitus, anxiety disorder, depression, insomnia, constipation, reduced mobility, long-term anticoagulant use, alcohol abuse, obstructive sleep apnea, and atrial fibrillation. Review of the comprehensive care plan, printed 2/25/26, showed a focus area for Substance Use that stated the resident had a history of substance use disorder, but it did not identify the resident’s specific substance use history, triggers, risks, or individualized interventions for staff to follow. The care plan also included a Trauma focus area stating the resident had a history of trauma that affected them negatively, but it did not describe the trauma history, identify potential triggers, or include individualized trauma-informed care approaches. During interview, the CC-F stated care plans should be updated when there was a change in condition and reviewed at least quarterly, and confirmed the care plan contained generic areas that were not person-centered. The DON also acknowledged the care plan contained templated focus areas and should have been individualized to reflect the resident’s specific needs and history.
Failure to Provide Needed ADL Assistance for Bathing, Nail Care, and Shaving
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for activities of daily living received needed bathing, grooming, oral care, and nail care services. One resident with severe cognitive impairment, dementia, anxiety, hypertension, chronic pain, insomnia, and major depression was assessed as dependent for personal hygiene, oral care, bathing, and all other ADLs. The resident’s care plan directed total assistance for bathing and oral care and extensive assistance for dressing and hygiene/grooming tasks, yet observations showed long fingernails with dark brown/black substance under the nails on multiple days. During morning care, a nursing assistant dressed the resident, changed the incontinent brief, applied deodorant, and assisted with oral care, but the resident brushed her hair with a toothbrush and the assistant did not provide a clean replacement toothbrush after it was used for hair. The assistant also stated that underarms, under breasts, and the peri-area were not usually washed with soap and water during partial bathing so the resident would not fuss, and that nail care beyond cutting and cleaning only happened on bath day. The RN and DON stated that partial bathing should include washing the face, hands, underarms, under breasts, and peri-area with soap and water, and that nails should be trimmed and cleaned during routine care. A second resident with dementia, insomnia, and weakness was dependent on staff for eating, oral hygiene, and all other ADLs and required total assistance for hygiene and grooming tasks. Observations showed coarse white facial hair covering the cheeks, chin, upper lip, and under chin over several days, and the hair remained unchanged during later observation. Family stated the resident’s spouse sometimes helped shave him, but not daily, and believed staff expected family to do it. Staff gave mixed statements about who provided shaving, while the clinical coordinator and DON stated residents should be assisted with shaving as frequently as desired and according to personal preference. The care plan did not include the resident’s preference for grooming frequency.
Unmonitored Skin Concern and Unsafe Wheelchair Transport
Penalty
Summary
The facility failed to identify, assess, and monitor a new skin concern for one resident with dementia, diabetes, and weakness who was dependent on staff for eating, oral hygiene, and all other ADLs. The resident’s physician orders included weekly skin assessments on bath day, but the care plan did not instruct staff to observe the skin or identify who to report concerns to, and no interventions were noted for the resident’s right thumb. The skin assessment documented no new skin alterations and did not include the dark, round, raised area next to the nail on the resident’s right thumb as a previously noted skin alteration. Review of the resident’s TAR and nurse notes for the month showed no monitoring of the dark, round, raised area on the right thumb and no documentation that the provider or NP was notified. During observation, the area was seen on the resident’s right thumb and remained unchanged on a later observation, with the resident denying pain. A family member stated the family was aware of the blood blister but did not know how or when it occurred and had not alerted the facility when it was noticed. A nursing assistant later stated the area had been noticed over the weekend and reported to the nurse, while another nursing assistant was not aware of any skin changes for the resident. The facility also failed to ensure safe wheelchair mobility for one resident with moderate cognitive impairment and multiple diagnoses including non-traumatic brain dysfunction, Alzheimer’s disease, heart failure, hypertension, diabetes mellitus, reduced mobility, and atrial fibrillation. During two observations, staff assisted the resident to the dining room in a wheelchair without foot pedals in place, and the resident’s feet were seen sliding or bouncing on the floor while the wheelchair was moving. The care plan lacked documentation for use of wheelchair foot pedals when staff assisted the resident with mobility, and staff interviews confirmed that foot pedals were expected to be used when pushing a resident in a wheelchair.
Failure to Follow Heel Offloading Interventions
Penalty
Summary
The facility failed to ensure interventions in the comprehensive care plan were carried out to prevent recurrence of pressure ulcers for a resident with intact cognition who required assistance with all ADLs and had diagnoses including type 2 diabetes mellitus with diabetic neuropathy and arthritis. The resident previously had a stage 3 pressure ulcer on the left heel that was documented as healed, but the EMR noted the resident remained at risk for skin breakdown and recurrence. The care plan included elevating the resident's heels on a heel manager when in bed and floating the heels on two pillows when in a recliner. Observations showed the resident repeatedly reclined in a chair with the legs elevated but without the required pillows under the legs, and the heels were resting directly on the recliner foot rest. This was observed multiple times over two days, including while breakfast was being delivered. On one observation, a single pillow was present, but the heels still rested on the foot rest. Staff interviews confirmed the resident had prior heel sores that had healed and that staff were expected to keep the heels floating and not touching the recliner. The DON stated staff were expected to follow the interventions in place to prevent recurring pressure ulcers, and the facility policy stated evidence-based prevention interventions would be implemented for residents at risk or with a pressure injury present.
Failure to Follow Ambulation Care Plan
Penalty
Summary
The facility failed to follow a therapy-recommended ambulation program for a resident whose quarterly MDS indicated intact cognition and a need for supervision or touch assistance with ambulation. The resident did not participate in a restorative nursing program, and the care plan directed staff to assist him to ambulate to meals with a front wheeled walker and to provide walking assistance with restroom use. The resident’s diagnoses included ataxia, nontraumatic intracerebral hemorrhage, and heart failure. During observations on multiple occasions, the resident propelled himself in a wheelchair from his bedroom to the dining room, and staff made no attempts to ask him to ambulate to meals. The resident stated he used to walk to meals but was no longer doing so, said staff did still offer but not like they used to, and reported that when he asked staff to walk with him they often had reasons not to and he stopped asking. Nursing assistant and nursing leadership interviews confirmed the resident was supposed to receive ambulation assistance to and from meals, that assistance should be offered and reoffered if refused, and that no progress notes were found documenting refusals. The DON stated that when therapy recommended an ambulation program, the resident should be assisted according to the care plan, and if the resident refused, staff should document it and notify family and therapy.
Failure to complete fall analysis and neurological monitoring after resident falls
Penalty
Summary
The facility failed to ensure a root cause analysis was completed after a fall to determine interventions to prevent additional falls, and failed to continue to assess for changes after a head injury per policy for one resident with severe cognitive impairment who was dependent on staff for all ADLs, including transfers and bed mobility. The resident’s diagnoses included non-traumatic brain dysfunction, Alzheimer’s disease, hypertension, diabetes mellitus, arthritis, a history of fractures, anxiety disorder, depression, metabolic encephalopathy, and paroxysmal atrial fibrillation. The resident had a documented fall on 8/5/25 when she slid from a chair onto the carpet while attending a musical activity; staff assessed her for injury and pain, noted ROM unchanged, and assisted her back to bed. On 8/8/25, staff assisted the resident out of bed and brought her to the common area for dinner, then left briefly to assist another resident with a bathroom transfer. While staff were away, another staff member observed the resident lying on the floor. Staff found her on her right side about three feet from her wheelchair, with the leg rest extended, bleeding from the nose and with a forehead laceration. Staff reported she had hit her head. She was sent to the ED, where CT scans of the head, face, pelvis, and spine were completed and reported as normal, and she received seven stitches to the forehead and top of the nose. The record documented the fall and hospital transfer, but did not include a root cause analysis of the fall or changes to the care plan to prevent future falls. The resident had another fall on 10/23/25 when she was found on the floor beside her bed with a skin tear to the right outer eyebrow, ongoing bleeding, left hand weakness, and a hematoma at the base of the left fifth finger. She was unable to describe what happened and was sent to the ED for further evaluation, where she was diagnosed with a closed displaced fracture of the shaft of the fifth metacarpal bone of the left hand and head injury. Facility IDT notes later described her as impulsive and noted she had attempted to self-transfer out of bed. Interviews with staff and leadership confirmed that after falls, interventions were expected to be implemented and neurological assessments were expected when a resident hit their head or when a fall was unwitnessed, but neurological assessments were not initiated or completed following the resident’s falls on 8/8/25 and 10/23/25.
Infection Control During Nebulizer Treatment
Penalty
Summary
The facility failed to ensure appropriate infection control practices were followed for one resident diagnosed with COVID-19 who received a nebulizer treatment. The resident’s face sheet, printed 2/26/26, listed COVID-19 with a diagnosis date of 2/18/26. During observation on 2/25/26 at 8:30 a.m., an LPN entered the resident’s room after donning PPE, left the room door fully open, set up the nebulizer, applied the face mask, and turned the machine on. At 8:41 a.m., the LPN turned off the nebulizer, cleaned the face mask and medication container with water, and placed them on a towel on the counter in the resident’s room before leaving and removing PPE. During interview, the LPN stated she was not aware of special instructions when administering aerosol breathing treatments to a resident diagnosed with COVID. The CC stated the resident was not assessed to self-administer the nebulizer and the facility did not have AIIR rooms, but expected the bedroom door to be kept closed during the treatment and for at least 15 minutes afterward. The DON also stated she expected the resident’s room door to be closed before the nebulizer treatment and remain closed for at least 15 minutes after it was finished. The facility’s COVID-19 Prevention, Response and Reporting policy dated 1/2025 stated aerosol-generating procedures should be performed cautiously, avoided if possible, and should take place in an AIIR if possible, with only essential HCP present.
Failure to Offer or Document Pneumococcal Vaccination
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was deficient because the facility did not ensure one of five residents reviewed for immunizations was offered and/or provided the pneumococcal vaccination series as recommended by the CDC. R5’s face sheet showed the resident was [AGE] years old, and the immunization record did not show any pneumococcal vaccine doses. R5’s EMR contained a signed consent dated 8/6/25 indicating the family consented to pneumococcal vaccination, but the record did not show the vaccine was offered or administered. The EMR also did not show that R5’s MIIC record was reviewed for prior vaccinations before admission. During interview, the DON stated that MIIC is reviewed on admission, consent is obtained after education if vaccinations are due, and the dose is then obtained from the pharmacy and administered. The DON reviewed R5’s EMR and could not locate the MIIC report or any indication that R5 had received pneumococcal vaccines. The facility policy dated 1/2026 stated each resident would be assessed for pneumococcal immunizations upon admission and offered a pneumococcal immunization unless medically contraindicated or already immunized.
Resident Rights Notice Not Updated
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident and displayed for residents, visitors, and staff to review. During observation on 2/25/26 at 3:45 p.m., the RBOR displayed by the memory care entrance was the year revised 2009 version. During interview on 2/25/26 at 3:50 p.m., the campus executive director stated she was aware of the changes to the [NAME] for assisted living but was not aware of the changes made 12/22/25 to the RBOR.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that survey results were posted in an accessible location for residents, staff, and visitors. During observation, a three-ring binder labeled "Survey Results" was noted in a clear plastic holder screwed to the wall to the left of the front desk, approximately five feet from the floor. During interview, the administrator stated that a resident in a wheelchair or a resident shorter than the height at which the binder was stored would not be able to access the binder without assistance, and stated, "It needs to come down a bit."
Failure to Accurately Reflect Resuscitation Wishes in EMR
Penalty
Summary
The facility failed to ensure that a resident's resuscitation wishes, as indicated on a signed POLST, were accurately reflected throughout the electronic medical record (EMR). This deficiency was identified during a review of the records for a resident who had passed away in the facility. The resident's POLST, signed and dated, indicated a wish for attempted resuscitation/CPR if found with no pulse and/or active breaths. However, a verbal order in the resident's physician's orders indicated a DNR/DNI status, which conflicted with the POLST. Interviews with staff revealed that there was confusion and inconsistency in the documentation of the resident's resuscitation wishes. The report highlights that the facility did not have or follow policies and procedures for implementing advance directives. Staff interviews revealed that there was a lack of clarity and consistency in verifying and documenting the resident's resuscitation wishes. The clinical coordinator and other staff members were unable to provide a clear reason for the discrepancy between the POLST and the EMR. Additionally, there was no documentation of any discussions or updates regarding changes in the resident's resuscitation wishes, and the facility failed to involve the provider to resolve the discrepancies. The deficiency was further compounded by the lack of a clear process for updating and verifying POLST forms and advance directives. Interviews with various staff members, including the interim DON, revealed that there were discrepancies between residents' code status in the EMR and their POLSTs. The facility's failure to ensure accurate and consistent documentation of resuscitation wishes had the potential to affect all residents in the facility, as it indicated a systemic issue with the management of advance directives and POLST forms.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to properly cool meat, specifically a whole turkey, in the main kitchen refrigerator, which was observed uncovered and undated. The turkey was intended for a turkey salad to be served three days later. The dietary director acknowledged that the turkey should have been broken apart and cooled to the proper temperature within the specified timeframe to prevent bacterial growth. The turkey was found to be at 46 degrees Fahrenheit, which was outside the safe cooling parameters, and the dietary director confirmed it should be discarded to avoid exposing residents with weakened immune systems to bacteria. Additionally, the facility did not maintain cleanliness in the second-floor kitchen's ice and water dispensing machine, which had visible mineral buildup and brownish particles. The dietary aide used this machine to dispense ice for residents, and the dietary director confirmed that the machine should be cleaned daily and maintenance should be notified of any buildup. The maintenance director was aware of ongoing issues with the machine but had not received recent specific concerns. The facility's policy required regular cleaning of the machine to prevent contamination. The dishwashing process in the first-floor kitchen was also deficient, with the dish machine not reaching the proper rinse temperatures and staff not following appropriate infection control techniques. The dish machine's temperature sensor showed incorrect readings, and an error code was displayed, indicating a need for maintenance. Staff were observed using the same gloves for handling both dirty and clean dishes, and dishes were not dried properly before being stacked. The dietary director and maintenance director confirmed these issues, and the facility's policy required proper hand hygiene and equipment handling to prevent contamination.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medications assessment was completed for a resident, identified as R9, who was observed with medications at their bedside. R9 was cognitively intact and had multiple diagnoses, including palliative care, depression, hypertension, renal disease, lymphedema, diabetes mellitus with diabetic neuropathy, arthritis, and osteoarthritis. Despite R9's cognitive status, the facility did not complete a self-administration assessment to determine if R9 could safely self-administer medications. R9's care plan also lacked direction related to medication self-administration. R9 was observed with Tums and Aspercreme at their bedside, and R9 reported using Tums for chest pain, which was effective. However, the facility's records did not indicate consistent documentation of Tums usage, and there was no physician's order for Aspercreme. Interviews with nursing staff revealed a lack of awareness and verification of medications at R9's bedside, and the self-administration assessment was only initiated after the observation. The facility's policy required a completed assessment and provider's orders for residents to self-administer medications, which was not adhered to in this case.
Infection Control Deficiencies in Hand Hygiene and Contact Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in managing contact precautions and hand hygiene for a resident diagnosed with Clostridium difficile (C. diff). The resident, who had severely impaired cognition and was on vancomycin treatment for C. diff, was observed in a room with signage indicating the need for contact and enteric precautions. However, staff did not consistently follow these precautions. A nursing assistant was seen exiting the resident's room without wearing a gown and using alcohol-based hand sanitizer (ABHS) instead of washing hands with soap and water, which is required for C. diff precautions. The assistant admitted to not understanding the difference between handwashing and using ABHS for this resident, despite training on transmission-based precautions. Another incident involved improper hand hygiene and glove use during personal care for a different resident. Two nursing assistants were observed assisting the resident with morning care without changing gloves between tasks or performing hand hygiene. One assistant used the same gloves to handle soiled linens, apply a clean brief, and perform other tasks, while the other assistant entered the room with gloves used in another resident's room and did not perform hand hygiene before assisting with perineal care. Both assistants acknowledged their failure to follow proper protocols, citing being in a hurry as a reason for the oversight. The facility's infection preventionist confirmed that several infection control policies were outdated and had not been reviewed annually as required. The interim director of nursing and other staff interviews highlighted expectations for proper hand hygiene and glove use, which were not met in these instances. The facility's policies clearly stated the need for handwashing with soap and water for residents with C. diff and emphasized that glove use does not replace hand hygiene, yet these protocols were not consistently followed, leading to potential risks of infection spread.
Failure to Ensure Updated Vaccinations for Residents
Penalty
Summary
The facility failed to ensure that three residents were offered and/or provided updated vaccinations for pneumococcal disease in accordance with CDC recommendations. Resident 9, who had chronic kidney disease and end-stage kidney disease, had previously received a PCV-13 vaccine but lacked documentation of consent or declination for further doses. The medical record did not include a discussion of shared clinical decision-making regarding additional pneumococcal vaccines. Similarly, Resident 20, with heart disease, alcohol abuse, and obstructive sleep apnea, had received prior pneumococcal vaccinations but lacked documentation of consent or declination for additional doses. The medical record also lacked a discussion of shared clinical decision-making for further vaccinations. Resident 30, who had diabetes, heart disease, and a history of breast cancer, declined the influenza vaccine for the current season and had previously received a pneumonia vaccine, but the record did not specify when or which vaccine was administered. The medical record lacked documentation of re-attempts at vaccination consent or declination for the current influenza season and did not include a discussion of shared clinical decision-making regarding pneumonia vaccinations. The facility's infection preventionist confirmed the use of the CDC's PneumoRecs VaxAdvisor to review eligibility for pneumococcal vaccinations but was unable to locate documentation of declinations or shared clinical decision-making for the residents involved. The interim director of nursing stated that the infection preventionist was responsible for overseeing immunizations, but any staff member could relay a resident's vaccination wishes. The facility's policy required offering influenza vaccines annually between October 1 and March 31 and pneumococcal vaccines upon admission, unless contraindicated or received elsewhere. The policy also directed staff to provide education on the benefits and potential side effects of immunizations and document the education and whether the resident received the immunizations. However, the facility failed to adhere to these policies, resulting in the deficiencies noted.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. The incident involved a resident who had been admitted following joint replacement surgery and had a history of falls. The resident required extensive assistance for daily activities and was at risk of falling. During an observation, the resident was found reaching for a call light that had fallen to the floor, making it inaccessible. The resident reported calling out for help for half an hour due to knee pain, but staff had not responded. Interviews with staff revealed that the call light was not within reach because it had fallen off the bed, and staff had not checked on the resident adequately. The registered nurse and nursing assistants involved acknowledged the oversight, with one nurse stating that the call light was a critical safety line for residents. The interim director of nursing confirmed that call lights were expected to be within reach and secured to prevent such incidents. The facility's policy required staff to ensure call lights were accessible, but this was not adhered to in this case.
Failure to Prevent Serving Allergenic Food to Resident
Penalty
Summary
The facility failed to ensure that a resident with a known allergy to cinnamon was not served food containing the allergen. The resident, who had undergone hip and knee replacement, was documented to have a cinnamon allergy in her care plan. Despite this, she was served a snickerdoodle cookie containing cinnamon and a breakfast meal with cinnamon raisin bread. The resident reported experiencing tongue swelling after consuming the cookie, which she was unaware contained cinnamon until she took a bite. The breakfast meal was served without a meal ticket, and the toast was prepared by a dietary aide and finished by a nursing assistant, who was unaware of the resident's allergy. The facility's culinary director acknowledged that the meal ticket system, which was supposed to prevent residents from selecting allergenic foods, failed to catch the cinnamon raisin bread selection. Additionally, the facility lacked a policy regarding food allergies, and the resident's allergy was not communicated upon admission but was noted during her initial care conference. The director of nursing and a nurse practitioner expressed concern over the resident being served allergenic food, highlighting the potential for a serious allergic reaction.
Failure to Implement Individualized Fall Interventions for Residents
Penalty
Summary
The facility failed to develop a person-centered baseline care plan upon admission and did not assess, revise, or implement new fall interventions for three residents who were admitted with fall risks and sustained falls after admission. The report highlights deficiencies in the initial 48-hour baseline care plans for these residents, which lacked individualized interventions based on their specific needs and conditions. The care plans did not adequately address the residents' cognitive impairments, cardiovascular diagnoses, pain conditions, and other relevant medical issues. One resident, admitted with a left femur fracture and a history of falls, was found on the floor shortly after admission. The initial care plan did not specify the required assistance for toileting and transfers, nor did it address the resident's cognitive impairments and other medical conditions. Despite being identified as a fall risk, the care plan lacked individualized interventions to mitigate this risk, leading to a fall shortly after admission. Another resident, admitted with multiple fractures and a traumatic brain injury, also experienced falls after admission. The care plan did not address the resident's incontinence or specify the required assistance for activities of daily living. The resident's cognitive impairments and pain management needs were not adequately addressed, and the care plan lacked specific fall prevention interventions. Similarly, the third resident, admitted with a urinary tract infection and a history of falls, had a care plan that did not address the use of a suprapubic catheter or the resident's cognitive impairments. The lack of individualized fall prevention strategies contributed to a fall after admission.
Failure to Implement Individualized Fall Interventions
Penalty
Summary
The facility failed to comprehensively assess fall risk and implement individualized fall interventions for three residents, leading to multiple falls. Resident 1, admitted with a left femur fracture and a history of falls, was identified as a high fall risk. Despite this, the facility did not complete a fall risk assessment upon admission, and the baseline care plan lacked individualized interventions. Resident 1 fell shortly after admission, and the care plan was not updated with new interventions to prevent further falls. Resident 2, admitted with a left femur neck fracture and a traumatic brain injury, was also identified as a fall risk. The facility did not complete a fall risk assessment upon admission, and the baseline care plan lacked individualized interventions. Resident 2 fell twice after admission, and the care plan was not updated with new interventions to prevent further falls. The facility failed to provide adequate supervision and assistance, leading to Resident 2 attempting self-transfers and falling. Resident 3, admitted with a urinary tract infection and a history of falls, was identified as a fall risk. The facility did not complete a fall risk assessment upon admission, and the baseline care plan lacked individualized interventions. Resident 3 fell after attempting to self-transfer, and the care plan was not updated with new interventions to prevent further falls. The facility failed to provide necessary adaptive devices and supervision, contributing to Resident 3's fall.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,016 citations issued within 25 miles in the last 12 months — including the 33 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brooklyn Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maranatha Care Center | 2.1 mi | ★★★★★ | 3 | 0 |
| The Villas At Osseo Llc | 2.4 mi | ★★★★★ | 2 | 0 |
| Park River Healthcare And Rehabilitation Center Ll | 3.5 mi | ★★★★★ | 22 | 2 |
| Woodlake Healthcare And Rehabilitation Center | 4.2 mi | ★★★★★ | 10 | 0 |
| The Estates At Fridley Llc | 4.4 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.