Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Sauer Health Care during CMS and state inspections, most recent first.
A resident on blood thinners experienced a fall that reopened an existing wound, but the LPN on duty did not perform neurochecks or immediately notify a provider, instead documenting the event in a communication book for review the next day due to lack of on-call coverage. The next morning, an RN reported the resident had a severe headache and altered cognition and expressed concern for a possible brain bleed, confirming that neurochecks and timely provider notification had not occurred. Later, frank blood was noted in the toilet without immediate physician notification, despite the DON’s expectation that such findings, along with the resident’s anticoagulant use and cognitive impairment, should trigger neurochecks, prompt provider contact, and possible ED transfer. The DON and RN reported that the facility had not maintained 24-hour on-call physician services for several years, contrary to facility policy requiring continuous physician availability for emergencies.
A resident with cognitive impairment, multiple comorbidities, a pressure injury, and active warfarin therapy experienced an unwitnessed fall that reopened a coccyx wound, with bleeding noted. Post-fall assessments documented stable VS and no pain, but neuro checks were not initiated and the physician was not actually notified as recorded. Later that night, frank blood in the toilet was observed and documented without neuro checks or provider notification, and a subsequent note attributed the bleeding to a skin tear. The next morning, the resident was lethargic, oriented x2, reporting significant head pain and breakthrough bleeding, and was transferred non-emergently to the ED, where an elevated INR was found and warfarin dosing was adjusted. The care plan lacked anticoagulation management focus, and interviews with nursing staff and the DON confirmed that required neuro assessments and timely provider notification after the fall and subsequent bleeding did not occur, contrary to facility policies on change of condition and fall management.
Two residents who required mechanical lifts for transfers were transferred without comprehensive, documented assessments of sling and harness sizing or consistent use of required safety components. One resident with stroke‑related hemiparesis and impaired balance experienced an incident in a sit‑to‑stand lift when feet were not correctly positioned on the platform and the leg strap was not used, resulting in the resident hanging in the lift until assisted to the floor. Another resident with multiple sclerosis and generalized weakness was dependent on a Hoyer lift, but no individualized sling size assessment based on height, weight, girth, and tailbone‑to‑neck measurements was documented. Care plans and assignment sheets did not specify sling or harness sizes or leg strap use, CNAs reported they did not know how to determine correct sizes and that leg strap use was inconsistent, and the DON and RN acknowledged there was no formal, documented process for sling/harness sizing or monitoring for changes, despite manufacturer instructions and an OT and equipment representative stating that full assessments and leg strap use are required for safe transfers.
A resident with moderately impaired cognition, stroke, CHF, mobility limitations, and documented urinary incontinence was not provided an individualized toileting program despite facility policy requiring comprehensive bladder assessments and tailored interventions. On admission and thereafter, no comprehensive bowel/bladder assessment was completed, the CAA did not identify the type of incontinence, and the care plan lacked specific toileting interventions such as scheduled toileting or prompted voiding. Staff expected the resident to use the call light and did not routinely offer toileting assistance, while the resident reported walking to the bathroom independently, sometimes forgetting to use a walker and experiencing incontinence. Nursing staff and the DON confirmed that comprehensive assessments and individualized toileting plans were not performed, even though the resident was frequently incontinent.
A resident with intact cognition but significant post-stroke physical impairments, including hemiparesis, limited ROM, incontinence, impaired vision, and a history of falls, required extensive assistance from 1–2 staff for transfers and toileting using a gait belt, walker, or EZ Stand lift. Over a 14-day period, call light logs showed this resident’s call light remained active more than 15 minutes on 38 occasions, with an average response time of about 27 minutes and several waits exceeding 40 minutes, especially in early morning and other busy periods. The resident reported frequent waits of about an hour, inconsistent responses, and call lights being turned off without care, and described multiple incontinence episodes related to delayed assistance. NAs stated that call lights ideally should be answered within 5–10 minutes but acknowledged that residents could wait up to 30 minutes during busy times, and the DON confirmed repeated complaints of waits over 20–30 minutes while being unable to provide a facility call light response policy when requested.
Expired and improperly stored food was found in the kitchen refrigerator and freezer, including marinara sauce and pepperoni past their dates, plus thawing chicken breasts and ground beef that were not properly labeled or packaged. Dietary staff said the meat would be served later that day and stated it was safe to serve, while the D confirmed thawing foods should be in original packaging in a pan and cooked as soon as possible after defrosting.
A resident with severe cognitive impairment, an indwelling catheter, and hospice services was observed with an uncovered urine drainage bag visible from the hallway, and staff confirmed it should have been covered for dignity. The resident’s call light was also observed coiled on the wall and not within sight or reach, while staff and family confirmed it should have been kept accessible for the resident to use.
The facility failed to complete monthly orthostatic BP monitoring for two residents receiving Seroquel. One resident had diagnoses including HF, arthritis, dementia, and depression, and the EMR showed orthostatic BP documentation was missing for multiple months despite a care plan intervention for monthly monitoring. Another resident with vascular dementia, neuropathy, muscle weakness, AFib, and left-sided hemiplegia had MAR/TAR orders for monthly orthostatic BP checks, but several months were not completed and there was no documentation of attempts or refusals. Staff, the DON, IP, and MD stated monthly orthostatic BP monitoring was expected for residents on antipsychotics.
Delayed SCSA MDS After Hospice Initiation: A resident with severe cognitive impairment, total dependence for care, an indwelling catheter, and diagnoses including Lewy Body neurocognitive disorder and non-Alzheimer’s dementia was started on hospice, but the EMR did not contain a timely SCSA MDS after hospice services began. The RN, IPCP, and DON verified hospice admission and confirmed the required MDS was missing.
Failure to update the care plan after a community fall. A resident who used a motorized wheelchair and needed assistance with ADLs fell in the community and sustained a broken humerus and broken ankle. The record lacked an RCA, and the current care plan did not include updated resident-specific interventions for falls or wheelchair use in the community. The DON and administrator stated the RCA was not done because the fall occurred outside the facility, and the risk assessment and updated care plan were not completed.
Pharmacy consultant reviews failed to identify missing orthostatic BP monitoring for two residents receiving Seroquel. One resident had dementia, depression, and heart failure; the other had vascular dementia, neuropathy, atrial fibrillation, and stroke-related hemiplegia. Both care plans required monthly orthostatic BP checks, but multiple months were undocumented in the MAR/TAR and the pharmacist did not note the omissions or recommend completion during monthly reviews.
The facility failed to consistently implement EBP for two residents with urinary catheters and extensive hands-on care needs. A PT provided therapy and handled a Foley catheter bag without gloves or a gown despite EBP signage, and staff caring for another resident performed catheter care, wound care, incontinence care, transfers, dressing, and bedding changes while wearing gloves but not gowns. Interviews confirmed staff and the DON expected gowns and gloves during high-contact care, and the facility policy referenced gown and glove use for activities such as dressing, hygiene, transfers, linen changes, and urinary catheter care.
A facility failed to ensure proper PPE use when staff moved between rooms of residents with and without COVID-19. A dietary aide entered a COVID-19 positive resident's room with only an N95 mask, then proceeded to other rooms without changing PPE. Staff interviews revealed confusion about PPE requirements, despite facility policies and CDC guidelines mandating full PPE for COVID-19 rooms.
A facility failed to implement person-centered interventions for a resident with a history of falls and cognitive impairment. Despite multiple falls, the care plan was not updated with specific strategies, relying instead on generic reminders. Staff interviews confirmed the absence of individualized interventions, contrary to facility policy requiring updates to care plans based on fall risks.
Failure to Provide 24-Hour On-Call Physician Coverage and Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide or arrange 24-hour on-call physician services and to ensure timely provider notification and appropriate post-fall assessment for a resident on blood-thinning medication. After the resident, who was new to the facility and taking blood thinners, fell at 7:15 p.m. on 2/4/26, an LPN assessed the resident, noted that an existing wound on the resident’s bottom had reopened, and applied a dressing. However, neurochecks were not performed, and the provider was not notified immediately. Instead, the LPN documented the fall in a communication book for the provider to review during rounds the next day, stating that there was no on-call provider available. The facility’s own policy required 24-hour physician coverage for emergencies, including contacting the primary physician first, then the on-call physician, and, if necessary, the medical director, and transporting the resident to the ED if no physician was reachable and immediate assessment was required. On the following morning, an RN caring for the same resident reported that the resident requested transfer to the ED for a headache rated 7/10 and expressed concern for a possible brain bleed due to the recent fall, use of blood thinners, and altered cognition. The RN confirmed that neurochecks had not been performed after the fall and that the provider had not been notified immediately. The DON stated that, per facility expectations, staff should assess for injury, take vital signs, initiate neurochecks, notify the provider, inform the family, and document in risk management after a fall, and confirmed that these steps were not followed for this resident, who also had moderate cognitive impairment. At 2:05 a.m. on 2/5/26, frank blood was observed in the toilet, but staff still did not notify the physician immediately, despite the DON’s statement that this finding should have prompted an ED transfer due to increased risk of bleeding and that normal vital signs alone could not rule out internal bleeding. The DON and RN both confirmed that the facility had not had 24-hour on-call physician coverage for the past four years, and local providers did not round at the facility, have access to records, or provide on-call coverage, affecting all residents.
Failure to Assess and Notify Provider After Fall in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and notify the physician of a change in condition for a resident on anticoagulant therapy following a fall. The resident had moderately impaired cognition and multiple diagnoses including stroke, chronic heart failure, gait and mobility abnormalities, and a stage 2 pressure injury on admission. The care plan identified a self-care deficit and moderate fall risk with interventions for assisted ambulation, ADLs, and call light use, but did not include a focus on anticoagulation management with individualized goals and treatment management, despite active warfarin orders. On the evening of the fall, the resident self-reported an unwitnessed fall and was found in a recliner with a reopened coccyx wound and bleeding from the bottom. The post-fall assessment documented normal range of motion, no pain, orientation to person, and the resident’s denial of head strike, with predisposing factors including impaired memory, gait imbalance, and ambulating without assistance. Although documentation indicated multiple notifications, the physician was not actually notified at the recorded time, and neurological checks were not initiated, contrary to facility expectations for unwitnessed falls and residents on anticoagulants. A follow-up note in the early morning hours documented stable vital signs and no new physical findings, stated that the provider did not need to be notified, and lacked any neurological assessment. Later that night, frank blood in the toilet was observed by a nursing assistant, and a progress note recorded this change along with stable vital signs, but again lacked a neurological assessment and provider notification. A subsequent note indicated no blood after toileting and attributed prior bleeding to a skin tear from the fall. Later that morning, the resident was documented as lethargic, oriented x2, with breakthrough bleeding on the right gluteal/thigh region and head pain rated 7/10, and was transferred non-emergently to the ED. In the ED, the resident was noted to have fallen while on blood thinners, complained of head pain, and had an elevated INR of 5.3, with CT scans negative for acute changes and warfarin dosing later adjusted. The DON and nursing staff interviews confirmed that neuro checks were not initiated after the unwitnessed fall, the provider was not notified at the time of the fall or when frank blood was first noted, and that these actions were inconsistent with facility policies on change of condition and fall management, particularly for residents on anticoagulants.
Failure to Assess and Communicate Proper Sling/Harness Sizing and Leg Strap Use for Mechanical Lifts
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and document appropriate sling and harness sizes, and to consistently use required safety components (leg strap) for mechanical lift transfers, as required by manufacturer instructions. Two residents who depended on mechanical lifts for transfers were affected. One resident had intact cognition with a history of ischemic stroke, left hemiparesis, hemiplegia, unsteadiness on feet, impaired balance, limited mobility, incontinence, impaired vision, and a history of falls. This resident required substantial to maximal assistance for transfers and used a motorized wheelchair. The care plan and group assignment sheet directed staff to use a gait belt and walker or an EZ Stand sit‑to‑stand lift, and later referenced use of a pivot/EZ Stand for transfers, but did not identify the required harness size or whether the leg strap was to be used. For this resident, the clinical record lacked any comprehensive assessment for harness size that incorporated the resident’s weight and torso circumference where the harness is applied, as required by the manufacturer. The record also did not address whether the leg strap should be used. A fall report documented that the resident was elevated in an EZ Stand lift with both feet under him and the leg strap not in use; his feet slipped off the platform, leaving him hanging in the lift until a nurse supported his weight and repositioned his feet so he could be lowered to the floor. The resident reported that his foot did not get all the way on the platform, both feet slipped off because his shoe slipped, and he was hanging on until help arrived. The record did not include a comprehensive assessment identifying the size of sling required for use of a full body mechanical lift. In subsequent interviews, the resident and the RN who responded to the incident both described that the resident’s left foot slipped out of his shoe, both legs were trapped underneath him, he was not strong enough to hold himself up, and the leg strap was not believed to have been used. The second resident had intact cognition with diagnoses of multiple sclerosis, generalized weakness, repeated falls, dependence on a wheelchair, and impaired range of motion in both lower extremities. This resident was dependent on staff for transfers, used a motorized wheelchair, and required assistance of two staff with a Hoyer full body mechanical lift. The care plan did not identify the size of sling required for safe transfers, and the record lacked a comprehensive sling size assessment including height, weight, girth, and the distance from tailbone to base of neck, as required by manufacturer guidelines. The resident reported that two staff transferred her with a Hoyer lift and that she did not know what size sling was used, assuming staff would know. Multiple nursing assistants reported that sling and harness sizes were not identified on care plans, Kardexes, or assignment sheets for residents requiring mechanical lifts. They stated that each resident had a sling or harness in the room, but they were unable or unsure how to determine the correct size, and if a sling became soiled they would obtain another from the supply or linen room without a reliable method to select the appropriate size, especially when tags were worn or unreadable. One nursing assistant reported inconsistent use of the EZ Stand leg strap among staff and expressed concern that the leg strap should be used to prevent legs from slipping out. Another assistant who performed EZ Stand transfers stated she had not received training on use of the leg strap and was unfamiliar with it. The RN and DON confirmed that the facility did not complete formal, documented sling or harness size assessments, relied on a weight‑based reference chart in the linen room, did not document sling/harness size in the medical record, care plan, or assignment sheets, and had no system to monitor weight changes that might require size adjustments. The occupational therapist and the EZ Way lift representative both stated that a full patient assessment is required to determine appropriate accessory size and type, that the leg strap is essential or policy for safe EZ Stand use, and that sizing must be based on manufacturer charts using resident‑specific measurements such as weight, torso circumference, and tailbone‑to‑neck distance.
Failure to Implement Individualized Toileting Program for Incontinent Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, and implement an individualized toileting program to maintain or improve bladder continence for a resident with urinary incontinence and multiple comorbidities. On admission, the resident’s MDS documented moderately impaired cognition, a history of stroke, chronic systolic and diastolic heart failure, muscle weakness, unsteadiness on feet, fatigue, gait and mobility abnormalities, and a cognitive communication deficit. The resident required partial to moderate assistance with toileting hygiene and dressing, used a walker and wheelchair, and had occasional urinary incontinence while remaining continent of bowel. Despite these findings and the resident’s use of diuretics, no trial of a toileting program such as scheduled toileting, prompted voiding, or bladder training was initiated on admission. The record lacked a comprehensive bowel and bladder assessment, and the CAA identified frequent urinary incontinence with modifiable factors but did not specify the type of incontinence or translate these findings into specific toileting interventions. The resident’s care plan identified a self-care deficit related to congestive heart failure and noted the need for one-person assistance with ambulation, dressing, hygiene, bed mobility, and toileting, as well as frequent bladder incontinence, but it did not address urinary incontinence with individualized interventions or a toileting program. Bladder records showed a mix of continent and incontinent episodes over several weeks. Observation and interview revealed the resident ambulated to the bathroom independently without using the call light, sometimes forgetting to use the walker and experiencing incontinence when trying to reach the bathroom, and reported not receiving staff assistance with toileting. A nursing assistant confirmed staff expected the resident to use the call light and did not routinely check or offer toileting assistance. The RN and DON both acknowledged that comprehensive bowel and bladder assessments, including three-day assessments, were not completed to develop individualized toileting plans, and that although the resident was frequently incontinent, no individualized toileting interventions were in place, contrary to the facility’s urinary incontinence policy requiring comprehensive assessment and individualized toileting programs.
Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet a resident’s needs, resulting in repeated delayed responses to call lights and delayed care. The resident had intact cognition but significant physical impairments, including a history of cerebral infarction, hemiparesis/hemiplegia, unsteadiness on feet, limited range of motion on one side of the body, incontinence, impaired vision, and a history of falls. The resident’s care plan identified an ADL self-care deficit related to these conditions and specified that the resident required substantial to maximal assistance from one to two staff for transfers using a gait belt and walker or a PRN EZ Stand lift. The resident reported relying on staff assistance for transfers and toileting and stated that call lights were used primarily to get in or out of bed or to use the bathroom. Over a 14-day period, the facility’s call light log for this resident showed that the call light remained active for more than 15 minutes on 38 occasions, with an average response time of approximately 27 minutes and 40 seconds. The longest delays, including multiple waits exceeding 40 minutes, occurred most frequently in the early morning hours between 5:00 a.m. and 9:00 a.m., with additional prolonged waits around midday and late afternoon to early evening. The resident reported that call lights often took about an hour to be answered, that staff had told him lights should be answered within 5–7 minutes, and that this did not occur in practice. He also reported that some call lights were turned off without assistance being provided and that he had experienced multiple episodes of incontinence related to these long response times. Staff interviews further described inconsistent and delayed call light responses. A nursing assistant stated that call lights ideally should be answered within five minutes but acknowledged that during busy times such as early mornings, after lunch, and shift changes, residents might wait up to 30 minutes, and confirmed that this resident frequently complained about long waits. Another nursing assistant reported that staff should aim to answer call lights within 10 minutes but that this did not always happen and confirmed the resident’s frequent complaints. The DON acknowledged that this resident regularly complained of long call light response times, considered waits over 20 minutes to be a problem, and noted that the resident’s complaints typically involved waits over 30 minutes, which she reviewed with him using the call light log. The DON and nursing assistants were unaware that the resident had experienced incontinence episodes due to delayed responses, and the facility was unable to provide a call light response policy when requested.
Expired and Improperly Stored Food in Kitchen
Penalty
Summary
Food stored in the facility refrigerator and freezer was found to be unlabeled, undated, expired, and in some cases uncovered during a kitchen tour. Observations included marinara sauce dated 9/29/25 with crystallization on the top and lid of the container, pepperoni dated 6/30/25 that was brown in color with crystallization on the container lid, and thawing chicken breasts in an unmarked plastic bag with a date of 12/27. Three 5-pound tubes of ground beef were also observed thawing with a date of 12/27. During a later kitchen walkthrough, the thawing meat remained in the refrigerator. Dietary staff stated the hamburger would be served that evening and the chicken would be cut up and served in soup that evening. The outdated pepperoni was still in the freezer until it was removed and discarded after staff checked the date. Dietary staff stated the hamburger and chicken were safe to serve. The dietary director confirmed thawing foods should be in the original packaging in a pan, that the hamburger tubes would take no longer than 2 days to thaw and should be served as soon as possible after thawing, and that chicken breasts would take no longer than overnight to thaw and should be served as soon as possible. The administrator stated the facility had a food safety and thawing policy, and the policy stated food is cooked as soon as possible after defrosting.
Uncovered catheter bag and inaccessible call light
Penalty
Summary
The facility failed to maintain dignity for a resident with an indwelling urinary catheter. R6’s quarterly MDS, dated 10/17/25, identified severe cognitive impairment, dependence on staff for all cares, hospice services, and diagnoses including neurocognitive disorder with Lewy Bodies, non-Alzheimer’s dementia, Parkinson’s disease, and arthritis. During observation on 1/5/26, R6 was lying in bed with eyes closed, and an uncovered urine drainage bag attached to the bed frame was visible from the hallway. Two staff members later walked past the room while the bag remained visible. Staff interviews confirmed the bag should have been hidden from view or covered for personal dignity, and the IP stated staff, residents, and visitors should not have to see another person’s urine. The facility also failed to ensure R6’s call light was accessible. During the same observation, the call light was coiled up and hanging on the wall next to the wall unit, not in sight or reach of the resident. Two staff members walked past the room later that day while the call light remained out of reach. Staff interviews confirmed the call light should have been within arm’s reach and within sight at all times, and the RN stated R6 had used the call light. FM-A stated the call light gave R6 comfort and that R6 used to use it. The facility did not provide the requested policy on call light placement and reasonable accommodation of needs.
Failure to Complete Monthly Orthostatic BP Monitoring for Residents on Antipsychotics
Penalty
Summary
The facility failed to complete required medication side effect monitoring for two residents who were receiving antipsychotic medications. For one resident, the quarterly MDS identified intact cognition, substantial assistance needs for toileting and personal hygiene, and no rejection of care. That resident had diagnoses including heart failure, arthritis, dementia, and depression, and was ordered quetiapine 50 mg at bedtime for major depressive disorder. The care plan identified use of Seroquel for hallucinations related to major depressive disorder with severe psychotic features and included monthly orthostatic blood pressure monitoring, but the EMR and monthly TARs showed orthostatic blood pressures were documented only in August and October, with no documentation found for the other reviewed months. For the second resident, the quarterly MDS showed no cognitive impairment and no behaviors, with partial to moderate assistance needed for personal and toileting hygiene and independence with chair-to-chair transfers. Diagnoses included vascular dementia, neuropathy, muscle weakness, atrial fibrillation, and left-sided hemiplegia from a stroke. The resident’s MAR included Seroquel 25 mg daily at 2 p.m. and 50 mg daily at 8 p.m., along with an order to obtain orthostatic blood pressures monthly. The TAR showed orthostatic blood pressures were not completed for March, April, June, July, November, and December, and the vital signs record and progress notes lacked documentation that the measurements were attempted or refused. During interviews, nursing staff, the DON, IP, and MD stated orthostatic blood pressures were expected monthly for residents taking antipsychotics and were used to monitor for medication effects and adverse drug events. Staff also stated that if a measurement was missed, it should be retried, and that missed tasks should be completed within the month. The facility policy on psychotropic medication management stated that orthostatic blood pressure monitoring would be completed as indicated for antipsychotic use in residents who were ambulatory or able to attempt to stand unassisted.
Delayed SCSA MDS After Hospice Initiation
Penalty
Summary
The facility failed to ensure a Significant Change in Status Assessment (SCSA) MDS was completed in a timely manner when hospice services were initiated for one resident. The resident’s quarterly MDS identified severe cognitive impairment, dependence on staff for all cares including oral hygiene, toileting, dressing, and turning side-to-side in bed, and an indwelling catheter. The resident’s medical conditions included neurocognitive disorder with Lewy Bodies and Non-Alzheimer’s Dementia, and the resident was also on hospice for end-of-life care. The EMR showed an admission MDS dated 1/13/25 and quarterly assessments dated 4/10/25 and 7/11/25, but no SCSA MDS was completed after hospice services began. During interviews, the RN stated the resident started hospice services in April 2025, and the IPCP and DON verified the resident was admitted to hospice on 4/17/25 and that the EMR lacked the required MDS SCSA.
Failure to Update Care Plan After Community Fall
Penalty
Summary
The facility failed to monitor, review, and update the care plan with resident-specific interventions after a fall for one resident, R23. R23’s quarterly MDS assessment dated 10/22/25 identified no cognitive impairment, use of a motorized wheelchair for mobility, and need for set up assistance for eating and hygiene, partial/moderate assistance for bed-to-chair transfers, and substantial/maximal assistance for dressing and bathing. The admission care plan dated 1/8/24 identified a fall risk with interventions including proper non-skid footwear and calling for assistance when help was needed. A later care plan dated 2/23/24 noted that R23 used an electric wheelchair throughout the facility and in the community, with interventions including a flag on the wheelchair, notifying staff when leaving the facility, and using sign-out and sign-in sheets. On 1/9/25 at 13:05, R23 fell in the community while in the motorized wheelchair and sustained a broken humerus and broken right ankle. The record lacked a root cause analysis of the fall, and the current care plan did not contain updated resident-specific interventions for falls or for use of the motorized wheelchair in the community. During interviews, the DON stated an RCA was not done because the fall occurred outside the facility and said the care plan should have been updated after the significant change MDS on 1/16/25. The administrator also confirmed that the RCA was not done because the fall did not happen at the facility, and that a risk assessment and updated care plan were not completed. A policy titled Falls Prevention and Management dated 1/4/25 stated that for any falls that may occur, witnessed, unwitnessed, or intercepted, evaluation, documentation, care plan, and task list must be followed.
Pharmacy consultant failed to identify missing orthostatic blood pressure monitoring for residents on antipsychotics
Penalty
Summary
The facility failed to ensure the pharmacy consultant identified irregularities during monthly drug regimen reviews for 2 residents who were receiving antipsychotic medications. Facility policy stated the pharmacist review involved a thorough review of the resident record and reporting findings with recommendations for improvement, including monitoring specific items such as blood pressure when ordered or indicated. Another facility policy on psychotropic medication management stated the pharmacy consultant would monitor drug therapy monthly with recommendations to the provider as indicated. One resident had diagnoses including heart failure, arthritis, dementia, and depression, and was ordered Quetiapine Fumarate (Seroquel) 50 mg at bedtime for major depressive disorder. The resident’s care plan identified use of Seroquel to manage hallucinations related to major depressive disorder with severe psychotic features and required monthly orthostatic blood pressures. Pharmacy reviews from June 2025 through December 2025 did not identify the missing orthostatic blood pressures. RN-C, the DON, and the IP reviewed the record and confirmed orthostatic blood pressures were not documented for June, July, September, November, and December 2025. The second resident had diagnoses including vascular dementia, neuropathy, muscle weakness, atrial fibrillation, and left-sided hemiplegia from a stroke, and received Seroquel 25 mg daily at 2 p.m. and 50 mg daily at 8 p.m. The care plan required monthly orthostatic blood pressures and pharmacist monitoring. The MAR/TAR showed orthostatic blood pressures were not completed for March, April, June, July, November, and December 2025, yet pharmacy reviews from January 2025 through December 2025 did not note the missing measurements or recommend they be completed. The DON confirmed the missing orthostatic blood pressures, and the pharmacist stated she would recommend completion if she noticed they were missing during monthly reviews.
Failure to Use EBP During Hands-On Resident Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were implemented in accordance with CDC recommendations for 2 residents with indwelling urinary catheters and other conditions requiring extensive hands-on care. One resident was admitted for short-term rehabilitation with diagnoses including epilepsy, seizures, stroke, diabetes, urinary tract infections, and a Foley catheter after failing two voiding trials. During therapy observation, the PT entered the room wearing only a surgical mask and provided hands-on assistance with standing, sitting, lifting the resident’s legs into bed, and handling the Foley catheter bag without gloves or a gown, even though an EBP sign was posted on the door. The DON later confirmed the resident was to be on EBP and that staff should use gown, gloves, and mask for hands-on care. A second resident had moderate cognitive impairment, required extensive assistance with activities of daily living, had an indwelling urinary catheter, pressure injuries, bowel and urinary incontinence, paraplegia, and neuromuscular bladder dysfunction. The resident’s care plan and treatment orders included catheter care, drainage bag and tubing changes, flushing the catheter, wound dressings, repositioning, and extensive staff assistance for daily care. During observation, staff performed multiple tasks including catheter bag changes, catheter care, wound care, incontinence care, repositioning, dressing, transfers, and bedding changes while wearing gloves but not gowns, despite EBP signage being present outside and inside the room and gowns being available nearby. Interviews showed staff understood some PPE expectations but did not consistently follow them. NA-E stated gowns and gloves are worn during catheter care and wound care and later acknowledged staff technically should have worn gowns when getting the resident ready for the day. TMA-A stated staff should wear gown and gloves for catheter care, while RN-A stated the resident was on EBP due to the urinary catheter and that staff should wear PPE when changing urinary bags or performing catheter care. The DON stated staff receive infection control training and that gowns and gloves should be worn during high-contact activities, and the facility policy referenced gown and glove use for high-contact care activities including dressing, bathing, transferring, hygiene, linen changes, and urinary catheter care.
Inadequate PPE Use During COVID-19 Precautions
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) when staff moved between rooms of residents with and without COVID-19 diagnoses. During observations, a dietary aide (DA-A) was seen entering the room of a COVID-19 positive resident, identified as being on enhanced respiratory precautions, wearing only an N95 mask without additional PPE such as gloves, gown, or eye protection. DA-A then proceeded to enter the rooms of other residents, some of whom were not on COVID-19 precautions, without changing the N95 mask or donning additional PPE, despite having contact with potentially contaminated surfaces. Interviews with staff revealed a lack of understanding and training regarding the necessity of full PPE when entering rooms of COVID-19 positive residents. The dietary manager and other staff members, including a registered nurse, expressed uncertainty or incorrect beliefs about PPE requirements, contradicting the facility's COVID-19 Plan and CDC guidelines. The infection preventionist confirmed that all staff were supposed to be trained to use full PPE in such situations, highlighting a gap between policy and practice.
Failure to Implement Person-Centered Fall Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate, person-centered interventions to prevent further falls and potential injury for a resident who was severely cognitively impaired and had a history of repeated falls. The resident's care plan identified risks for falls related to gait and balance problems, incontinence, safety unawareness, use of psychotropic medication, and wandering. Despite these identified risks, the facility did not update the care plan with specific interventions after multiple falls occurred. The resident experienced several falls over a period of months, with each incident being documented in progress notes. However, the interventions following these falls were limited to generic reminders for the resident to use the call light for assistance. The care plan was reviewed multiple times, but no resident-specific interventions were implemented, even after the resident sustained a bruise from a fall. Interviews with facility staff, including a nursing assistant, registered nurse, and the director of nursing, confirmed that the resident only had generic fall interventions in place and lacked person-centered strategies. The facility's policy required that care plans be updated to reflect current fall risks and interventions, but this was not adhered to in the case of the resident. The director of nursing acknowledged that the resident should have had specific interventions due to the high risk for falls, such as physical therapy consults, direct supervision, and proper footwear. The lack of individualized interventions contributed to the ongoing risk of falls and potential injury for the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Anne Extended Healthcare | 0.5 mi | ★★★★★ | 14 | 0 |
| Lake Winona Manor | 3.3 mi | ★★★★★ | 4 | 0 |
| Marinuka Manor | 17.2 mi | ★★★★★ | 2 | 0 |
| Good Shepherd Lutheran Home | 17.9 mi | ★★★★★ | 2 | 0 |
| Whitewater Health Services | 19.5 mi | ★★★★★ | 3 | 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.