Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southview Acres Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
The facility failed to accurately document skin conditions on weekly bath audits for multiple residents with known pressure ulcers, diabetic ulcers, and other wounds. Several residents with documented stage 3 and stage 4 pressure injuries, diabetic foot ulcers, and an abscess were consistently recorded on weekly bath audits as having no new or old skin alterations, despite concurrent wound treatment records. Interviews with RNs and LPNs showed that staff focused on identifying new skin issues during baths or skin checks and often did not record existing wounds, and one RN reported that staff had previously been instructed not to include existing wounds on the audits. No written policy on weekly bath audits was provided, contributing to inconsistent and incomplete medical record documentation.
Failure to submit PBJ staffing data to CMS occurred when the facility’s quarterly staffing report was not filed correctly. The administrator stated the data was handled by the corporate team, but the wrong facility’s information was uploaded instead of this facility’s staffing data. The facility policy required timely submission of direct care staffing information, including agency and contract staff, based on payroll and other auditable data.
A resident admitted with lumbar stenosis and other postprocedural state left the facility AMA, but the medical record lacked documentation that the primary physician was notified. Notes showed the resident's wife took the resident home and requested medications, the nurse educated them about AMA and did not release the medications, and a spine center later called to verify the resident had left AMA without meds. The ADON/IP confirmed the physician was not updated, and the DON stated the provider needed to be notified when a resident left AMA.
The facility failed to provide and document written bed-hold/transfer notices for two residents who were sent to the hospital after acute events, and failed to notify the State LTC Ombudsman of the emergency transfers. Records for both residents lacked documentation that the bed-hold notice was offered, signed, or scanned into the EMR, despite staff stating that written notice, consent, and EMR documentation were expected. The facility policy also required written notice to the resident or representative and a copy to the Ombudsman.
A facility failed to accurately code MDS assessments for three residents. Two residents had Section GG dashed as not assessed on their most current MDS, and another resident’s MDS incorrectly showed no hospice care despite an active hospice order and staff confirmation that hospice services were in place. The MDSC stated Section GG was reviewed in team meetings and hospice status was based on a chaplain list, but the resident’s MDS still did not reflect the correct hospice information.
Failure to Care-Plan Pain Management: A resident with chronic pain, COPD, PTSD, repeated falls, failure to thrive, and heart failure had scheduled and PRN opioid and non-opioid pain medications ordered, but no pain care plan was included in the care plan. The resident reported ongoing chest pain rated 7, and an LPN confirmed the pain management had not been care-planned; the DON stated staff were expected to assess pain and monitor for side effects and pain therapy effectiveness.
The facility failed to revise care plans for two residents with chronic pain to include specific non-pharmacological pain interventions. One resident had dementia, heart failure, and kidney failure, and staff reported using music, redirection, snacks, reminiscing, heat, ice, fresh air, one-on-one time, and reassurance, but these were not care planned. The other resident had severe cognitive impairment, total ADL dependence, and frequent PRN opioid use; staff reported repositioning, holding hands, and using a broda chair before giving pain meds, but the EMR and care plan did not document these interventions.
Failure to Update Pressure Injury Prevention Interventions: A resident developed a stage III coccyx pressure injury, but the care plan was not updated with new, specific pressure-reducing interventions after the wound appeared. Staff reported the resident was not on a specific turning and repositioning schedule, interventions varied by aide, and the clinical manager confirmed the care plan had not been updated since the pressure injury developed. The DON stated new care planned interventions would be expected even though the resident was on hospice.
Failure to provide routine dental assessments and services for two residents. One resident with intact cognition, traumatic subdural hemorrhage, weakness, dysphagia, and substantial oral care needs reported mouth soreness, missing teeth, and no dental visit since admission; a dental assessment noted broken natural teeth and recommended routine dental referral, but no routine dental care was documented. Another resident with severe cognitive impairment, dementia, and dysphagia had impaired dentition and dependence for oral hygiene, but the EMR lacked dental orders or assessments, and staff could not verify any dental visit or services provided.
The facility failed to ensure PPE and hand hygiene were used as required for two residents. One resident on EBP had an indwelling catheter, a pressure ulcer, and needed extensive assistance with transfers and personal care, yet two NAs transferred the resident without gowns despite an EBP sign directing gown and glove use. Another resident on contact precautions with ESBL and an ostomy received meds from an LPN who handled the med cart and laptop, then entered the room without hand hygiene, gloves, or other PPE, despite the posted hand hygiene instructions.
A resident with moderate cognitive impairment and a history of behavioral issues alleged physical abuse by an LPN after falling out of bed. The facility did not conduct a thorough investigation, as staff and residents from the relevant unit were not interviewed, and the accused LPN was allowed to return to work before the investigation was complete, contrary to policy. This resulted in a failure to protect the resident during the investigation.
A facility failed to follow proper infection control measures during incontinence care for a resident with a suprapubic catheter. Two NAs did not wear gowns as required by Enhanced Barrier Precautions (EBP) signage and failed to adhere to glove use and hand hygiene protocols. They handled soiled materials without changing gloves or sanitizing hands, and one NA handled soiled wipes without gloves. Interviews revealed a lack of awareness and adherence to EBP protocols, despite clear facility policies.
A facility failed to maintain privacy during wound care for a claustrophobic resident who preferred an open door, exposing the resident's wound to the public. Additionally, a patient care sheet with personal information was left unattended on a medication cart in a hallway under construction, potentially affecting multiple residents. Staff interviews revealed a lack of alternative privacy measures and documentation, violating the facility's confidentiality policy.
A resident admitted with intact cognition and multiple medical conditions, including heart failure and diabetes, did not have a comprehensive care conference conducted as required by facility policy. Despite the resident's goal to return to the community and expressed concerns about communication issues, the facility failed to hold a care conference to ensure continuity of care and resident participation in care-planning. Interviews with staff confirmed the absence of documentation for such a meeting.
The facility failed to complete quarterly MDS assessments in a timely and comprehensive manner for two residents. One resident's MDS was incomplete with several sections marked 'In Progress,' while another's MDS had critical sections marked 'Not assessed' due to missing assessments. The registered nurse confirmed these deficiencies, which were not in accordance with the facility's policy on MDS completion and submission timeframes.
The facility failed to develop and maintain comprehensive care plans for two residents, leading to deficiencies in person-centered care. One resident's care plan did not include information about their prosthetic leg, resulting in inadequate staff training and assistance. Another resident's care plan did not reflect their preference to use the toilet, despite their ability to sense the need to urinate. The lack of documentation and staff awareness of the residents' needs and preferences contributed to the deficiencies.
A resident with severe cognitive impairment was observed with long, soiled nails despite being dependent on staff for personal hygiene. The facility's policy required regular nail care, but staff failed to notice or address the resident's condition, and there was no documentation of nail care being provided. Interviews with staff confirmed that nail care should be done on bath days and documented, but this was not adhered to in this case.
A facility failed to reassess and provide activities for a resident on the short-term unit, who expressed interest in activities but was not offered any due to mobility issues and lack of an activities calendar in her room. The resident's care plan lacked specific interventions, and the facility did not have a re-evaluation process for evolving health needs, contributing to the deficiency.
The facility failed to implement comprehensive toileting programs for two residents who were incontinent of bowel and bladder. Despite being cognitively intact and expressing a desire to use the toilet, the residents were not provided with appropriate interventions or trials of toileting programs. Staff interviews and documentation revealed a lack of attempts to offer the use of a toilet or bedpan, leading to deficiencies in care.
A resident received an antibiotic without an end date following hip surgery, leading to prolonged administration. The facility failed to monitor and evaluate the necessity of continued use, resulting in the resident taking a higher than usual prophylactic dose. The infection control preventionist later discovered the antibiotic was intended for only 18 days, highlighting a lapse in communication and oversight.
A resident experienced a delay in diagnosis and treatment for C. diff due to the facility's failure to complete laboratory services. Despite orders for testing, the initial specimen was incorrectly collected, and there was no follow-up on the results. The resident tested positive after a new order was placed.
A resident with dysphagia and other medical conditions was not provided with the ordered nectar-thick liquids, receiving non-thickened drinks instead. The nursing assistant relied on memory rather than checking meal slips, leading to the resident consuming inappropriate liquids and experiencing a wet-sounding cough. The DON confirmed the error, which was against the facility's therapeutic diet policy.
A resident on Enhanced Barrier Precautions had side rails covered with shredded foam, making them unsanitary and difficult to clean. Despite facility policy requiring daily cleaning of hard surfaces, housekeeping staff admitted the foam could not be effectively cleaned. The infection control preventionist confirmed the need for replacement due to the resident's vulnerability.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care. One resident reported inadequate dressing and repositioning, while another was observed without required protective devices. The facility failed to implement and document necessary interventions, increasing the risk of pressure ulcers.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
Inaccurate Weekly Skin Audit Documentation for Residents With Known Wounds
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records, specifically weekly bath/skin audits, for multiple residents with known wounds. For one resident with dementia, bilateral above-knee amputations, vascular disease, and reduced mobility, the MDS indicated no ulcers or skin problems, yet wound documentation showed treatment for a stage 4 pressure ulcer on the right above-knee amputation site between 3/23/26 and 3/25/26. Despite this, the weekly bath audits on 3/17/26 and 3/24/26 either documented only non-tender lymph nodes on the right upper hip or indicated no new or old skin alterations, and did not reflect the existing stage 4 pressure ulcer. Another resident with paraplegia and multiple documented pressure ulcers and wounds, including stage 3 and stage 4 pressure ulcers of the hips, heels, ankle, shin, calf, and medial malleolus, had numerous weekly bath audits over several weeks that consistently indicated no new or old skin alterations. This conflicted with wound documentation showing ongoing treatment for an open lesion on the right Achilles, stage 3 pressure ulcers on the right heel and right medial calf, an unstageable right medial malleolus wound, a left shin wound, and a stage 3 left heel pressure ulcer on multiple dates. Additional residents with diagnoses including malignant neoplasm of the prostate with stage 3 and stage 4 pressure ulcers, type 2 diabetes with skin ulcers and a stage 4 heel ulcer, and end-stage renal disease with peripheral vascular disease and documented pressure ulcers and an abscess, also had weekly bath audits that reported no new or old skin alterations while concurrent wound records showed ongoing treatment for heel ulcers, calf ulcers, toe pressure ulcers, and a coccyx abscess. Interviews with nursing staff revealed inconsistent understanding and practices regarding documentation on weekly bath audits. Several RNs and LPNs stated that during baths or skin checks they look for redness, swelling, open wounds, and other skin issues, and that new findings should be documented on the weekly bath audit, with some indicating they would chart only if there was something new. One LPN stated she would chart “nothing new” if there were no new skin alterations. Another RN stated that any new or existing wound should be noted on the weekly bath audit, but also reported that prior to approximately three months earlier, staff had been instructed not to document existing wounds on these audits. A requested policy on weekly bath audits was not provided, and the lack of clear, consistent documentation practices led to weekly bath audits that did not accurately reflect residents’ known and treated wounds.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for fiscal year quarter 1 2026, including staffing data based on payroll and other verifiable and auditable records. The Payroll Based Journal Staffing Data Report dated 3/4/26 showed that the facility did not submit data for the quarter. During interview, the administrator stated the PBJ information had been submitted through the corporate team and later explained that the wrong facility’s information had been uploaded in place of this facility’s staffing information and did not stick in the system. A facility policy titled Payroll Based Journal, dated 3/2/25, stated that the facility was required to submit staffing information by the February 14 deadline for quarter 1 submissions and that Section 6106 of the ACA requires electronic submission of direct care staffing information, including agency and contract staff, based on payroll and other auditable data.
Failure to Notify Physician When Resident Left AMA
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for 1 resident who left the facility against medical advice. The resident was admitted with lumbar stenosis without neurogenic claudication and other specified postprocedural state, and later left the facility on 1/10/26. The medical record lacked documentation that the resident's primary physician was informed of the AMA departure. A progress note documented that the resident's wife arrived early in the morning, requested the resident's medications be prepared, and stated she was taking the resident home; the nurse educated the resident and wife about AMA and told them the facility could not release the medications. A later note documented a spine center calling to verify that the resident had left AMA and without medications. During interview, the ADON/IP verified the primary physician was not updated, and the DON stated the provider needed to be notified when a resident left AMA. The facility policy stated the assigned nurse would contact the primary physician to inform them of the resident's decision to leave AMA.
Failure to Document Bed-Hold Notices and Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of facility-initiated transfers to an acute care facility on an emergent basis and failed to ensure a written bed-hold notice was provided and documented in the EMR for 2 residents reviewed for hospitalizations. The report identified that both residents had severe cognitive impairment and multiple diagnoses, including dementia-related conditions and other chronic illnesses, and were transferred to the hospital after acute events. For one resident, the record showed an unwitnessed fall with injury on 12/15/25 and a later fall with major injury on 1/24/26, both resulting in transfer to the ED. For the other resident, the record showed an ER visit on 2/19/26 for a medication-related concern with transfer to the hospital and return the same day. In each case, the progress notes did not show that a bed-hold or transfer form was offered, signed, or documented, and one note also failed to indicate that the form was offered to the resident’s emergency contact. Interviews with nursing and administrative staff showed the expected process was to provide a written bed-hold and transfer notice, obtain resident or guardian consent when needed, document the discussion in the progress note, and scan the signed form into the EMR. The DON stated the director of social services was responsible for notifying the Ombudsman of discharges and transfers, while the social services director stated she sent discharge notifications monthly but was unaware that transfer and hospitalization notices also had to be sent. The facility policy stated that for an immediate transfer or discharge required by urgent medical needs, the resident and/or representative would be notified in writing of the bed-hold policy and a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman.
Inaccurate MDS Coding for Functional Status and Hospice Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 3 of 5 residents reviewed for MDS accuracy. R5’s annual MDS showed the resident was admitted on 1/13/25, but Section GG Functional Abilities and Goals was dashed as not assessed. R8’s quarterly MDS also had Section GG dashed as not assessed, and the resident was admitted on 11/22/24. These entries showed that the functional assessment section was not completed for either resident on the most current MDS reviewed. R25’s quarterly MDS indicated the resident was not receiving hospice care, even though the Order Summary Report showed an active order for hospice services signed on 9/4/25 with a diagnosis of Parkinson’s disease. During interview, an LPN stated R25 had been receiving hospice care since admission to the facility. The MDSC stated Section GG was reviewed daily in morning team meetings and based on the EMR, that baths were coordinated within the 3-day lookback when possible, and that hospice status was determined from a chaplain-provided list. The MDSC confirmed R25’s MDS did not indicate hospice services when it should have, and the facility policy stated the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments and reviews.
Failure to Care-Plan Pain Management
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented for one resident reviewed for pain management. The resident's admission MDS indicated he was cognitively intact, had no behaviors, did not refuse care, and required substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, and transfers. The MDS also indicated he received scheduled and PRN pain medications, as well as opioid and antipsychotic medications. His clinical diagnoses included chronic obstructive pulmonary disease, chronic pain, post-traumatic stress disorder, repeated falls, failure to thrive, and heart failure. The resident's orders included scheduled hydromorphone, PRN hydromorphone, PRN acetaminophen, lidocaine cream to the left chest wall twice daily, and gabapentin three times daily. His care plan did not include a pain care plan. During interview, the resident stated he had chest surgery last year and had experienced pain since then, rating his pain as 7 and saying it came and went. The nurse manager/LPN stated the resident had problems with pain and had scheduled an appointment to see a doctor due to severe foot pain. The LPN later verified that pain management had not been care-planned, and the DON stated the resident should have had a care plan for pain and that staff were expected to assess pain and monitor for side effects and pain therapy effectiveness.
Care plans lacked comprehensive pain management interventions
Penalty
Summary
The facility failed to revise the care plan to include a comprehensive pain management plan for 2 residents with a history of pain. For one resident, the quarterly MDS showed moderately impaired cognition and diagnoses including heart failure, kidney failure, and dementia, with scheduled pain medication but no as-needed pain medication or non-medication interventions during the look-back period. The resident’s care plan identified acute/chronic pain and a goal of satisfactory pain control, but the only intervention listed was to evaluate for non-verbal indicators of pain, with no description of the resident’s pain pattern or specific non-pharmacological interventions. The resident’s medication orders included scheduled acetaminophen for chronic pain, a lidocaine patch for the mid-upper back, and as-needed methocarbamol for pain. Nursing staff described the resident’s pain as sporadic, sometimes in the back or upper back, and stated they used interventions such as music, redirection, snacks, reminiscing, heat, ice, fresh air, one-on-one time, and reassurance, but these interventions were not reflected in the care plan. The DON stated non-pharmacological pain interventions should be outlined in the care plan, but acknowledged this might take time as staff get to know residents. For the second resident, the annual MDS showed severe cognitive impairment, total dependence for ADLs, and receipt of scheduled and as-needed pain medication without non-pharmacological interventions. The resident had orders for oxycodone, methocarbamol, diclofenac gel, and acetaminophen, and the MAR showed as-needed oxycodone was given seven times in ten days. The care plan identified chronic pain related to upper extremity contracture and shoulder injuries, but only stated to medicate with as-needed medications if non-medication interventions were ineffective, without identifying what those interventions were. The EMR lacked documentation or care planning for non-pharmacological pain interventions, while staff stated they repositioned the resident, held his hands, got him into a broda chair, and then offered pain medication if pain signs continued.
Failure to Update Pressure Injury Prevention Interventions
Penalty
Summary
The facility failed to ensure a resident was reassessed and failed to implement new interventions to prevent skin breakdown after the resident developed a stage III pressure injury to the coccyx. The resident’s quarterly MDS showed substantial staff assistance was needed for personal hygiene, dressing, and bathing, and the resident was dependent on staff for toileting. The resident was identified as at risk for pressure ulcers but had no pressure ulcers at that time. The care plan addressed potential skin impairment related to immobility and incontinence and included a pressure reducing wheelchair cushion and pressure reducing mattress. After the coccyx wound was documented, the care plan dated 1/16/26 included wound care and keeping the resident’s skin clean and well lubricated, but it lacked new, specific pressure reducing interventions to prevent new or reopened pressure injuries. A wound note stated the stage III coccyx pressure injury had reopened the prior week and that the plan of care remained effective. Later documentation showed the wound resolved, but interviews revealed staff used barrier cream and a silicone dressing even without an active pressure injury, the resident was not on a specific turning and repositioning schedule, and the care plan had not been updated since the pressure injury developed. The clinical manager stated interventions depended on which aide was working, and the DON stated new care planned interventions would be expected after the development of a pressure injury, even with hospice services.
Failure to Provide Routine Dental Assessments and Services
Penalty
Summary
The facility failed to provide assessments and routine dental services for 2 residents reviewed for dental care. One resident had a significant change MDS indicating intact cognition, traumatic subdural hemorrhage with loss of consciousness, weakness, dysphagia, and substantial assistance needed for oral hygiene. During observation, the resident stated his mouth was sore and showed several missing teeth, and he said he had not seen a dentist since admission and wanted to. The resident’s dental assessment completed by Apple Tree Dental identified broken natural teeth, the need for staff supervision with oral care, and recommended a routine dental referral and non-urgent dental care needs, but the medical record lacked documentation of routine dental care or a dental appointment. The resident’s care plan did not address oral care specifically. The second resident’s quarterly MDS identified severe cognitive impairment and dependence on staff for all cares including oral hygiene, with diagnoses of dementia and dysphagia. The care plan identified impaired dentition with no dentures, but the physician orders and EMR did not indicate an order for dental services, and the record did not show dental assessments were done. Staff interviews showed differing expectations about how dental referrals were obtained and when residents should be seen, but the HUC could not find the resident’s last dental visit and the DON verified the EMR did not show dental services were offered or provided. The facility policy stated that all dental services provided are recorded in the resident’s medical record.
Failure to Use PPE for EBP and Perform Hand Hygiene for Contact Precautions
Penalty
Summary
The facility failed to ensure appropriate PPE was worn for enhanced barrier precautions for a resident with an indwelling urinary catheter and a sacrum/coccyx pressure ulcer. The resident’s records showed cognitive impairment, physical behaviors toward others with no impact to the resident, and diagnoses including atrial fibrillation, hypertension, non-Alzheimer’s dementia, depression, PTSD, neurogenic bladder, and obstructive and reflux uropathy. The resident’s care plan and orders identified EBP, and the functional care plan indicated extensive assistance was needed for transfers, dressing, and toileting hygiene, including use of a mechanical lift. During observation, the resident had an EBP sign posted directing staff to use a gown and gloves during personal cares and transfers. The resident was observed being transferred from bed to wheelchair by two NAs after personal cares, with the sling under the resident, and neither NA wore a gown during the transfer. One NA stated she had provided catheter care and peri care after bowel incontinence, removed her gown, and then placed the sling under the resident to prepare for transfer, and she acknowledged she was supposed to wear a gown during transfers but did not use one. The other NA stated she only touched the Hoyer lift and believed a gown was not needed if she did not touch the resident. The facility also failed to ensure hand hygiene was performed for a resident on contact precautions with ESBL noted in the EMR banner and an ostomy. During medication administration, an LPN prepared crushed medications at the medication cart, handled drawers and the laptop, and then entered the resident’s room without washing or sanitizing hands and without gloves or other PPE. The resident’s door had a contact precautions sign stating everyone must clean their hands before entering and when leaving the room. The LPN verified she did not wash hands or apply gloves or PPE before entering the room, while the unit nursing manager stated staff were expected to wear PPE when entering the room to give meds for residents on contact precautions and that hand hygiene was important.
Failure to Thoroughly Investigate Abuse Allegation and Protect Resident During Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with moderate cognitive impairment and a history of behavioral issues, including accusations against staff. The resident, who had restless leg syndrome, a history of falls, and impaired safety awareness, made allegations that a staff nurse physically abused him during an incident where he rolled out of bed. Despite the resident's history of making unsubstantiated claims, the facility's policy required a comprehensive investigation, including interviews with all relevant staff and residents, and removal of the alleged perpetrator from resident contact until the investigation was complete. The investigation was incomplete as staff and residents on the unit where the alleged abuse occurred were not interviewed. Only a few nurses and residents from a different unit were questioned, and key staff who had provided care to the resident were not included in the inquiry. The social worker and director of nursing acknowledged that interviews with staff and residents from the transitional care unit (TCU), where the incident allegedly took place, were not conducted. Additionally, the facility's own policy, which mandates thorough documentation and interviews with all potential witnesses and involved parties, was not followed. Furthermore, the staff member accused of abuse was allowed to return to work with resident contact before the investigation was completed, contrary to facility policy. The alleged perpetrator was suspended for only one shift and then returned to duty prior to the conclusion of the investigation. This action failed to ensure the protection of the resident and other vulnerable individuals during the investigation process, as required by both facility policy and regulatory standards.
Infection Control Lapses During Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during incontinence care for a resident who required extensive assistance with personal hygiene and had a suprapubic catheter. The resident's Enhanced Barrier Precautions (EBP) signage indicated that staff needed to wear gloves and gowns during high-contact activities such as changing linens and providing hygiene. However, during an observation, two nursing assistants (NAs) entered the resident's room without wearing gowns, despite the EBP sign and available personal protective equipment (PPE) outside the room. The NAs proceeded with incontinence care, including handling soiled materials and adjusting the resident's bed and linens, without adhering to proper glove use and hand hygiene protocols. The NAs failed to remove soiled gloves, sanitize their hands, and apply new gloves as required by the facility's hand hygiene and EBP policies. One NA even handled soiled wipes without gloves, acknowledging the mistake but attributing it to feeling rushed. Interviews with the NAs revealed a lack of awareness and adherence to the EBP signage and protocols. The infection preventionist and director of nursing confirmed the expectations for gown and glove use, as well as hand hygiene, during personal care for residents on EBPs. The facility's policies clearly outlined the need for hand hygiene before and after resident contact, after glove removal, and when moving between contaminated and clean body sites during care.
Privacy Breach During Wound Care and Exposed Resident Information
Penalty
Summary
The facility failed to maintain privacy during wound care for a resident who expressed being claustrophobic and preferred to keep their doorway open. During an observation, the resident's room door was left wide open while two staff members performed a dressing change on the resident's leg, exposing red-colored tissue and bodily drainage to the public hallway. Despite the resident's preference for an open door, the facility did not assess or offer alternative privacy options, such as portable curtains or repositioning the mobile cart, to ensure privacy for the resident and others passing by. Additionally, the facility did not secure resident identifiable personal care information on a mobile medication cart. A patient care sheet containing personal information was left exposed and unattended on the cart in a hallway where construction workers were present. This oversight had the potential to affect multiple residents whose information was listed on the care sheet. Interviews with staff, including the Director of Nursing and Social Services Designee, revealed a lack of consideration for alternative privacy measures and documentation of such options in the resident's medical record. The facility's policy on confidentiality and personal privacy was not adhered to, as evidenced by the exposed care sheet and the lack of privacy during the resident's wound care.
Failure to Conduct Comprehensive Care Conference for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care-planning process was implemented for a resident, identified as R222, who was reviewed for participation in care-planning. R222 was admitted to the care center with intact cognition and had several medical conditions, including heart failure, diabetes mellitus, and arthritis. The resident's goal was to return to the community, and an active discharge plan was in place. However, the facility did not conduct a comprehensive care conference meeting with R222, which is essential for ensuring continuity of care and promoting resident participation in care-planning. R222 expressed concerns about the lack of communication and the absence of a care conference since their admission. The resident noted that various disciplines, such as nursing, dietary, and therapy, approached them individually rather than in a group setting, which they believed contributed to communication issues. Despite the facility's policy requiring an initial care conference shortly after admission, there was no evidence in R222's medical record that such a meeting had been offered or held. Interviews with facility staff, including the social services designee and the social services director, confirmed the absence of a documented care conference for R222. The staff acknowledged the importance of care conferences in ensuring that services for care are explained and potential barriers to discharge are identified. The facility's policy outlined that social services were responsible for scheduling these meetings, but discrepancies in documentation practices and adherence to policy may have contributed to the oversight.
Incomplete and Untimely MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Set (MDS) assessments were completed in a timely and comprehensive manner for two residents. For one resident, identified as R50, the significant change MDS indicated severe cognitive impairment, hallucinations, and hospice care. However, the subsequent quarterly MDS was incomplete, with multiple sections such as Hearing, Speech and Vision, Behavior, and Bladder and Bowel marked as 'In Progress' and lacking data. The registered nurse confirmed that the MDS was not finished within the required timeframe and that corresponding assessments were also incomplete, leading to sections being marked as 'not assessed.' For another resident, identified as R108, the quarterly MDS was signed as completed, but critical sections like Cognitive Patterns and Mood were marked as 'Not assessed' due to the absence of corresponding assessments such as BIMS and PHQ-9. The registered nurse verified that these sections were not completed because the social services department had not conducted the necessary assessments. The facility's policy on MDS completion and submission timeframes was not adhered to, resulting in these deficiencies.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and maintained for two residents, R142 and R139, leading to deficiencies in person-centered care. For R142, the care plan did not include information about the resident's prosthetic leg, despite the resident's need for assistance with ambulation using the prosthetic. Interviews revealed that only a few staff members were trained to assist with the prosthetic leg, and the resident expressed frustration that most staff were not knowledgeable about its use. The care plan and Kardex lacked documentation regarding the prosthetic leg, and there was a lack of coordination in training staff to assist the resident properly. For R139, the care plan did not reflect the resident's preference to use the toilet instead of incontinence pads, despite the resident's ability to sense the need to urinate and express this preference. The care plan also failed to document the resident's fluctuating ability in transfers, as the resident was able to use an EZ stand with assistance during physical therapy sessions. Interviews with staff indicated a lack of awareness and documentation regarding the resident's preferences and abilities, with staff defaulting to incontinence care without offering the use of a toilet or bedpan. The deficiencies in care planning for both residents highlight a lack of comprehensive, person-centered care plans that reflect the residents' needs and preferences. The facility's failure to update care plans and ensure staff training and coordination resulted in inadequate care for the residents, as evidenced by the lack of documentation and staff awareness of the residents' specific needs and preferences.
Failure to Provide Routine Nail Care for Resident
Penalty
Summary
The facility failed to ensure routine personal hygiene care, specifically nail care, for a resident with severe cognitive impairment who was dependent on staff for assistance. The resident, identified as R47, was observed multiple times with long, soiled nails containing debris, despite the facility's policy requiring regular nail care. The resident's care plan did not specify nail length preferences, and there was no documentation of nail care being offered or provided, even though the resident expressed a desire for his nails to be clipped. Interviews with staff, including a nursing assistant and a registered nurse, revealed that nail care should be completed on bath days and could be done in between if needed. However, the staff failed to notice or address the resident's nail condition. The director of nursing confirmed that nail care should be documented and verified by nurses, but this was not done in R47's case. The facility's policy emphasized the importance of nail care in preventing skin problems, yet the lack of adherence to this policy resulted in the deficiency.
Failure to Provide and Reassess Activities for Resident
Penalty
Summary
The facility failed to comprehensively reassess and develop interventions to ensure activities of interest were advertised, offered, and/or provided for a resident (R222) on the short-term unit. Upon admission, R222 was identified as having intact cognition and expressed interest in activities such as reading, keeping up with the news, and engaging in favorite activities. However, the Therapeutic Recreation/Activity Evaluation lacked details on in-room options for these interests, and the care plan did not include specific interventions to address R222's needs. R222, who was initially non-weight bearing due to a leg boot, expressed difficulty in attending activities and noted the absence of an activities calendar in her room. Despite being open to participating in activities, R222 reported that no one offered activities to her. The nursing assistant confirmed that R222 rarely left her room and was not specifically offered activities. The therapeutic recreation coordinator and chaplain acknowledged that activities were not typically programmed on the TCU, and residents were expected to attend activities on other floors. The facility's failure to reassess R222's activity needs after her health improved and to provide in-room activities contributed to the deficiency. The lack of a re-evaluation process for residents with evolving health needs and the absence of a facility activities programming policy further highlighted the deficiency. R222's medical record showed limited participation in activities, and there was no evidence of reassessment to promote her quality of life.
Failure to Implement Toileting Programs for Incontinent Residents
Penalty
Summary
The facility failed to ensure comprehensive assessment and development of interventions for bladder and bowel incontinence for two residents, R142 and R139. R142, who was cognitively intact and had multiple medical conditions including chronic kidney disease and benign prostatic hyperplasia, was always incontinent of bowel. Despite being a candidate for a bowel training program, no trial of a toileting program had been attempted since admission. The care plan indicated interventions such as taking the resident to the toilet upon request and checking every two hours, but these were not effectively implemented. Interviews revealed that R142 often had to wait over an hour to be changed after an incontinent episode, and staff had not monitored or established a bowel schedule for him. R139, also cognitively intact, required substantial assistance with toileting care and was always incontinent of urine. Despite expressing a desire to use the toilet and being able to sense the need to urinate, no trial of a toileting program had been attempted. The care plan lacked evidence of a current or past toileting program, and progress notes did not document any attempts to offer the use of a toilet or bedpan. Interviews with staff indicated that R139 was not offered the toilet or bedpan, and there was no documentation of any toileting schedule attempted during her admission. The facility's policy on bowel disorders indicated that staff and physicians should identify individuals with bowel dysfunction and assess symptoms related to bowel function. However, the facility did not provide a policy on toileting programs when requested. The lack of comprehensive assessment and implementation of toileting programs for residents R142 and R139 led to deficiencies in providing appropriate care for their incontinence needs.
Failure to Monitor and Discontinue Antibiotic Therapy
Penalty
Summary
The facility failed to ensure that a resident's antibiotic regimen was appropriately monitored and evaluated for continued use. A resident, who had intact cognition and no signs of infection, was prescribed 500 mg of cephalexin four times a day for prophylaxis following a hip fracture surgery. The hospital discharge orders did not specify an end date for the antibiotic, and the facility continued administering the medication without verifying the duration of treatment. The resident expressed uncertainty about the necessity of the antibiotic, as she believed it should have been discontinued earlier. The facility's infection control preventionist later discovered that the orthopedic provider intended for the antibiotic to be given for only 18 days. However, due to a lack of communication and oversight, the antibiotic was not discontinued as planned. The physician's assistant, who was not the original ordering provider, was unaware of the antibiotic order and stated that the facility should have contacted him or the hospital to determine an appropriate end date. The facility's failure to track and review the antibiotic order led to the resident receiving a higher than usual prophylactic dose for an extended period, contrary to the facility's Antibiotic Stewardship policy.
Failure to Complete Laboratory Services for C. diff Testing
Penalty
Summary
The facility failed to ensure that an order for laboratory services was completed for a resident who was experiencing symptoms consistent with Clostridium difficile (C. diff) infection. The resident, who was cognitively intact and required assistance with toileting and personal hygiene, had two orders for C. diff testing, one on December 16 and another on December 31. Despite a stool specimen being collected on December 17, the lab informed the facility on December 30 that the specimen was incorrectly collected. A new order was placed, and the resident tested positive for C. diff on January 5. Interviews with staff revealed a lack of follow-up on the initial test results. The licensed practical nurse was unsure of the process if results were not received, and the clinical nurse manager confirmed that the initial specimen was collected in the wrong container. The director of nursing stated that it was expected for nursing staff to follow up with the lab if results were not received within 24-48 hours. The failure to follow up on the initial test led to a delay in diagnosis and treatment for the resident, who had been experiencing diarrhea for about a month.
Failure to Provide Ordered Drink Consistency for Resident
Penalty
Summary
The facility failed to provide the ordered drink consistency for a resident, identified as R82, who was reviewed for dining. R82 had intact cognition and was diagnosed with heart failure, kidney disease, malnutrition, dysphagia, and had a recent diagnosis of RSV and pneumonia. The resident's care plan required a mechanical soft diet with all liquids thickened to a nectar consistency due to swallowing difficulties. However, during an observation, R82 was served non-thickened liquids, including water, coffee, orange juice, and milk, which were not in accordance with the prescribed nectar-thick consistency. The nursing assistant responsible for serving the drinks relied on memory rather than checking the meal slips to determine the correct liquid consistency for residents. This led to R82 consuming non-thickened orange juice, resulting in a wet-sounding cough. The DON confirmed that R82 was supposed to receive nectar-thick liquids and acknowledged the error. The facility's policy required therapeutic diets to be prescribed to support the resident's treatment and plan of care, which was not adhered to in this instance.
Inadequate Cleaning of Resident's Side Rails on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for cleaning hard surfaces in a resident's room, specifically for a resident on Enhanced Barrier Precautions (EBP). The resident, identified as R39, had severe cognitive impairment and multiple medical conditions, including an indwelling catheter and pressure ulcers. Observations revealed that the side rails of R39's bed were covered with shredded and broken foam, secured with black tape, making them unsanitary and difficult to clean. Both LPN-A and RN-A confirmed the poor condition of the side rails and their inability to be properly cleaned and disinfected. Interviews with housekeeping staff revealed a lack of consistent cleaning practices for the side rails, despite the facility's policy requiring daily cleaning of all hard surfaces, including bed rails. Housekeepers HK-C, HK-A, and HK-B acknowledged the expectation to clean side rails daily but admitted that the foam covering on R39's side rails was not in good condition and could not be effectively cleaned. The infection control preventionist also confirmed that the foam padding should be replaced as it was not sanitary and could not be cleaned appropriately, especially given the resident's vulnerability and EBP status.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess, care plan, and implement interventions to prevent recurrent pressure ulcers for two residents with a history of pressure ulcers. One resident, identified as R142, reported having a bed sore on his bottom that was not properly covered with a dressing, and staff only applied cream. The resident expressed concerns about not being repositioned every two hours as required and having to wait too long for assistance when incontinent. Despite having a care plan that included interventions such as applying barrier cream and using a pressure-relieving mattress, there was no consistent documentation of the resident's refusal to turn and reposition, and the care plan lacked a turning and repositioning schedule. Another resident, identified as R39, was observed multiple times without the ordered protection between his knees, both in bed and while seated in a wheelchair. The resident's care plan required a pillow between the knees when in bed and a blue wedge abductor when in a wheelchair to prevent tissue breakdown. However, these interventions were not consistently implemented, as observed during several instances. The nursing staff and practitioners were expected to follow the care plan and kardex for positioning and applying the necessary protective devices, but this was not adhered to, increasing the resident's risk for pressure ulcers. The facility's policy on pressure ulcers and skin breakdown required a full assessment and documentation of pressure sores, including location, stage, and current treatments. However, the facility failed to consistently implement and document the necessary interventions for both residents, leading to the development and recurrence of pressure ulcers. The lack of timely notification to the physician and wound care team further contributed to the deficiency, as immediate action was not taken to address the new pressure areas.
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 1,033 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 West Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Inver Grove Heights | 0.6 mi | ★★★★★ | 10 | 0 |
| Walker Methodist Westwood Ridge Ii | 1.3 mi | ★★★★★ | 8 | 0 |
| Woodlyn Heights Healthcare Center | 1.4 mi | ★★★★★ | 17 | 0 |
| Cerenity Care Center On Humboldt | 3.2 mi | ★★★★★ | 12 | 0 |
| Shirley Chapman Sholom Home East | 4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Southview Acres Healthcare Center.
100% money-back within 48 hours.
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.