Average — CMS composite of the measures below.
The next survey window likely opens around November 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 St Johns On Fountain Lake during CMS and state inspections, most recent first.
Wet pans and bowls were observed stored before fully drying in the kitchen, despite the dietary director stating dishes were supposed to air dry completely before storage. The facility also failed to consistently monitor dishwasher water temperatures in 3 neighborhood kitchens; staff reported no outside temperature display on one machine, orange test strips were not consistently used or dated, and temperature logs were incomplete or missing across multiple months.
A resident with intact cognition and multiple chronic conditions had several OTC medications stored on her overbed table without a self-administration assessment or physician order. Staff found Aspercreme, lidocaine cream, Preparation H, eye drops, Neosporin, Imodium, Claritin, and an unidentified capsule in the room, and the resident said some items were ordered online and used for pain, dry eyes, diarrhea, and hemorrhoid discomfort. An LPN, RN, and DON all confirmed she was not approved to self-administer medications and that staff had not known the medications were in the room.
A resident with OSA and dementia did not have CPAP use included in the care plan, and staff gave inconsistent accounts of whether CPAP was being applied or how the equipment was cleaned and maintained. An RN acknowledged there was no order to assist with bedtime CPAP application and that the care plan should have included it. Another resident with dementia, behavioral symptoms, and a trauma assessment indicating probable PTSD also had no care plan addressing PTSD, despite staff and family describing trauma-related triggers, nightmares, startle responses, and nighttime agitation.
Failure to Provide Individualized 1:1 Activities: A resident with CKD, depression/anxiety, hearing loss, weakness, and palliative care had a care plan for individualized and 1:1 activity visits, but was repeatedly observed alone in bed, bored, and lonely. He said he could not enjoy TV due to poor hearing, wished for more visits, and reported that activity staff only dropped off books and magazines without staying to engage with him. Staff confirmed they did not complete specific 1:1 activities, and the activity record did not show any 1:1 visits.
Incomplete Weekly Skin Assessments for Stage Four Coccyx Pressure Ulcer: A resident with diabetes, CKD, hemiplegia, and an unhealed stage four coccyx pressure ulcer had weekly skin checks documented, but most lacked wound measurements and key characteristics such as drainage, tissue type, and surrounding skin findings. Nursing staff acknowledged the documentation was inconsistent, and the RN and DON confirmed the assessments were not comprehensive enough to show whether the wound was improving or worsening.
Failure to assess safe smoking and provide an ash receptacle. A resident with tobacco use and COPD said she smoked several times a day, kept cigarettes and a lighter in her room and on her wheelchair, and did not recall a smoking assessment or being told the campus was smoke free. She reported putting out cigarettes with her fingers, bringing the remains back into the building, and throwing them away in tissue, while staff were unsure whether a smoking risk assessment had been done and the DON did not know how she was disposing of ashes and cigarettes.
Failure to Offer Fluids Consistently to a Dependent Resident: A resident with severe dementia who depended on staff for drinking was not offered fluids on a consistent basis. Staff observations showed water left out of reach, no water offered during extended observation periods, and dark, strong-smelling urine. A family member reported the resident was usually only offered drinks at meals, and an LPN acknowledged she did not assess the resident or communicate to NA staff to push fluids after being told about the urine findings.
A resident with OSA and significant cognitive impairment was observed using CPAP while staff handled the mask and machine inconsistently, with the mask left on top of the machine and moisture remaining in the reservoir during multiple observations. Staff gave conflicting statements about who was responsible for cleaning the CPAP equipment and how often it should be cleaned, and the DON confirmed the facility’s CPAP policy lacked clear guidance on cleaning the machine, supplies, and reservoir.
A resident with dementia, severe cognitive impairment, agitation, refusals of care, and nighttime verbal behaviors had a trauma-informed screening that was positive for a traumatic event and probable PTSD indicators, including nightmares and guilt/blame related to the events. SS and nursing staff confirmed no further trauma assessment was completed and the care plan addressed behaviors but not PTSD or past trauma, despite the resident’s war history, nighttime triggers, and family report of being startled and triggered by fireworks.
A resident was not protected from a significant medication error, as required, with no further details provided about the circumstances or the resident's condition.
A resident with significant cardiac and liver conditions experienced a medication error involving Torsemide. After the error was discovered, the DON destroyed the unused medication but failed to document the prescription numbers, quantity, and date of destruction as required by facility policy. The medication destruction log and the resident's medical record did not reflect the proper disposition of the medication.
A facility failed to follow infection control practices when a resident's urinary drainage bag was found on the floor, and loose laundry was sent down a chute unbagged. Staff interviews revealed awareness of proper procedures, but these were not consistently followed, posing infection risks.
The facility failed to maintain proper holding temperatures for hot foods, with cheese quesadillas and bacon observed below the required 135°F. Additionally, infection control practices were not followed, as a cook handled food without gloves and did not wash hands after handling broken glass. The DON acknowledged the need for re-education on infection control.
A resident with a history of fractures and other conditions experienced a fall and later complained of neck pain, which was not immediately reported to the physician. The resident's condition worsened, leading to an eventual transfer to the emergency department where additional fractures were diagnosed. Staff interviews confirmed the oversight in communication, and the facility's policy on physician notification was not provided.
A resident with a history of diabetes and other health issues developed pressure ulcers on both heels while in a facility. Despite the care plan requiring weekly comprehensive skin assessments, the facility failed to conduct these assessments consistently. The resident's condition and the facility's documentation practices contributed to the deficiency, as confirmed by staff interviews.
The facility failed to address the consultant pharmacist's recommendations for two residents, leading to medication management deficiencies. One resident with diabetes and chronic kidney disease did not receive recommended follow-up for ACEI/ARB therapy, and another was prescribed duloxetine with an inappropriate indication. Despite receiving the recommendations, the DON did not ensure they were acted upon, resulting in medication irregularities.
The facility failed to implement enhanced barrier precautions (EBP) for two residents during high-contact care activities, despite CDC guidelines and care plan instructions. One resident with bullous pemphigoid and another with a urostomy were observed receiving care without EBP. Staff interviews revealed a lack of adherence to EBP protocols, despite education and audits by the infection preventionist.
A resident with quadriplegia fell from a mechanical lift due to improper use and lack of comprehensive assessments for sling size, resulting in ongoing pain. The facility failed to ensure staff followed manufacturer's recommendations, and there was no system in place for determining appropriate sling sizes. Interviews revealed staff were unaware of proper sling size determination, and the facility's investigation did not address sling size or type used during the transfer.
A facility failed to update a resident's care plan after a significant decline in health status, resulting in inaccurate care instructions for mobility and activities of daily living. Despite the resident's return from the hospital with new needs, no comprehensive assessment or care plan update was completed.
The facility failed to administer medication per physician order and did not evaluate and address medication errors to prevent recurrence for a resident with moderate cognitive impairment and a life expectancy of less than six months. The resident received double doses of Ativan on multiple occasions, and the facility did not document monitoring for overdose response or complete a causal analysis to prevent similar errors.
Wet Dishware Stored and Dishwasher Temperatures Not Monitored
Penalty
Summary
The facility failed to ensure metal pans in the main kitchen were dry before being stored. During the initial kitchen tour, several metal pans and bowls were observed stacked upside down on a wire shelving unit, and one 9 x 13-inch pan and three extra-large stainless bowls were wet. The dietary director stated staff were supposed to place wet dishes on a wire rack in the clean side of the dish room to dry completely before storage, and that dishes were trained to be dried fully before being stored. The dietary director also stated it was important to ensure no bacteria grew on pans used to prepare and cook resident food. The facility also failed to ensure dishwasher water temperatures were monitored in 3 of 3 neighborhood kitchens to verify proper sanitization of dishes. In the third-floor neighborhood kitchen, assistant cooks stated there was no way to monitor the dishwasher water temperature because there was no temperature display on the outside of the machine. The dietary director later stated staff were supposed to use orange temperature strips in the dishwasher with each load, but some staff were not aware of that. Temperature logs were incomplete or missing: November documentation showed only 20 of 60 possible entries, September and October logs were blank, and December had no entry for the available date. In the second-floor kitchen, used orange strips were present but were not dated, and neither the assistant cook nor the dietary director could locate water temperature logs for September through December. In the first-floor kitchen, handwritten logs showed incomplete documentation for September, October, and November, with only 31 of 60, 32 of 62, and 23 of 60 possible entries recorded, respectively.
Unassessed Medications Kept in Resident Room
Penalty
Summary
The facility failed to ensure that a resident who had medications in her room had been appropriately assessed and determined safe to self-administer them. The resident had diagnoses including fibromyalgia, chronic pain syndrome, dry eye syndrome, irritable bowel syndrome with diarrhea, osteoporosis, bursitis of the hips, and anxiety. Her quarterly MDS indicated intact cognition, clear speech, and that she could understand and be understood, but her care plan stated she was not appropriate to self-administer medication. During observation, multiple OTC medications were found on the resident’s overbed table, including Aspercreme, lidocaine cream, Preparation H, eye drops, and Neosporin. On a later observation, the medications were still present, and additional items were seen, including two Imodium softgels, two Claritin tablets, and one unidentified capsule. The resident stated she had ordered the medications from Amazon and described using several of them for pain, dry eyes, diarrhea, hemorrhoid discomfort, and a skin biopsy site. She was unaware of the Claritin and did not know what the unidentified capsule was. Staff interviews confirmed the resident did not have an order for self-administration and had not been assessed for it. An LPN stated a resident could not have medications in the room without a physician order and that the resident’s boyfriend had brought medications in without staff knowing. An RN stated nursing would need to conduct a self-administration assessment and obtain physician input, and the DON stated staff were uncertain about residents bringing in their own medications and would need re-education. The facility policy required a nurse assessment, a written order, and secure storage for residents who self-administer medications.
Care Plans Missing CPAP Management and PTSD-Related Interventions
Penalty
Summary
The facility failed to ensure R24’s care plan included management of CPAP use. R24 had diagnoses of obstructive sleep apnea and dementia, and the quarterly MDS indicated severe cognitive impairment and dependence on staff for most activities of daily living. Orders dated 3/5/25 indicated it was okay to use home settings on the CPAP machine every shift, and orders dated 3/8/25 addressed cleaning the mask, nasal pillows, tubing, headgear, and wiping off the flow generator, but the orders did not include when or how to apply CPAP. R24’s care plan did not include CPAP use. During interviews, staff members gave inconsistent information about whether R24 used CPAP and how the equipment was maintained. A family member stated R24 wore CPAP at night but it did not always stay on and was not aware if the mask was cleaned. One NA stated she did not know if R24 used CPAP, while another NA stated she did not think he wore it. An LPN stated she did not know if R24 wore CPAP and said the mask was cleaned once a week on Saturdays, with the reservoir filled by a nurse. RN-A acknowledged there was not an actual order to assist R24 with applying CPAP at bedtime and confirmed CPAP was not included on the care plan. RN-A stated CPAP should have been care planned and acknowledged the lack of direction could lead to improper use and improper cleaning of the equipment. Observations showed R24 in bed with CPAP not on, with the mask and tubing draped over the bedside table. Later observation found minimal water in the CPAP reservoir, and RN-A was not certain who was responsible for monitoring and adding water. RN-A later stated she learned CPAP masks should be cleaned daily, the remaining water in the reservoir should be emptied daily, and the reservoir rinsed with warm water, but this had not been done for R24. The DON was informed that CPAP had not been on the care plan and that there had not been an actual order to apply CPAP at night; the DON was unaware of this and also unaware the mask was only being cleaned weekly. The facility also failed to ensure a care plan was initiated after a trauma assessment identified a history of PTSD for R27. R27 had diagnoses including dementia with behavioral disturbance, agitation, and repeated falls. The quarterly MDS showed severe cognitive impairment, verbal behavioral symptoms, rejection of care, and use of antipsychotic and antidepressant medication. The CAA for cognitive loss/dementia included psychiatric or mood disorder, and the trauma-informed assessment indicated R27 answered yes to experiencing a traumatic event and endorsed symptoms consistent with probable PTSD, including nightmares and guilt or inability to stop blaming himself or others. Staff interviews confirmed the trauma assessment had been completed, but the care plan did not address potential PTSD. Social services stated the plan of care did not include a plan to address potential PTSD, though it did include a behavioral plan for refusals of care and behaviors. Nursing staff described behaviors that could be related to trauma triggers, including nighttime agitation, being startled by noise, and verbal outbursts telling staff to get out of the room. Family members reported R27 had a difficult war experience, was on edge and startled easily after returning home, and still had triggers such as fireworks. The DON stated a further assessment should have been completed after the trauma assessment and expected a plan of care to be initiated if PTSD history was confirmed.
Failure to Provide Individualized 1:1 Activities
Penalty
Summary
The facility failed to ensure individualized activities were provided for a resident with chronic kidney disease, adjustment disorder with depressed mood and anxiety, hearing loss, muscle weakness, and palliative care. The resident’s MDS indicated intact cognition, no behaviors or rejection of care, a preference for books, newspapers, and magazines, an interest in keeping up with current news, and no interest in group activities. The care plan dated 10/14/25 identified that the resident was alert and oriented, enjoyed music, reading, classic television shows, and war movies, and included interventions for staff to converse with the resident during care, provide activities compatible with his interests and preferences, and provide a 1:1 activity program. During observations and interviews, the resident was repeatedly found alone in bed, bored, and lonely, with the TV on but no volume or captions. He stated he could no longer enjoy television because of poor hearing and inability to read captions, that he was unable to get out of bed anymore, and that he wished more people would visit him during the day. He also stated activity staff brought books and magazines but only dropped them off and did not stay to visit or do an activity with him. Activity staff stated they offered group activities daily and delivered books, magazines, and TV channels, but did not specifically do one-to-one activities because there was not enough time. The life enrichment director stated that if the care plan indicated one-to-one activity visits, the resident should have been getting them, and that dropping off books and magazines and turning on the television did not qualify as individual activities. The facility activity follow-up report for November 2025 showed the resident was offered group and independent activities on most days, but did not indicate any one-to-one activities.
Incomplete Weekly Skin Assessments for Stage Four Coccyx Pressure Ulcer
Penalty
Summary
The facility failed to ensure weekly comprehensive skin assessments were completed for a resident with an unhealed stage four pressure ulcer on the coccyx. The resident had diagnoses including diabetes, chronic kidney disease, hemiplegia, and hemiparesis following stroke, and required substantial assistance with toileting and bed mobility. He was occasionally incontinent of bowel and bladder, did not walk, used an electric scooter, and was identified as at risk for pressure injury with one stage four ulcer present on admission. The resident’s orders included daily wound care to the coccyx, and the care plan directed weekly treatment documentation to include measurement of each area of skin breakdown, tissue type, exudate, and other notable changes. The facility’s skin checks were documented weekly on an electronic flowsheet, but most of the weekly entries did not include wound measurements or wound characteristics. Of seven weekly skin checks reviewed since admission, only one contained all required documentation; the others were missing measurements, characteristics, or both. The admission skin check also lacked staging and wound characteristics such as tunneling, epithelial tissue, granulation, slough, eschar, exudate, odor, skin edge condition, surrounding tissue, and induration. A wound provider note documented the coccyx pressure ulcer as chronic, stage four, measuring 2 cm x 2 cm x 1.5 cm with moderate serous and serosanguineous drainage, exposed subcutaneous tissue, full-thickness loss, and a mix of granulation tissue and slough/fibrin. A later wound provider note stated the sacral wound had reduced in size with healthy red granulation tissue and no signs of infection. During interviews, nursing staff acknowledged the documentation was inconsistent and lacked elements of a comprehensive wound assessment, and the RN stated she had not reviewed each section of the electronic skin check tool. The DON stated she would have expected a complete assessment to know whether the wound was improving or worsening.
Failure to Assess Safe Smoking and Provide Ash Receptacle
Penalty
Summary
The facility failed to assess safe smoking for one resident who had diagnoses of tobacco use and COPD, was cognitively intact, and used a motorized wheelchair for mobility. The resident’s care plan identified her as a smoker and stated she would not suffer injury from unsafe smoking practices, but the record did not show a smoking order and staff were not aware of a smoking risk assessment tool. The resident stated she had smoked throughout her six-month stay, kept cigarettes and a lighter in her room and on her wheelchair, and did not recall having a safe smoking assessment or being told the campus was smoke free. The resident reported that she smoked outside in the parking lot and, when finished, put out cigarettes with her fingers, rolled the remains into her shirt, brought them back into the building, wrapped them in a tissue, and threw them in the wastebasket. She also stated she had not been given an ash receptacle, and a partially used cigarette was observed on a piece of paper on her overbed table. The DON stated the facility was smoke free and knew the resident smoked in the parking lot, but did not know how she was disposing of ashes and cigarettes at the time. The facility smoking policy stated residents who wished to smoke were to be assessed at least quarterly, but staff interviews showed uncertainty about whether the assessment had been completed before the DON later reviewed the policy and had a smoking assessment completed for the resident.
Failure to Offer Fluids Consistently to a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with Alzheimer's disease and severe dementia, who was dependent on staff for eating and drinking, was offered fluids on a consistent basis. The resident's MDS showed severe cognitive impairment, unclear speech, substantial/maximal assistance with eating and drinking, and dependence on staff for activities of daily living. The care plan identified a potential for hydration problems related to dementia and Alzheimer's disease, and the Kardex directed staff to offer fluids with all cares and meals and at least every three hours while awake. During a seven-day review, the resident averaged 660 ml of fluid intake per day and 787 ml of urine output per day. The family member stated staff did not offer drinks except at mealtimes and said the resident should be drinking more often. During observation, the resident was not offered water while in bed, and a mug of water on the bedside table was out of reach. The urinary drainage bag contained dark gold urine, and a nursing assistant stated the urine smelled strong and that she would report it and push fluids. A nurse acknowledged being told the urine was yellow and smelled strong but did not assess the resident, document the urine characteristics, communicate to nursing assistants to push fluids, or inform the clinical care manager. The clinical care manager and DON stated the nurse should have assessed the resident and reported the findings so the provider could be updated.
Inconsistent CPAP Cleaning and Maintenance
Penalty
Summary
The facility failed to ensure staff followed the manufacturer’s guidelines for cleaning and maintaining a resident’s CPAP equipment. The resident had diagnoses including epilepsy, cerebral infarction, and obstructive sleep apnea, and the MDS indicated moderate cognitive impairment and dependence on staff for all activities of daily living. The care plan included CPAP use at baseline, with interventions for cleaning the mask, nasal pillows, tubing, and headgear, and wiping the flow generator. Physician orders also directed CPAP cleaning and wiping of the mask, nasal pillows, and tubing every shift, while the manufacturer’s manual directed daily cleaning of the humidifier tub and mask cushion and weekly cleaning of the humidifier tub, mask cushion, headgear, air tubing, and outlet connector. During observation, the resident was seen using the CPAP mask while the machine was running, and staff turned off the machine and removed the mask. Nursing assistants stated the nurse was responsible for cleaning the mask, machine, and reservoir. Later observations showed the CPAP mask left on top of the machine and moisture remaining in the water reservoir. The same pattern was observed again later in the day, with the mask and tubing still sitting on top of the machine and moisture still present in the reservoir. On the following day, the resident was again observed with the CPAP mask on while the machine was running, and a noise was heard coming from around the mask. An LPN readjusted the mask, but the noise returned. Staff then turned off the machine and removed the mask, and an NA stated they were not responsible for cleaning the CPAP machine or supplies. Interviews with nursing staff showed inconsistent understanding of how often and how to clean the CPAP mask, tubing, and reservoir, and the DON confirmed the facility’s CPAP policy and instructions lacked guidance on cleaning the machine, supplies, and reservoir, with variance in how the supplies were cleaned and how often.
Failure to Reassess Trauma History and Address Possible PTSD
Penalty
Summary
The facility failed to comprehensively assess and reassess past trauma and to implement care plan interventions using a trauma-informed approach for one resident with dementia, agitation, repeated falls, severe cognitive impairment, and behavioral symptoms. The resident’s quarterly MDS showed a BIMS score of 5, verbal behavioral symptoms toward others, rejection of care, and need for substantial to maximal assistance with transfers, toileting, and bed mobility. The resident was also receiving antipsychotic and antidepressant medications. The care plan addressed verbal aggression, threats, striking staff, refusals of care, and behaviors, but it did not include a history of PTSD. A Trauma Informed Care assessment indicated the resident answered yes to experiencing a traumatic event. In a probable PTSD interview, the resident answered yes to having nightmares about events and to feeling guilty or unable to stop blaming self or others for the events or problems they caused. Social services stated the initial trauma assessment was completed in February 2025 and that no further trauma assessment had been completed, even though the initial screening showed positive indicators possible of PTSD. Social services also confirmed the care plan did not include a plan to address potential PTSD, only a behavioral plan addressing refusals of care and behaviors. Staff interviews showed the resident sometimes talked about war, had nighttime behaviors, and could become verbally upset when staff entered the room at night. A family member stated the resident had been in the army, had been on edge and startled easily after returning home, and still became triggered by fireworks. The DON stated further assessment should have been completed after the February 2025 trauma assessment and that a care plan would be expected if PTSD history were confirmed. The facility policy required universal screening, use of screening tools that are culturally relevant and sensitive, further assessment when indicated, individualized care plans addressing past trauma, and identification and reduction of triggers that may re-traumatize the resident.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, but does not provide further details regarding the specific actions, inactions, or events that led to the error. No additional information about the residents involved or their medical conditions at the time of the deficiency is included in the report.
Failure to Document Medication Disposition for a Resident
Penalty
Summary
The facility failed to maintain proper documentation regarding the disposition of medications for a resident with multiple complex medical conditions, including hypertensive heart disease with heart failure, atrial fibrillation, a prosthetic heart valve, a defibrillator, and chronic liver disease. Specifically, after a medication error was identified in which the resident received an incorrect dosage of Torsemide, the Director of Nursing (DON) destroyed four prescription cards of the medication but did not document the prescription numbers, quantity, or date of destruction as required. The medication destruction log did not include the destroyed Torsemide, and the resident's medical record lacked evidence of the medication's proper disposition. Interviews with facility staff and review of the facility's Medication Destruction Policy confirmed that all medications delivered to the facility are considered the property of the resident and that a log must be completed for any medication disposed of, including specific details such as resident name, prescription number, quantity, date, and staff signature. The consulting pharmacist and registered nurse both acknowledged that the required documentation was missing for the destroyed Torsemide, and the DON admitted to not recording the necessary information at the time of destruction.
Infection Control Lapses in Catheter and Laundry Handling
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a resident with an indwelling urinary catheter. The resident's urinary drainage bag was observed laying on the floor, which is against the facility's infection control policy. The Licensed Practical Nurse (LPN) who administered medication to the resident did not initially address the issue, and upon inquiry, acknowledged that the catheter bag should not be on the floor as it could lead to a urinary tract infection (UTI). The facility's policy on catheter care did not specify the proper positioning of the urinary drainage bag to prevent such occurrences. Additionally, the facility did not adhere to proper procedures for handling soiled linens. Observations revealed that loose and contaminated laundry was sent down the laundry chute without being secured in a plastic bag, contrary to the facility's policy. Staff interviews confirmed that linens were sometimes thrown down the chute unbagged due to haste, and there was no signage to remind staff of the proper procedure. The facility's policy on soiled linen handling required linens to be bagged to prevent contamination, but it did not include specific instructions for using the laundry chute. Interviews with the Director of Nursing (DON) and other staff members indicated awareness of the proper procedures, yet these were not consistently followed. The DON acknowledged that placing catheter bags on the floor and sending loose linens down the chute posed infection control concerns. Despite staff training, these lapses in protocol were observed, highlighting a need for reinforcement of infection prevention practices within the facility.
Failure to Maintain Food Safety and Infection Control
Penalty
Summary
The facility failed to maintain proper holding temperatures for hot foods, specifically cheese quesadillas and bacon, which were observed to be below the required 135 degrees Fahrenheit. The cheese quesadillas were initially removed from the oven at 136 degrees Fahrenheit but dropped to 127 degrees Fahrenheit after being left partially uncovered on the stove. Similarly, bacon was observed on a warm burner without a lid, with a holding temperature of 119.9 degrees Fahrenheit. The Culinary Services Manager acknowledged the failure to maintain adequate holding temperatures, which contradicted the facility's policy requiring hot foods to be held at a minimum of 135 degrees Fahrenheit. Additionally, the facility failed to ensure proper infection control practices during food preparation and service. A cook was observed handling food without gloves and touching food contact surfaces without washing hands. After a collision in the kitchen, the same cook handled broken glass and peaches without washing hands before returning to food preparation tasks. The Director of Nursing recognized the need for immediate re-education on infection control, as these practices have the potential to affect all residents on the unit. The facility's hand hygiene policy emphasizes the importance of hand hygiene in preventing the spread of infection, which was not adhered to in these instances.
Failure to Notify Physician of Neck Pain After Fall
Penalty
Summary
The facility failed to notify the physician of a resident's neck pain following a fall, which was a deficiency identified during the survey. The resident, who had a history of Parkinsonism, pneumonia, atrial fibrillation, and fractures, experienced an unwitnessed fall while reaching for an item. Although the resident initially complained of mild foot pain, later in the day, he began to experience neck pain, which was not immediately communicated to the physician. The nursing staff documented the resident's complaints of neck pain and offered pain relief, but the physician was not notified until the following morning when the resident's condition worsened. The resident was eventually transferred to the emergency department, where further fractures were diagnosed. Interviews with the medical staff, including the resident's doctor and nurses, confirmed that the physician should have been notified immediately when the resident began complaining of neck pain. The director of nursing and other staff members acknowledged the oversight in communication, noting that the physician was initially contacted after the fall but not when the neck pain developed. The facility's policy on physician notification was requested but not provided, indicating a possible gap in procedural adherence or documentation.
Failure to Conduct Weekly Skin Assessments for Pressure Ulcers
Penalty
Summary
The facility failed to ensure weekly comprehensive skin assessments with measurements were completed for a resident reviewed for pressure ulcers. The resident, who was cognitively intact and required substantial assistance with daily activities, had a history of type one diabetes, cancer, hypertension, renal insufficiency, and chronic kidney disease, making them at risk for developing pressure ulcers. Despite having two unstageable pressure injuries on both heels, the facility did not conduct the required weekly skin assessments after the initial discovery of the ulcers on October 10, 2024, until October 24, 2024. The resident's care plan included interventions such as pressure-relieving devices and weekly documentation of the skin injuries' measurements and characteristics. However, the facility's documentation was inconsistent, with missing entries for the required weekly assessments. The resident's treatment administration record indicated a lack of comprehensive skin checks, and the facility's staff confirmed that the assessments were not completed as expected. The resident's condition, including diabetes and poor perfusion, was noted to contribute to the risk of skin breakdown, but the facility did not adhere to its policy of weekly wound assessments. Interviews with facility staff, including the nurse manager and consulting wound nurse, revealed that the resident's pressure ulcers were acquired in-house and were not documented with the necessary measurements and comprehensive descriptions. The facility's pressure injury policy required weekly wound assessments and documentation, but this was not followed, leading to a deficiency in the care provided to the resident. The facility's director of nursing and administrator acknowledged the lapse in completing the weekly skin checks and the need for comprehensive assessments.
Failure to Address Pharmacist Recommendations for Medication Management
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations for two residents, leading to deficiencies in medication management. For one resident, identified as R59, the consultant pharmacist recommended a follow-up on the potential need for ACEI/ARB therapy due to the resident's diabetes and chronic kidney disease. Additionally, there was a lack of indication for the use of aspirin. Despite these recommendations being documented in the resident's chart, the facility did not address them, as confirmed by the Director of Nursing (DON) and the nurse manager. The DON acknowledged receiving the recommendations but failed to ensure they were acted upon by the provider. Another resident, identified as R55, was prescribed duloxetine with an inappropriate indication of cognitive impairment. The consultant pharmacist issued multiple notices requesting clarification or an appropriate indication for the medication, but these were not addressed. The DON admitted to receiving an email about the duloxetine recommendation but had not taken action. The nurse manager, who was not involved in the pharmacy review process, confirmed the lack of action on the recommendations. The facility's policy requires the consultant pharmacist to perform a medication regimen review for each resident and report any irregularities to the attending physicians. However, in these cases, the facility did not follow through on the pharmacist's recommendations, resulting in medication irregularities for the residents. The DON was responsible for ensuring these recommendations were addressed but failed to do so, leading to the deficiencies noted in the report.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to utilize enhanced barrier precautions (EBP) for two residents during high-contact care activities, as observed by surveyors. The Centers for Disease Control (CDC) guidelines indicate that EBP should be used during high-contact care activities for residents with infections or colonization with multi-drug resistant organisms (MDRO), or for those with chronic wounds or indwelling medical devices. Despite these guidelines, staff did not implement EBP for two residents, R1 and R2, who required such precautions due to their medical conditions. Resident R1, diagnosed with bullous pemphigoid, had severe cognitive impairment and required assistance with dressing, bathing, and hygiene. R1 had a left foot ulceration and underwent wound debridement. Despite the care plan indicating the need for EBP during high-contact care activities, staff were observed transferring R1 and assisting with toileting without using EBP. Similarly, Resident R2, who had a urostomy and severe cognitive impairment, required assistance with transfers and care. Staff were observed transferring R2 without using EBP, despite the care plan's instructions. Interviews with staff revealed a lack of adherence to EBP protocols, with some staff unaware of the need to use EBP during high-contact care activities. The infection preventionist stated that education on EBP was provided at meetings, and audits were conducted, but the deficiency persisted. The Director of Nursing expected EBP to be followed and accessible, yet observations indicated otherwise. The facility's EBP policy outlined the need for gloves and gowns during close contact care for residents with MDRO history or colonization, but this was not consistently implemented.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to safely use a full body mechanical lift according to the manufacturer's recommendations, resulting in harm to a resident (R1) who fell from the lift. R1, who was diagnosed with quadriplegia and had bilateral range of motion impairment, was dependent on staff for all activities of daily living except eating. The incident occurred when nursing assistants were transferring R1 from a wheelchair to a bed, and the right shoulder sling loop/strap detached from the lift, causing R1 to fall approximately three feet to the floor. This fall resulted in ongoing pain in R1's shoulders and neck region. The facility also failed to ensure comprehensive assessments were completed to determine the proper sling size for residents requiring transfers with a mechanical lift. R1's care plan and nursing assessments did not specify the sling size or type, and staff used whatever sling was available in the room without a clear process for determining the appropriate size. Interviews with staff revealed a lack of awareness and training on how to properly determine sling sizes, and the facility did not have a system in place for sling assessments. Additionally, the facility's investigation into the fall did not address whether the appropriate sling size and type were used during R1's transfer. Maintenance logs indicated that the lifts were not inspected immediately following the incident, and the facility was using a different brand of lifts than documented. The lack of proper sling size determination and failure to follow safety protocols contributed to the deficiency, as staff did not check the tension of the sling loops/straps before moving the resident, leading to the fall.
Failure to Update Care Plan After Resident's Health Decline
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident with moderately impaired cognition and a terminal illness. The resident's care plan initially included interventions for mobility assistance, but after a significant decline in health status, the care plan was not updated to reflect the resident's new needs. The resident experienced a decline in mobility and communication abilities, was sent to the emergency room, and returned with a new diagnosis and treatment plan, but no comprehensive assessment or updated care plan was completed upon their return to the facility. Interviews with the clinical manager and the director of nursing revealed that the resident's care plan was not accurate for their level of care related to mobility and activities of daily living after the change in condition. The clinical manager acknowledged that a mobility assessment had not been completed, and the director of nursing confirmed that a comprehensive assessment should have been conducted to re-establish the resident's baseline and update the care plan accordingly. Both staff members recognized the deficiency in the care planning process. The facility's policy on care planning indicated that the interdisciplinary team is responsible for developing resident care plans based on assessments and that these plans should be updated following significant changes in a resident's condition. Despite this policy, the facility did not complete the necessary assessments or update the care plan for the resident after their return from the hospital, leading to a failure in providing appropriate care for the resident's needs.
Failure to Administer Medication Per Physician Order and Address Medication Errors
Penalty
Summary
The facility failed to administer medication per physician order and did not evaluate and address medication errors to prevent recurrence for a resident with moderate cognitive impairment and a life expectancy of less than six months. The resident's medication administration record (MAR) showed discrepancies in the administration of Ativan, with doses given incorrectly on multiple occasions. A medication error report indicated that the resident received double doses of Ativan, but the facility did not document monitoring of the resident for overdose response or vital signs before the next dose. Additionally, the facility did not complete a causal analysis to prevent similar errors in the future. The Director of Nursing (DON) was informed of the medication error but had not investigated or provided education to prevent further errors. The DON confirmed that the resident's record lacked documentation of monitoring and assessing after the error. The facility's Medication Error Policy required a medication error report to be completed and signed by the responsible person, with follow-up actions as needed. However, the DON had not yet implemented any measures to prevent recurrence. The administrator expected nurses to follow the medication administration policy and refer errors to the DON for follow-up.
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What surveyors actually found near you
We read the 70 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Albert Lea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thorne Crest Retirement Center | 2 mi | ★★★★★ | 26 | 0 |
| Good Samaritan Society - Albert Lea | 2.6 mi | ★★★★★ | 5 | 0 |
| New Richland Care Center | 16.2 mi | ★★★★★ | 2 | 0 |
| Parkview Care Center | 17.3 mi | ★★★★★ | 12 | 0 |
| Lutheran Retirement Home | 17.5 mi | ★★★★★ | 8 | 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.