Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Tweeten Lutheran Health Care Center during CMS and state inspections, most recent first.
QAPI committee failed to identify, investigate, and analyze repeated pressure ulcer concerns or develop documented action plans. Monthly meetings showed ongoing tracking of falls, bruises, infections, skin events, call light response, bowel/bladder documentation, and MDS/CASPER triggers, including pressure ulcers, but there was no root cause analysis, prioritization of high-risk issues, interdisciplinary performance improvement project, or monitoring for effectiveness. The IPQA stated she had minimal QAPI training, was unsure of her role, and could not provide a written action plan; she also said the committee collected data but the information did not go anywhere else.
Failure to Honor Resident Repositioning Preference: A resident with severe cognitive impairment, Parkinson's disease, dementia with Lewy bodies, and a pressure ulcer was observed appearing uncomfortable and asking an NA to reposition his feet. The NA refused the request twice and told the resident to sit back and relax, despite the resident being dependent on staff for position changes. An LPN and RN stated the resident could not reposition himself and that staff should have honored his request.
A resident was discharged from Medicare Part A skilled services without receiving the required NOMNC before coverage ended. The resident’s family was not aware of the appeal rights, and facility staff said they did not issue the notice because the resident was going home and there was confusion about whether it was needed, even though staff later stated it should have been issued. Therapy notes showed the resident still needed standby assist for mobility and 24-hour care with family help for ADLs and transfers.
Failure to Obtain Baseline AIMS Assessment for a Resident on Antipsychotic Medication. A resident with dementia, psychotic disorder, and cognitive impairment received olanzapine throughout the review period, but the medical record did not contain a baseline AIMS/tardive dyskinesia assessment. The pharmacy care plan identified the need for tardive dyskinesia monitoring, and the RN confirmed the resident should have had a baseline assessment on admission per facility practice and policy.
The facility failed to consistently implement ordered pressure injury interventions for two residents. One resident with Parkinson’s disease and dementia had care plans and provider orders for barrier ointment, heel off-loading, and protective green boots at all times, but staff repeatedly left the boots off during the morning and did not apply them during repositioning or care. Another resident with cognitive impairment and a heel pressure injury had heel boots ordered when in bed, yet the boots were found in the closet while the resident lay in bed with the affected heel in contact with the other foot, and staff did not apply the boots during the observation.
A resident with moderate cognitive impairment and dependence for transfers and toileting was observed being moved with an EZ Stand lift and then left attached to the lift while on the commode. Staff did not disconnect the harness, and one NA stated there was no safety assessment for leaving him hooked up; another noted he had slipped out of the lift before. The lift manual required unhooking the sling and removing the lift after positioning the resident on the commode, and nursing staff stated residents should not be left on the lift unless directly visualized.
Hydration Not Kept Within Reach for Resident at Risk for Dehydration: A resident with Parkinson’s disease, Lewy body dementia, and severe cognitive impairment was identified as at risk for dehydration, with a care plan directing staff to keep fluids accessible and encourage fluids throughout the day. During repeated observations, the resident’s water pitcher remained on a side table next to the bed and not within reach while he sat in front of the TV, and multiple staff members left the room or took him to activities or lunch without offering hydration, even after he asked for root beer. An LPN stated the resident could not move within his room and needed water within arm’s length, and an RN confirmed the care plan required fluids to be accessible and offered whenever staff interacted with him.
A resident with PTSD and anxiety disorder was not consistently provided trauma-informed care when the facility failed to honor her request for no male staff to assist with ADLs. Staff, including an NA and multiple RNs, were aware of the resident’s trauma history and preference, but male staff still provided personal cares, and the request was not included in the care plan.
A facility failed to obtain routine and requested dental services for two residents. One resident with dementia and loose-fitting partials reported that staff said they would arrange dental care, but the record had no documentation of appointment requests or attempts. Another resident with intact cognition reported tooth sensitivity and missing teeth, and staff confirmed the request had been pending since the previous fall, with no completed dental appointment documented.
Failure to use PPE, disinfect shared equipment, and properly place catheter bag. A resident on EBP was assisted with transfers and toileting by an NA who entered the room without the required gown and gloves despite an EBP sign being posted. The same NA did not disinfect the EZ Stand before it was reused with another resident. In a separate event, staff used a facility lift with two residents and placed it back in the hall and then reused it without disinfection. Staff also observed a resident with a urinary catheter whose drainage bag was laying directly on the floor instead of being hung or placed in a dignity bag.
A resident with dementia and Parkinson's Disease was not properly monitored or assessed for pressure ulcer risk, and interventions such as heel boots and offloading were delayed or inconsistently documented. Wound assessments were incomplete, lacking key details and timely updates, and weekly comprehensive assessments by an RN were not consistently performed, contrary to facility policy.
A resident with cognitive impairment and a history of wandering was able to exit the facility in extremely cold weather after activating an exit alarm, with staff failing to immediately retrieve her despite visual confirmation. Additionally, another resident experienced multiple falls without comprehensive root cause analysis or timely updates to care plans and interventions. Staff interviews indicated insufficient training and inconsistent implementation of safety protocols.
The facility did not ensure an RN was on duty for at least eight consecutive hours in a 24-hour period, as required. Although posted staffing information indicated RN coverage, the actual schedule showed only LPNs were present, and the DON confirmed the absence of RN coverage. The facility's staffing policy did not specify the need for eight consecutive hours of RN coverage, potentially affecting all residents.
The facility did not immediately investigate suspicious bruises of unknown origin found on two residents, as required by its abuse prohibition policy. One resident with cognitive and physical impairments was found with a breast bruise, and another with multiple medical conditions had a bruise near the rectum. In both cases, there was no documentation of how the injuries occurred or evidence of staff interviews, and the DON confirmed that investigations should have been initiated but were not.
Two residents with significant medical conditions were found with bruises of unknown origin in suspicious locations. In both cases, the LPN who discovered the injuries did not immediately notify the administrator or DON, and reporting to the State Agency was delayed or not completed, contrary to facility policy requiring prompt reporting of potential abuse.
A resident with severe cognitive impairment and a history of falls was admitted and experienced two additional falls. The baseline care plan did not identify the resident's fall risk or include updated interventions from fall investigations, despite new measures being identified after each incident. The DON confirmed the care plan was incomplete and not updated as required.
Two residents experienced multiple falls and pressure ulcer events, but their care plans were not promptly updated to include new interventions identified during investigations and IDT reviews. Despite specific recommendations such as increased assistance, safety checks, and offloading devices, these were not consistently added to the care plans. Staff interviews revealed confusion about responsibility for care plan updates, contributing to the deficiency.
A resident with cognitive impairment and a history of wandering did not receive ordered occupational therapy evaluation, treatment, or cognitive testing due to a breakdown in communication and follow-up between nursing and therapy staff. The order was transcribed but not relayed to the therapy department, resulting in the services not being provided as directed.
The facility posted inaccurate nurse staffing information by listing an RN for a day shift when, in fact, an LPN worked that shift. The DON discovered the error after verifying the nurse's license, resulting in a staff posting that did not reflect the actual personnel on duty. This inaccuracy had the potential to affect all residents in the facility.
The facility failed to ensure proper hand hygiene practices among staff, affecting multiple residents. Nursing assistants and an LPN were observed not performing hand hygiene before and after resident contact, between glove changes, and after touching potentially contaminated surfaces. Additionally, the facility lacked an infection surveillance system, with no tracking of infections since July 2024, contrary to the facility's Infection Prevention and Control Plan.
The facility failed to maintain a clean and sanitized kitchen environment, potentially leading to cross-contamination or foodborne illness. During inspections, several kitchen items were found unclean with crusted food and debris. The dietary manager confirmed the issues and stated that all staff are trained on proper cleaning procedures, but the presence of dirty items indicates a failure to adhere to these procedures.
A facility failed to complete a Level II PASARR for a resident with mental disorders, including schizoaffective and bipolar disorders. Despite the resident's need for psychiatric care and psychotropic medications, the facility did not request the necessary screening, as confirmed by staff interviews and the facility's policy requirements.
The facility did not document that three staff members, including two LPNs and a housekeeper, were offered or educated about the COVID-19 vaccine. Interviews revealed a lack of awareness and documentation regarding vaccine offers and education, despite the facility's policy requiring such actions.
A resident with congestive heart failure and hypernatremia experienced harm due to the facility's failure to conduct a comprehensive nutritional assessment and monitor for dehydration. Despite being on diuretics and a pureed diet with thickened liquids, the resident's fluid intake was inadequately monitored, leading to multiple hospitalizations for severe health issues. Staff interviews revealed a lack of awareness and systems to monitor fluid intake, and facility policies on dehydration were not effectively implemented.
A facility failed to create a comprehensive care plan for a resident with acute respiratory failure with hypoxia. The care plan lacked specific goals and interventions for respiratory assessment and monitoring, despite the resident's recent hospitalization for severe hypotension and respiratory failure. Staff interviews confirmed the absence of necessary interventions in the care plan.
A resident with intact cognition and diagnoses of hypernatremia and hyperosmolality experienced frequent loose stools while receiving scheduled bowel medications, including docusate sodium. Despite documentation of large, loose stools and staff reports, the facility continued administering the medication without proper evaluation. Interviews revealed that bowel medications were not consistently held, and the provider was not notified promptly, contrary to the facility's bowel management policy.
A resident with Alzheimer's and psychotic disorder reported an incident of physical abuse by staff, which was not reported to the administration or State Agency within the required timeframe. The resident felt unsafe during the incident but has since felt secure. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to in this case.
A resident with Alzheimer's and other conditions reported an incident of physical abuse by two staff members, which was not thoroughly investigated by the facility. The investigation lacked interviews with all relevant parties and did not implement protective measures, contrary to the facility's policy.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, as required by their care plan. Observations showed no signage or PPE available, and staff were unaware of EBP requirements. Interviews confirmed that EBP was not implemented for any residents, despite the facility's policy outlining the need for staff training and PPE availability.
QAPI Committee Failed to Analyze Repeated Pressure Ulcer Concerns
Penalty
Summary
The facility failed to ensure its QAPI committee identified, investigated, analyzed, and responded to high-risk issues related to pressure ulcers by developing and implementing action plans for process improvement. Review of QAPI minutes from December 2025 through March 2025 showed the facility consistently collected and reported quality data, but the documents did not include root cause analysis, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, or monitoring for effectiveness. Across the monthly meetings, the facility tracked multiple indicators, including falls, bruises, medication errors, infections, PPE compliance, influenza vaccination rates, call light response, bowel and bladder documentation, and MDS/CASPER triggers such as pressure ulcers, falls with major injury, psychotropic use, UTI, ADL decline, mobility decline, and excess weight loss. The December meeting reflected data collection across departments, including 2 bruises, 1 medication error involving incorrect medication administration, 4 infections, 19 audits completed, PPE compliance at 87.7%, and a 63.9% influenza vaccination rate. Nursing audit findings included 6.57% of call lights not answered timely and bowel/bladder documentation completion rates between 67% and 89.7%. MDS review identified multiple triggered areas, including pressure ulcers, falls, anxiety/hypnotic use, behavioral symptoms, and excess weight loss, but there was no documentation showing which risks were prioritized, what caused the concerns, or whether interdisciplinary action plans were developed. The January, February, and March meetings continued to show repeated identification of the same concerns without documented analysis or action planning. January data included 14 falls, 10 bruises, 5 infections, low gown and glove compliance, worsening bowel and bladder documentation, and MDS triggers including pressure ulcers. February data included 12 falls with 1 major injury and 1 VA-reportable event, 12 skin events, 8 bruises, 8 infections, and continued pressure ulcer triggers below threshold. March data included 12 falls with 1 major injury and 1 VA-reportable event, 13 skin events, 2 bruises, 1 medication error involving a missed dose due to misreading an order, 6 infections, and continued pressure ulcer triggers. During an interview on 4/2/26, the IPQA stated she had been in the role for 3 months, had minimal training in QAPI, was unsure of her role and what was required by regulation, and said the committee collected and presented data but that the information did not go anywhere else. She stated the root cause for high incident rates was not analyzed, pressure ulcers were identified as a problem area but were attributed to improved nursing documentation, and she could not provide a written action plan for any areas discussed.
Failure to Honor Resident Repositioning Preference
Penalty
Summary
The facility failed to honor a resident's request for repositioning and positioning preference for 1 of 1 resident reviewed for pressure ulcers. The resident had severe cognitive impairment, was dependent on staff for toileting, bathing, dressing, personal hygiene, transfers, and position changes, and had diagnoses including Parkinson's disease, dementia with Lewy bodies, and a pressure ulcer of the right heel. The resident's care plan addressed bilateral heel and low back pain and included monitoring for pain and discomfort, but during observation the resident appeared visibly uncomfortable, rocking back and forth, trying to move his feet, and showing a slight grimace. When the resident used the call light and asked a nursing assistant to reposition his feet, the nursing assistant told him his feet needed to stay where they were and did not reposition him. The resident repeated that he was uncomfortable and again asked for his legs and feet to be repositioned, but the nursing assistant again refused and told him to sit back and relax. During interviews, the nursing assistant did not remember refusing the request, while an LPN and an RN stated the resident was unable to reposition himself, staff assistance was required, and it was inappropriate to refuse his request for repositioning. Facility policies referenced resident freedom of choice and providing appropriate care and services for residents unable to perform ADLs independently.
Failure to Issue Required Medicare Non-Coverage Notice Before Discharge
Penalty
Summary
The facility failed to timely provide the required liability and appeal rights notices before discharge from Medicare Part A services for one resident. The resident’s last day of covered Medicare Part A skilled services was identified as 3/4/26 on the CMS-20052 SNF Beneficiary Protection Notification Review form, which also indicated the facility/provider initiated discharge from Medicare Part A services before benefit days were exhausted. Section 2 of that form stated the Notice of Medicare Non-Coverage (NOMNC, CMS-10123) was not issued because the resident discharged immediately after LCD. Progress notes showed the resident had a last covered date from PT on 3/2/26 and OT on 3/3/26, with discharge home on 3/4/26. Notes on 3/3/26 stated the family would arrive on 3/4 to take the resident home, and on 3/4/26 discharge paperwork was discussed with the family before the resident was discharged home. The resident’s POA did not have documentation of receiving the required NOMNC. The resident’s PT discharge summary stated the resident would continue to need standby assist for all mobility, and the OT discharge summary stated the resident would require continued 24-hour care with family assistance for all ADLs and safety with front wheeled walker transfers. During interviews, the family member stated the resident was discharged due to preference and funding reasons and was unfamiliar with the NOMNC and the option to appeal Medicare coverage ending. Facility staff stated they usually issue the NOMNC a couple of days before LCD, but in this case did not issue it because the resident was discharging home and there was confusion about whether it was required; staff later stated the NOMNC should have been issued.
Failure to Obtain Baseline AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to obtain a care-planned baseline assessment for tardive dyskinesia for 1 of 2 residents reviewed for antipsychotic medication use. R15 was admitted on 10/17/25 with diagnoses including vascular dementia with moderate psychotic disturbances, psychotic disorder, and non-traumatic brain dysfunction. The quarterly MDS indicated R15 was moderately cognitively impaired, could not complete the assessment, and exhibited fluctuating disorganized thinking with daily behaviors not directed at others. The MDS also showed R15 was receiving an antipsychotic, antianxiety, and antidepressant medications. R15’s MAR showed olanzapine was administered from admission through the review period, with dose changes over time, including 5 mg daily, then 5 mg twice daily, then 10 mg twice daily, and later 5 mg in the morning and 10 mg in the evening. The pharmacy review care plan dated 10/17/25 stated R15 was receiving an antipsychotic medication and should have an assessment for tardive dyskinesia per physician. The medical record did not contain a baseline AIMS assessment. During interview, the nursing manager confirmed residents receiving antipsychotic medications have AIMS assessments done on admission and every 6 months, and confirmed R15’s record did not show an AIMS assessment and should have had a baseline assessment upon admission. The facility policy titled Psychotropic Drug Use dated 2/2025 stated baseline tardive dyskinesia assessment will be completed with reassessment every six months and as needed for antipsychotic medications.
Failure to Implement Heel Off-Loading and Pressure Injury Interventions
Penalty
Summary
The facility failed to monitor and implement individualized pressure ulcer interventions for 2 residents with pressure injury risk and existing heel wounds. R4 had Parkinson’s disease, dementia with Lewy bodies, severe cognitive impairment, dependence on staff for most ADLs, and a care plan and physician orders directing barrier ointment to the heels, off-loading heels when in bed, and use of protective green boots at all times. Although R4’s right heel pressure injury was documented as healed/resurfaced, staff observations on 3/31/26 showed R4 sitting in a Broda chair in the dining hall and later in his room without the protective boots on, with the boots left on the bed. During multiple interactions that morning, staff repositioned or assisted R4 without applying the boots, and one NA declined to move R4’s legs when he said they were uncomfortable. Staff interviews showed uncertainty about the boot requirement, and an LPN confirmed the boots were not applied until after lunch despite the order for continuous use. R24’s quarterly MDS showed moderate cognitive impairment, dependence on staff for most ADLs, and risk for pressure injuries with use of pressure-reducing devices. The care plan directed pressure off-loading boots on both feet in bed and no shoes until the pressure injury healed, and the MAR directed heel boots every shift when available. On 3/31/26, R24 was observed in bed with heel boots on the top shelf of the closet rather than on his feet. RN-B stated R24 frequently refuses care and that staff keep his feet elevated, but during the observation R24’s foot was touching the bed and the blister-like area on the outside of the left heel was in close contact with the top of his right foot. RN-B did not apply the heel boots during the observation. Additional staff interviews reflected inconsistent understanding of the heel boot interventions for both residents. One NA stated she was unsure whether R4 was supposed to wear the boots all the time and believed both heel wounds were healed. Another NA stated R24 wore heel boots at night, while another said he wore them all the time now. The IPQA and case manager RN stated R24 should wear heel boots every time he was lying down and should not wear shoes until healed. The facility policy on pressure ulcer/skin breakdown stated its purpose was to reduce or prevent pressure ulcers and outline care to promote healing.
Unsafe Use of Sit-to-Stand Lift During Toileting
Penalty
Summary
The facility failed to follow the manufacturer's instructions for safe operation of a Drive EZ Sit to Stand lift and failed to ensure safe supervision while a resident remained attached to the lift during toileting. R20 had moderate cognitive impairment, was dependent on staff for toileting, dressing, and transfers, and his care plan directed staff to use an EZ Stand with an XL harness for all transfers, with no leg strap per resident request. His care plan also identified him as a fall risk and directed staff to ensure he was in a safe position before assisting with the EZ lift and that all safety measures were in place. During observations, nursing assistants assisted R20 from his recliner to his commode using the EZ Stand and then left the room without disconnecting his harness from the lift. One nursing assistant stated she did not think there was a safety assessment for leaving R20 attached during toileting and noted he had slipped out of the EZ Stand previously during toileting. Another nurse stated residents generally should not be left on the EZ Stand while on the commode or toilet, and a different nurse stated residents should not be left on the EZ Stand unless directly visualized by staff. The lift manual instructed staff to lower the patient onto the commode, lock the casters, unhook the sling from all attachment points, instruct the patient to lift their feet off the footplate, remove the sling, and pull the lift away.
Hydration Not Kept Within Reach for Resident at Risk for Dehydration
Penalty
Summary
The facility failed to ensure that a resident at risk for dehydration had hydration available and within reach. The resident had diagnoses including Parkinson’s disease, dementia with Lewy bodies, and a pressure ulcer of the right heel. The quarterly MDS indicated severe cognitive impairment, dependence on staff for toileting, bathing, dressing, personal hygiene, position changes, and transfers, and the resident required set up/clean up assistance with eating and oral hygiene. The care plan dated 1/2/25 identified the resident as at risk for dehydration related to comorbidities, poor coordination, tremors, and decreased fluid intake, and included interventions to keep fluids accessible, assist with fluids as needed, and encourage fluids up to 2000 cc per day. During multiple observations, the resident was seated in his room in front of the television while his water pitcher remained on the side table next to the bed and not within reach. A social services staff member visited the room and left without moving the water within reach or offering hydration. A nursing assistant answered the resident’s call light, told him she was taking him to activity, and left without offering hydration. Later, an activity assistant returned the resident to his room, placed him in front of the television, left the room after the resident asked for root beer, and did not address the request. Another nursing assistant then took the resident to the dining hall for lunch after he again asked for root beer. A licensed practical nurse stated the resident could not move within his room and needed his water within reach of his chair to drink without assistance, and an RN confirmed the care plan meant fluids should be within arm’s length and offered whenever staff interacted with him.
Failure to Honor Resident’s Trauma-Related Preference for Female Staff
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident with PTSD and anxiety disorder by not consistently honoring her request for no male staff members to provide personal care. The resident’s quarterly MDS assessment indicated intact cognition and need for substantial assistance with toileting, dressing, and personal hygiene. Her trauma-informed care assessment documented a history of physical, verbal, or sexual abuse, with triggers including the time of day and nightmares, and coping strategies such as talking to staff, calling someone, and getting a hug or hand massage. Records and interviews showed that a male staff member provided personal cares on multiple occasions despite the resident’s stated preference and staff awareness of it. The resident reported that she had told the social service designee and all staff members that she did not want male staff assisting with ADLs because of her PTSD, and she became tearful during the interview while describing that the request had not been consistently honored. A male nursing assistant confirmed he provided cares even though he knew of the request, stating the resident did not ask him to leave. Multiple nursing assistants and nurses stated they were aware of the resident’s request, and the registered nurse case manager confirmed the request was not included in the care plan. The social service designee also confirmed awareness of the resident’s trauma history and the completed trauma-informed care assessment.
Failure to Obtain Requested Dental Services
Penalty
Summary
The facility failed to obtain routine dental services and requested dental services for 2 residents. One resident had moderate cognitive impairment, diagnoses including unspecified dementia without behavioral disturbance and interstitial pulmonary disease, and orders for Biotene for dry mouth and a mechanical soft diet. Although the resident’s oral cavity assessment noted an upper partial and no referral was necessary, speech therapy documented loose-fitting partials. The resident stated that he had requested dental services because his upper partial was fitting loosely and that staff said they would get it set and let his wife know at the last care conference meeting. The registered nurse case manager confirmed that the resident requested a dental appointment during the care conference in February and said she was in the process of contacting the spouse about availability, but the record contained no documentation of dental appointment requests or attempts to make an appointment. A second resident with intact cognition, diagnoses including myotonic muscular dystrophy, chronic diastolic heart failure, dry mouth, and GERD, expressed a desire to see a dentist because of sensitivity to hot and cold foods and missing teeth, and stated the request had been communicated to staff the previous fall. The RN case manager and social service designee both confirmed the request and stated they were working on getting an appointment or referral set up, but the record showed no completed dental service arrangement.
Failure to Use PPE, Disinfect Shared Equipment, and Properly Place Catheter Bag
Penalty
Summary
The facility failed to ensure proper use of PPE for a resident on Enhanced Barrier Precautions. R20’s MDS indicated he had moderate cognitive impairment, was dependent on staff for toileting, dressing, and transfers, and his care plan directed staff to use an EZ Stand for all transfers. During observation, a nursing assistant entered R20’s room without applying the required PPE despite an EBP sign being posted on the door, then assisted him with a transfer from his recliner to the commode, removed lower clothing, and handed him an empty urinal. The same nursing assistant later returned to assist R20 from the commode to the recliner and again entered without the appropriate PPE. The facility also failed to ensure shared resident equipment was disinfected between uses. After assisting R20, the nursing assistant did not disinfect the EZ Stand and placed it in the hall for reuse. Shortly afterward, the same EZ Stand was taken to another room and used with a second resident without being disinfected. In a separate observation, two nursing assistants used a facility lift to transfer one resident from chair to bed, placed the lift in the hall without disinfecting it, and then one of the assistants took the same lift to another room to transfer another resident from chair to bed without cleaning it first. The lift was later placed in an empty room without being disinfected. The facility further failed to ensure proper placement of a catheter bag for R11. R11’s MDS indicated he was cognitively intact, dependent on staff for toileting, dressing, and position changes, and had BPH with obstructive and reflux uropathy requiring a urinary catheter. During observation, the catheter bag was noted laying directly on the floor. Staff stated the bag should not be on the floor and should be inside a dignity bag or hung on the chair, and the infection preventionist confirmed that catheter bags should be placed in a dignity bag or hung on the chair and not directly on the floor.
Failure to Monitor and Manage Pressure Ulcers
Penalty
Summary
A resident with diagnoses of dementia and Parkinson's Disease was not properly monitored or assessed for pressure ulcer risk, despite being identified as at risk for pressure injuries and requiring maximum assistance for mobility. The resident's care plan included interventions such as an air mattress, skin inspections, and heel protectors, but documentation showed inconsistencies and delays in implementing these interventions. For example, heel boots were not added to the care plan until eight days after a left heel wound was identified, and there was no documentation of offloading measures prior to the appearance of redness on the heel. Wound assessments for the resident were incomplete and lacked comprehensive details such as wound characteristics, pain, drainage, and surrounding skin condition. Several wound management reports failed to include necessary information or to document the use of pressure-relieving interventions. Additionally, weekly comprehensive wound assessments by a registered nurse were not consistently performed or documented, and the care plan was not promptly updated to reflect new or worsening wounds. Interviews with nursing staff and the DON confirmed that comprehensive wound assessments were not being reviewed to ensure wounds were not worsening and that appropriate treatments were being used. The facility's own policy required weekly head-to-toe skin inspections and comprehensive wound assessments for residents with wounds, but these procedures were not followed, resulting in delayed identification and management of pressure ulcers for the resident.
Failure to Prevent Elopement and Inadequate Fall Risk Management
Penalty
Summary
The facility failed to immediately respond to an elopement incident involving a resident with mild cognitive impairment, chronic kidney disease, and a history of wandering. The resident, identified as an elopement risk and equipped with an exit alarm bracelet, was able to leave the facility without appropriate clothing for extremely cold weather. When the exit alarm sounded, staff initially searched the wrong area and did not immediately pursue the resident outside, despite visual confirmation of her location. The resident was eventually found by a staff member approximately 15 minutes later, outside and exposed to cold temperatures, with red face and very cold hands. Additionally, the facility did not conduct comprehensive investigations or root cause analyses for multiple falls experienced by another resident with cognitive impairment and impaired mobility. The fall investigations often lacked thorough assessments of contributing factors such as toileting needs, call light placement, and footwear. Interventions were inconsistently implemented or documented, and care plans were not promptly or adequately revised to address the identified risks and causal factors for repeated falls. Staff interviews revealed gaps in training and understanding of elopement prevention and response protocols. Documentation and care planning for fall prevention were incomplete, with delays in updating interventions and a lack of comprehensive analysis following each incident. The facility's policies required individualized interventions and ongoing evaluation, but these were not consistently followed, resulting in repeated deficiencies in accident prevention and resident supervision.
Failure to Provide Required RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of eight consecutive hours within a 24-hour period on one day during the review period. Specifically, on 12/13/25, posted nurse staffing information indicated that an RN was scheduled for the day shift, but the actual daily schedule showed only licensed practical nurses (LPNs) were present, with no RN coverage documented for that 24-hour period. During an interview, the director of nursing (DON) confirmed that there was no RN coverage on that date, despite the posted information. Review of the facility's Nurse Staffing Hours policy revealed that while it required posting of total and actual hours worked by nursing staff, it did not specify the requirement for RN coverage for eight consecutive hours in a 24-hour period. This deficiency had the potential to affect all thirty-six residents residing in the facility.
Failure to Immediately Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to immediately investigate injuries of unknown source in accordance with its abuse prohibition policy for two residents. One resident with Alzheimer's and Parkinson's disease, who was dependent for transfers and had moderate cognitive impairment, was found with a bruise of unknown origin on the right breast. There was no documentation in the resident's record or incident reports regarding how or when the bruise occurred, nor evidence that staff interviews were conducted. Another resident with heart failure, diabetes mellitus, and atrial fibrillation, who was dependent with toileting hygiene and transfers and had intact cognition, was found with a dark bruise near the rectum. The resident attributed the bruise to a recent bowel movement and denied abuse or pain, but again, there was no further information or staff interviews documented in the records or incident reports. During an interview, the DON confirmed that bruises found on the breast or anal region are considered suspicious for abuse and should trigger an immediate investigation, which did not occur in these cases. The facility's policy requires that all reports of abuse, including injuries of unknown source, be promptly and thoroughly investigated, with results documented. The policy specifically lists bruising in areas such as the inner thigh, chest, face, and breast, or bruises of unusual size or in atypical locations, as requiring immediate investigation to rule out abuse. Despite these requirements, investigations were not initiated for either resident after their injuries were discovered.
Failure to Timely Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to immediately report injuries of unknown origin to the administrator and did not notify the State Agency (SA) within the required reporting guidelines for two residents. One resident with Alzheimer's and Parkinson's disease, who was dependent for transfers and had moderate cognitive impairment, was found to have a bruise on the right breast of unknown origin. The LPN who discovered the bruise believed it was caused by a sit-to-stand lift and, since the resident denied abuse, did not report the injury to the administrator immediately, instead sending an email notification several hours later. The bruise was not investigated or reported to the SA as required. Another resident, with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation, and who was dependent with toileting and transfers, was found to have a dark bruise near the anal region. The LPN who identified the bruise did not notify the DON or administrator immediately, as the resident believed the bruise was from a bowel movement and denied abuse. Notification to administration was delayed and sent via email at a later time. The facility's policy required that allegations involving abuse be reported no later than two hours after the allegation is made, but this protocol was not followed in either case.
Failure to Update Baseline Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a baseline care plan for falls was continuously evaluated and updated to reflect interventions identified as a result of fall investigations for a resident with neurocognitive disorder with Lewy bodies and polyneuropathy. Upon admission, the resident was noted to have severe cognitive impairment, a history of falls, and required supervision for transfers. The initial baseline care plan did not identify the resident's level of fall risk or include appropriate fall prevention interventions. Following two witnessed falls in the dining area, additional interventions such as one-to-one supervision, increased staff assistance, and specific instructions for transfers and ambulation were identified during fall investigations. Despite these incidents and the identification of new interventions, the baseline care plan was not updated to reflect the changes. The DON confirmed that although the resident was recognized as high fall risk at admission and a baseline care plan was created, it did not specify the risk level or include the necessary interventions to mitigate future falls. The facility's policy requires that a baseline care plan be developed and implemented within 48 hours of admission to address health and safety concerns, but this was not followed in the resident's case.
Failure to Timely Revise Care Plans After Falls and Pressure Ulcer Events
Penalty
Summary
The facility failed to revise and update care plans in a timely manner for two residents who were reviewed for falls and pressure ulcers. For one resident with diagnoses of malignant neoplasm of the lung and brain, and moderate cognitive impairment, multiple falls occurred over a period of time. Each fall investigation identified specific interventions such as increased assistance during transfers, regular toileting intervals, use of call lights, 15- or 30-minute safety checks, and environmental modifications like fall mats and visible signs. However, these interventions were not consistently or promptly incorporated into the resident's care plan following each incident, despite being identified as necessary in fall investigations and interdisciplinary team (IDT) reviews. Additionally, another resident with dementia and Parkinson's Disease, who was at risk for pressure ulcers and had existing skin breakdown, did not have their care plan updated to reflect new interventions after a skin integrity event. The event identified the need for offloading heels with pillows and boots, but these interventions were not added to the care plan. The care plan also lacked clarity regarding the measurement units for wounds and did not specify all required interventions for pressure ulcer prevention and management. Interviews with facility staff revealed a lack of clarity and accountability regarding who is responsible for updating care plans after new interventions are discussed or implemented. Both nursing and administrative staff indicated they were either unaware of their responsibilities or had not received training on revising care plans, resulting in delays and omissions in care plan updates. The facility's own policy requires timely care plan revisions when there are changes in condition or interventions, but this was not followed in the cases reviewed.
Failure to Implement Physician Orders for Occupational Therapy and Cognitive Testing
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for occupational therapy evaluation, treatment, and cognitive testing was implemented according to professional standards for one resident. The resident had diagnoses including mild cognitive impairment, chronic kidney disease, and a history of breast cancer, and was noted to have daily wandering behaviors and moderate cognitive impairment. The physician assistant issued an order for occupational therapy and cognitive testing, with instructions for therapy to provide the results to the provider. Despite the order being transcribed and placed in the therapy box by the registered nurse case manager, it was not communicated to the therapy director or followed up on by nursing staff. Interviews revealed that the occupational therapy department had not received the order, and the director of nursing confirmed that the order was not communicated as required. The physician assistant stated that her expectation was for orders to be processed promptly and communicated to the appropriate staff. A policy for following physician orders was requested but not provided.
Inaccurate Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the accuracy of its daily nurse staffing posting on 12/13/25. The posted information indicated that a registered nurse (RN) worked the day shift, but a review of the nursing schedule and subsequent verification by the director of nursing (DON) revealed that an LPN actually worked that shift. The DON initially believed the scheduled nurse was an RN, but upon checking the license, discovered the error, resulting in an inaccurate staff posting. The facility's policy requires accurate posting of the names, hours, and roles of nursing staff for each shift, but this was not followed on the date in question. This discrepancy had the potential to affect all 36 residents in the facility.
Inadequate Hand Hygiene and Lack of Infection Surveillance
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were implemented by staff, affecting six residents observed for handwashing/hand hygiene. Nursing assistants and an LPN were observed not performing hand hygiene before and after resident contact, between glove changes, and after touching potentially contaminated surfaces. For instance, a nursing assistant assisted multiple residents with meals without washing hands between interactions, and another did not perform hand hygiene after transferring residents. An LPN was seen touching her face with gloved hands and then proceeded to care for a resident without washing hands. These actions were contrary to the facility's stated expectations for hand hygiene. Additionally, the facility lacked a system for infection surveillance to identify possible communicable diseases or infections. The Director of Nursing admitted that no infection surveillance had been conducted since July 2024, and the medical director expressed concern over this oversight. The facility's Infection Prevention and Control Plan required an infection control surveillance system, but this was not being implemented, leaving the facility without a mechanism to track and respond to infections among residents and staff.
Failure to Maintain Clean and Sanitized Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean and sanitized kitchen environment, which could potentially lead to cross-contamination or foodborne illness affecting all residents, staff, and visitors. During an initial tour of the kitchen, several large pans, mixing bowls, and containers were found to be unclean with dry crusted food on them. The dietary manager acknowledged the dirty items and removed them from the storage area. Additionally, several dirty utensils were found in storage drawers. A follow-up observation revealed more dirty kitchen items, including large pans with dried food and a baking pan with paper debris, which were confirmed by a cook to be dirty and in need of cleaning. The dietary manager explained the facility's sanitary policy and confirmed that the dishwasher was functioning properly. The manager acknowledged the unclean items found during the initial tour and stated that they were discussed with the staff and removed for cleaning. The facility employs about 10 kitchen staff, some of whom are new, and all are trained on proper cleaning and sanitization procedures. The facility's policy requires all kitchen items to be cleaned, rinsed, and sanitized after each use, with staff expected to inspect items for cleanliness before storage. Despite this policy, the presence of dirty kitchen items indicates a failure to adhere to these procedures, potentially leading to foodborne illness.
Failure to Complete PASARR Level II Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed or clarified for a resident with a mental disorder. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, narcissistic personality disorder, and anxiety, was on a medication regimen that included psychotropic medications. Despite these conditions, the facility did not initiate a request for a PASARR Level II screening, which was necessary due to the resident's mental health concerns and extended stay. Interviews with facility staff, including the social services worker and the director of nursing, revealed a lack of awareness and action regarding the resident's PASARR status. The social services worker acknowledged the need for a Level II assessment, and the director of nursing was unaware of the resident's PASARR status and the missed psychiatric appointments. The facility's policy required a Level I PASARR prior to admission and a referral for a Level II screening if necessary, but this process was not followed, leading to the deficiency.
Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to maintain documentation that staff were offered or provided education regarding the benefits and potential risks associated with COVID-19 vaccination for three staff members, including two Licensed Practical Nurses (LPN-A and LPN-B) and a housekeeper (HSK-A). During interviews, the Human Resources Director stated there was no documentation of the COVID-19 vaccine being offered or education provided to these staff members. The Director of Nursing was unaware if employees were offered the COVID-19 vaccine, and the Medical Director expected the facility to ensure staff were educated on the risks and benefits and offered the vaccine. The facility's policy, dated November 2024, required that each staff member be offered the vaccine and provided education, with documentation maintained, but this was not followed.
Failure to Monitor and Address Dehydration Risk
Penalty
Summary
The facility failed to ensure a comprehensive nutritional assessment and monitoring for signs of dehydration for a resident, leading to harm. The resident, who had intact cognition and diagnoses including congestive heart failure and hypernatremia, was on diuretics and required a regular diet. However, the nutritional assessment did not account for the resident's diuretic use or specify daily fluid needs. The resident's fluid intake was consistently low, and there was no comprehensive assessment or care plan addressing the risk of dehydration. The resident experienced multiple hospitalizations due to severe health issues, including profound hypernatremia and hypovolemia, which were attributed to poor oral intake and inadequate fluid monitoring. Despite being on a pureed diet with thickened liquids, the resident's fluid intake was not adequately monitored, and the care plan did not include interventions to prevent dehydration. Interviews with staff revealed a lack of awareness and systems in place to monitor fluid intake and dehydration risk. The facility's policies on dehydration and nutrition interventions were not effectively implemented, as evidenced by the resident's low fluid intake and frequent loose stools, which increased the risk of dehydration. The registered dietician admitted to not comprehensively assessing the resident's fluid needs, and the interim director of nursing acknowledged the absence of a monitoring system for fluid intake. The physician assistant highlighted the need for close monitoring of residents with low fluid intake and chronic loose stools to prevent dehydration and related complications.
Failure to Develop Comprehensive Care Plan for Respiratory Condition
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with acute respiratory failure with hypoxia. Upon review, it was found that the resident's care plan, spanning from October 8 to November 13, did not include a respiratory plan of care with specific goals and individualized interventions to manage the resident's respiratory condition. The resident had been hospitalized for severe hypotension and acute respiratory failure with hypoxia due to a choking/aspiration event and was discharged with new dietary orders. Despite these significant health issues, the care plan lacked interventions for respiratory assessment and monitoring. Interviews with facility staff, including an LPN and the interim director of nursing, confirmed that the resident's care plan did not address the necessary interventions for the resident's respiratory condition. A physician assistant also stated that a resident with such a diagnosis should have a care plan with person-centered interventions, including a full respiratory assessment twice a day and monitoring for changes. The facility's policy on care planning emphasized the need for comprehensive, person-centered care plans with measurable objectives and timetables, which were not reflected in the resident's care plan.
Failure to Monitor and Evaluate Necessity of Bowel Medications
Penalty
Summary
The facility failed to adequately monitor and evaluate the necessity of bowel medications for a resident, leading to the administration of unnecessary drugs. The resident, who had intact cognition and was diagnosed with hypernatremia and hyperosmolality, was frequently incontinent of bowel and received scheduled bowel medications, including docusate sodium, Citrucel, and Miralax. Despite having loose stools throughout her stay, the facility continued to administer these medications without proper evaluation of their necessity. The resident's bowel movements were consistently documented as large and loose, with frequent episodes of incontinence. Despite these observations, the medication administration record indicated that docusate sodium was given twice daily, except on a few occasions due to hospitalization or loose stools. Progress notes highlighted that the resident experienced loose stools and stomach upset, yet bowel medications were not consistently held, and the provider was not notified promptly. Interviews with nursing staff revealed that the resident's loose stools were reported to nurses, but bowel medications were still administered. The interim director of nursing confirmed that the docusate sodium was unnecessary and should have been given only as needed. The facility's bowel management policy emphasized the importance of assessing individual needs and holding medications in cases of diarrhea, but these guidelines were not followed, resulting in the continued administration of unnecessary bowel medications.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the administration and State Agency (SA) within the required timeframe. A resident, who was admitted with diagnoses including Alzheimer's disease and psychotic disorder, reported an incident where two staff members allegedly attempted to force her into bed against her usual routine, causing her distress and bruising on her arms. The resident reported feeling unsafe during the incident but has since felt secure as the staff involved have not been seen again. The incident was not reported to the administration or the SA immediately, as required by the facility's policy. The social worker and former Director of Nursing (DON) were aware of the allegation but did not report it to the administrator or the SA within the mandated two-hour window. The administrator was only informed of the incident several days later, highlighting a failure in the facility's abuse reporting protocol. The facility's policy clearly states that all allegations of abuse must be reported immediately, but this protocol was not followed in this case.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a resident with Alzheimer's disease, auditory hallucinations, and a psychotic disorder. The resident, who required partial to moderate assistance with daily activities, reported an incident where two staff members allegedly attempted to force her into bed against her usual routine, resulting in her feeling disrespected and sustaining bruises on her arms. The resident identified the staff involved as two black females and mentioned that two white female staff intervened after she called for help. The facility's investigation was inadequate as it only included interviews with the resident and two staff members who typically worked the evening shift. It did not involve interviews with other residents, additional staff fitting the description of the alleged perpetrators, or the staff who intervened. Furthermore, the investigation did not identify or implement any protective interventions to ensure the safety of the resident or others. The facility's policy on abuse prevention and investigation was not followed, as it requires a comprehensive investigation process, including interviews with all relevant parties and a thorough documentation of findings. The social worker and administrator acknowledged the shortcomings in the investigation, noting that it should have been more thorough to ensure resident safety.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, which is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms. The resident's care plan identified the need for EBP due to wounds, requiring the use of gowns and gloves during high-contact resident care activities. However, observations revealed that there was no signage indicating EBP on the resident's door, and no personal protective equipment (PPE) was available outside the room. Nursing assistants were observed transferring the resident without using gowns or gloves, and they were unaware of the requirement to use EBP for residents with wounds. Interviews with staff, including a licensed practical nurse (LPN) and a registered nurse (RN), confirmed that EBP was not being implemented for any residents in the facility. The LPN verified the absence of signage and PPE carts, while the RN mentioned that the previous infection preventionist was aware of the EBP regulation but did not implement it. The interim director of nursing (IDON) also indicated a lack of awareness regarding the regulation and confirmed that EBP had not been implemented during her tenure. The facility's policy on Enhanced Barrier Precautions, dated November 2023, outlined the requirements for implementing EBP, including staff training, availability of PPE, and proper signage. Despite this policy, the facility did not adhere to these guidelines, resulting in a failure to protect residents from potential infection risks associated with wounds and indwelling medical devices. The lack of implementation and awareness among staff contributed to the deficiency in infection control practices.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 85 citations issued within 25 miles in the last 12 months — including the 5 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spring Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Lea Senior Living | 12.5 mi | ★★★★★ | 12 | 2 |
| Valley View Healthcare & Rehab | 14.4 mi | ★★★★★ | 0 | 0 |
| Good Shepherd Lutheran Home | 17.6 mi | ★★★★★ | 2 | 0 |
| The Highlands | 18.2 mi | ★★★★★ | 2 | 0 |
| Wellington Place | 18.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.