Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Viewcrest Health Center during CMS and state inspections, most recent first.
A resident with cerebral palsy and other conditions fell and sustained a head injury due to improper use of a mechanical lift. The nursing assistant used a non-EZ Way sling and attempted the transfer alone, contrary to the care plan requiring two staff. The facility lacked a system to assess and document appropriate sling size, contributing to the incident.
The facility failed to ensure proper glove use and hand hygiene during care for two residents. An RN did not perform hand hygiene between glove changes while providing wound care, and a NA did not wear the required PPE or change gloves during incontinence care. Both staff members admitted to forgetting procedures due to nervousness, contrary to facility policies on hand hygiene and enhanced barrier precautions.
The facility failed to provide consistent bedtime snacks, resulting in a 15-hour gap between dinner and breakfast, affecting 93 residents. Despite expectations from the DON and administrator, interviews revealed that the evening snack pass was not consistently occurring, and snack logs were missing for June and July 2024. The facility's policy required no more than 14 hours between meals unless a bedtime snack was provided, which was not adhered to.
A facility failed to store cold beverages at safe temperatures, affecting 16 residents. A dietary aide prepared beverage carts with milk and juice, but one cart had items on a second shelf not kept on ice. The dietary manager later found these items at unsafe temperatures, leading to their disposal.
A resident with spastic quadriplegic cerebral palsy and asthma was observed self-administering a nebulizer without being assessed as safe to do so. The resident's care plan required nurse-administered inhalers and nebulizers, and an earlier assessment confirmed the resident could not self-administer medication. Despite this, an LPN set up the nebulizer treatment, mistakenly believing there was an order for self-administration. The facility's policy required an assessment for self-administration, which was not conducted.
A facility failed to complete and retain a Level I PASARR for a resident with mental health needs, including anxiety, depression, and bipolar disorder. The PAS document in the resident's medical record did not indicate if a PASARR Level I was completed or if a Level II was recommended. The DSS confirmed this oversight, and the DON stated that the DSS was responsible for the PASARR. The facility's policy required a PAS to be completed and retained for all admissions.
A facility failed to maintain respiratory equipment for a resident with cerebral palsy and asthma. The nebulizer and oxygen equipment were not properly cleaned or dated, as confirmed by staff interviews. The resident used the nebulizer twice daily and oxygen at night, but the facility did not adhere to maintenance guidelines, leading to a deficiency.
A medication administration error occurred when an LPN in her orientation phase was instructed to administer medications without proper resident identification, resulting in a resident receiving another patient's medications. The resident developed severe bradycardia and required hospitalization and a temporary pacemaker.
Failure to Follow Transfer Protocols Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the manufacturer's recommendations, facility policy, and the resident's transfer care plan, resulting in a significant incident involving a resident. The resident, who had cerebral palsy, abnormal posture, functional quadriplegia, and scoliosis, required extensive assistance with two people for transfers using a mechanical lift. However, during a transfer, the resident was improperly handled by a single nursing assistant using a non-EZ Way brand sling, which was not appropriate for the resident's weight. This led to the resident falling from the lift and sustaining a laceration to the back of the head. The incident occurred when the nursing assistant, unaware of the proper procedures, attempted to transfer the resident alone using a green sling that was not compatible with the EZ Way lift. The nursing assistant did not consult the care plan and was not aware that two staff members were required for the transfer. As a result, the resident slid out of the sling and fell to the floor, causing injury. The nursing assistant had received safe-transfer training but did not know the specific requirements for this resident's transfer. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policies and the manufacturer's instructions. The director of nursing confirmed that the green sling used was not an EZ Way brand and should not have been used. Additionally, there was no process in place for assessing the appropriate sling type and size for residents, which contributed to the incident. The facility's failure to ensure proper equipment and procedures were followed led to the resident's fall and injury.
Removal Plan
- Reviewed policies on use of mechanical lifts, including the assessment and size of the slings.
- Re-assessed all residents who utilize a mechanical lift to ensure they have the proper brand and size sling.
- Updated resident care plans.
- Sling assessments completed with significant change.
- Removed non EZ Way brand slings from the facility.
- Re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing.
- Completed audits observing staff transferring residents with mechanical lifts, results brought to QAPI committee.
Infection Control Deficiencies in Glove Use and PPE
Penalty
Summary
The facility failed to ensure proper glove use and hand hygiene during incontinence care and wound care for two residents. For one resident, a registered nurse (RN) did not perform hand hygiene between glove changes while providing wound care to the resident's left lower extremity. The RN was observed changing gloves multiple times without washing hands, despite handling wound dressings and applying ointments. The RN later admitted to forgetting to wash hands due to nervousness, acknowledging that hand hygiene should have been performed between glove changes. Another resident, who required extensive assistance with toilet use and was on enhanced barrier precautions (EBP) due to chronic wounds, did not receive care with the appropriate personal protective equipment (PPE). A nursing assistant (NA) entered the resident's room without wearing a gown, which was required under EBP. The NA also failed to change gloves and perform hand hygiene after removing soiled gloves during incontinence care. The NA admitted to forgetting to wear the correct PPE and to sanitize hands after glove removal, citing nervousness as the reason for the oversight. The facility's policies on hand hygiene and EBP were not followed as expected by the staff.
Failure to Provide Consistent Bedtime Snacks
Penalty
Summary
The facility failed to consistently offer and provide a nutrient and/or calorie substantive snack after the dinner meal and before bedtime, resulting in a 15-hour gap between the evening and morning meals. This deficiency had the potential to affect 93 out of 94 residents who consume food orally. Interviews with residents and staff revealed that a bedtime snack pass was not consistently occurring. One resident reported that it had been months since a snack was offered after dinner and before bedtime. The dietary manager stated that snacks were supposed to be offered at 2:30 p.m. and 7:30 p.m., with the kitchen staff responsible for the afternoon snack pass and nursing staff for the evening snack pass. However, nursing assistants confirmed that the evening snack cart was not delivered to the units, and a bedtime snack pass did not occur as expected. The director of nursing and the administrator both expressed the expectation that a bedtime snack should be offered to each resident every evening due to the long interval between dinner and breakfast. Despite this expectation, the facility's snack sheet logs for June and July 2024 were not provided, and the last documented snack pass occurred on May 4th, 2024. The facility's policy on the Weight Monitoring Program, dated January 18, 2021, stated that there should be no more than 14 hours between a substantial evening meal/snack and breakfast the following day unless a nourishing snack is served at bedtime. This policy was not adhered to, leading to the identified deficiency.
Improper Storage of Cold Beverages
Penalty
Summary
The facility failed to ensure that cold beverage items were stored at appropriate temperatures to prevent foodborne illness, affecting 16 out of 94 residents who were served beverages from the dining room beverage cart. On the morning of the incident, a dietary aide prepared five cold beverage carts, each with a bin containing half-gallon containers of assorted milk and juice. However, one cart also had milk and juice containers on a second shelf that were not placed in a bin or on ice. These items included opened and unopened milk and juice containers, which were required to be refrigerated after opening. During the meal service, all 16 residents in the dining room received milk or juice from the beverage cart, with all items served being held on ice. However, the extra beverages on the second shelf were not kept on ice, and the dietary aide was unaware of the hazards associated with this practice. After the meal service, the dietary manager measured the temperatures of the beverages on the second shelf, which ranged from 48 to 54 degrees Fahrenheit, exceeding the facility's policy of serving cold items at 40 degrees Fahrenheit or below. The dietary manager deemed these items unsafe to serve and discarded them.
Failure to Ensure Safe Administration of Nebulized Medications
Penalty
Summary
The facility failed to ensure the safe administration of nebulized medications for a resident who was observed to self-administer a nebulizer without being assessed as safe to do so. The resident, who had intact cognition and diagnoses including spastic quadriplegic cerebral palsy, asthma, chronic cough, and shortness of breath, required substantial assistance with oral care and was dependent for hygiene and transfers. The resident's care plan indicated that a nurse should administer inhalers and nebulizers as the resident was unable to do so independently. An assessment conducted earlier in the year confirmed that the resident was unable to self-administer medication. Despite this, the resident was observed using a nebulizer in bed without supervision, with the mouthpiece near her face while she appeared to be asleep. A Licensed Practical Nurse (LPN) later confirmed setting up the nebulizer treatment for the resident, mistakenly believing there was an order for self-administration. The Medication Administration Record did not reflect such an order. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the resident had not been assessed for self-administration and that an order was necessary for safety. The facility's policy required an assessment for self-administration based on cognitive and physical status, which was not followed in this case.
Failure to Complete and Retain PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure a Level I Pre-Admission Screening and Resident Review (PASARR) was completed and retained in the medical record for a resident with mental health needs. The resident, who had intact cognition and diagnoses of anxiety, depression, and bipolar disorder, was admitted to the facility without a completed PASARR Level I or a recommendation for a Level II assessment. During an interview, the Director of Social Services (DSS) confirmed that the PAS document in the resident's medical record, dated January 8, 2018, did not indicate whether a PASARR Level I was completed or if a Level II was recommended. The Director of Nursing (DON) stated that the DSS was responsible for completing the PASARR. The facility's policy, dated March 7, 2022, required that all individuals seeking admission receive a Pre-Admission Screening and that the PAS notice be retained by the care center.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to properly care for the respiratory equipment of a resident with spastic quadriplegic cerebral palsy, asthma, chronic cough, and shortness of breath. The resident's care plan required the administration of inhalers and nebulizers, monitoring of lung sounds, and observation for oxygen needs. However, the facility did not adhere to the prescribed maintenance of the nebulizer and oxygen equipment. The nebulizer machine was observed with tubing connected to the chamber and mouthpiece, containing residual liquid, and the oxygen tubing was undated. The resident confirmed the use of oxygen at night and the nebulizer twice daily. Interviews with facility staff revealed inconsistencies in the maintenance of respiratory equipment. An LPN admitted to not disassembling and rinsing the nebulizer chamber and mouthpiece after a treatment, while an RN stated that the equipment should be changed weekly and dated. The Director of Nursing emphasized the importance of dating the tubing and cleaning the nebulizer components for infection control and medication safety. Facility documents outlined guidelines for cleaning and replacing respiratory equipment, which were not followed, leading to the deficiency.
Medication Administration Error Leads to Hospitalization
Penalty
Summary
The facility failed to follow its medication administration policy, resulting in a significant medication error for one resident. On the day of the incident, an LPN in her orientation phase was instructed by another LPN to administer medications to a resident without being given the resident's name or shown a picture. This led to the resident receiving another patient's medications, which included several drugs that were not prescribed to her. The error was discovered when the LPN returned to the medication cart and realized the mistake upon seeing the correct resident's picture. The resident who received the incorrect medications had a history of longstanding persistent atrial fibrillation, transient ischemic attack, and cerebral infarction. After receiving the wrong medications, which included a beta blocker and calcium channel blocker, the resident developed severe bradycardia and was sent to the hospital. The hospital records confirmed that the resident was admitted with diagnoses of accidental overdose, drug-induced bradycardia, and atrial fibrillation with slow ventricle response. The resident required a temporary pacemaker due to the severity of the bradycardia. Interviews with the involved staff and the director of nursing confirmed that the facility's medication administration policy was not followed. The policy required nurses to verify the resident's identity using the electronic medication administration record photograph and, if in doubt, to ask another staff member. The nurse who dispensed the medications should have been the one to administer them, but this procedure was not followed, leading to the medication error and subsequent hospitalization of the resident.
Removal Plan
- The facility added the medication administration policy to be included in the staff meeting.
- The facility sent out a facility-wide text requiring all staff who administer medication to complete computer-based education related to medication administration.
- The facility performed medication administration audits.
- The facility provided education to all staff members responsible for medication administration, which included administration of medications and ensuring the 6 rights of medication administration was being followed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 133 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hilltop Healthcare Rehabilitation And Skilled Nurs | 2.9 mi | ★★★★★ | 17 | 0 |
| Benedictine Health Center | 3.5 mi | ★★★★★ | 23 | 2 |
| Bayshore Residence And Rehabilitation Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Aftenro Home | 3.9 mi | ★★★★★ | 17 | 0 |
| The North Shore Estates Llc | 4.6 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Viewcrest Health Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.