Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Colonial Springs Healthcare Center during CMS and state inspections, most recent first.
A resident with intact cognition and dependence on staff for ADLs, including toileting and use of a sit-to-stand lift, reported that a CNA became frustrated with the lift during bathroom assistance and cursed using the "f" word in the resident’s room. The resident felt the language was inappropriate and reported the incident to an LPN, the Social Service Director, and then the Administrator. Facility policy states residents have the right to be treated with dignity and respect, and in interviews the CNA, other CNAs, the DON, and the Administrator all acknowledged that cursing around residents is disrespectful and not acceptable.
A resident with a hip fracture diagnosis and intact cognition experienced multiple room transfers between different halls, but the facility failed to provide and document required written notice before these room changes. Facility policies required prompt written and advance notice to the resident and, when applicable, the representative for any room or roommate transfer. Registration records showed several room changes, yet only one room/roommate change notice form was found, and staff interviews (including SSD, CNA, LPN, DON, and the Administrator) confirmed that while notification and documentation were expected practices, there was no documentation of notifications for several of the resident’s room moves.
A resident with a history of hip fracture experienced a fall while attempting an independent transfer from a wheelchair to bed. Staff responded, initially noted no injury, and obtained STAT X‑rays of the resident’s right upper extremity, which later showed findings consistent with a radial neck fracture of indeterminate age. Although facility policy required timely notification and documentation of changes in condition, accidents, injuries, and diagnostic results to the physician, resident, and family/responsible party, the medical record contained no documentation that the resident’s family or responsible party was notified of the fall, the X‑ray orders, or the X‑ray results. In interviews, an LPN, an RN, the DON, and the Administrator all confirmed that such notification and documentation were expected but had not occurred in this case.
The facility failed to maintain a complete and timely grievance process for a resident and the resident’s family member, despite multiple complaints about care, use of briefs instead of pullups, missing personal items, and a reported $10 payment to an aide. Although the facility’s policy required escalation of unresolved complaints, maintenance of a grievance log, and written notice of investigation results, staff did not consistently enter grievances on the log, did not document follow-up steps or resolutions, and did not obtain or record confirmation from the complainant. Progress notes and interviews with the SSD, DON, and Administrator showed that some grievances were only partially documented, some were omitted from the log entirely, and outcomes of certain investigations were unknown or not recorded, resulting in an incomplete grievance process for the resident’s concerns.
The facility failed to complete a required baseline care plan within 48 hours of admission for a resident admitted with multiple pelvic fractures who required assistance with toileting, hygiene, bathing, and lower body dressing. Policy required licensed nursing staff to complete admission assessments within 24 hours and initiate a nursing care plan based on identified needs, using an electronic template that includes admission status, responsible party information, and medications. Record review showed no baseline care plan in the resident’s chart, and interviews with the MDS RN, an MDS LPN, RN staff, the DON, and the Administrator confirmed that the admitting or on-duty nurse was responsible for this task, that an admission audit process existed to flag incomplete paperwork, and that staff believed the care plan had been completed when it had not.
Staff failed to maintain safe transfer practices when one resident was jostled in a sit‑to‑stand mechanical lift and another was transferred without a gait belt. In the first case, a cognitively intact resident with prior ankle injury, weakness, and fall risk reported that a CNA became frustrated when a sit‑to‑stand lift got stuck on damaged flooring, repeatedly raising and lowering the lift so the resident swayed and experienced chest soreness and fear. Other staff confirmed the lift frequently got stuck on a notch in the floor, and maintenance reported the floor had sunk after a lift was placed on it too soon, but no work orders had been submitted about the lift wheels locking up. In the second case, a resident with severe cognitive impairment and total dependence for mobility was observed being transferred from bed to wheelchair by a CNA who did not use an available gait belt, instead lifting and pivoting the resident by holding around the back. The CNA believed the resident was care planned not to use a gait belt, while multiple CNAs, therapy staff, nursing staff, the DON, and the Administrator all stated that gait belts should always be used for such transfers and that this resident was not exempt from gait belt use.
The facility failed to administer time-sensitive medications as ordered and within policy-defined time frames for two residents. One resident on apixaban and flecainide had BID and Q12H doses that were either undocumented or given at widely varying times, without corresponding nursing notes explaining missed or late doses. Another resident with a sacral pressure ulcer and on anticoagulant therapy had metoprolol ordered for early morning administration but consistently received it several hours later, again without documentation of the variance. Staff interviews, including CMTs, RNs, the NP, the pharmacist, the DON, and the Administrator, showed inconsistent understanding of the liberalized medication pass and which medications were exempt, contributing to inconsistent adherence to ordered administration times.
The facility failed to prevent possible food contamination due to improper storage and preparation practices. The ice machine had microbial growth, a dented can of pumpkin was stored for use, and scoops were improperly left in containers of sugar and cornstarch. Staff were unclear about responsibilities and proper procedures, leading to potential contamination risks.
The facility failed to maintain a sanitary environment by not ensuring the cleanliness of fans in the walk-in refrigerator and freezer, as black and brown substances were observed on the fan casings. There was no policy or clear responsibility for cleaning these fans, leading to confusion among dietary and maintenance staff about their roles in maintaining cleanliness.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital, affecting five residents. Despite the policy requiring notification upon admission and within 24 hours of an emergency transfer, documentation was lacking. Interviews revealed inconsistent practices and a lack of awareness among staff regarding the distribution of the bed hold policy.
The facility failed to document physician orders for catheter placement and care for two residents, leading to deficiencies in catheter management. One resident had severe cognitive impairment and an indwelling catheter without documented orders, while another returned from the hospital with a catheter but lacked documented orders until days later. Staff interviews revealed inconsistencies in the process of obtaining and documenting these orders.
The facility failed to ensure proper pharmacy services for controlled substances, as staff did not consistently document medication counts and administration on controlled drug record logs. Instances included single staff signing shift count sheets and discrepancies in tablet counts for residents. Interviews revealed non-compliance with policy, as some staff did not perform counts with another member and occasionally passed narcotics without verification.
A facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter to a resident upon discharge from Medicare Part A services. The resident, who needed to stay in the facility for further care, did not receive documentation of estimated costs for non-covered services and had to research these costs independently. The Social Services Director and Administrator acknowledged the oversight, as the SNFABN was not issued due to a misunderstanding of the requirements.
Facility staff failed to complete quarterly MDS assessments for two residents within the required 92-day timeframe due to a glitch in the tracking system. The MDS Coordinator, who was primarily responsible for assessments, and the Assistant MDS Coordinator, who recently began assisting, confirmed the oversight. The Administrator was unaware of the tracking system and the untimely assessments.
A resident with a history of subarachnoid hemorrhage and diabetes required tube feeding, but the facility failed to administer it consistently as ordered. Observations showed the feeding was often not attached or running, and staff interviews revealed confusion about the feeding schedule. The facility's policy required adherence to physician orders, but unclear orders led to inconsistent feeding administration.
The facility failed to maintain a medication error rate below 5%, with errors involving the improper timing of levothyroxine administration for two residents. The medication was given after breakfast and with other medications, contrary to orders for it to be taken at 6:00 A.M. on an empty stomach. Staff interviews confirmed awareness of the issue, but cited challenges in adhering to the schedule due to the number of residents.
A facility failed to report an incident of inappropriate touching between two residents to the state agency within the required timeframe. The incident involved a resident with cognitive impairment and another with a history of bipolar disorder and dementia. Staff interviews revealed inconsistencies in understanding reporting requirements, with some staff unsure if the incident constituted abuse. The DON and Administrator provided conflicting views on the necessity of reporting, leading to the facility's failure to comply with its abuse/neglect policy.
The facility failed to investigate an incident where a resident was found touching another resident's genitalia, contrary to its abuse/neglect policy. Despite the policy requiring immediate investigation and documentation, no formal investigation was conducted, and the incident was not reported to the DHSS. Interviews revealed staff uncertainty in handling such situations, and the facility did not verify consent from the involved residents.
Failure to Maintain Resident Dignity When CNA Used Profanity During Care
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to be treated with dignity and respect when a CNA used disrespectful and profane language in the resident’s presence. The facility’s Resident Rights policy, revised 10/01/21, states that residents have the right to be treated with dignity and respect. The affected resident had been admitted with a diagnosis including dislocation of the right ankle joint and, per the quarterly MDS dated 02/20/26, had intact cognitive skills, no documented behaviors, was dependent for toileting and personal hygiene, and required substantial/maximal assistance with showering. The resident’s care plan, reviewed 02/26/26, documented that the resident required extensive to total assistance with one to two staff for all ADLs and directed staff to use a calm, reassuring approach. On the evening of 02/14/26 at approximately 9:30 P.M., the resident reported that while being assisted to the bathroom with a sit-to-stand lift that was hard to turn, CNA F became frustrated with the equipment and cursed, using the “f” word, in the resident’s room. The resident stated they did not feel the CNA’s language was appropriate and felt the CNA used inappropriate language. The resident reported the incident to an LPN and the Social Service Director, who told the resident to inform the Administrator; the resident then went to the Administrator’s office and reported that the CNA was mad at the sit-to-stand lift and cursed. In interviews, the Administrator acknowledged receiving a delayed report that the resident thought the CNA was unprofessional and did not appreciate the language. CNA F stated that cursing around a resident is not respectful and is a form of abuse, and other staff, including another CNA, the DON, and the Administrator, all stated that staff should not curse around residents and that staff are expected to be respectful.
Failure to Provide and Document Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide and document written notice to a resident before multiple room changes, contrary to its own policies on room and roommate transfers and notification guidelines. The facility’s policies required prompt written notification to the resident and, when applicable, to the resident’s representative for any change in room or roommate assignment, as well as advance notice of such transfers. Resident #1, admitted with a diagnosis including a fracture of the neck of the left femur and assessed as cognitively intact on the MDS, experienced several room changes between different halls. Registration records showed the resident was admitted to a room on the 100 hall, then transferred to the 200 hall, later moved back to the 100 hall for quality-of-care purposes, and then again transferred to the 200 hall. Record review showed only one room/roommate change notice form dated 04/18/25 for a move to the 100 hall, and no documented room/roommate change notices for the other room changes. The Social Service Director reported that staff typically call the family or speak with the resident regarding room changes, provide a room/roommate change request card, and do not move residents if they do not want to move, but she could not find documentation of notifications for the resident’s moves back to the 200 hall. CNA and nursing staff interviews indicated that social services are responsible for informing residents of room changes and that staff should document room changes and consent in progress notes, but such documentation was absent in this case. The DON and Administrator both stated that staff are expected to document room changes and resident/family notification in the progress notes, yet this was not done for Resident #1, resulting in noncompliance with the requirement to provide written notice before room changes.
Failure to Notify Family/Responsible Party of Fall and X‑ray Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of a resident’s family or responsible party of a change in condition following a fall and subsequent diagnostic findings. Facility policy revised in January 2025 required that physicians, residents, and families be notified in a timely manner of clinical and environmental changes, including accidents or injuries, and that such notifications be documented. Resident #1, admitted with diagnoses including a left femur neck fracture, experienced a fall when attempting to transfer independently from a wheelchair to bed. A CNA heard a crash, found the resident sitting on the floor, and staff assessed the resident with no injuries initially noted. A nurse obtained a STAT order from a nurse practitioner for X‑rays of the resident’s right shoulder, humerus, elbow, forearm, and wrist, and the X‑rays were completed as ordered. X‑ray reports from the same day documented soft tissue swelling and changes along the radial neck suggesting a fracture of indeterminate age, with an impression of an abnormal radial neck region. A later progress note described that after the fall the resident complained of right arm pain, an X‑ray showed a radial neck fracture of indeterminate age, and that the medical director and orthopedic physician were aware and ordered a sling. However, there was no documentation that the resident’s family or responsible party was notified of the fall, the X‑ray orders, or the X‑ray results. During interviews, an LPN, an RN, the DON, and the Administrator each stated that staff are expected to notify the resident and/or responsible party of falls, injuries, and X‑ray results and to document this notification in the progress notes, but they acknowledged that such documentation was not present for this resident.
Failure to Maintain Complete and Timely Grievance Documentation for Resident and Family Complaints
Penalty
Summary
The deficiency involves the facility’s failure to implement a complete and consistent grievance process, including timely documentation of grievances, follow-up steps, and resolutions for a resident and the resident’s family member. The facility’s grievance policy states that residents or their representatives may register complaints or grievances without fear of reprisal, and that grievances include complaints about care, abuse or neglect, and other issues that are not resolved at the time of the complaint by staff present. The policy further requires that unresolved complaints be escalated to supervisors, the Patient Advocate, and the Administrator as needed, and that the Patient Advocate maintain a log of complaints and grievances, with written notice to the complainant at the completion of the investigation, including steps taken, results, and date of completion. The resident involved had been admitted with a diagnosis including a fracture of the neck of the left femur and had intact cognitive skills, requiring partial to moderate assistance with toileting, showering, bathing, and personal hygiene. A nurse’s progress note documented that the resident’s family member complained to a CNA that the resident had not received breathing treatments that day and objected to the resident wearing a brief instead of a pullup. The nurse noted that management and social services were not available in the building at that time, and when the nurse later asked the family member if there were any issues needing resolution, the family member stated that everything was fine. Subsequently, the Social Services Director (SSD) documented receiving an email from the family member expressing concerns about the resident’s care, including breathing treatments and use of briefs, as well as missing personal items such as lotion, Kleenex, a turquoise ring, and a watch. The SSD shared the email with the Administrator and DON and noted that a staff member reported the family member had thrown wipes at them, and that the plan was to remove that staff member from providing care to the resident and to offer moving the resident to another hall. The facility’s complaint/concerns log recorded a complaint from the resident’s family member about missing rings, lotion, and a watch, and noted that replacement items were provided, but did not document any discussion with, or signature of, the resident or the family member who filed the grievance. A later progress note by the SSD, created weeks after the event date, described responding to another email from the family member about missing items and documented that the facility replaced multiple rings, lotion, and a watch, and informed the resident and family, but again did not reflect complete grievance documentation as required by policy. Another progress note by the DON described contacting the family member regarding concerns from the prior night, with the family member referring the DON to staff and a formal grievance before hanging up; however, this grievance was not entered on the facility’s grievance log. Interviews with the CNA, SSD, DON, and Administrator confirmed that the SSD was responsible for grievances, that staff were expected to report complaints to her, and that grievance forms and logs existed, but also revealed that the SSD did not document resolutions on the grievance log, did not have a form with a written resolution to return to complainants, and did not know the outcome of an investigation into a reported $10 payment from the resident to an aide. The DON acknowledged that resolutions of grievances were not documented, and the Administrator stated he expected documentation of who was spoken to, whether the grievance was resolved, and the response to the complainant, but these elements were missing, demonstrating the facility’s failure to maintain a complete grievance process for the resident’s grievances. Additional information from interviews further supports the incomplete grievance process. The SSD stated that if residents spoke with staff about complaints, staff should email or inform her, and that she reported grievances to the Administrator and DON and attempted to respond within 24 hours. She also reported receiving an email from the resident’s family member about an aide receiving $10 from the resident and said she informed the Administrator, but she did not document the resolution on the grievance log and did not know the results of that investigation. The DON described that grievances should be taken to social services, that grievance forms were available in a binder, and that staff discussed grievances in morning meetings with department heads, but she admitted she did not document grievance resolutions even though she believed they probably should be documented. The Administrator indicated that SSD should document who she talked with, whether the grievance was resolved, and the date, and that staff should document the response to the person who filed the grievance, yet he was not aware of the reported $10 payment. These documented omissions and inconsistencies in logging grievances, documenting follow-up steps, and recording resolutions for the resident’s and family member’s complaints constitute the identified deficiency in the facility’s grievance process. Overall, the events show that multiple complaints and concerns from the resident’s family member regarding care issues, missing personal items, and a possible financial concern were not consistently or fully documented as grievances in accordance with the facility’s own policy. The grievance log lacked entries for at least one formal grievance referenced by the family member, and existing entries did not include documentation of discussions with the complainant or confirmation of resolution. Staff interviews confirmed that there was no standardized form with a documented resolution returned to the complainant and that outcomes of certain investigations were unknown or not recorded. These actions and inactions demonstrate that the facility did not have a complete grievance process in place for this resident, as required by its policy and regulatory expectations.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete a baseline care plan within 48 hours of admission for one resident. Facility policy titled "Assessments in Long Term Care" required licensed nursing staff to initiate an admission assessment upon the resident’s arrival and complete nursing and screening assessments within 24 hours, with the nursing care plan initiated based on identified needs from that assessment. The facility’s initial care plan form was to include admission status, identification of the responsible party or resident offered a copy of the initial care plan, and information on resident medications. For the resident in question, the face sheet showed an admission date of 01/26/26 with diagnoses including multiple pelvic fractures, and progress notes documented arrival from the hospital that afternoon. The admission MDS dated the same day showed intact cognitive skills and a need for partial/moderate assistance with toileting and personal hygiene, and substantial/maximal assistance with showering, bathing, and lower body dressing. Despite these documented needs, review of the medical record showed no documentation that a baseline care plan was completed for this resident. The MDS Coordinator/RN stated that the admitting charge nurse is responsible for completing the baseline care plan upon admission, using a computer template, and that it should be completed within 24 hours along with admission notes; however, the RN confirmed there was no baseline care plan for this resident. Another MDS Coordinator/LPN reported that they perform an admission audit within 48 hours, circling incomplete items and returning them to the nurses’ desk, and acknowledged that staff did not complete the baseline care plan, though they believed it had been done and that the next nurse should complete any missing items. RN C stated nursing staff should complete the baseline care plan upon admission. The DON and the Administrator both indicated that the admitting nurse or nurse on duty is expected to complete the baseline care plan, including assessments and offering a copy to the resident and/or family, but this did not occur for the resident involved.
Unsafe Mechanical Lift Use and Failure to Use Gait Belt During Resident Transfers
Penalty
Summary
The deficiency involves the facility’s failure to keep residents free from accident hazards and to provide adequate supervision during transfers, specifically in the use of a sit‑to‑stand mechanical lift and a gait belt. Facility policy on patient/resident handling, revised April 2025, states that safe procedures for providing care are a high priority, that handling incidents are to be analyzed for trends with appropriate follow‑up, and that employees are encouraged to report hazards and make safety suggestions. Despite this, staff actions during two separate transfer situations did not align with safe handling practices described by facility leadership and other staff. In the first incident, a cognitively intact resident with a history of right ankle dislocation, generalized weakness, dependence on staff for transfers and ADLs, pain related to a previous fracture, and risk for falls reported that a CNA became frustrated while using a sit‑to‑stand lift during a bathroom transfer. The resident stated that the lift was hard to turn and that the CNA raised and lowered the lift, letting it hit the floor while the resident hung by the arms and swayed, causing upper chest soreness and fear. The resident reported having to yell at the CNA to calm down. Interviews with the CNA confirmed that two wheels on the lift locked up when attempting to roll the resident out of the bathroom, that the lift was stuck, and that the resident began swinging in the lift, causing concern the resident might fall. Other staff, including another CNA and nursing staff, reported that the floor in the resident’s room and bathroom was “horrible,” that the lift frequently got stuck on a notch or damaged area of the floor, and that the resident had reported being jostled and scared when the CNA shook the lift to get it unstuck. The Maintenance Supervisor reported that a new floor had been installed in the resident’s room about a year earlier and that staff placed a sit‑to‑stand lift on it before the 24‑hour curing period, causing the floor to sink. He stated he had not received a work order or complaint about the lift wheels locking up, and that staff had previously indicated the lift was usable and were transporting residents across the bathroom floor. The DON and Administrator both stated that staff were expected to report issues with floors and equipment, including lift wheels locking up, and the DON acknowledged that rocking a lift back and forth to free it from a floor notch created safety issues. The CNA involved stated he was not aware whether maintenance had been informed of the lift getting stuck during the incident. In the second incident, a resident with dementia, severely impaired cognitive skills, and total dependence on staff for mobility and ADLs was observed being transferred from bed to wheelchair by a CNA without the use of a gait belt, despite a gait belt hanging on the wall next to the bed. The CNA rolled the resident to a sitting position, sat the resident on the edge of the bed, then placed both hands around the resident’s back, stood the resident, pivoted, and seated the resident in a wheelchair. In interview, the CNA stated that he or she normally used a gait belt for all residents but believed this resident was care planned not to use one due to potential resistance, and therefore did not use a gait belt during the observed transfer, even though the resident was not combative or resistant at that time. Multiple staff, including other CNAs, OT staff, an LPN, the DON, and the Administrator, stated that staff should always use a gait belt during one‑person transfers when a lift is not used, that gait belts are the safest way to transfer, and that there was nothing in this resident’s care plan indicating a gait belt should not be used. These events demonstrate that, in both cases, staff actions during transfers did not follow the safe handling expectations described by facility leadership and other staff, and that known environmental and equipment issues with the sit‑to‑stand lift and flooring were not effectively reported or addressed through the facility’s established hazard reporting processes.
Failure to Administer Time-Sensitive Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that met residents’ needs by not administering medications as ordered and not adhering to specified administration times. The facility’s own Medication Administration and Documentation policy allowed a liberalized medication pass with a three-hour window before and after scheduled times for certain oral medications, but it also stated that medications with a narrow therapeutic index, such as anticoagulants, should not be liberalized if ordered at a specific time on the MAR. The policy further indicated that medications are considered late if given more than three hours after their scheduled time and that missed doses require provider consultation. Despite this, staff did not consistently follow ordered times or document missed or late doses. For one resident admitted with multiple pelvic fractures and on anticoagulant therapy, physician orders included apixaban 5 mg PO BID and flecainide 25 mg PO every 12 hours. The MAR for a ten-day period showed missing documentation for both the morning and evening doses on certain days and administration times that varied widely from the expected BID schedule, including doses given at 7:00 A.M., 8:01 P.M., 10:17 A.M., 6:29 P.M., 12:14 P.M., 7:10 P.M., 10:00 A.M., 6:58 P.M., 10:55 A.M., and 7:15 P.M. Nurses’ notes for this period did not contain documentation explaining missed doses or doses given outside the ordered time frame. The NP stated that apixaban should be given eight hours between doses and that giving it earlier would be a medication error, while the pharmacist indicated it was typically scheduled at 9:00 A.M. and 9:00 P.M. due to its half-life. For another resident with a diagnosis including a sacral pressure ulcer and on anticoagulant medication, there was an order for metoprolol succinate 12.5 mg to be given daily at 6:00 A.M. The MAR showed that during the same review period, this medication was consistently administered much later in the morning, with times ranging from 9:20 A.M. to 11:10 A.M. Nurses’ notes contained no documentation related to these administrations occurring outside accepted time frames. Interviews with multiple staff, including CMTs, RNs, the NP, the pharmacist, the DON, and the Administrator, revealed inconsistent understanding of the liberalized medication pass, with varying descriptions of allowable time windows and which medications were considered time-specific, contributing to the failure to administer medications within the ordered or policy-defined time frames for these residents.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents possible contamination. Observations revealed that the ice machine's deflector shield had multiple black spots, indicating microbial growth. Despite the facility's policy requiring regular cleaning of ice machines, there was confusion among staff about who was responsible for cleaning the inside of the machine. The Maintenance Director, who was responsible for cleaning, was unaware of the black spots, and the Administrator was also not informed about the issue. Additionally, a large dented can of pumpkin was found on the shelf, which contradicts the FDA's guidelines that dented cans may present a serious potential hazard. Staff interviews revealed inconsistent practices regarding the handling of dented cans. Furthermore, scoops were found partially submerged in containers of sugar and cornstarch, which could lead to contamination. Staff members had differing opinions on whether this practice was acceptable, indicating a lack of clear guidelines or training on proper food storage practices.
Sanitation Deficiency in Walk-in Refrigerator and Freezer
Penalty
Summary
The facility failed to maintain a sanitary environment for residents and staff by not ensuring the cleanliness of fans located in the walk-in refrigerator and freezer. Observations on two separate occasions revealed black and brown substances on the plastic casings of the refrigerator and freezer fans. The facility did not have a policy addressing the maintenance of these fans, and the weekly cleaning schedule did not list staff responsible for cleaning them. Interviews with various staff members, including dietary aides, the Assistant Dietary Manager, the Maintenance Director, and the Administrator, revealed a lack of clarity and communication regarding responsibility for cleaning the fans. Dietary staff were unsure of their role in cleaning the fans, and the Maintenance Director admitted to not knowing when the fans were last cleaned, although he acknowledged that they should not have black or brown substances on them. The Administrator confirmed that maintenance was responsible for cleaning the fans, but there was no evidence of a structured process to ensure this task was completed regularly.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave. This deficiency was identified for five residents who were transferred to the hospital. The facility's policy requires that residents and their families be informed of the bed hold policy in writing upon admission and within 24 hours of an emergency transfer. However, the facility did not adhere to this policy, as evidenced by the lack of documentation showing that the bed hold policy was provided to the residents or their representatives. For Resident #32, the medical record did not contain a copy of the bed hold policy sent with the resident or to the resident's representative after the resident was transferred to the emergency room for multiple head lacerations. Similarly, for Resident #35, the facility checklist did not indicate that bed hold information was provided when the resident was transferred to the hospital following a fall and other medical issues. The same issue was noted for Resident #261, whose transfer documentation lacked any indication that the bed hold policy was provided. Interviews with facility staff revealed a lack of awareness and inconsistent practices regarding the distribution of the bed hold policy. The Business Office Manager was unaware of the bed hold policies, and the Social Services Director acknowledged that there was no written notification sent to residents or their representatives. Registered nurses and the Assistant Director of Nursing provided conflicting information about the process, indicating a systemic issue in ensuring compliance with the facility's bed hold policy requirements.
Failure to Document Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure proper catheter usage and care according to standards of practice, as evidenced by the lack of physician's orders for catheter placement and care for two residents. Resident #29, who was admitted with diagnoses including obstructive and reflux uropathy, retention of urine, and acute kidney failure, had a severe cognitive impairment and an indwelling catheter. Despite the care plan indicating the need for catheter care and assessment, there were no physician's orders documented for the indwelling catheter or its care. Resident #32, admitted with renal failure, returned from a hospital stay with a catheter due to urinary retention. However, the facility staff did not document any orders for the catheter placement or care until several days after the resident's return. Observations showed the resident with a catheter bag attached to the wheelchair, but the necessary orders were only entered into the system after the deficiency was noted. Interviews with facility staff, including RNs, CNAs, and the ADON, revealed a lack of clarity and consistency in the process of obtaining and documenting physician's orders for catheter care. Staff members indicated that orders should be entered by nurses or doctors, and that catheter care tasks appear on work lists, but there was a failure to ensure that all residents with catheters had the appropriate orders documented in their medical records.
Inadequate Documentation and Reconciliation of Controlled Substances
Penalty
Summary
The facility failed to ensure proper pharmacy services for the consistent counting, reconciliation, and destruction of controlled substances. This deficiency was identified through observations, interviews, and record reviews, revealing that staff did not consistently document the number of medication packages and doses of controlled medications at the change of shift on the controlled substance shift change log. Additionally, there was a failure to document the administration of medications on individual resident controlled drug record logs for three residents. The facility's policy required that controlled substances be counted at shift changes and discrepancies be resolved immediately, but these procedures were not consistently followed. Specific instances of non-compliance included single staff members signing the shift count sheet instead of the required two, and missing documentation for several shifts. For example, on multiple occasions, only one staff member signed the shift count sheet, and there were no documented counts for certain days. Furthermore, discrepancies were found in the controlled drug records for three residents, where the actual tablet count did not match the documented count. Interviews with staff revealed that some did not perform counts with another staff member and occasionally passed narcotics without verifying the count. The Director of Nursing (DON) and the Administrator both expressed expectations for narcotic counts to be completed at every shift change and whenever narcotic keys were exchanged. However, these expectations were not met, as evidenced by the lack of documentation and unresolved discrepancies. Staff interviews indicated a lack of adherence to the facility's policy, with some staff members admitting to not counting narcotics with another staff member and failing to document administered doses on the controlled drug record logs.
Failure to Provide SNFABN for Medicare Part A Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for a resident who remained in the facility upon discharge from Medicare Part A services. The resident, identified as Resident #49, was admitted to the facility and had a Medicare Part A skilled services episode starting on October 14, 2024, with the last covered day being December 6, 2024. The facility initiated the discharge from Medicare Part A services before benefit days were exhausted but did not provide the required SNFABN or an alternative denial letter to the resident or their legal representative. During interviews, the resident stated that they signed the Notice of Medicare Non-Coverage (CMS-10123-NOMNC) but did not receive any documentation showing the estimated cost of services that would not be covered after the last covered day. The resident had to conduct their own research to determine the daily cost of room/board and therapy, as they needed to stay in the facility until they could bear weight on their affected leg and transfer independently. The Social Services Director (SSD) and the Administrator acknowledged the oversight, with the SSD indicating that they were instructed to issue the SNFABN only if a resident was staying for long-term care, which led to the failure to provide the necessary notice to the resident.
Failure to Complete Timely MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to complete quarterly Minimum Data Set (MDS) assessments for two residents within the required 92-day timeframe. Resident #18's last MDS assessment was recorded on 07/24/24, and no subsequent assessment was documented for over 129 days. Similarly, Resident #77's last assessment was on 07/29/24, with no follow-up assessment documented for over 124 days. The facility's census was 109, and the absence of timely assessments was attributed to a glitch in the tracking system, which led to the omission of the next assessment dates for these residents. Interviews with the MDS Coordinator and Assistant MDS Coordinator revealed that until recently, the MDS Coordinator was solely responsible for conducting these assessments. The Assistant MDS Coordinator, who had recently begun assisting, confirmed the oversight in the tracking system that resulted in the missed assessments. The Administrator was unaware of the tracking system used by the MDS Coordinator and was not informed of any untimely assessments, although they expected assessments to be completed within the designated timeframe.
Inconsistent Tube Feeding Administration Due to Unclear Orders
Penalty
Summary
The facility failed to provide enteral nutrition per standards of practice for Resident #102, who was on a tube feeding regimen. The resident had a history of nontraumatic subarachnoid hemorrhage, type 2 diabetes mellitus, and a personal history of aneurysm rupture, which necessitated the use of a feeding tube due to poor oral intake and frequent changes in condition. The physician had ordered continuous feeding of Jevity 1.5 calorie at 30 ml per hour for 18 hours, with a 6-hour break to promote eating during the day. However, the orders were not clear, and staff did not consistently administer the tube feeding as prescribed. Observations revealed inconsistencies in the administration of the tube feeding. On several occasions, the tube feeding was either not attached or not running when it should have been, and the resident was observed not eating during meal times. Interviews with nursing staff, including RNs and LPNs, indicated confusion regarding the tube feeding schedule. Some staff believed the feeding was continuous, while others mentioned a rotating schedule without a set time for turning the feeding on and off. This inconsistency led to the tube feeding being turned off and on at varying times, not aligning with the physician's orders. The facility's policy required tube feeding to be administered by licensed nursing personnel according to physician orders, with documentation of feeding, water flush, intake, and output. However, interviews with the ADON, DON, and the facility's pharmacist highlighted a lack of familiarity with the resident's specific orders and a failure to ensure clarity in the orders. The administrator acknowledged the issue of unclear tube feeding orders, emphasizing the need for staff to seek clarification when necessary.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.14% error rate due to improper administration of levothyroxine for two residents. The errors occurred when the medication was not administered at the specified time of 6:00 A.M., before breakfast, and separate from other medications, as per physician orders. Instead, the medication was given after breakfast and alongside other medications, contrary to the instructions for it to be taken on an empty stomach. Resident #98, diagnosed with Alzheimer's disease and a thyroid disorder, was observed receiving levothyroxine at 9:05 A.M., after breakfast, and with other medications. The Registered Medication Technician (RMT) acknowledged administering the medication at the wrong time and with other medications, despite knowing it should be given at 6:00 A.M. on an empty stomach. Similarly, Resident #101, with a diagnosis of hypothyroidism, received levothyroxine at 8:57 A.M., after breakfast, and with other medications. The RMT admitted to the same error, citing the challenge of administering medications separately due to the number of residents. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed the expectation that levothyroxine should be administered before breakfast and on an empty stomach. The facility's policy allows a liberal three-hour window for medication administration, but specific instructions for certain medications, like levothyroxine, were not being followed. The DON and Administrator were aware of the issue, acknowledging that the medication timing was not in compliance with physician orders.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse/neglect policy by not reporting an allegation of inappropriate touching between two residents to the State Survey Agency within the required two-hour timeframe. The incident involved Resident #1, who was cognitively intact and had a history of bipolar disorder, Parkinson's disease, and dementia, and Resident #2, who had moderate cognitive impairment and a history of major depressive disorder and stroke. The incident was documented in nursing notes, but there was no record of the facility reporting the allegation to the Department of Health and Senior Services (DHSS). Interviews with staff revealed a lack of clarity and consistency in understanding the reporting requirements for such incidents. Certified Nurse Assistants (CNAs) and Licensed Practical Nurses (LPNs) expressed differing views on whether the incident constituted abuse and whether it needed to be reported to the state agency. Some staff believed that the guardian's or Durable Power of Attorney's (DPOA) decisions regarding residents' sexual activity should guide their actions, while others recognized the need to report the incident as potential abuse. The Director of Nursing (DON) and the Administrator also provided conflicting statements regarding the necessity of reporting the incident to the state agency. The DON did not consider the incident as needing to be reported, citing the absence of an abuse allegation, while the Administrator acknowledged the need to separate the residents and notify the guardians but did not ensure the incident was reported to the state agency. This inconsistency in policy implementation and understanding among staff and management contributed to the facility's failure to report the incident as required.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse/neglect policy effectively, as evidenced by the lack of a documented investigation into an incident involving inappropriate touching between two residents. The incident occurred when one resident was found touching another resident's genitalia in the courtyard. Despite the facility's policy requiring immediate investigation and documentation of such allegations, no written investigation was completed, and the Department of Health and Senior Services (DHSS) did not receive any report of the incident. Resident #1, who was cognitively intact and had a guardian, was involved in the incident. The resident had a history of bipolar disorder, Parkinson's disease, and dementia. The nursing notes indicated that the resident was educated about the inappropriateness of their actions, and both residents were placed on 15-minute checks. However, the facility did not conduct a formal investigation or document the incident as required by their policy. Resident #2, who had a Durable Power of Attorney (DPOA) and a history of major depressive disorder and stroke, was the other party involved. The resident expressed that such an incident would be considered traumatic. Despite this, the facility did not verify consent from Resident #2 or conduct a thorough investigation. Interviews with staff revealed a lack of clarity on handling such situations, and the facility's management did not follow through with the necessary steps to ensure compliance with their abuse/neglect policy.
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.
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What surveyors actually found near you
We read the 79 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Buffalo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buffalo Prairie Center For Rehab And Healthcare | 0.5 mi | ★★★★★ | 17 | 1 |
| Parkview Health Care Facility | 17.4 mi | ★★★★★ | 0 | 0 |
| Citizens Memorial Healthcare Facility | 17.9 mi | ★★★★★ | 11 | 0 |
| Webco Manor | 22.9 mi | ★★★★★ | 5 | 0 |
| Marshfield Care Center For Rehab And Healthcare | 23.5 mi | ★★★★★ | 8 | 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.