Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St John's Lutheran Home during CMS and state inspections, most recent first.
Controlled Substance Documentation Discrepancies: The facility failed to accurately account for and document controlled substance doses for three residents. MARs and narcotic sign-out records did not match for multiple doses, with some doses documented on one record but not the other. Staff stated that MAR documentation and narcotic sign-out sheets should match and that every narcotic dose needed to be documented on both records.
Resident dignity and rights concern during activity: A resident had an incontinent episode during a group activity and had to leave to be cleaned up after an LPN loudly announced in front of others that there was a big mess needing attention. Staff later reviewed the event and described it as involving resident dignity and rights, with the LPN stating she was frustrated while caring for the resident due to the resident’s intellectual disability.
A caregiver violated a resident’s privacy during incontinence care by using a personal cell phone to contact an outside CNA who was not employed by the facility while the resident was present. Staff observed the caregiver on a video call, and a written statement noted the camera was turned toward the resident’s buttocks area and the mess on the floor.
Failure to Protect Resident from Staff Abuse: A staff member yelled at a resident during an activity session after the resident had a BM and continued making comments about the mess in front of the resident. A witness reported the staff member was going off about how big and gross the mess was, and the resident was later found in her wheelchair without pants or a brief, with BM on the bathroom walls. The resident was also documented as almost falling from her w/c and needing a Hoyer lift and shower chair for cleanup due to diarrhea.
Misappropriation of a resident's medication occurred when two unlabeled syringes were found in a med cart and video showed a staff member placing them there. Pharmacy identified the contents as oral lorazepam and oral morphine sulfate, and the resident's open lorazepam bottle was short by 2.5 ml compared with the narcotic count sheet. The report states the misappropriation was substantiated.
Late Reporting of Abuse Allegation: The facility failed to report an allegation of resident abuse within the required timeframe. An abuse allegation involving a resident and NF1 was verbally reported to a new staff member, who stated she was not aware of the 24-hour reporting requirement. The incident was later submitted to the State Survey Agency, and another staff member acknowledged the allegation was reported late. The facility policy required abuse to be reported no later than 24 hours after the allegation is made to the DON or designee and other officials.
A facility failed to accurately record, monitor, and reconcile lorazepam oral liquid for one resident. Unlabeled syringes were found in a med cart, and review of the bottle and narcotic sign-out sheet showed a 2.5 ml discrepancy between the amount on hand and the amount documented. Staff described the usual controlled substance process, but pharmacy audits identified discrepancies with controlled substances and did not specifically address the accuracy of lorazepam oral liquid.
Surveyors found that expired food items were not discarded, and perishable foods were not properly labeled or dated in several areas of the facility. Dietary staff did not have or follow written policies for food storage and handling, and dish sanitization water was not tested due to a lack of test strips, despite policy requirements for safe food handling and sanitation.
Staff did not consistently perform hand hygiene after assisting residents or while preparing and serving food, including serving coffee and feeding multiple residents without washing hands between contacts. Enhanced barrier precautions were not implemented for a resident with a chronic wound, as staff provided care without required PPE. Additionally, a staff member failed to follow glove use protocols during food preparation, using the same glove for multiple tasks and handling both food and soiled items.
The facility did not report findings of a resident-to-resident verbal altercation to the State Survey Agency within the required timeframe, and also failed to report allegations of resident-to-resident physical abuse within 24 hours as required by policy. Delays were attributed to unclear staff responsibilities and incidents occurring over a weekend, resulting in late notifications and documentation.
The facility did not make grievance forms readily available in common areas, failed to provide a secure method for anonymous written grievance submission, and did not ensure residents were informed about how to file grievances anonymously. A resident was unaware of the process, and staff confirmed forms were only available in an office, not accessible to residents.
A resident receiving oxygen therapy via nasal cannula at 2 L/min, as ordered by a medical provider, did not have this treatment included in their care plan. Staff confirmed the omission and were unsure why the care plan was not updated to reflect the resident's oxygen needs.
The facility did not update care plans to reflect the specific activity preferences and participation of two residents, nor did it include enhanced barrier precautions for a resident with an indwelling urinary catheter. Staff interviews and record reviews showed that individualized interventions and infection control measures were missing from the care plans, despite observations of resident needs and facility policy requirements.
Two residents experienced medication errors when staff delayed insulin administration until after a meal and incorrectly documented and omitted a scheduled dose of pantoprazole, resulting in a medication error rate above five percent.
The facility failed to meet residents' nutritional needs and follow planned menus. Staff did not review diet orders or menus, served meals not on the menu, and used improper serving methods. Inadequate meal preparation led to insufficient portions and lack of appropriate substitutes.
The facility failed to update care plans for three residents, leading to deficiencies in addressing their current needs. A resident dealing with grief lacked interventions for coping, another with frequent falls did not have a care plan including a camera for fall prevention, and a third resident's care plan was outdated, not reflecting a recent move. Staff acknowledged the need for timely updates.
The facility did not post daily nurse staffing information in four cottages housing 51 LTC residents. During a survey, it was observed that no postings were present. Interviews with staff revealed a lack of awareness about the absence of postings in the cottages, although staffing was posted on the rehabilitation unit.
The dietary department failed to provide residents with a nourishing diet and did not adhere to therapeutic diet requirements, leading to potential negative nutritional outcomes. Staff members did not review diet orders, resulting in improper serving sizes and failure to follow dietary guidelines. Interviews revealed a lack of awareness and adherence to dietary protocols, with staff failing to consult residents about meal preferences and not ensuring consistent nutrition.
The facility failed to provide sufficient and competent staff in food services, leading to delayed meal service and inadequate dietary management. Cooks were shared between cottages, causing meal delays, and staff lacked training on dietary changes and resident allergies. Observations showed understaffing led to missed cleaning duties and improper meal preparation, increasing risks for residents.
The facility failed to accommodate resident dietary needs in the [NAME] Cottage, as staff did not review diet orders or menus, leading to inappropriate meal service. Staff were unaware of special diets, and residents were not asked about meal preferences. Observations showed non-compliance with textural modifications, such as unminced sausage for residents on a minced and moist diet.
The facility's kitchens in the Powers, [NAME], and [NAME] Cottages were found to have significant sanitation issues, including dirty floors, improperly labeled and stored food, and poor hand hygiene practices by staff. Observations revealed black film on kitchen floors, leaking freezers, and sticky cupboard doors. Staff members were seen using contaminated gloves to handle food, and interviews highlighted concerns about cleanliness and a shortage of cooks affecting cleaning routines.
The facility failed to maintain proper infection control and PPE use during a COVID-19 outbreak. Staff were observed mishandling clean and dirty linens, improperly washing hands, and being unaware of outbreak status due to missing signage. A staff member was seen without a mask in an outbreak area.
A facility failed to assess two residents' ability to self-administer medications before leaving them unattended. A staff member left medications on a table and exited the dining area to take a phone call, without ensuring the residents had been assessed or had a physician's order for self-administration. Interviews confirmed the requirement for such assessments and orders, but reviews of the residents' records showed these were not in place.
A facility failed to accurately complete a resident's Quarterly MDS assessment. A staff member noted the resident often refused showers and personal care, and during one instance, observed redness in the resident's groin. Despite the nurse's recommendation for treatment, the resident refused care. The MDS assessment did not document these refusals, and the staff member responsible for the assessment could not explain the omission.
The facility failed to create timely baseline care plans for two residents. One resident, admitted for end-of-life care, had no care plan completed before passing away. Another resident with complex medical needs had a delayed and incomplete care plan, missing critical information on ADL assistance, seizure precautions, and speech therapy. Facility policy requires baseline care plans within 48 hours of admission.
A facility failed to consistently assess and document a resident's skin condition as part of preventative care. A staff member noticed redness in a resident's perineum during a shower and informed a nurse, who suggested treatment options that the resident refused. A review of records showed a lack of routine skin assessments, despite the facility's policy requiring weekly assessments.
A resident experienced repeated falls resulting in back injuries, and the facility failed to identify root causes or evaluate interventions. Despite frequent checks and camera monitoring, the care plan did not address falls individually or update interventions. The resident was removed from the Fall Management Program, and no new strategies were implemented, contrary to facility policy.
A resident dealing with grief and confusion after the loss of a spouse did not receive timely mental health services. Despite expressing feelings of missing his wife, the resident's care plan lacked interventions for grief or loneliness. Although a staff member provided some emotional support, there were no documented social services notes or evidence of grief counseling. Behavioral health counseling was ordered only after the resident's son reported forgetfulness.
The facility failed to limit PRN psychotropic medications to 14 days or document rationale for extended use for two residents. One resident continued using clonazepam PRN for insomnia without a stop date, despite a pharmacist's recommendation for adjustment. Another resident had lorazepam PRN for anxiety without a stop date, and the provider declined discontinuation despite no use in 30 days. A staff member noted awareness of the 14-day limit, but one physician did not always follow the policy.
A facility failed to obtain a signed consent for a pneumococcal vaccine for a resident who was confused and unable to consent. A staff member noted that the nurse should have contacted the resident's legal representative to discuss the vaccine's risks and benefits and to obtain consent. The facility's policy requires determining immunization status upon admission and offering vaccination to those without documentation, with vaccine type based on age and previous immunizations.
A facility failed to report an allegation of resident neglect within the required 24-hour timeframe. The incident occurred over a two-day period and was communicated to staff via email, but the report to the State Survey Agency was delayed. Staff member B acknowledged the delay, citing a lack of timely information despite being aware of the reporting requirements.
A resident's morning insulin was administered three hours late due to a delay in returning to their room after breakfast. The insulin, scheduled for 7:00 a.m., was given at 10:11 a.m. without re-checking the resident's blood sugar or notifying the physician about the delay.
Controlled Substance Documentation Discrepancies
Penalty
Summary
The nursing facility failed to ensure that controlled substance medications were accurately accounted for and documented in residents’ EHRs and medication records for 3 of 3 sampled residents (#2, #6, and #9). Review of resident #9’s MAR and narcotic sign-out sheet showed discrepancies on 3/30/26, when the MAR documented 0.5 ml at 9:33 a.m. but the narcotic sign-out documented 0.25 ml at 9:00 a.m., and on 4/1/26, when the MAR showed no dose while the narcotic sign-out documented 0.5 ml at 7:15 p.m. and 9:00 p.m. Review of resident #2’s records showed discrepancies on [DATE]/11/26, when the MAR documented 0.25 ml at 5:00 p.m. but the narcotic sign-out showed none, and on [DATE]/17/26, when the MAR documented 0.25 ml at 8:00 a.m. but the narcotic sign-out showed none. Review of resident #6’s MAR and narcotic sign-out also showed discrepancies. On 1/22/26, the MAR showed none while the narcotic sign-out documented 0.5 ml at 2:00 p.m. and 7:10 p.m.; on [DATE]/23/26, the MAR documented the resident was sleeping at 9:00 a.m. and not given medication, while the narcotic sign-out documented 0.5 ml at 10:37 a.m.; and on [DATE]/26/26, the MAR showed none while the narcotic sign-out documented 0.5 ml at 3:00 a.m. During interviews, staff member J stated the MAR documentation and narcotic sign-out sheet should match and that discrepancies needed to be reported. Staff member B stated the facility expectation was that every dose of a narcotic needed to be documented on both the narcotic sign-out sheet and the resident’s MAR.
Resident Dignity and Rights Concern During Activity
Penalty
Summary
The facility failed to ensure a resident’s right to a dignified existence for 1 of 3 sampled residents. During a group activity, resident #8 had an episode of incontinence and had to leave the activity to be cleaned up. The facility-reported incident stated that NF1 loudly announced, in front of other residents and staff, that there was a big mess needing to be cleaned up, referring to the resident’s situation. Staff interviews and record review showed that staff member E reported NF1 had been picking on resident #8, and the resident became upset and incontinent of stool during the activity. Staff member C reviewed the incident, spoke with staff who witnessed it, and determined there was no malicious intent, but that the event involved resident dignity and resident rights rather than abuse. Staff member B stated NF1 was trying to get someone to assist the resident and did not identify the resident by name or specify the type of mess needing to be cleaned up. NF1 later admitted feeling frustrated when caring for resident #8 due to the resident’s intellectual disability.
Privacy Breach During Incontinence Care
Penalty
Summary
Keep residents' personal and medical records private and confidential was violated when a caregiver used a personal cell phone during incontinence care for a resident who had an episode of bowel incontinence. During the care, the caregiver contacted a CNA who was not employed by the facility to ask for advice about how to handle the resident's resistance to care, allowing an unauthorized person to be involved while the resident was present. Facility records and staff statements showed the caregiver was observed on a phone call while performing incontinence care, and the call was identified as a video call because the camera was on. A written statement noted the caregiver turned the camera toward the resident's buttocks area and the mess on the floor. In an interview, the caregiver stated she called someone for advice on caring for someone resistant to care and identified the person as a CNA who was not employed by the facility; she denied that the call was a video call.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by a staff member during an activity session. A facility-reported incident stated that the staff member yelled at the resident because she had a bowel movement during the session and continued to complain in front of the resident about how far behind she was because of the mess the resident made. A staff witness stated the staff member was "going off" about how big and gross the mess was in front of the resident, and the witness later heard the resident screaming and found her in her wheelchair without pants or a brief, with bowel movement on the bathroom walls. The resident was documented as hanging off her wheelchair and almost to the floor, and staff used a Hoyer lift to move her into a shower chair for cleaning because she needed a shower due to diarrhea. In the investigation, the staff member stated the resident was incontinent several times, became resistive to care, and was left in her room without a brief or pants, but denied that her conversation with the resident was inappropriate. The facility substantiated the abuse allegation after interviewing the resident and the other residents in the cottage, and the report states the resident had no injuries.
Misappropriation of Resident Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when medication belonging to the resident was found missing. A facility-reported incident described that two unlabeled syringes were discovered in a medication cart at the cottage, and video surveillance showed a staff member placing the syringes in the cart. Pharmacy identified the contents as oral lorazepam and oral morphine sulfate. The only open bottle of lorazepam belonged to the resident, and when the bottle was measured, it contained 23.5 ml compared with 26 ml expected on the narcotic sign-out sheet, showing a shortage of 2.5 ml. During observation, staff demonstrated the process for dispensing and documenting oral lorazepam using a syringe and narcotic sign-out sheet. In interview, staff described that the unlabeled syringes were found during medication pass and reported to nursing leadership, and that surveillance review identified the staff member responsible for placing the syringes in the cart. The report states the misappropriation of the resident's medication was substantiated and that the staff member was terminated.
Late Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident abuse in a timely manner for 1 of 5 residents sampled for timeliness of reporting abuse allegations. A Facility-Reported Incident for an event that occurred on 3/13/26 was submitted to the State Survey Agency on 3/17/26 and documented an allegation of resident abuse made by staff member E. During an interview, staff member D stated she received a verbal report of the abuse allegation involving resident #8 and NF1, took notes while interviewing staff member H on 3/13/26, and also spoke with staff member E about what she witnessed. Staff member D stated she was new to her position and was not aware that allegations of abuse had to be reported within 24 hours of the incident. Staff member D stated she received an email from her supervisor on 3/16/26 regarding reporting timeframes for reportable events and then became aware that reportable events needed to be reported within 24 hours. Staff member B stated he knew the abuse allegation was reported late. The facility policy titled Abuse, dated August 2022, stated abuse is reported no later than 24 hours after the allegation is made to the DON or designee and to other officials, including the State Survey Agency.
Controlled Substance Recordkeeping and Reconciliation Failure
Penalty
Summary
The facility failed to develop and implement a system that accurately recorded, monitored, and reconciled the dispensing of lorazepam oral liquid for 1 of 3 sampled residents. A Facility-Reported Incident submitted to the State Survey Agency described that two unlabeled syringes were found in the medication cart in [NAME] Cottage on 4/3/26. One syringe contained 0.4 ml of clear liquid identified as oral lorazepam, and the other contained a trace amount of red liquid identified as oral morphine sulfate. The open bottle of lorazepam and the narcotic sign-out sheet were taken to the pharmacy, where the measured amount in the bottle was 23.5 ml, while the sign-out sheet showed 26 ml should have remained, a difference of 2.5 ml. During interview, staff member B described the usual process for dispensing, storing, and destroying lorazepam oral liquid, including documenting the amount removed and the amount remaining each time a dose was administered. Staff member B stated that after the diversion was identified in April 2026, lorazepam oral liquid was no longer dispensed in a brown multidose bottle and was instead dispensed as 15 ml in a 30 ml syringe. A pharmacy audit dated 3/31/26 showed several discrepancies with controlled substances, including two bottles of lorazepam oral liquid. A later pharmacy audit dated 5/21/26 did not identify discrepancies in the dispensing and administration of lorazepam oral liquid, and although one audit monitored the four LTC cottages for controlled substance sign-out sheet accuracy, there was nothing regarding the accuracy of lorazepam oral liquid. The facility policy titled Controlled Substances Recordkeeping required each dose to be recorded on the controlled substance reconciliation count sheet and counts to be verified at the end of each shift.
Expired Food and Inadequate Sanitation Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to dispose of expired food items and did not ensure proper labeling and dating of perishable foods in multiple cottages and the main storage room. Several food items, including coffee creamers, sliced cheese, ham, milk, prune juice cups, grape juice, chips, and fig newtons, were found to be expired or lacked open dates. Staff confirmed that expired items should be discarded and that all items should be dated, but these practices were not consistently followed. Additionally, staff reported the absence of dietary policies for food storage and handling, relying only on verbal instructions to follow Serve Safe guidance. Further observations revealed that dietary staff did not test the sanitizer water used for dishwashing, as there were no test strips available in any of the cottages. Staff stated that Ecolab managed the sanitizer units and checked them monthly, but no in-house testing was performed. Review of the facility's food safety policy indicated requirements for proper food handling, labeling, and dating, as well as the use of leftovers within three days, but these procedures were not being implemented as outlined.
Failure to Follow Hand Hygiene, Glove Use, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to perform appropriate hand hygiene after assisting residents and while preparing and serving food. Observations included a staff member assisting a resident to a dining table, touching the resident, and then serving coffee to multiple residents without performing hand hygiene between contacts. Another staff member was seen feeding two residents alternately without any hand hygiene during the meal, and a third staff member assisted three residents with their meals after moving a stool with bare hands, again without performing hand hygiene. The facility also failed to implement enhanced barrier precautions (EBP) for a resident with a chronic wound. The resident was observed with a wound dressing on her left foot, and staff assisted her with transfers and personal care without wearing an isolation gown, despite facility policy requiring EBP for residents with chronic wounds during high-contact care activities. Interviews revealed confusion among staff regarding which residents required EBP and when to use personal protective equipment (PPE). Additionally, staff did not follow proper glove use and hand hygiene protocols during food preparation. One staff member was observed wearing a glove on one hand while cooking, then using the same gloved hand to handle ready-to-eat food, touch various surfaces, and handle soiled items before removing the glove. Facility policies required hand washing before donning gloves, changing gloves as often as hands need to be washed, and not using the same gloves for multiple tasks, but these procedures were not followed.
Failure to Timely Report Abuse Allegations and Investigation Findings
Penalty
Summary
The facility failed to report the findings of a facility-reported incident to the State Survey Agency within the required timeframe for two residents involved in a verbal altercation. The incident occurred in a cottage dining room, where one resident was witnessed yelling at and insulting another. Although both residents were evaluated by staff and one was assessed for behavioral health treatment, the facility did not submit the investigation findings to the State Survey Agency until two days after the required deadline. Interviews with staff revealed confusion and lack of clear assignment regarding who was responsible for submitting follow-up reports, contributing to the delay. Additionally, the facility did not report allegations of resident-to-resident abuse to the State Survey Agency within 24 hours for another incident involving a physical altercation between two residents, resulting in a visible injury. The delay occurred because the incident happened on a weekend, and the responsible staff member did not review or report the event until the following Monday. The facility's own policy requires notification to the State Survey Agency within 24 hours and submission of investigation documentation within five business days, which was not followed in these cases.
Failure to Provide Anonymous Grievance Submission Process and Readily Available Forms
Penalty
Summary
The facility failed to develop and implement a policy and procedure that allowed residents to submit written grievances anonymously, did not provide residents with readily available grievance forms, and did not offer a secure receptacle for anonymous grievance submission. During an observation, no documentation was found in the common areas regarding how residents could file a grievance, and no grievance forms or secure submission boxes were present. Staff interviews confirmed that grievance forms were kept in a staff office and not accessible to residents in the common areas, and that there was no secure method for anonymous submission. A resident interviewed was unaware of the location of grievance forms or the process for submitting an anonymous grievance, stating she would typically inform staff of any issues. Review of the facility's grievance policy indicated that forms should be available adjacent to the Resident Rights posting and that grievances could be submitted anonymously via a compliance hotline, but these procedures were not observed in practice during the survey.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who required oxygen therapy. Observation revealed the resident was using a nasal cannula with an oxygen concentrator set at 2 liters per minute, as ordered by the medical provider. However, review of the resident's current care plan showed no focus, goal, or interventions related to oxygen therapy. During an interview, a staff member confirmed that the care plan had not been updated to include the resident's oxygen therapy, and was unsure why this omission occurred. The deficiency was identified through observation, interview, and record review, which confirmed that the resident's care plan did not address the ordered oxygen therapy, despite the resident actively receiving this treatment.
Failure to Update Care Plans for Activities and Infection Control
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect resident-centered activity preferences and infection control measures for sampled residents. For one resident, observations and interviews revealed that although she participated in some activities, such as church services and family visits, her care plan did not document her specific preferences, the importance of church, or her limited participation in group activities. Staff interviews confirmed that changes in activity participation were not consistently documented in the care plan, and the care plan lacked individualized interventions such as one-to-one visits. Another resident, who was hard of hearing and rarely participated in group activities, also had a care plan that did not reflect her interests or preferences. Despite being dependent on staff for social needs and having recently moved cottages, her activity assessment was incomplete, and care team meeting notes were left blank regarding activities. The care plan failed to include her enjoyment of family visits and music or the use of one-to-one visits to address her needs. Additionally, a resident with an indwelling urinary catheter had enhanced barrier precaution signage on her door, but there was no personal protective equipment available for staff, and her care plan did not include interventions for enhanced barrier precautions. Staff interviews indicated that care plans were not updated to include these precautions, despite facility policy requiring such updates for residents with indwelling medical devices. The care plan only addressed the presence of the catheter and related self-care deficits, omitting necessary infection control interventions.
Medication Error Rate Exceeds Five Percent Due to Administration and Documentation Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a calculated error rate of 5.41 percent during the survey period. One incident involved a staff member delaying the administration of insulin to a resident until after the resident had finished breakfast, despite a physician's order specifying that insulin should be given before meals. In another case, a staff member administered acetaminophen to a resident during breakfast but incorrectly documented it as pantoprazole in the medication administration record (MAR), and did not administer the pantoprazole as scheduled before the resident ate, contrary to the physician's order for administration at 7:00 a.m. These actions resulted in medication errors for two residents out of a sample of twenty-five.
Failure to Meet Nutritional Needs and Follow Menus
Penalty
Summary
The facility failed to ensure that meals served to residents met their nutritional needs and that staff adhered to the planned menu or offered appropriate substitutes. During observations, staff members did not review residents' diet orders or the menu prior to meal service. Staff member N served bacon using her hands instead of the required scoop size and did not follow the menu, serving regular toast or pancakes instead of the planned banana french toast. Additionally, residents were not asked for their meal preferences. On another occasion, staff member P did not follow the menu and served plain scrambled eggs instead of the planned confetti eggs, cereal, hashbrowns, and toast. The cook ran out of hashbrowns, and no substitute was offered. Further observations revealed that staff member R did not have enough pancakes for all residents and failed to provide a minced meat substitute for breakfast, as required. Instead, she planned to provide double portions of meat at lunch. Eggs sterling was on the menu, but plain scrambled eggs were served, and there were not enough eggs for all plates. Staff member R redistributed eggs from already dished plates to ensure all residents received some, indicating a lack of preparation and adherence to dietary requirements.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to update the comprehensive care plans for three residents, leading to deficiencies in addressing their current needs. Resident #41, who was dealing with grief after the death of his wife, did not have a care plan that included interventions for coping with grief, despite staff awareness of his situation. Staff member G admitted to not updating the care plan, acknowledging a lack of diligence in this area. Resident #47, who experienced frequent falls and back pain, did not have a care plan that included the use of a camera for fall prevention, an intervention mentioned by staff member F. Staff member I emphasized the collective responsibility to ensure timely updates to care plans. Additionally, resident #3's care plan was outdated, still reflecting adjustment issues related to a move that occurred over a year ago. The care plan had not been revised to address a more recent move, which could have contributed to the resident's resistance to showers and incontinence care. Staff member C noted the resident's resistance might be due to being new to the cottage, indicating a need for updated care planning to reflect the resident's current situation.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in the four cottages housing 51 long-term care residents. This deficiency was identified during a survey conducted from August 12 to August 15, 2024. Observations during the survey revealed that no nurse staffing postings were present in any of the cottages. During an interview on August 14, 2024, at 8:17 a.m., a staff member was unable to identify where the nurse staffing information was posted in two of the cottages, although they mentioned that staffing was posted on the rehabilitation unit. Another staff member interviewed on August 15, 2024, at 11:55 a.m., was unaware that there were no staff postings in the cottages.
Dietary Department Fails to Meet Residents' Nutritional Needs
Penalty
Summary
The dietary department failed to provide residents with a nourishing diet and did not adhere to therapeutic diet requirements, leading to potential negative nutritional or health outcomes. Observations revealed that staff members did not review diet orders or therapeutic menus, resulting in improper serving sizes and failure to follow dietary guidelines. For instance, staff member N did not measure portions when serving bacon and used unwashed berries, while staff member P was unaware of special diets and did not ensure uniform serving sizes. Additionally, staff member P ran out of hash browns and did not provide substitutes, and staff member R did not have enough pancakes or eggs to meet the menu requirements. Interviews with staff members indicated a lack of awareness and adherence to dietary protocols. Staff member O admitted to not regularly checking on the cottages and expressed doubt that diets were being followed. Staff members also failed to consult residents about their meal preferences, and there was a general lack of communication and understanding regarding dietary needs. The report highlights multiple instances where dietary staff did not follow established procedures, leading to inconsistent and potentially inadequate nutrition for the residents.
Inadequate Staffing and Competency in Food Services
Penalty
Summary
The facility failed to ensure sufficient staffing with the necessary competencies and skillsets in the food and nutrition services, leading to delayed meal service and inadequate dietary management. During an entrance conference, staff members A and B revealed that cooks were shared between two cottages, resulting in meal preparation and service delays. An observation on 8/14/24 showed that the cook, staff member P, served breakfast 53 minutes late without assistance, contrary to the posted meal time. Staff member P, a CNA not typically involved in cooking, was unaware of dietary changes and resident allergies, indicating a lack of proper training and familiarity with the kitchen operations. Further observations revealed that the facility was understaffed, leading to missed cleaning duties and inadequate meal preparation. On 8/15/24, staff member R was observed with insufficient pancakes and failed to provide a minced meat substitute for breakfast, demonstrating a lack of knowledge about dietary requirements. Breakfast was again served late, highlighting the ongoing staffing and competency issues in the food and nutrition services, which increased the risk of negative outcomes for residents in the affected cottages.
Failure to Accommodate Resident Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodated resident allergies and preferences in the [NAME] Cottage. Observations revealed that staff members did not review resident diet orders or menus prior to meal service. For instance, during a meal service, banana French toast was not served as per the menu, and minced bacon was served with syrup poured on top without considering resident preferences. Additionally, staff members were unaware of the number of special diets required, with one staff member expressing uncertainty about potential allergies to watermelon among residents. Further observations indicated that staff did not adhere to the required textural modifications for residents on specialized diets. For example, sausage was not minced for residents on a minced and moist diet, and no minced meat substitute was provided. Staff members admitted to not having time to prepare the food as required and planned to compensate by providing double portions at a later meal. The lack of adherence to dietary requirements and failure to consult residents about their meal preferences contributed to the deficiency.
Sanitation and Hygiene Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchens of the Powers, [NAME], and [NAME] Cottages, as observed during a survey. The kitchen floors had a heavy accumulation of black film along the edges, and there was water leaking from a freezer door with a towel placed on the floor to absorb it. The freezer had a buildup of ice and rust-colored stains, and there were unlabeled and undated food items in both the freezer and refrigerator. The pantry refrigerator was dirty, with brown smears, red debris, and cheese-like shreds. Additionally, the cupboard doors were sticky, and there was no sanitizing solution for kitchen towels. The handles of the refrigerators and oven were soiled, and several spice containers were left open. Staff members were observed practicing poor hand hygiene and glove use. Staff member P was seen touching her hair and sticky cupboards with gloved hands and then handling food without changing gloves. She also used contaminated gloves to scoop food and handle resident plates. Staff member N similarly used the same pair of gloves to open cupboards, handle food, and serve residents, without changing gloves or washing hands. These practices were observed during breakfast service, where food items were also found to be improperly labeled and stored. Interviews with staff revealed concerns about sanitation and cleanliness in the kitchen. Staff member Q expressed concerns about the dirty vent cover and sprinkler head, while staff member T noted the vents were dirty and difficult to clean without a ladder. Staff member O, who visited the cottages weekly, was unaware of the freezer issues. The facility was experiencing a shortage of cooks, leading to missed cleaning tasks. The registered dietitian's audits highlighted unresolved issues, including dirty kitchen floors, lack of hand hygiene, and improperly labeled leftovers.
Infection Control and PPE Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection control practices and the use of appropriate personal protective equipment (PPE) during a COVID-19 outbreak. Observations revealed that a staff member, NF4, was seen carrying clean towels against her uniform and transporting dirty linens uncovered, placing them on the floor near the washing machine. Another staff member, R, was observed washing her hands but turning off the faucet with wet hands before drying them and proceeding with breakfast service. Additionally, during an interview, it was disclosed that the [NAME] Cottage was in outbreak status due to a positive COVID-19 test by a staff member. However, staff member E was seen changing a lightbulb without wearing a mask and was unaware of the outbreak status due to the absence of signage at the employee entrance. Staff member C acknowledged the lack of outbreak signage and stated she would address it immediately.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for their ability to self-administer medications before being left unattended while taking medications. During an observation, a staff member left medications for two residents on a table in the dining room and then left the area to take a phone call, leaving the residents unattended. This action occurred without any other nursing staff present to observe the residents taking their medications. Interviews with staff revealed that there was a requirement for an assessment of the resident's ability to safely self-administer medications and a physician's order permitting self-administration. However, reviews of the electronic health records for the two residents involved showed no such assessments or physician's orders. This oversight indicates a failure to adhere to the necessary protocols for medication administration in the facility.
Failure to Accurately Complete Resident Assessment
Penalty
Summary
The facility failed to accurately complete the Quarterly resident assessment for one of the sampled residents. During an interview, a staff member reported that the resident often refused showers and personal care assistance, opting instead for a sponge bath. On one occasion, while assisting the resident with a shower, the staff member noticed redness in the resident's groin area and notified a nurse, who recommended treatment with nystatin powder or cream. However, the resident refused the recommended treatments. Despite these refusals, the Quarterly MDS assessment did not document any behaviors related to the rejection of care during the assessment period. Another staff member, responsible for the assessment, acknowledged awareness of the resident's regular refusal of care but could not explain why this behavior was not coded in the MDS. This oversight led to the deficiency in accurately completing the resident's assessment.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for two residents within the required 48-hour timeframe after admission. For the first resident, who was admitted for a short end-of-life stay, no baseline care plan was created, and the resident passed away six days after admission. Staff acknowledged that the care plan was not completed, possibly due to the resident's short stay. The facility's policy mandates that baseline care plans be initiated within 48 hours of admission by the interdisciplinary team (IDT). For the second resident, who was admitted with multiple complex medical conditions including epilepsy, dysphagia, and a suprapubic catheter, the baseline care plan was initiated late and lacked critical information. The care plan did not address the resident's need for assistance with activities of daily living (ADLs), seizure precautions, or speech therapy, despite these being pertinent to the resident's condition. The facility's policy requires that initial care plans include the primary reason for admission and be completed comprehensively within 21 days.
Failure to Document Routine Skin Assessments
Penalty
Summary
The facility nursing staff failed to consistently assess and document the skin condition of a resident as part of preventative skin care measures. During an interview, a staff member revealed that while assisting a resident with a shower, they noticed redness in the resident's perineum and informed a nurse, who suggested treatment options. However, the resident refused the recommended treatments. A review of the resident's electronic health record from January to August showed a lack of routine skin assessments, with only a few notes regarding the resident's skin condition, including a wound on the chin and the red groin. The facility's Skin at Risk Program indicated that skin assessments should be performed weekly, but documentation did not reflect this practice.
Failure to Address and Prevent Repeated Falls
Penalty
Summary
The facility failed to adequately address and prevent repeated falls for a resident who experienced multiple falls, resulting in back injuries. The resident expressed reluctance to ask for help, which contributed to the falls. Despite the implementation of frequent checks and a camera monitoring system, the facility did not effectively monitor the resident, as evidenced by the lack of staff presence in the nurses' room to observe the camera feed. The resident's care plan, initiated in July 2024, did not identify the root causes of the falls or evaluate the effectiveness of existing interventions. The care plan grouped the falls together without addressing them individually or updating interventions based on specific incidents. Post-fall documentation for several incidents failed to identify specific causes or evaluate the effectiveness of interventions, and no new strategies were implemented to prevent future falls. The resident was removed from the Fall Management Program because the provider deemed the falls unavoidable, and staff did not attempt new interventions. The facility's policy required root cause analysis and intervention for each fall, but this was not followed. The Quality Assurance and Performance Improvement committee was responsible for ensuring high-risk residents were included in the Fall Management Program, but the resident was not reviewed by the fall IDT team.
Failure to Provide Mental Health Services for Grieving Resident
Penalty
Summary
The facility failed to provide necessary mental health services to a resident who was experiencing grief and confusion following the death of his spouse. The resident expressed feelings of missing his wife and confusion, indicating a need for mental health support. Despite the resident's family visiting and a staff member providing some emotional support, the resident's care plan was not updated to include interventions for grief or loneliness. Additionally, there were no documented social services notes or evidence of grief counseling provided to the resident. A staff member mentioned placing an order for behavioral health counseling only after the resident's son reported his father's forgetfulness. The lack of documentation and timely intervention contributed to the deficiency identified by the surveyors.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days or had documented rationale for extended use by the physician for two residents. For one resident, a pharmacist recommended alternatives to a sleep aid/antianxiety medication, but the physician ordered clonazepam PRN without a stop date. The resident used the medication almost nightly, and despite a pharmacist's recommendation to adjust the regimen and document the next evaluation timeframe, the resident continued on the medication without further documentation through the survey date. For another resident, lorazepam was ordered PRN for anxiety without a stop date, and the resident received it twice in one month. The pharmacy noted the medication had not been used in 30 days, but the provider declined discontinuation and planned to review it within 60 days. An interview with a staff member revealed that medical providers were aware of the 14-day limit for PRN medications, but one physician did not always adhere to the policy. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless the physician documented a rationale and duration for extended use.
Failure to Obtain Consent for Pneumococcal Vaccine
Penalty
Summary
The facility failed to obtain a signed consent for the administration of a pneumococcal vaccine for one of the sampled residents. The resident in question was confused and unable to consent to the administration of the vaccine. During an interview, a staff member indicated that the nurse should have followed up with the resident's legal representative to educate them on the risks and benefits of the pneumococcal vaccination and to obtain their consent or declination. The facility's policy requires that the pneumococcal immunization status of all residents be determined upon admission and that vaccination be offered to those who cannot provide documentation of previous vaccination status. The policy also states that the type of pneumococcal vaccine should be determined based on the resident's age and previous immunizations, following current CDC recommendations.
Failure to Timely Report Allegation of Resident Neglect
Penalty
Summary
The facility failed to report an allegation of resident neglect within the required 24-hour timeframe. The incident involved a staff member allegedly neglecting a resident, which occurred between July 27 and July 29, 2024. The allegation was communicated to staff members J and K via email on July 30, 2024. However, the initial report to the State Survey Agency was not submitted until August 1, 2024, exceeding the 24-hour reporting requirement. During an interview, staff member B acknowledged the delay, attributing it to not being informed of the allegation in a timely manner, despite being aware of the reporting timelines. The facility's policy mandates that the Department of Public Health and Human Services Certification Bureau be notified within 24 hours of such incidents.
Delayed Insulin Administration
Penalty
Summary
The facility failed to provide medications in a timely manner for one of the sampled residents, resulting in a deficiency. During an observation and interview, a staff member was found administering morning insulin to a resident three hours past the scheduled time. The insulin was supposed to be given at 7:00 a.m., but it was administered at 10:11 a.m. The delay occurred because the nurse waited for the resident to eat before giving the insulin, and the resident did not return to their room until after 10 a.m. Additionally, the resident's blood sugar was not re-checked before administering the insulin, and there was no documentation indicating that the physician was notified about the late administration.
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 153 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Billings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspen Meadows Health And Rehabilitation Center | 1.7 mi | ★★★★★ | 21 | 0 |
| Skyline Heights Nursing And Rehabilitation | 2.1 mi | ★★★★★ | 23 | 1 |
| Yellowstone River Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 13 | 0 |
| Billings Rehabilitation And Nursing Llc | 6 mi | ★★★★★ | 29 | 0 |
| River Ridge Rehabilitation And Nursing Llc | 8.3 mi | ★★★★★ | 29 | 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 October 2026) and official state health department websites.