Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sweet Memorial Nursing Home during CMS and state inspections, most recent first.
Failure to monitor weight loss and complete timely nutritional assessments: Two residents had significant, documented weight loss, but weights were not consistently obtained or recorded, quarterly nutrition reviews were not completed on time, and one care plan was not updated to reflect ongoing severe weight loss. One resident was observed sleeping through breakfast and later had oversized dentures noted, while another appeared thin and gaunt and was offered food but no supplement despite recent severe weight loss and incomplete weight tracking.
Incomplete care planning affected side rails, EBP, and nutrition management. Two residents had side rails in place, but their care plans did not identify the rails or include related interventions, risks, or monitoring. Another resident with a catheter had no EBP signage or PPE observed and no care plan focus for EBP. A resident with unplanned weight loss had a diet order for the highest calorie supplement, but staff were unaware of the order and the supplement had not been given.
A MAII in training passed meds without direct LPN/RN supervision, and staff did not follow medication administration rights for three residents. A CNA in MAII training mixed MiraLAX into a resident’s water mug and into another resident’s juice, left before confirming the residents finished the drinks, and mixed the medication into a honey-thickened beverage that became pudding-like. The DON and charge nurse stated MiraLAX should be mixed with the proper amount of fluid and that staff should ensure the resident completes the medication.
The facility failed to review its infection prevention and control program annually and did not follow EBP standards for two residents with suprapubic indwelling catheters. Staff observed caring for the residents without EBP signage or the required PPE, and staff stated they used standard precautions or were unaware of any additional PPE needed. The residents’ orders and care plans addressed catheter care, but did not address EBP.
Improper Wheelchair Seatbelt Restraint Use: A resident with severe cognitive impairment and a hx of falls from the WC was placed in a seatbelt restraint after a fall, but the record did not show a documented medical symptom supporting restraint use, a pre-restraint assessment, or assessment of the resident’s ability to self-release. The order, consent, and care plan also lacked duration, monitoring, and effectiveness parameters, and staff noted the restraint was being used for positioning/fall prevention.
A resident with dementia and agitation was given multiple scheduled and PRN psychotropic meds, including Ativan, Seroquel, Exelon, Namenda, and ABH cream, while staff described using the meds to manage behaviors and keep staff safe. The resident was observed unable to stay awake and later sleeping, and the record lacked medication consent showing the diagnosis, risks, and benefits for the current psychotropic orders.
Care plan goals and interventions were not updated for two residents with changed conditions. One resident had dementia behaviors and multiple PRN psychotropic orders, including PRN Ativan and ABH gel, but the care plan only listed monitoring for side effects and effectiveness, and staff could not explain the dosing parameters or limits. Another resident had severe wt loss with a 17% loss over 6 months, yet staff said the resident had not been identified for wt loss monitoring or an IDT update, and the care plan still reflected a goal to maintain wt at 169 lbs.
Missing Smoking Safety Assessment and Care Plan: The facility failed to complete a smoking safety assessment and smoking care plan for a resident who smoked and sometimes went out with family or with other residents during supervised smoking times. Staff could not provide the required documentation, and the resident’s cigarettes and lighter were kept locked in the med cart. The facility’s smoking policy required an admission smoking evaluation, a Safe Smoking Evaluation, and care plan documentation for smoking-related privileges and restrictions.
A resident with dementia was repeatedly left in a noisy, crowded area behind the nurses’ station with no staff present, became visibly overwhelmed, and continued to seek help using the phone and asking to go home. Staff gave inconsistent responses, left her unattended with food, and allowed repeated wandering and exit-alarm events, despite a care plan calling for positive interaction, diversion, behavior monitoring, and WanderGuard use.
A resident with dementia and agitation received PRN ABH cream and PRN Ativan orders with dose ranges but no clear parameters for use or limits when combined with other meds. Staff observed the resident becoming overly sedated and hard to rouse after repeated PRN doses, including while asleep in a wheelchair. Staff also reported they had not been given guidance on psychotropic side effects or monitoring, and informed consent for the psychotropic meds was not provided.
Failure to obtain routine dental care for a resident with denture needs. A resident who was edentulous and had a history of poorly fitting dentures was observed without usable dentures, and staff reported they had not received a referral to the dentist or denture clinic. The resident’s dentures were later found in her room, while the care plan lacked interventions to complete the goal of getting the dentures fixed. Records also showed decreased intake and weight loss, and no dental appointment or progress notes were provided.
A resident who had fallen from a wheelchair was placed in a reclined wheelchair with a seatbelt after the physician ordered it, but no OT seating evaluation was completed to assess wheelchair fit, positioning, or the need for the device. Staff documented that the resident was private pay and the family declined the OT consult due to cost, and the seatbelt was then used without a documented clinical assessment.
Facility failed to review and update its Facility Assessment annually and when needed to revise MOUs for lab services and the EOP. Review showed suggested updates for lab and evacuation arrangements, but the assessment had not been updated since September 2024 and the 2025-2026 updates were not completed. An A stated help was needed to finish the assessment, and a G had reviewed it and made suggestions.
A deficiency was cited for failing to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight.
The facility did not report initial allegations or final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within required timeframes. Incidents included delayed reporting of suspected drug diversion, physical altercations between residents, and unexplained bruising, with staff confirming that notifications to authorities and final summaries were not made promptly.
The facility did not thoroughly investigate multiple alleged abuse incidents and unexplained bruising among residents. In several cases, altercations such as slapping, choking, and physical aggression were not followed by interviews, root cause analysis, or preventive interventions. Documentation was incomplete, and staff relied only on event reports without conducting further investigation.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not maintain a secure or detailed system for tracking controlled substances, allowing significant quantities of medications to go missing for several residents. A nurse continued to access and sign for narcotics for months after discrepancies were first identified, and the consultant pharmacist was not promptly involved in the investigation or monitoring. The facility's policy for immediate notification and reconciliation was not followed, leading to delayed reporting to authorities.
Two residents did not receive appropriate social services interventions after experiencing abuse from another resident, including one who felt isolated and vulnerable after being moved and another who was left upset and crying. Staff failed to assess or document the residents' psychosocial well-being following these incidents, and required depression assessments were not completed as scheduled.
The facility failed to investigate resident-to-resident altercations involving three residents. A staff member suspected an injury was due to an unwitnessed altercation, but the report did not explore this. In another case, two incidents of physical altercations were reported, lacking observations, interviews, and corrective actions. A staff member downplayed the incidents as mistreatment due to cognitive impairments.
The facility failed to oversee personal refrigerators in resident rooms, affecting three residents. Observations revealed missing temperature gauges and unlabeled food items, with one refrigerator having a thick ice buildup. Staff interviews showed unclear responsibility for refrigerator management, and the facility could not provide a relevant policy.
The facility failed to update care plans for several residents, including the discontinuation of a catheter, oxygen use, and bed rails. Additionally, a resident and their representative were not involved in the care planning process. Staff acknowledged the need for improvements in care planning.
The facility had a medication error rate of 8.16%, exceeding the acceptable limit of 5%. Errors included incorrect dosages of gabapentin and vitamin B-12 for two residents, and a failure to document held medications for another resident due to low blood pressure. These issues were identified during observations and interviews with staff.
A staff member failed to perform hand hygiene between administering medications to multiple residents. Despite touching residents' eating utensils and dishes, the staff member did not wash hands between residents, believing it unnecessary as she did not touch the pills directly. Upon interview, the staff member acknowledged the oversight.
A resident with severe cognitive impairment was struck twice by another resident who was having difficulty adjusting to the facility. The incidents were not classified as abuse by staff due to cognitive impairments and lack of injuries, but the facility failed to identify triggers or protect the resident from further abuse.
A facility failed to provide a baseline care plan to a resident or their representative. The resident reported not receiving any information about the care plan, and the representative confirmed the lack of communication. A review of the medical record showed no evidence of the care plan being provided, and no documentation was submitted upon request during the survey.
A facility failed to create a comprehensive care plan for a resident with broken and decayed teeth. Despite the resident's assessment indicating dental problems, the care plan lacked documentation or planning for dental services. A staff member confirmed that dental issues should be included in care planning, highlighting a lapse in the facility's process.
A resident experienced discomfort due to a poorly fitting wheelchair and the positioning of an oxygen tank. Despite informing CNAs, there was a lack of communication among staff, and the resident was not evaluated for proper wheelchair positioning during her physical therapy initial examination.
A resident experienced pain due to a callus on her left foot, which the facility failed to address appropriately. Despite a physician's order for a podiatry consult dated in September, the appointment was not scheduled. The resident reported ongoing pain, and an observation confirmed the presence of the callus. A staff member acknowledged that the consult had not been scheduled.
A facility failed to comply with the 14-day limit on as-needed antipsychotic medications for a resident with dementia, anxiety, and depression. The resident received olanzapine without the required physician evaluation and reordering every 14 days. Staff interviews revealed a misunderstanding of the policy and reliance on the EHR system to manage medication discontinuation, leading to a deficiency in medication administration practices.
The facility failed to discard expired Half and Half cartons in the walk-in cooler. Observations on consecutive days revealed cartons past their use by date, and a staff member confirmed that these should have been discarded, indicating a lapse in food safety protocols.
The facility failed to document and offer pneumococcal vaccines to two residents. One resident's history showed no record of receiving any pneumococcal vaccines, and the staff member responsible for immunizations could not provide information on the offering or declination of these vaccines. Another resident's history showed receipt of the Prevnar 13 vaccine but lacked documentation for Prevnar 20 or Pneumovax 23. The staff member was unable to explain the absence of these records.
Failure to monitor weight loss and complete timely nutritional assessments
Penalty
Summary
The facility failed to routinely monitor and document weights, complete comprehensive quarterly nutritional assessments in a timely manner, and revise a resident care plan to address severe weight loss for two residents. Resident #15 had a regular diet with small portions and a supplement ordered if she did not eat a meal. She was observed sleeping through breakfast and later sitting in a dining chair with dentures that were notably oversized in her mouth when speaking. Her record showed a 17% weight loss over six months and a 9.75% loss over three months, and a Mini Nutritional Assessment completed in November 2025 showed she was at risk of malnutrition. A dietitian recommendation in November 2025 documented a 4 oz supplement of choice three times daily at meals due to significant weight loss, and her care plan, last updated in June 2025, included a focus on unplanned weight loss related to sleeping and refusing to get out of bed with a goal of maintaining weight at 169 pounds. Resident #20 was observed appearing thin and gaunt, and later stated she had not had breakfast when she was walking in the hallway with staff. She was offered a sandwich and cola but was not offered a nutritional supplement. Her weight record showed severe weight loss, including 6% of body weight in 29 days and 8% in 92 days. The weight documentation was incomplete, with weights not obtained or documented weekly in September and November 2025 and no documented weights from the end of December 2025 through late January 2026. The dietitian weight graph also showed missing weekly entries and no comments addressing the missing weights. Resident #20’s nutritional assessments were not completed timely to evaluate the severe weight loss. Her annual nutrition assessment in August 2025 identified high nutritional risk, low BMI, and recommended supplements with meals. A quarterly Mini Nutritional Assessment in September 2025 showed malnutrition and weight loss greater than 6.6 pounds over three months, and a comprehensive quarterly nutrition review in September 2025 documented significant weight loss and low BMI. Another quarterly Mini Nutritional Assessment in December 2025 again showed malnutrition, but the record did not show a comprehensive quarterly nutritional assessment by the dietitian after September 2025. Her care plan, revised in December 2025, continued to address unplanned weight loss, but the record did not show it was revised to reflect the severe December weight loss or the lack of intake documented in the provider note.
Incomplete Care Planning for Side Rails, Infection Control Precautions, and Weight Loss
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for the use of side rails for two residents. One resident had a side rail observed on the right side of the bed, and another resident had two side rails observed on the bed, but each resident’s comprehensive care plan failed to identify the side rails or include related interventions, risks, or monitoring. During interview, staff stated that side rails required a physician’s order and should be included on the resident’s care plan. The facility also failed to comprehensively care plan enhanced barrier precautions for a resident with a catheter, as no PPE supplies or signage indicating infection control precautions were observed outside or inside the room and the care plan did not identify the need for enhanced barrier precautions. In addition, a resident with a history of obesity and unplanned weight loss had a nutrition note documenting weight loss and a request for a protein supplement, and a physician order for the highest calorie supplement available was present, but staff later stated they were unaware of the order and the resident had not been receiving the supplement. The resident’s care plan included a nutritional problem and a goal to prevent further weight loss and return to 165 pounds, with an intervention to offer the highest calorie supplement.
Unsupervised MAII in Training and Improper Medication Administration
Penalty
Summary
The facility failed to ensure that a Medication Aide II (MAII) in training had direct supervision of a licensed nurse while passing medications. Staff member N stated she was a CNA who had completed an online MAII course but had not yet taken or passed the certification test and was not yet certified. During the medication pass, she stated that the supervising nurse, staff member M, could be anywhere and was not directly supervising her. Staff member M stated he was the charge nurse and would try to make himself available if she needed assistance, and staff member B stated that while an aide was enrolled in the MAII curriculum, a nurse needed to be there to supervise them, although not necessarily standing over them. The facility did not provide the requested MAII certification document for staff member N during the survey. The facility also failed to ensure medications were administered according to professional standards for the rights of medication administration for residents #1, #10, and #31. Staff member N mixed MiraLAX into resident #10’s gray plastic drinking mug that was sitting on the bedside table, stirred it with a straw, and replaced the lid. She stated the mug was about one-third full of water but could not state the amount in ounces, and she said she would mix MiraLAX in a resident’s water mug or other beverage because it was “the best place to put it.” She also stated she would return every so often to make sure the resident had finished drinking the MiraLAX. During breakfast, staff member N poured a white powdered medication into resident #1’s red juice and mixed it, then left the dining room without ensuring the resident finished the juice. She also poured a white powdered medication into resident #31’s honey thickened orange juice and stirred it; the drink became thicker to the consistency of pudding, and a bottle of Thick-it was on the table. Staff member N left without ensuring resident #31 finished the orange juice containing the medication. Staff member M stated MiraLAX should usually be mixed with eight ounces of fluid and that it was important to ensure a resident completed medications before leaving. Staff member B stated MiraLAX should be mixed with the appropriate amount of fluid, that staff should watch a resident if unsure they could finish the drink, and that it would not be recommended to mix MiraLAX into a resident’s water mug because it would be hard to monitor whether all of the medication was taken.
Infection Control Program Review and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure its infection prevention and control program was reviewed at least annually. A review of the infection prevention and control program policies and procedures showed there was no documentation of an annual review. During interviews, staff stated the policy review dates were reflected in policy headers, that the Med Pass policies were the most recently reviewed, and that the infection control program policies had not been reviewed annually. The facility also failed to follow current standards of practice for enhanced barrier precautions for residents with suprapubic indwelling catheters. During observation, resident #7’s room did not have signage indicating enhanced barrier precautions and there was no PPE posted outside or inside the room. The resident stated he had a catheter and staff did not wear gowns when providing catheter care or other care. Staff stated standard precautions were used for the resident’s catheter care and that only gloves were required, and one staff member did not identify the resident as requiring enhanced barrier precautions despite the indwelling catheter. Resident #7’s treatment administration record showed orders for a suprapubic catheter change every four weeks and daily catheter flushes as needed, and the physician orders did not address enhanced barrier precautions. The care plan identified the resident’s suprapubic catheter but did not address enhanced barrier precautions. For resident #26, staff were observed assisting with toileting while the resident had an indwelling catheter, but there was no enhanced barrier precaution signage or supplies outside the room and staff wore only gloves. Staff stated they were not aware of any additional PPE needed for catheter care. Resident #26’s physician orders included suprapubic catheter care and scheduled catheter and bag changes, and the care plan addressed the suprapubic catheter but did not address enhanced barrier precautions.
Improper Wheelchair Seatbelt Restraint Use
Penalty
Summary
The facility failed to ensure that a seatbelt used on a resident in a wheelchair was used for a documented medical symptom, and the restraint was not supported by a documented pre-restraint assessment. Resident #3 had severe cognitive impairment with BIMS scores of 3 on two MDS assessments and a history of falls from the wheelchair. After a fall out of the wheelchair, the physician documented that a seatbelt should be used so the resident could not fall forward again, and the family was notified and agreed to the seatbelt. The facility’s informed consent identified the restraint as a seatbelt to wheelchair for "DX: Fall," but it did not identify an appropriate medical symptom for restraint use and did not document the resident’s ability to release the seatbelt independently. Observations showed inconsistent use of the seatbelt. On one observation, the resident was seated in a reclined wheelchair with the seatbelt present but not fastened; on another observation, the seatbelt was fastened across the resident’s waist and secured to the wheelchair frame, and the resident did not independently remove it during the observation. Staff stated the seatbelt was required for positioning, that the resident had not been assessed for the ability to release it independently, and that the resident’s hands were not very strong. Staff also stated there was no process to revisit the consent if the resident declined or changed, or to monitor the effectiveness of the intervention. The physician order for the seatbelt listed the diagnosis as falls but did not include duration or monitoring parameters. The care plan included the seatbelt for a history of falls from the wheelchair, but it did not address how the seatbelt would be monitored for effectiveness, how long it would be used, or the resident’s ability to self-release it. The facility policy stated restraints are not to be used for fall prevention, require a specific medical symptom, a pre-restraint assessment, a time period for use, and ongoing re-evaluation and monitoring; these elements were not documented for this resident.
Psychotropic Medications Used Without Proper Consent or Clear Diagnosis Support
Penalty
Summary
The facility failed to ensure psychopharmacological medications were not used as chemical restraints, that medications were prescribed for appropriate diagnosis management, and that informed consent was obtained for the medications for one resident. Staff member B stated the resident was not appropriate for the facility because of behaviors the staff could not handle, and also stated the facility was still figuring out what combination of medications would work to keep staff safe from the resident's behaviors. Staff member B reported using several medications for behaviors, including multiple PRN orders for Ativan and hourly ABH gel, and stated she was more aggressive in giving PRN medications and higher doses because they did not have much effect on the resident. The floor nurses, however, were described as more apprehensive about using anything other than the lowest doses. The resident was observed in the dining room unable to stay awake and rocking back and forth in a wheelchair, and later was observed sleeping in her room. The resident's record showed admission in July 2025 with no medications and a primary diagnosis of dementia with agitation. By January 2026, the MAR/TAR included Exelon patch, Seroquel at bedtime, scheduled Ativan twice daily for dementia with behaviors and anxiety, Namenda twice daily, ABH cream every hour as needed for anxiety, agitation, and aggressive behavior, and two PRN Ativan orders for agitation with different dose ranges. When psychoactive medication consents were requested, the only documentation provided was a late-entry progress note stating the POA attended a family care conference and agreed with the current plan of care; there was no medication consent showing the diagnosis, risks, and benefits for the resident's current medication orders.
Care Plan Not Updated for Psychotropic Medication Use and Severe Weight Loss
Penalty
Summary
The facility failed to develop and update care plan goals and interventions for two residents based on changes in their conditions. For one resident, the care plan was last revised on 10/25/25 and included a focus area for daily use of antipsychotic medications related to dementia behaviors affecting safety, with a goal of minimal behaviors and staff redirection of inappropriate behaviors and exit-seeking. The only intervention listed was to monitor for side effects and the effectiveness of the medication. During interview, staff stated the resident had multiple PRN psychotropic medication orders used with scheduled medications to manage behaviors, including PRN Ativan with a dose range for nurses to use, but staff could not explain the parameters for selecting the dose and stated there was no ordered limit on the amount of PRN Ativan and PRN hourly ABH gel because the medications did not have much effect on the resident. For another resident, the care plan was last updated 6/5/25 and included a focus area for unplanned/unexpected weight loss due to sleeping and refusing to get out of bed, with a goal of maintaining a weight of 169 pounds through the 6/2/26 review. Review of the resident’s weights showed a severe weight loss of 17% over 6 months, with weights of 174.0 pounds on 8/4/25, 159.5 pounds on 11/3/25, and 143.5 pounds on 1/19/26. Staff stated the resident had not been identified as having weight loss, so she was not monitored by the IDT or had an update in her care plan. The facility policy stated care plans are revised when residents’ conditions change and reviewed and updated when there has been a significant change in condition, when the desired outcome is not met, and at least quarterly.
Missing Smoking Safety Assessment and Care Plan
Penalty
Summary
The facility failed to assess a resident for smoking safety and failed to develop a smoking care plan for 1 of 20 residents sampled. Staff reported that the resident sometimes went out to smoke with family when they visited and also went out with other residents during designated supervised smoking times. During observation, staff showed the resident’s cigarettes and lighter locked inside the medication cart. When the surveyor requested the resident’s smoking care plan and smoking safety assessment, no documentation was provided by the end of the survey. During interview, staff stated they searched back to the resident’s admission and did not find a smoking safety assessment or a smoking care plan for the resident. Staff stated the resident should have had a smoking risk assessment and care plan completed, and that it was the expectation to complete a smoking risk assessment and care plan for any resident who smokes. The facility’s smoking policy stated that resident smoking status is evaluated upon admission, that a Safe Smoking Evaluation includes the resident’s tobacco use, method of tobacco use, desire to quit, and ability to smoke safely with or without supervision, and that smoking-related privileges, restrictions, and concerns are to be noted on the care plan.
Failure to Manage Dementia-Related Overstimulation and Wandering
Penalty
Summary
The facility failed to identify and implement interventions to prevent triggers contributing to the overstimulation of a resident with dementia and failed to use the least restrictive and effective interventions for her dementia-related behaviors. The resident was observed behind the nurses’ station trying to reach the phone while a vocally calling-out male resident was placed directly in front of the nurses’ station with no staff present. The resident became overwhelmed by the noise, placed her head in her hands, shook her head, and stated she needed to get away from the noise and call her mother so she could go home. Later, the resident was again behind the nurses’ station with eight other residents parked in the area, the television on, and no staff present. Her breakfast tray was left in the dining room with toast, jam, coffee, water, juice, banana, and soggy cereal that had begun to dry and become crusty, and the tray was later cleared without the resident having eaten breakfast. The resident continued to seek help using a cordless phone and asked to go home. A staff member told her the phone was busy and then told her she could go home on a bus in two hours if she wanted to take a catnap until then. The resident then left the nurses’ station, wandered past other residents, and set off a side exit door alarm; staff then pushed her wheelchair back to the nurses’ station with her feet dragging on the floor. Later, a staff member gave her a bag of crackerjacks and walked away while she was wandering at the nurses’ station. The resident also wandered later in the day and set off the front entrance Wanderguard alarm, after which staff reset the alarm and wheeled her back down the hallway. Staff stated the resident was not appropriate for the facility and that they were not equipped for her wandering and aggressive behaviors, and that staff had been directed to let her get out of the doors and follow her. Her care plan included anticipating and meeting her needs, providing positive interaction, minimizing disruptive behaviors with diversionary tasks, monitoring behavior episodes for causes, and keeping the WanderGuard on at all times.
Unnecessary Psychotropic Use Without Parameters or Consent
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by using psychopharmacological medications without appropriate diagnosis management, without informed consent, and without clear parameters for PRN use. Resident #2 had a primary diagnosis of dementia in other diseases classified elsewhere, unspecified severity with agitation, and no other psychiatric diagnoses, anxiety, depression, or mood disorders were documented on admission. The resident’s MAR/TAR showed PRN ABH cream ordered every 1 hour as needed for anxiety, agitation, and aggressive behavior, along with two PRN Ativan orders allowing 0.5 mg to 1 mg every 4 hours as needed for agitation, with no parameters for which dose to give or limits when combined with scheduled medications in a given timeframe. Survey observations showed resident #2 was repeatedly medicated and then noted to be overly sedated and difficult to rouse. The resident received two ABH gel doses on one day and an additional PRN Ativan dose later that day, then received two more ABH gel doses the next day. During an observation, staff attempted several times to wake the resident for scheduled medications while she was asleep in her wheelchair; she briefly awakened, took lorazepam, gabapentin, and memantine, and then fell back asleep. Another observation later that morning found the resident unable to stay awake in the dining room. Staff interviews showed the PRN antipsychotic renewal was handled by nursing staff and that the provider was unsure of the appropriate dosage for resident #2, resulting in dose ranges without parameters. Staff also stated they usually used the lower Ativan dose because they were uncomfortable with the higher dose, and that they had not been provided guidance on side effects or adverse reactions associated with antipsychotics or on monitoring after PRN psychotropic administration. A request for psychotropic medication informed consents for resident #2 was made, but none were provided by the end of the survey.
Failure to Obtain Routine Dental Care for Resident with Denture Needs
Penalty
Summary
The facility failed to obtain routine dental care for resident #8, who was edentulous with one natural tooth and was not wearing any dentures when observed. Staff members stated they did not receive a referral for the resident to be seen by the dentist or denture clinic, even though the facility’s denture clinic providers had been in the building earlier in the month. One staff member later stated the resident’s family had her dentures, that she had not been seen by the denture care clinic, and that the staff would get her lined up for an appointment. Another staff member was unaware the resident had dentures until the resident indicated where they were, and the dentures were then found beside the resident’s sink. Record review showed the resident’s baseline care plan documented that she had dentures but did not have them with her because family had them for repairs. The comprehensive care plan identified a nutritional problem, diabetes, and no teeth, with a goal that her dentures be fixed as soon as possible, but there were no interventions or tasks listed to carry out that goal. The facility’s nutrition report showed decreased intake and a 3.5-pound weight loss. The resident’s MDS initially indicated broken or loosely fitting dentures, but a later MDS marked that item no. No dental appointment or progress notes were provided when requested, and the facility policy stated that if dentures are damaged or lost, the resident is to be referred for dental services within 3 days.
Failure to Obtain OT Evaluation Before Using Wheelchair Seatbelt
Penalty
Summary
The facility failed to ensure an OT evaluation was completed for a resident who had fallen from a wheelchair and needed assessment of wheelchair positioning and the need for a seatbelt. After the resident’s fall, the physician documented that a better fitting wheelchair with foot supports was needed and requested an OT consult for a seating evaluation. However, staff documented that the resident was private pay and that the family would have to pay out of pocket for the OT evaluation, and the family later declined the OT appointment because of cost. Despite the lack of a documented OT assessment, the facility implemented a seatbelt on the resident’s wheelchair by physician order and obtained restraint consent from the family. Observations showed the resident seated in a reclined wheelchair with the seatbelt present, and later fastened across the waist and secured to the wheelchair frame. The record did not show a documented assessment of the seatbelt’s fit, the resident’s positioning, the effect on mobility, or the resident’s ability to safely use the device.
Facility Assessment Not Updated
Penalty
Summary
The facility failed to ensure its Facility Assessment was reviewed and updated annually and when necessary to update memorandums of understanding for laboratory services and the emergency operations plan. Review of the Facility Assessment updates showed entries in 10/2025, 12/2025, and 1/2026 indicating suggested updates, including help from staff member G, updated name information with the local hospital for lab services, and an updated memorandum for emergency evacuation to the local hospital. However, the Facility Assessment itself did not show that it had been updated since September 2024, and the suggested updates for 2025 and 2026 were not completed. During an interview, staff member A stated she needed help updating the Facility Assessment and that staff member G had reviewed it and made suggestions, but the facility had not been able to complete the 2025 assessment.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their conditions at the time, are not provided in the report. The deficiency centers on the lack of comprehensive protection for residents against abuse and neglect, as required by regulatory standards.
Failure to Timely Report Abuse, Neglect, and Misappropriation Incidents
Penalty
Summary
The facility failed to report initial allegations and final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within the timelines required by federal regulations for multiple residents. In one instance, a potential drug diversion involving resident medications was identified, but the facility delayed reporting the suspicion to the State Survey Agency and local law enforcement, choosing instead to complete an internal medication audit first. The initial report to the State Survey Agency was not made until several weeks after the investigation began, and law enforcement and the board of nursing were not contacted until even later. Additional incidents involved delayed reporting of physical altercations between residents and a case of unexplained bruising. In several cases, the initial reports or final summaries were submitted days after the events occurred, exceeding the required reporting timelines. Interviews with staff confirmed the delays and revealed a lack of immediate action in notifying authorities as required. The facility did not provide timely final summaries for several incidents, and in one case, no further investigation was conducted into the cause of a resident's bruising.
Failure to Investigate Alleged Abuse and Unexplained Injuries
Penalty
Summary
The facility failed to thoroughly investigate multiple alleged abuse incidents and unexplained injuries among residents. In one case, a resident was found with bruises of unknown origin on her foot, thigh, and calf, but there was no clear documentation in the medical record describing the bruises or their causes. Staff acknowledged that no further investigation was conducted beyond noting that the resident bruised easily, and no interventions or root cause analysis were completed. Additionally, several resident-to-resident altercations were not adequately investigated. These included incidents where one resident slapped, punched, or choked other residents, and another incident where a resident sprayed alcohol and sanitizer on another's face. The facility's documentation did not include interviews with involved parties, root cause analysis, or implementation of interventions to prevent recurrence. Progress notes often lacked details about the events, contributing factors, or steps taken to protect residents. Staff interviews revealed that the facility relied solely on event reports and risk management forms for investigations, with no further investigative actions taken.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Secure and Monitor Controlled Substances Resulting in Drug Diversion
Penalty
Summary
The facility failed to maintain an adequate system for storing and monitoring controlled substances, resulting in missing medications for multiple residents. The investigation revealed that the facility used loose-leaf, unnumbered paper in a binder to track controlled drugs, which did not correspond to the medication cards and allowed for easy removal of both medication and records. This lack of a secure and detailed tracking system enabled discrepancies to go undetected, and several residents were found to be missing significant quantities of their prescribed medications, including Seroquel, Alprazolam, Mirtazapine, Tramadol, and Norco. The initial missing medication was identified when a resident ran out of Seroquel 14 days earlier than expected, and further review uncovered additional losses affecting other residents. Staff interviews indicated that a specific nurse was the common factor in the missing medication cases, yet this nurse continued to work and sign for narcotics for over two months after the first discrepancy was identified. The consultant pharmacist was not promptly informed of the diversion and did not participate in the investigation or monitor narcotics reconciliation logs. The facility's policy required immediate notification and monitoring in the event of discrepancies, but these procedures were not followed, and the local police and board of nursing were not contacted until months after the initial discovery of missing medications.
Failure to Provide Social Services After Abuse Incidents
Penalty
Summary
The facility failed to provide adequate medically-related social services to support the psychosocial well-being of two residents following incidents of abuse by another resident. One resident reported feeling isolated after being moved to a different area of the building due to repeated incidents involving another resident, including having hand sanitizer squirted in her eyes, which resulted in ongoing eye issues and feelings of vulnerability. Despite these events, there were no documented interventions or follow-up by social services to address her emotional well-being, and required assessments such as the PHQ-9 were not completed as scheduled. Another resident was observed crying and upset after being physically grabbed by the same resident, but staff attributed her distress to her usual behavior and did not assess or document her psychosocial or emotional health following the incident. Progress notes lacked information on interventions to prevent further abuse or to address the resident's emotional response to the event. These actions and omissions demonstrate a failure to ensure residents' highest practicable level of physical and psychosocial well-being through appropriate social services interventions.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate resident-to-resident altercations, alleged to be abuse, involving three residents. In one incident, a staff member reported an injury of unknown origin on a resident's forehead, suspecting it was not from a fall due to the resident's inability to get back into her wheelchair without assistance. The staff member believed the injury might have resulted from an unwitnessed altercation with her roommate, who was known to be aggressive. However, the facility's report did not explore this possibility or document the resident's room change for safety. In another case, two incidents of physical altercations between two residents were reported, where one resident was seen punching and hitting the other. The investigations lacked observations of the aggressor's interactions with others, interviews with residents and staff, and documentation of corrective actions to protect the victim and other vulnerable residents. A staff member involved in the investigation downplayed the incidents as mistreatment rather than abuse due to the cognitive impairments of the residents involved.
Lack of Oversight for Personal Refrigerators in Resident Rooms
Penalty
Summary
The facility failed to provide proper oversight for the use of personal refrigerators in residents' rooms, affecting three sampled residents. During observations, it was noted that the personal refrigerators lacked temperature gauges, which are necessary to ensure food is stored at safe temperatures. Additionally, there were multiple instances of food items being stored without labels or dates, and one refrigerator had a thick layer of ice built up inside and outside the freezer compartment. These deficiencies were observed in the personal refrigerators of three residents, indicating a lack of consistent management and oversight. Interviews with facility staff revealed a lack of clarity and responsibility regarding the management of personal refrigerators. A staff member from the housekeeping department indicated that the housekeeping supervisor was responsible for managing the refrigerators, but there was no clear protocol for when the supervisor was absent. Another staff member was unaware of how many residents had personal refrigerators or how they were managed for food safety. The facility was unable to provide a policy on personal refrigerators when requested, further highlighting the oversight issues.
Deficiencies in Care Plan Updates and Resident Involvement
Penalty
Summary
The facility failed to update and revise comprehensive care plans for several residents, leading to deficiencies in care documentation and planning. Resident #18's care plan did not reflect the discontinuation of a Foley catheter, despite a physician's order to begin bladder training and remove the catheter. Additionally, the care plan for resident #15 lacked details on the administration of oxygen, which was observed to be improperly used, and the resident experienced difficulty breathing without it. Furthermore, the care plans for residents #12, #18, and #27 did not document the use of bed rails or their intended purpose, indicating a lack of comprehensive care planning. The facility also failed to involve resident #20 or their representative in the care planning process. Resident #20 reported not being asked about their care plan, and their representative confirmed no communication from the facility regarding the plan of care. The electronic health record for resident #20 lacked documentation of their involvement in care planning, and no care plan meeting was held after the development of the comprehensive care plan. Staff member B acknowledged the need for updates and improvements in care plans, highlighting a gap in the facility's care planning process.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 8.16%. This deficiency was observed in three residents. For one resident, a staff member incorrectly administered gabapentin by using a 1 ml syringe and filling it to the 0.1 ml line instead of the required 1 ml, leading to an underdose. The error was realized and corrected after the initial administration. Another resident was supposed to receive 5000 mcg of vitamin B-12 but was given only 500 mcg due to the staff member administering a single tablet of 500 mcg instead of the required dosage. Additionally, a staff member held two medications for a resident due to a systolic blood pressure reading below 110 mmHg, as per the facility's standing order. However, the staff member failed to document that the medications were held, and the Medication Administration Audit Report inaccurately showed that the medications were administered. This discrepancy was acknowledged by the staff member during a follow-up interview.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility staff failed to perform proper hand hygiene during medication administration for three residents. During observations in the main dining room, a staff member was seen administering medications to residents without performing hand hygiene between each resident. Specifically, the staff member did not wash hands after administering medications to one resident before preparing medications for another. This occurred despite the staff member touching residents' eating utensils and dishes during the medication pass. When interviewed, the staff member acknowledged that she should have performed hand hygiene between residents but believed it was unnecessary since she did not touch the pills directly.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a vulnerable resident from physical abuse by another resident. Resident #30, who had severe cognitive impairment and exhibited wandering behaviors, was struck on two separate occasions by resident #29. The first incident occurred on 10/17/24, when resident #29, who was having difficulty adjusting to the new environment, struck resident #30 on the right shoulder. The facility's investigation did not identify any possible triggers for the abuse or how resident #30 would be protected from further incidents. Additionally, resident #30's care plan did not address the increased risk of abuse due to her wandering behaviors. A second incident occurred on 10/24/24, when resident #29 hit resident #30 on the head and pulled her hair. Despite the facility's policy to prevent abuse, the care plan for resident #29 did not identify resident #30 as a potential target of abusive interactions. Staff members involved in the investigations of both incidents did not classify them as abuse, citing the residents' cognitive impairments and lack of injuries. However, the facility's failure to protect resident #30 from further abuse was evident, as no effective measures were implemented to prevent recurrence.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to a resident or the resident's representative, as required. During an interview, the resident stated she did not receive any information or communication regarding her baseline care plan from the facility. Additionally, the resident's representative confirmed that they had not received any communication from the facility about the baseline care plan. A review of the resident's medical record showed no documentation or evidence that the baseline care plan was provided to either the resident or the representative. Despite a request for documentation regarding the provision of the baseline care plan, no information was provided before the end of the survey.
Failure to Address Dental Issues in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with dental issues. During an observation, the resident was noted to have broken teeth in her lower jaw. The Social Service History & Initial Assessment documented that the resident had dental problems, specifically broken and decayed teeth. Despite this assessment, the resident's care plan did not include any documentation or planning related to her dental issues or the provision of dental services. A staff member confirmed that such issues should be care planned, indicating a lapse in the facility's care planning process.
Failure to Assess Wheelchair Positioning Needs
Penalty
Summary
The facility failed to identify and assess the wheelchair positioning needs for a resident, leading to discomfort due to a poorly fitting wheelchair. The resident reported that her wheelchair was too narrow and that the oxygen tank positioned on the back of her wheelchair caused her discomfort. Despite informing CNAs about the pain, there was a lack of communication and awareness among staff members regarding the issue. One staff member acknowledged being informed by the resident about the pain and had notified the maintenance department, but another staff member was unaware of any wheelchair maintenance concerns. Additionally, a review of the resident's physical therapy initial examination revealed that she was not evaluated for proper wheelchair positioning.
Failure to Provide Proper Foot Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, resulting in the resident experiencing pain due to a callus on her left foot. The resident reported on December 2nd that she had been experiencing pain from the callus and that the facility had not addressed it. A progress note from September 6th indicated the presence of the callus and mentioned that the foot clinic had been treating it, with the resident expressing a desire for a podiatrist to evaluate the residual callus. A physician's order dated September 9th called for a podiatry consult for the callus, but the appointment was not scheduled. On December 4th, an observation confirmed the presence of the callus, and a staff member stated that the consult had not been scheduled despite the doctor's order.
Failure to Reorder PRN Antipsychotic Medication Every 14 Days
Penalty
Summary
The facility failed to ensure compliance with the 14-day limit on as-needed antipsychotic medications for a resident diagnosed with dementia, anxiety, and depression. The resident was prescribed olanzapine 2.5 mg twice daily as needed for agitation, but the order did not specify a duration or stop date. The resident's medication administration records (MAR) showed multiple doses were administered over several months without the required physician evaluation and reordering every 14 days. Despite a pharmacy progress note indicating the need for reordering, the medication was not appropriately managed, leading to a deficiency in medication administration practices. Interviews with facility staff revealed a lack of adherence to the policy requiring physician evaluation and documentation for the continuation of as-needed psychotropic medications. Staff members were aware of the 14-day limit but failed to ensure the medication was reordered as required. One staff member mistakenly believed the electronic health record system would automatically discontinue the medication, while another did not address the need for reordering in the monthly medication regimen review. The facility's policy on psychotropic medication use was not followed, resulting in the deficiency.
Failure to Discard Expired Dairy Products
Penalty
Summary
The facility failed to properly manage the storage of dairy products, specifically Half and Half, in their walk-in cooler. During observations on two consecutive days, cartons of Half and Half with a use by date of 12/3/24 were found on the top shelf to the right of the entrance. On 12/4/24, 11 cartons were observed, and on 12/5/24, eight cartons remained. During an interview, a staff member acknowledged that dairy products should have been discarded by their use by date, indicating a lapse in adherence to food safety protocols.
Failure to Document and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure proper screening and documentation for pneumococcal vaccinations for two residents. Resident #27's vaccination history did not indicate receipt of any pneumococcal vaccines, and staff member J, responsible for immunizations for two months, could not provide information on whether the vaccines were offered, received, or declined since the resident's admission. Similarly, resident #16's vaccination history showed receipt of the Prevnar 13 vaccine but lacked documentation of the Prevnar 20 or Pneumovax 23 being offered, given, or declined. Staff member J was unable to explain the absence of these records.
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 citations issued around you in the last 12 months — including the 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 Chinook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northern Montana Care Center | 20.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sweet Memorial Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.