Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prince Of Peace Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and dysphagia, ordered a pureed diet, accessed a brownie from an unattended snack cart while agitated and independently moving about the unit. Staff attempted to intervene, but the resident shoved the brownie into his mouth and choked; EMS later pronounced the resident deceased. The snack cart had food items openly displayed, and a CNA acknowledged leaving it unattended and knowing the brownie was not consistent with the resident’s diet order.
A resident experienced a decline in ADLs, with MDS documentation changing from set-up or clean-up assistance for upper and lower body dressing and personal hygiene to substantial/maximal assistance. The facility did not complete an SCSA in response to the change, and an administrative nurse confirmed the SCSA should have been completed.
Hand hygiene and glove use were not followed during observed resident care. A CNA cared for a resident on Enhanced Barrier Precautions for MRSA, removed PPE, and then went to another resident without sanitizing hands. In another observation, a CNA changed gloves multiple times during toileting care for a resident but did not perform hand hygiene between glove changes. An administrative nurse confirmed staff should sanitize hands between residents and after removing soiled gloves and applying clean gloves.
A resident who required a Hoyer lift with two staff for transfers fell during a transfer when a sling loop disengaged from the lift bar after the resident shifted weight. Two CNAs and an LPN were present. The incident resulted in a head laceration requiring staples. Investigation found that the sling strap slid and detached due to the resident's movement and the configuration of the lift bar.
Inadequate Supervision Allowed Resident to Access Inappropriate Food
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with Alzheimer’s disease, dysphagia, and a prescribed IDDSI level 4 pureed diet when the resident accessed and ingested a brownie from a snack cart. The resident had a history of coughing or choking during meals or when swallowing and was observed independently mobilizing in a wheelchair while engaged in a phone call and becoming increasingly agitated. Staff reported that the resident took a brownie from the snack cart, and when staff attempted to intervene, the resident shoved the entire piece into his mouth and gulped it down, resulting in choking. The resident was pronounced deceased at the scene by EMS. The incident occurred while the snack cart was on the unit with food items arranged openly on top without protective coverings. A CNA, an activity staff member, and an administrative staff member were present on the unit, and the CNA reported leaving the snack cart unattended while speaking with another resident. The CNA confirmed awareness that the resident was on a pureed diet and that the brownie was not consistent with the resident’s diet order.
Failure to Complete SCSA After ADL Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for Resident #22 after the resident experienced a decline in activities of daily living (ADLs). The Long-Term Care Facility RAI 3.0 User's Manual states that a significant change is a major decline or improvement in status that will not normally resolve without intervention, affects more than one area of health status, and requires interdisciplinary review and/or care plan revision. It also states that an SCSA is appropriate when there is a consistent pattern of changes, including decline in ADL physical functioning. Review of Resident #22's record showed an SCSA MDS dated 11/06/25 that identified set-up or clean-up assistance with upper and lower body dressing and personal hygiene. A quarterly MDS later identified substantial/maximum assistance with upper and lower body dressing and personal hygiene. The facility did not complete an SCSA related to this decline in ADLs. During interview on 04/15/26 at 2:43 p.m., an administrative nurse confirmed the facility should have completed an SCSA.
Hand Hygiene and Glove Use Not Followed During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards for 2 of 13 sampled residents during observed cares. Review of the facility’s Hand Hygiene policy, dated September 2023, stated that hand hygiene should be performed before and after direct resident contact, before and after entering isolation precaution settings, before and after assisting a resident with personal cares, and before and after assisting a resident with toileting, with soap and water required after toileting. Resident #22’s care plan identified Enhanced Barrier Precautions related to MRSA and directed staff to sanitize hands after PPE removal. During observation of Resident #22, a CNA entered the room, performed hand hygiene, applied a gown and gloves, and assisted the resident to the bathroom. After perineal care, the CNA removed the gown and gloves and assisted the resident into a recliner, then went to care for another resident without performing hand hygiene. During observation of Resident #23, a CNA performed hand hygiene and donned gloves for toileting care, removed a soiled brief and gloves, then applied new gloves and continued care without performing hand hygiene between glove changes. The CNA repeated this pattern while assisting the resident to stand, providing perineal care, applying a brief, pulling up pants, transferring the resident to a wheelchair, and cleaning stool from the toilet seat. An administrative nurse confirmed staff should perform hand hygiene between residents and after removing soiled gloves and applying clean gloves.
Resident Fall Due to Improper Sling Attachment During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and proper use of assistive devices during a transfer with a mechanical lift. The resident, who was on hospice services and required the assistance of two staff members for transfers using a Hoyer lift, was being transferred by two CNAs with an LPN present. During the transfer, while the resident was elevated in the sling, she shifted her weight, resulting in a loud pop as a sling loop disengaged from the lift bar. This caused the lift bar to shift to a perpendicular position, and the resident fell from the sling to the floor, sustaining a laceration to the forehead that required staple closure. A thorough investigation, including reenactments and staff interviews, determined that the resident's movement during the transfer caused the right upper sling strap to slide along the moveable strap attachment bar, which then rotated perpendicular to the main crossbar. This configuration, combined with the resident's poor bodily control, led to the upper sling strap disengaging from the bar, resulting in the fall. Upon assessment, the resident was found on the floor with the upper right loop of the lift pad unattached to the bar, and was subsequently transported to the hospital for treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ellendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Oakes | 22.9 mi | ★★★★★ | 11 | 1 |
| St Rose Care Center | 26.3 mi | ★★★★★ | 12 | 0 |
| Aberdeen Health And Rehab | 36.3 mi | ★★★★★ | 13 | 1 |
| Avera Mother Joseph Manor Retirement Community | 37 mi | ★★★★★ | 9 | 0 |
| Prairie Heights Healthcare | 37.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.