Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rolette Community Care Center during CMS and state inspections, most recent first.
Hot water temperatures on the 200 wing were not properly monitored, and surveyors found multiple resident rooms with excessively high temperatures, including 137 and 133 degrees F. Maintenance staff said he was checking temperatures weekly, but later admitted he was doing it quarterly and could not produce documentation. The survey team determined an IJ existed because the elevated water temperatures placed residents at immediate jeopardy for hot water burns.
Kitchen sanitation and temperature monitoring failures were identified when surveyors observed mold-covered fruit, expired and mold-covered condiments, dust and dirt on cooler fans and shelving, grease buildup on equipment, and food particles on bulk bin lids. The upright beverage refrigerator was at 50 degrees, temperature logs were missing on multiple days and often above the acceptable range, and a dietary staff member measured sanitizer at 50 ppm instead of the target 200 ppm. Staff also reported they did not know where the cleaning schedule was located and that the ice machine had not been cleaned.
Administrator Not Accountable to Governing Body: The facility administrator failed to report to and remain accountable to the governing body. The unsigned job description assigned the administrator responsibility for implementing the board's directives and overseeing day-to-day operations, but the administrator stated he was not on every board meeting, was unsure who the board members were, and was only present in the facility sometimes a couple of times a year. An administrative staff member also stated the facility was actively seeking more board members.
QAPI Committee Did Not Include Required Members at Quarterly Meetings: The facility failed to ensure all required QAPI committee members attended each quarterly meeting reviewed. Attendance forms showed incomplete participation across the meetings, and administrative staff confirmed the administrator was not a QAPI member and did not attend the meetings, although one staff member said the administrator had joined one meeting via Zoom at an unknown time.
Failure to complete a SAM assessment for a resident with medications at the bedside. A clear plastic cup containing six pills was observed on the bedside table, and the resident identified them as morning meds that had been there since that morning. The record lacked documentation that the IDT assessed whether self-administration was safe and clinically appropriate, and an administrative staff member confirmed the assessment was not completed.
Failure to secure eMAR privacy occurred when a medication cart was left unattended in the living area with the eMAR open to a resident's record for 26 minutes. Facility policy stated eMARs are to be locked when not in direct use, and an administrative nurse confirmed staff were expected to lock the eMAR whenever the cart was unattended.
Staff did not follow physician orders for two residents and did not follow enteral tube medication procedure for another resident. One resident with DM had blood sugars above the call-MD threshold without documentation that the provider was notified, and another resident with CKD on dialysis had multiple weight changes beyond the ordered 4-lb range without provider notification. In a separate event, an RN crushed medication and poured it into a resident’s PEG tube without diluting it first, contrary to facility policy.
A resident with hemiplegia of the L UE and contractures did not consistently receive the ordered carrot hand positioner or small towel roll for the left hand. Survey observations found the left hand contracted in a gripped position without the device in place, while the device was on the nightstand. The resident stated staff were not placing the support and denied refusing it.
Unsafe Medication Storage and Labeling: Surveyors observed an unlocked and unattended med cart with meds left on top, an expired glucagon syringe pen in a med cart, and three unlabeled Novolog insulin pens. Facility policy required meds to be stored in locked compartments, outdated meds to be handled through the dispensing pharmacy, and all resident meds to be properly labeled.
A resident with a physician order for a pureed diabetic diet with honey thickened liquids was found to have a meal card listing nectar thick liquids instead. The resident had a recent decline in intake related to coughing and trouble swallowing. Facility policy required tray identification checks by food service and nursing staff, and an administrative dietary staff member confirmed meal cards are used to identify special diets and supplements.
Staff failed to follow hand hygiene and EBP requirements during resident care. Two CNAs transferred a resident on EBP without washing hands or wearing gloves and a gown, and a nurse and CNA caring for another resident with a feeding tube did not perform hand hygiene after touching the resident, changing gloves, or leaving the room. An admin nurse confirmed the expected hand hygiene practices.
A long-term care facility failed to follow infection control standards, leading to potential infection spread. A CNA did not properly doff an N95 mask after leaving a COVID-positive resident's room and entered rooms of COVID-negative residents. Staff also neglected enhanced barrier precautions for a resident with a feeding tube, and a nurse failed to disinfect a wound care container before returning it to the treatment cart. These actions violated infection control protocols and risked spreading infections.
The facility did not ensure that the dietary manager had the necessary qualifications to serve as the director of food and nutrition services. An administrative manager confirmed that the dietary manager lacked the required training and certification for the position, which could potentially lead to foodborne illness among residents, staff, and visitors.
The facility failed to submit MDS assessments on time for several residents, as required by the Long-Term Care Facility RAI User's Manual. A quarterly MDS for a resident was completed 30 days late, another resident's MDS was transmitted 44 days late, and a third resident had multiple late submissions, including a discharge return anticipated MDS completed 51 days late. Additionally, a resident's quarterly MDSs were not submitted within the required timeframe. A facility nurse confirmed the delay in submissions.
The facility failed to accurately code the MDS for several residents, affecting the reflection of their current status and needs. A resident's feeding tube was not identified, and another's weight was inaccurately recorded. Additionally, the MDS did not reflect the administration of various medications for multiple residents, as confirmed by an administrative staff member.
The facility did not update comprehensive care plans for several residents, affecting communication and care continuity. A resident's care plan lacked enhanced barrier precautions for a feeding tube, while another's did not include a new fall intervention. Two residents' care plans missed enhanced barrier precautions despite isolation signage. A resident with renal disease had a vague care plan not addressing dialysis-related nutrition, and another's plan did not reflect precautions for an indwelling catheter.
A facility failed to provide a resident or their representative with a written notice of transfer to the hospital, as required for informed decision-making. This deficiency was identified during a review of the resident's medical records, which lacked evidence of the notice. An administrative staff member confirmed the oversight.
The facility failed to follow professional standards and physician's orders for two residents. A nurse did not prime an insulin pen correctly, risking inaccurate dosing. One resident did not receive prescribed ROM exercises, and their oxygen equipment was not changed as ordered. Another resident's abnormal blood glucose levels were not reported to the physician. These deficiencies were confirmed through staff interviews and record reviews.
The facility failed to ensure proper documentation and evaluation of psychotropic medication use for two residents. One resident received alprazolam without a valid order, and the need for continued use was not evaluated after 14 days. Another resident on Seroquel did not receive a timely tardive dyskinesia assessment, as required. These deficiencies were confirmed by an administrative nurse during the survey.
The facility did not ensure the secure storage of medications, as two unlocked and unattended carts were observed. Facility policy requires medications to be stored in locked compartments and carts not to be left unattended if open. An administrative nurse confirmed the expectation for staff to lock medication carts and secure medications when not in use.
Failure to Monitor Hot Water Temperatures on 200 Wing
Penalty
Summary
The facility failed to monitor hot water temperatures in resident rooms on the 200 wing, and surveyors found elevated temperatures in multiple rooms during the on-site recertification survey. Water temperatures taken in resident rooms on the 200 wing showed 137 degrees Fahrenheit in room [ROOM NUMBER] and 133 degrees Fahrenheit in room 208, and additional rooms on the same wing were also measured at elevated temperatures, including 122, 121, and 126 degrees Fahrenheit. The survey team consulted with the State Survey Agency and determined that an Immediate Jeopardy situation existed on 09/29/25 because the hot water temperatures placed all residents at immediate jeopardy for hot water burns. During the survey, maintenance staff was interviewed about the water temperature checks. Maintenance [NAME] stated he was doing weekly water temperature checks and had a spreadsheet, but no water temperature documentation could be found. When asked again, he admitted he was not checking water temperatures weekly and was doing them quarterly. He also stated he adjusted the hot water heater because he found the temperature was 115 degrees and felt that was too high, and he turned it down to 105 degrees. Surveyors also observed that hot water was unavailable or only became warm after a delay in some rooms on the 200 wing.
Kitchen sanitation and temperature monitoring failures
Penalty
Summary
The facility failed to maintain cold storage areas and kitchen equipment in a sanitary manner in 1 of 1 kitchen. During observation, surveyors found a box of raspberries covered in mold, an upright beverage refrigerator at 50 degrees Fahrenheit, and later found thick black dust and dirt on the walk-in cooler fans and dust on shelving where food was stored. Surveyors also observed mold on the lids and sides of gallon containers of ranch dressing, mustard, and coleslaw dressing, with the ranch and mustard expired and the coleslaw dressing dated June 2025. Additional observations included four quarts of heavy whipping cream dated 09/22/25, grease buildup on the stove handle and inside the oven, and bulk storage container lids for flour, thickener, and sugar covered with food particles. Review of the facility's refrigerator temperature logs for the upright refrigerator showed 20 of 58 days without a recorded temperature and 18 of 39 recorded temperatures above 40 degrees Fahrenheit, ranging from 41 to 48 degrees. Staff interviews confirmed the sanitizing solution target was 200 ppm, but a dietary staff member tested the sanitization bucket at 50 ppm. Staff also stated they did not know where the cleaning schedule was located, and an administrative staff member said the facility had not cleaned the ice machine and had no cleaning schedules or logs to document routine cleaning of the kitchen and kitchen equipment.
Administrator Not Accountable to Governing Body
Penalty
Summary
The facility administrator failed to report to and remain accountable to the governing body. Review of the administrator job description showed the administrator was responsible for implementing the board's wishes and directives, supervising staff and employee operations, and handling internal oversight and timely implementation of state and federal requirements. The job description also stated the administrator was expected to work a minimum of 40 hours per week with a regular schedule and additional hours as needed, but the document was unsigned and revised on 03/12/23. During the survey, an administrative staff member identified only two board members and stated the facility was actively seeking more board members. In a phone interview, the administrator stated that if the board had questions they could call him, that they met "every once in a while," and that he was not on every meeting. He also stated that if something needed to be brought to the board, the Business Office Manager or DON would notify them. When asked who the board members were, he said he was not even sure at the moment and believed there were three board members. He further stated that his presence in the facility depended on whether he was needed and that it was sometimes only a couple of times a year.
QAPI Committee Did Not Include Required Members at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance and Performance Improvement (QAPI) Committee attended all four quarterly meetings reviewed, including October 2024, January 23, 2025, April 24, 2025, and July 24, 2025. Review of the QAPI team member attendance forms on 09/30/25 showed that the October 2024 meeting had three committee members present, the January 23, 2025 meeting had five members present, the April 24, 2025 meeting had five members present, and the July 24, 2025 meeting had four members present. The forms did not identify that all required QAPI team members attended the quarterly meetings. During interviews on 09/30/25, administrative staff confirmed the facility administrator was not a member of the QAPI committee and had not attended the QAPI meetings. One administrative staff member identified the current QAPI committee members as the DON, who is also the Infection Control Nurse, the Business Office Manager, the MDS RN, an environmental services staff member, the Medical Director, the pharmacist, the RHIT who is also the SSD, and the QA staff member. Another administrative staff member stated the administrator was not a member of the QAPI committee, although the administrator had attended one QAPI meeting via Zoom, but the staff member could not identify when.
Failure to Complete Self-Administration of Medication Assessment
Penalty
Summary
The facility failed to complete a self-administration of medication (SAM) assessment for Resident #4, despite the resident having medications at the bedside. The facility policy titled Self-Administration of Medication's stated that the interdisciplinary team assesses each resident to determine whether self-administration of medications is safe and clinically appropriate, and that if it is deemed safe and appropriate, this is documented in the medical record and care plan. Review of Resident #4's record found no SAM assessment. During observation on 01/13/26 at 12:30 p.m., a clear plastic medication cup containing six pills was seen on the resident's bedside table, and the resident identified the pills as morning medications that had been on the table since that morning. The medications listed for the morning included aspirin, Coreg, Metformin, folic acid, cyanocobalamin, and Colace. An administrative staff member later confirmed that the facility failed to complete a SAM assessment.
Failure to Secure eMAR Privacy
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when the electronic medication administration record (eMAR) was left unlocked and open on a medication cart that was unattended in the living area. Review of the facility policy titled Security of the Medication Cart showed that eMARs are to be kept locked when not in direct use. Observation on 09/30/25 at 5:46 p.m. showed the medication cart unattended with the eMAR opened to a resident's record for 26 minutes. During an interview on 09/30/25 at 8:30 p.m., an administrative nurse confirmed that nursing staff were expected to lock the eMAR at all times when the medication cart was unattended.
Failure to Follow Orders for Blood Sugar, Weight Changes, and PEG Medication Administration
Penalty
Summary
Staff failed to follow physician orders and professional standards of practice for Resident #12, who had diabetes mellitus, when blood sugars were documented above the ordered call-physician threshold of greater than 450. Review of blood sugars from 08/16/25 through 09/17/25 showed readings of 451, 455, and 475, and an administrative nurse confirmed the record did not show that the provider was notified of these results. Staff also failed to follow a physician order for Resident #14, who had chronic kidney disease with renal dialysis, requiring the provider to be called for a weight increase or decrease of 4 pounds from a baseline weight of 146 pounds. The resident’s recorded weights showed decreases of 7.5 pounds, 11 pounds, 5.5 pounds, 12 pounds, and 26 pounds from baseline, and an administrative nurse confirmed the record did not show that staff notified the provider of these weight changes. In a separate event, a nurse administered crushed medication through Resident #3’s PEG tube without diluting it in water first, despite the facility policy stating crushed medication should be diluted with at least 30 mL of purified water and administered separately. The nurse crushed the medication into a medicine cup with no water, poured it into the PEG tube, and then poured water down the tube.
Failure to Provide Hand Positioning Device for Resident with Left Hand Contracture
Penalty
Summary
The facility failed to ensure that Resident #15, who had hemiplegia of the left upper extremity and contractures, received the necessary hand devices to maintain or improve range of motion and prevent contractures. The care plan directed staff to use a carrot hand positioner or a small towel roll for the resident’s left hand, but observations on all days of survey showed the resident’s left hand contracted in a gripped position with no rolled towel or carrot hand positioner in place, while the carrot hand positioner was found on the resident’s nightstand. During interview, the resident stated staff were not placing the carrot support or a rolled washcloth to the left hand and denied pain with placement and denied refusing the device. The medical record did not show any refusal of the carrot hand positioner or rolled washcloth to the left hand.
Unsafe Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure safe and secure storage of medications, discard expired medications, and label medications for 1 of 2 medication carts. Review of the facility policy titled Medication Labeling and Storage stated that medications are to be stored in locked compartments, discontinued or outdated medications are to be handled through the dispensing pharmacy, and medication labels are to include required information such as the medication name, dose, strength, expiration date, resident name, route, and instructions. Observation on 09/28/25 at 5:20 p.m. showed an unlocked and unattended medication cart in the main living area with medications on top of the cart for 26 minutes. Observation on 09/29/25 at 7:23 p.m. showed a medication cart containing a glucagon syringe pen with an expiration date of October 2024. Observation on 09/30/25 at 7:30 p.m. showed three unlabeled Novolog insulin pens in the medication cart. During interview on 09/30/25 at 9:00 p.m., an administrative nurse stated she expected staff to lock the medication cart, store all medications in the cart when the nurse was not within sight, discard expired medications, and label all resident medications.
Incorrect Liquid Consistency on Meal Card
Penalty
Summary
The facility failed to ensure a resident received liquids in the consistency ordered by the physician. Resident #13 had a physician’s order dated 08/20/2024 for a pureed diabetic diet with honey thickened liquids, and a nursing progress note dated 09/01/25 documented a recent decline in food intake due to coughing and trouble swallowing. During record review, Resident #13’s meal card was found to identify nectar thick liquids, which differed from the physician’s order for honey thickened liquids. The facility policy on tray identification stated that food services would use diet identification methods to identify diets, the Food Services Manager or supervisor would check trays before transport, and nursing staff would check each food tray for the correct diet before serving residents. An administrative dietary staff member confirmed that meal cards identify special diets and supplements and that staff had no way to communicate changes with the dietitian.
Failure to Follow Hand Hygiene and EBP During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards for Resident #22 and Resident #3. Resident #22’s record showed Enhanced Barrier Precautions (EBP), and a sign outside the room directed caregivers to clean their hands before entering and when leaving the room and to wear gloves and a gown for high-contact resident care activities, including transferring and device care or use. During observation, two CNAs transferred Resident #22 from a wheelchair to a bed without washing their hands and without wearing gloves and a gown. Resident #3’s record showed diagnoses of dysphagia and gastrostomy status, and the care plan stated the resident needed EBP related to an indwelling feeding tube. During observation, a nurse entered the room and administered a nutritional supplement through the feeding tube, touched the feeding tube and other items in the room, removed PPE, and left without performing hand hygiene. In another observation, a CNA donned a gown and gloves, provided incontinent care, removed soiled gloves, applied new gloves without hand hygiene, applied protective barrier cream, then removed the soiled gown and gloves and exited the room without performing hand hygiene. An administrative nurse confirmed staff were expected to perform hand hygiene when entering the room, between glove changes, and when exiting the room.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards for several residents, leading to a deficiency in infection prevention and control. During the survey, it was observed that a certified nurse aide (CNA) did not properly doff an N95 mask after exiting the room of a COVID-positive resident and before entering the rooms of COVID-negative residents. This action had the potential to spread infection throughout the facility. Additionally, the CNA was seen carrying a trash bag from a COVID-positive resident's room without removing the gown, N95 mask, and face shield, which violated the facility's policy on droplet/contact precautions. Further observations revealed that staff did not follow enhanced barrier precautions (EBP) for residents requiring such measures. For instance, a resident with a feeding tube did not have appropriate signage indicating the need for EBP, and staff failed to don gowns or gloves when transferring the resident from a wheelchair to a bed. This oversight in implementing EBP could contribute to the transmission of multi-drug resistant organisms (MDROs) within the facility. Another incident involved a nurse who did not clean a plastic container used for wound care before removing it from a resident's room and placing it back in the treatment cart. This failure to disinfect supplies before exiting a resident's room with EBP further exemplifies the facility's lapses in maintaining proper infection control practices. These deficiencies highlight the need for strict adherence to infection control protocols to prevent the spread of infections among residents, staff, and visitors.
Removal Plan
- Review Infection Control, Isolation and personal protective equipment (PPE) policies.
- Post signs demonstrating proper donning and doffing of PPE on all doors of COVID positive resident rooms.
- Educate all staff on proper application of gowns, masks (including N95), gloves, when to perform hand hygiene, and PPE guidelines for donning and doffing for COVID positive residents and residents in isolation.
Dietary Manager Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the dietary manager possessed the necessary qualifications to serve as the director of food and nutrition services. During an interview, an administrative manager confirmed that the dietary manager lacked the required training for the position. Specifically, the dietary manager had not completed the education necessary for certification as a dietary manager, certified food service manager, or obtained national certification for food service management and safety from a recognized certifying body. This deficiency has the potential to result in foodborne illness affecting residents, staff, and visitors.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to ensure timely electronic data submission of required Minimum Data Set (MDS) assessments for several residents, as identified during a survey. Specifically, the facility did not meet the regulatory requirements for timely submission of MDS assessments for three sampled residents and one supplemental resident. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual specifies that MDS data must be transmitted electronically no later than 14 calendar days after the MDS completion date. However, the facility did not adhere to these guidelines, resulting in late submissions. For Resident #4, a quarterly MDS was completed 30 days late. Resident #5's quarterly MDS was transmitted 44 days late. Resident #20 had multiple late submissions, including a discharge return anticipated MDS completed 51 days late, an entry tracking MDS transmitted 61 days late, and a quarterly MDS completed 31 days late. Additionally, Resident #75's quarterly MDSs were not submitted within the required timeframe. A facility nurse confirmed the failure to submit MDSs in a timely manner during a phone interview.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for five residents, which affected the reflection of their current status and needs. For Resident #1, the MDS was incorrectly coded by not identifying the presence of a feeding tube, despite a physician's order for Jevity 1.5 cal via PEG tube. Resident #18's MDS inaccurately recorded their weight as 155 pounds instead of the actual 167 pounds. These inaccuracies in the MDS could potentially impact the development of a comprehensive care plan for these residents. Additionally, the facility failed to accurately document medication administration in the MDS for several residents. Resident #13's MDS did not reflect the administration of clindamycin, tramadol, aspirin, and insulin, all of which were recorded in the medication administration record (MAR). Similarly, Resident #16's MDS failed to document the administration of azithromycin, and Resident #18's MDS did not include the administration of bumetanide. Resident #20's MDS omitted the administration of quetiapine and amoxicillin. These omissions were confirmed by an administrative staff member during the survey.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for seven out of twelve sampled residents, which limited staff's ability to communicate needs and ensure continuity of care. For Resident #1, the care plan did not include enhanced barrier precautions despite the resident having a feeding tube, as observed when a medication aide donned a gown and gloves for these precautions. Resident #5's care plan was not updated to include a new fall intervention, even though a progress note indicated fall precautions were in place. Similarly, Resident #7's care plan lacked documentation of the use of a pommel cushion, which was observed during the survey. Additionally, the care plans for Residents #9 and #10 did not reflect the need for enhanced barrier precautions, as indicated by the presence of isolation carts and signage outside their rooms. Resident #18's care plan was vague and did not address dialysis-related nutrition, despite the resident's high nutrition risk due to end-stage renal disease and type 2 diabetes. Lastly, Resident #20's care plan failed to include enhanced barrier precautions, even though the resident required an indwelling urinary catheter. An administrative staff member confirmed the expectation for these precautions to be documented in the care plans.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their representative, which is a requirement for ensuring informed decision-making regarding transfer rights. This deficiency was identified during a review of the medical records of a resident who was transferred to the hospital. The review, conducted over several days, revealed that the medical record did not contain evidence of a written transfer notice for the hospital transfer that occurred on June 28, 2024. An administrative staff member confirmed during an interview that the facility did not complete the required Notice of Transfer for the hospitalization of the resident.
Failure to Follow Professional Standards and Physician's Orders
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of insulin for a resident. During an observation, a nurse did not follow the manufacturer's guidelines for priming an insulin pen, which required holding the pen with the needle pointing up. Instead, the nurse primed the pen in a horizontal position, potentially leading to an inaccurate insulin dose. This was confirmed by an administrative nurse during an interview. Additionally, the facility did not follow physician's orders for two residents. One resident, who had cerebral palsy and was dependent on supplemental oxygen, did not receive prescribed range of motion exercises regularly, and their oxygen and nebulizer tubing were not changed as ordered. Furthermore, a tardive dyskinesia assessment was not completed as required. Another resident with Type 2 Diabetes Mellitus had several instances of blood glucose levels outside the specified parameters, yet the facility failed to notify the physician as ordered. These deficiencies were confirmed through staff interviews and record reviews.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents remained free from unnecessary psychotropic medications, specifically for two residents reviewed for psychotropic medication use. For one resident, the facility did not properly document or evaluate the need for continued use of alprazolam, a medication for anxiety. The resident received alprazolam without a valid order, as the medication was discontinued previously, and no new order was documented. Additionally, the facility did not have the physician or prescriber evaluate the resident's need to extend the medication beyond the initial 14 days, as required by the facility's policy. Another resident was prescribed Seroquel, an antipsychotic medication, with a requirement for a tardive dyskinesia (TD) assessment every six months. The facility failed to complete the TD assessment as scheduled, leaving it incomplete and not conducting another assessment within the required timeframe. This oversight was confirmed by an administrative nurse during the survey, indicating a lapse in monitoring and documentation for residents on psychotropic medications.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, as evidenced by two unlocked and unattended carts observed during a survey. The facility's policy on medication labeling and storage mandates that all medications be stored in locked compartments and that carts used to transport medications should not be left unattended if open or accessible to others. However, during an observation, a medication cart with medications on top and a treatment cart were found unlocked and unattended in the 200-hallway. An administrative nurse confirmed that staff are expected to lock the medication cart and keep all medications secured when not in use or when the nurse or medication aide is not within sight or accessing them.
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 3 citations issued within 25 miles in the last 12 months — 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 Rolette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dunseith Com Nursing Home | 14.1 mi | ★★★★★ | 3 | 0 |
| Heart Of America Care Center | 22.2 mi | — | 0 | 0 |
| Good Samaritan Society - Bottineau | 28.9 mi | ★★★★★ | 15 | 0 |
| Towner County Living Ctr | 31.3 mi | ★★★★★ | 8 | 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.