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 Strasburg Nursing Home during CMS and state inspections, most recent first.
Failure to observe medication administration occurred when a nurse prepared a resident's meds, stated the resident was SAM, and left pills on the table without assisting or watching the resident take them. The resident's record showed the resident did not wish to participate in SAM, and another nurse confirmed the resident should have been observed or assisted with taking the medications.
Medication labels did not match the MAR for one resident during a med pass. An RN prepared dicyclomine for a resident whose order and MAR showed 20 mg BID, but the medication label stated half tablet, or 10 mg BID. The nurse confirmed the order and administered 20 mg, and an administrative nurse later confirmed the mismatch.
Infection control standards were not followed during dressing changes for two residents. One resident on EBP for a suprapubic catheter with chronic cellulitis and wound drainage had a nurse perform glove changes without hand hygiene and without a gown, while also handling wound supplies without hand hygiene. Another resident with a right heel pressure ulcer had dressing supplies, including gauze, scissors, tape, and cleaning solutions, placed directly on a cloth chair instead of a clean surface.
A resident reported missing $100 after placing it in a drawer before taking a shower. Despite the facility's policy requiring reporting of such incidents, the administrative nurse confirmed the incident was not reported to the SSA, placing residents at risk for misappropriation of property.
A resident reported $100 missing after a shower, but the facility failed to initiate an investigation as required by their policy. Despite the resident's intact cognition and confirmation from his daughter about the money, no investigation was conducted, leaving the issue unresolved.
The facility did not follow professional standards for insulin pen preparation and administration for two residents. Nurses failed to prime the insulin pens correctly by not holding them upward, contrary to the facility's policy. An administrative staff member confirmed the expectation for staff to adhere to this policy.
A facility failed to provide necessary personal hygiene assistance to a resident with dementia who required setup help and verbal reminders. A nurse helped the resident change clothes but did not assist with hygiene, stating assistance would be given when the resident allowed it. An administrative nurse expected the nurse to assist with hygiene during dressing.
A facility failed to adhere to its catheter care policy for a resident with an indwelling urinary catheter. The policy required catheter bags to be emptied at the end of each shift, but observations showed the bag was not emptied as required, leading to discomfort for the resident. The resident had a history of urinary issues, and the catheter bag was found to contain excessive urine on multiple occasions. An administrative staff member confirmed the expectation for catheter bags to be emptied at least once per eight-hour shift.
The facility failed to follow infection control standards for a resident with a Foley catheter, as CNAs did not use gowns or gloves during transfers and did not perform hand hygiene after removing gloves. The administrative nurse confirmed the lack of staff education on enhanced barrier precautions, leading to potential infection spread.
Failure to Observe Medication Administration for Resident Not Participating in SAM
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 14 residents reviewed for self-administration of medication, Resident #21. The facility policy stated that a licensed nurse would complete the self-administration of medications screen, the interdisciplinary team would make the determination based on the screen, and reassessment would be completed quarterly and as needed. Resident #21's record showed a self-administration assessment dated 01/19/26 that lacked the resident's choice to not self-administer medications, and a progress note dated 01/28/26 stated that the resident did not wish to participate in SAM. During observation on 04/01/26 at 7:41 a.m., a nurse prepared the resident's medications, stated that he was SAM, placed a cup of pills on the table, mixed a powdered stool softener in water, and returned to the medication cart without assisting or observing the resident take the medications. A staff nurse later confirmed that the nurse should observe or assist Resident #21 with taking his medications.
Medication Label Did Not Match MAR for One Resident
Penalty
Summary
Medication labels and provider orders did not match for one resident during a medication pass. Resident #21 had a provider order dated 02/11/26 to increase dicyclomine to 20 mg twice a day. During observation on 04/01/26 at 7:41 a.m., Nurse #5 prepared the resident’s medications, and the MAR identified dicyclomine 20 mg twice a day. The medication label, however, indicated to administer half a tablet, or 10 mg, twice a day. The nurse confirmed the provider’s order and administered 20 mg. During an interview later that morning, an administrative nurse confirmed that Resident #21’s dicyclomine label did not match the resident’s MAR.
Infection Control Failures During Dressing Changes
Penalty
Summary
The facility failed to follow infection control and prevention standards during dressing changes for two residents. Review of facility policy showed that enhanced barrier precautions required gown and glove use during high-contact resident care activities, including chronic wound care and dressing changes, and the dressing change policy required hand hygiene before and after glove use and stated that dressings and supplies were never to be placed on the resident's bed, with an over-the-bed table to be used and disinfected before and after the procedure. Resident #2 had enhanced barrier precautions related to a suprapubic catheter with chronic cellulitis and wound drainage around the site. During observation, a nurse performed hand hygiene, donned gloves, removed a soiled dressing, removed gloves, and then applied clean gloves without performing hand hygiene before cleansing and redressing the site. The nurse did not wear a gown during the dressing change and later removed gloves, did not perform hand hygiene, placed wound supplies into a basket and into the nightstand drawer, and applied the resident's shoes before performing hand hygiene and leaving the room. Resident #24 had a pressure ulcer to the right heel, and during observation a nurse removed dressing supplies from a plastic basin, opened gauze, and placed the gauze, scissors, tape, and cleaning solutions directly on a cloth chair instead of using a clean surface.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of resident property to the State Survey Agency (SSA) within the required 24-hour timeframe. This deficiency involved a resident who reported missing $100, which was given to him as a Christmas gift. The resident had received the money from his daughter after she cashed a check for him. He placed the money in a drawer before taking a shower, and upon returning, found the money missing. Despite the resident's report to the nursing staff and their subsequent search, the money was not found. The facility's policy mandates that any alleged violations, including misappropriation of resident property, be reported to the SSA in accordance with state law. However, an administrative nurse confirmed that the incident was not reported to the SSA. The failure to report the alleged violation placed the resident and potentially other residents at risk for misappropriation of property. The resident's medical records and interviews with the resident and his family corroborated the timeline and details of the incident.
Failure to Investigate Missing Resident Property
Penalty
Summary
The facility failed to initiate an investigation into an alleged violation of misappropriation of resident property for a resident who reported missing money. The facility's policy on misappropriation of resident property requires a thorough investigation of all allegations, but this was not followed in the case of the resident who reported $100 missing after a shower. Despite the resident's report and the involvement of his daughter, who confirmed the money was given to him, the facility did not start or complete an investigation. Interviews with the resident and his family indicated that the resident had intact cognition and it was not typical for him to misplace items. The resident reported the missing money to the nurse, and although staff searched for the money, it was not found. The administrative nurse confirmed that no investigation had been initiated, which is a failure to adhere to the facility's policy and protect the resident's property.
Failure to Follow Insulin Pen Priming Procedure
Penalty
Summary
The facility failed to adhere to professional standards of practice in the preparation and administration of insulin for two residents. During observations, it was noted that a nurse did not prime the insulin pen correctly for Resident #12, as the pen was not held upward during priming. Similarly, another nurse failed to prime the insulin pen upward for Resident #9. The facility's policy on insulin pen usage, which was reviewed, clearly states that the pen should be primed by holding it with the needle pointed upward. An administrative staff member confirmed that the expectation was for staff to follow this policy.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who required assistance with personal hygiene received the necessary support. The resident, who has a self-care performance deficit related to dementia, was observed needing setup help and verbal reminders for personal hygiene. During an observation, a nurse assisted the resident in selecting clothing and changing out of pajamas but did not provide the needed assistance or verbal reminders for personal hygiene. When questioned, the nurse indicated that assistance would be provided when the resident allowed it. An administrative nurse later stated that the expectation was for the nurse to assist the resident with personal hygiene while helping with dressing.
Failure to Adhere to Catheter Care Policy
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter. The facility's policy required catheter bags to be emptied at the end of each shift, which is three times per day. However, observations and record reviews revealed that the resident's catheter bag was not emptied as per the policy. On one occasion, the catheter bag contained approximately 1200 cc of urine at 4:43 p.m. and increased to 1300 cc by 5:50 p.m., with the resident expressing discomfort. The bag was eventually emptied at 7:53 p.m., containing 2000 cc of urine. Additionally, records showed that from January 6th to January 20th, the catheter bag was emptied only twice in a 24-hour period on four separate days. The resident involved had a medical history that included obstructive and reflux uropathy, benign prostatic hyperplasia, and a history of urinary tract infections. The care plan indicated the resident had an indwelling suprapubic catheter due to urinary obstruction. During an interview, an administrative staff member confirmed that the catheter should have been emptied before 8:00 p.m. and stated that certified nurse assistants were expected to empty catheter bags at least once per eight-hour shift. This failure to adhere to the facility's catheter care policy could lead to urinary tract infections, unnecessary discomfort, and urinary retention or obstruction.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding enhanced barrier precautions (EBP) and hand hygiene, for a resident with a Foley catheter. The facility's policy required the use of gown and gloves during high-contact activities for residents at increased risk of multidrug-resistant organism (MDRO) acquisition. However, observations revealed that certified nurse aides (CNAs) did not don gowns or gloves when transferring the resident from a recliner to a wheelchair and from a toilet to a wheelchair. Additionally, a CNA failed to perform hand hygiene after removing gloves and before donning new gloves during the resident's care activities. The administrative nurse confirmed that the facility did not educate staff on the proper use of gown and gloves for residents under enhanced barrier precautions. The lack of adherence to the facility's policy and the failure to perform hand hygiene as required by the policy were observed during multiple instances of resident care. These deficiencies in infection control practices have the potential to spread infection throughout the facility.
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 Strasburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wishek Living Center | 29.8 mi | ★★★★★ | 0 | 0 |
| Wentz Living Center | 31.5 mi | ★★★★★ | 1 | 0 |
| Avera Eureka Health Care Center | 36.6 mi | ★★★★★ | 0 | 0 |
| Ashley Medical Center Nursing Home | 38.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Strasburg 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 July 2026) and official state health department websites.