Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Meadows On University during CMS and state inspections, most recent first.
A facility failed to provide enough nursing staff and related services to meet resident needs, with multiple residents reporting call light waits of 15 minutes to 2 hours, especially in the evenings, nights, and on weekends. Resident council minutes documented repeated complaints about unanswered call lights, staff turning them off, and staff not returning after acknowledging requests. Staff interviews also showed staffing shortages, including a CNA call-in and a nurse stating she was the only nurse in the building until noon despite other nurses being scheduled.
Failure to provide scheduled bathing assistance affected four sampled residents with ADL needs. Records showed residents with impaired physical functioning, personal hygiene deficits, paraplegia, and muscle weakness were scheduled for bathing twice weekly, but baths were missed, refused without alternate times being documented, or not documented at all. An admin staff member stated residents should be bathed per schedule and refusals should be reported to the nurse and documented.
Standing water was not promptly cleaned from a central hallway and near the Dakota Dining Room, with water observed trailing across the floor and dripping from a ceiling AC unit into a bucket that created a puddle extending into the doorway threshold. The water remained in place for extended periods, and a yellow caution sign was later placed over the area while the puddle continued to grow. An MNT supervisor stated staff are expected to monitor for water and other safety hazards and clean them up promptly.
Improper Food Storage and Monitoring: Food items in the kitchen and kitchenette were not properly labeled, dated, monitored, or discarded. Surveyors observed a container of green beans dated 05/05/26 in the walk-in refrigerator, plus an unlabeled, undated bottle of V8 juice with visible mold and an unlabeled, undated Subway sandwich at the south nursing station kitchenette. The dietary manager confirmed staff should monitor refrigerators to ensure expired, unlabeled, and unidentified items are discarded.
Staff failed to follow infection control practices during resident care, medication pass, and laundry handling. A CNA and a nurse performed high-contact care for residents with soiled gloves, did not consistently perform hand hygiene after glove removal, and did not use gown and glove PPE as required for EBP. A medication aide administered an inhaler without hand hygiene, and the laundry room had mixed clean and soiled items with inadequate PPE availability.
A facility failed to complete SNFABNs for two residents whose Medicare Part A services ended. Review found one notice did not document whether the resident or representative chose to continue services, discontinue services, or request a demand bill, and another notice also lacked the estimated cost of services and a beneficiary or representative signature. An administrative nurse confirmed both notices were incomplete.
Failure to maintain a clean and homelike environment: Surveyors observed food debris, wrappers, crumbs, sticky residue, dust-coated fans, a water trail, and other clutter in resident rooms, hallways, common areas, and the dining room. An admin staff member stated staff were expected to clean wheelchairs, including footrests, and the maintenance supervisor stated all staff were expected to monitor work areas and address environmental concerns promptly.
A facility failed to review and revise care plans for two residents to reflect current status. One resident’s care plan did not include the resident’s stated limits on his sister’s involvement in care, and another resident’s care plan still identified the resident as a smoker even though an RN confirmed the resident was not a smoker and the resident also stated he/she does not smoke.
Failure to follow wound dressing orders occurred for a resident with a skin tear to the R lower extremity. The ordered dressing was to be changed daily and as needed, but observations showed an occlusive dressing dated one day, then undated and uninitialed dressings, and the TAR lacked documentation of dressing changes on several days. An admin staff member stated staff were expected to follow the physician’s orders for dressing type and frequency.
Medication administration errors exceeded the allowed rate, with 2 errors found during observation of 25 medications. An RN prepared an insulin pen without priming it with the needle pointing upward, and a medication aide gave Advair without instructing a resident to rinse the mouth after use, contrary to the pharmacy label and manufacturer instructions.
Failure to post the resident census on the daily nurse staffing sheet was identified on multiple survey days. The facility policy required the staffing sheet to be posted daily with the current resident census, but observation showed the census number was missing. An administrative staff member stated she expected HR staff to complete and post the daily census/staffing report.
A newly admitted resident did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. The resident's assessment indicated needs for assistance with transfers and toileting, but the baseline care plan lacked interventions for these areas. An administrative staff member confirmed the omission.
A CNA did not follow infection control protocols for a resident with C. diff, failing to wear a gown, perform hand hygiene with soap and water, or assist the resident with hand hygiene after providing care. The CNA used hand sanitizer instead of washing hands as required by facility policy for contact precautions.
A resident with diabetes and malnutrition experienced significant weight loss due to staff failing to accurately monitor and document food and supplement intake, provide necessary encouragement and assistance during meals, and update the care plan to reflect the need for 1:1 meal support. Observations showed discrepancies between actual intake and recorded documentation, with supplements and meals often left unassisted and no alternative menu items offered when food was refused.
Multiple residents dependent on staff for ADLs were observed with untrimmed, dirty nails, inconsistent oral care, and inadequate assistance during meals. Staff failed to provide regular hygiene support and proper meal setup, resulting in residents struggling to maintain personal cleanliness and access food, despite care plans indicating the need for such assistance.
Surveyors observed that the kitchen was not maintained in a clean and sanitary condition, with dust and debris found on the warewashing machine, uncovered bowls, a dishware cart, and the floor in the dishwashing area. A dietary staff member confirmed that cleanliness standards were not met.
Staff failed to follow infection control standards during high-contact care activities, including not wearing required gowns for enhanced barrier precautions, improper glove use, and inadequate hand hygiene after perineal care and dressing changes. In several cases, staff did not retract the foreskin during male perineal care, and continued with other tasks without proper hand hygiene, increasing the risk of infection spread among residents.
Staff did not honor a resident's request to have a bladder scan before toileting cares and proceeded with care tasks against the resident's wishes. During the process, a CNA made an unprofessional comment, which the resident found inappropriate. Facility policy requires staff to treat residents with dignity and respect at all times, and the actions observed did not meet these standards.
A resident with quadriplegia was repeatedly left without access to a call bell that could be independently activated, despite a care plan specifying the need for specialized call bell placement. Staff were observed leaving the call bell out of reach after providing care, and the resident reported this occurred frequently. Facility policy and staff interviews confirmed the expectation that call bells should be accessible and usable by the resident.
Surveyors found that three residents' MDS assessments were inaccurately coded: one resident with serious mental illness was not coded as such, another with a suprapubic catheter was incorrectly coded for both indwelling and external catheters, and a third with Parkinson's Disease did not have this active diagnosis reflected in their MDS. These errors were confirmed by administrative and corporate staff.
A resident with impaired skin integrity and incontinence did not receive timely skin assessments or regular incontinence care as required by their care plan and physician's orders. Staff failed to document or treat multiple wounds on the resident's feet, and incontinence care was often provided only once or twice daily, leading to prolonged periods of wetness and increased risk for further skin breakdown.
A facility failed to administer rapid-acting insulin within the recommended timeframe for a resident, potentially risking a hypoglycemic reaction. Additionally, another resident with CHF did not receive their scheduled Lasix dose due to unavailability, which could exacerbate their condition.
A resident with limited mobility did not receive appropriate toileting and incontinence care, as evidenced by records showing infrequent check and change over a 29-day period. The resident reported long periods without changes, and an administrative staff member confirmed that the facility's expectation was for more frequent assistance.
The facility failed to serve meals at palatable temperatures to two residents. A CNA delivered a cold meal to a resident, who refused to eat it, and a nurse delayed serving a meal, resulting in a fish stick being served at 120.5°F. Another resident reported frequently receiving cold food. This failure may negatively impact residents' meal consumption.
The facility failed to follow infection control standards, as a staff member entered a resident's room without a mask despite influenza precautions, and a nurse did not perform hand hygiene after glove removal before assisting another resident with a meal.
Insufficient Nursing Staff and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff and related services to meet resident needs for 4 of 18 sampled residents and 12 additional residents who required staff assistance. The deficiency was identified through review of the facility policy on call light accessibility and timely response, resident council meeting minutes, and confidential interviews with residents, family, and staff. The facility policy stated that all staff members who see or hear an activated call light are responsible for responding, and if they cannot provide what the resident desires, the appropriate person should be notified. Resident council meeting minutes documented repeated complaints of long call light response times, unanswered call lights after 6:00 p.m., staff turning off call lights, and staff failing to return after acknowledging requests. During interviews, residents reported call light waits ranging from 15 minutes to two hours, with several stating delays were worse in the evenings, at night, on weekends, and during certain daytime hours. One resident reported a call light was on from 9:30 p.m. to midnight, and another stated staff often said they were short staffed. Staff interviews also reflected staffing concerns, including a CNA reporting six CNAs on day shift when seven were scheduled due to one sick call, and a nurse stating she was the only nurse in the building until noon despite another nurse being scheduled for LTC. An administrative nurse stated call lights were expected to be answered as soon as possible and no longer than 15 minutes.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide the necessary bathing services for 4 of 18 sampled residents who required assistance with activities of daily living. Facility policy stated that residents unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the records for four residents showed scheduled bathing assistance was not consistently provided or documented as required. Resident #1 had a care plan for impaired physical functioning related to fatigue and weakness and was scheduled for showers twice weekly, but the bathing record showed showers were received on only four of nine scheduled bath days, with one refusal and two entries marked not applicable without explanation. Resident #10 had a care plan for impaired physical functioning and was scheduled for bathing twice weekly, but the record showed only two baths on eight scheduled bath days and six refusals, with no documentation that an alternate time or day was offered. Resident #30, who had a hospitalization from May 21-29, 2026, was also scheduled for bathing twice weekly, but the record lacked documentation of a bath or refusal on three scheduled bath days. Resident #55 had impaired personal hygiene and ADL self-care deficit related to paraplegia and muscle weakness, was scheduled for bathing twice weekly, and the record showed baths on eight of 15 scheduled bath days with no documentation for seven scheduled bath days. An administrative staff member stated residents were expected to be bathed according to schedule and that refusals should be reported to the nurse and documented in the resident record.
Standing Water Not Promptly Cleaned in Hallway and Near Dining Room
Penalty
Summary
The facility failed to provide adequate housekeeping services to keep an area free from standing water and prevent accidents. On 06/07/26 at 11:05 a.m., a trail of water was observed on the floor extending down the central hallway, and the water remained there until 11:48 a.m. On 06/07/26 at 11:30 a.m., water was observed dripping from the ceiling air-conditioning unit into a bucket near the Dakota Dining Room, with a puddle surrounding the bucket and extending under and into the doorway threshold of the dining room; the water remained on the floor until 1:10 p.m. Later that day at 2:28 p.m., water was still dripping into the bucket near the Dakota Dining Room, and a yellow caution sign was placed over the puddle, which had increased in size by 3:05 p.m. During interview on 06/09/26 at 3:20 p.m., the maintenance supervisor stated all staff are expected to monitor for water on the floor and other potential safety hazards and clean them up promptly to prevent accidents and maintain a safe environment.
Improper Food Storage and Monitoring
Penalty
Summary
Food items were not stored, labeled, dated, monitored, or discarded in accordance with facility policy and professional standards in the kitchen and kitchenette observed. Facility policy stated refrigerated food should be labeled, dated, and monitored so it is used by the use-by date and discarded, and food brought by family or visitors should be labeled with the resident's name, item, and use-by date. The policy also stated perishable foods should be discarded on or before the use-by date or three days from opening, and foods showing signs of foodborne danger, including mold growth, should be discarded. During observation, a container of green beans dated 05/05/26 was found in the walk-in refrigerator. In the kitchenette at the south nursing station, a bottle of V8 juice was observed without a date or label and had visible mold growth inside the bottle, and an unlabeled, undated Subway sandwich was also observed. The dietary manager confirmed staff should monitor refrigerators to ensure expired, unlabeled, and unidentified food items are discarded.
Infection Control Failures During Resident Care, Medication Pass, and Laundry Handling
Penalty
Summary
The facility failed to follow infection control and prevention standards during resident care, medication administration, and laundry handling. For a resident with an enhanced barrier precautions sign on the door, a CNA entered the room, applied gloves, completed perineal care, removed the soiled gloves, and then put on new gloves to assist the resident to a sitting position and transfer the resident with a stand lift without performing hand hygiene after removing the soiled gloves. The CNA also did not apply a gown before completing the high-contact care activity. During care for another resident, a nurse performed toileting and perineal care, reached into her pocket and used a walkie talkie while still wearing soiled gloves, then removed the gloves and moved the resident’s wheelchair and removed the resident’s pants and shoes without hand hygiene. A CNA then assisted the resident into the wheelchair and to the sink after removing soiled gloves without hand hygiene. In the laundry room, soiled laundry area contained gloves but no additional PPE supplies, lift slings and repositioning devices were stored on top of the washing machine, and the clean laundry area contained a covered container of soiled kitchen towels. During medication administration, a medication aide prepared an inhaler, entered a resident’s room, and administered the inhaler without performing hand hygiene upon entering the room or before giving the medication. Facility policy stated that gloves do not replace hand hygiene, that hand hygiene should be performed before donning gloves and immediately after removing them, that EBP requires targeted gown and glove use during high-contact care activities, and that soiled laundry must be kept separate from clean laundry at all times.
Incomplete SNFABN Documentation for Medicare Part A Terminations
Penalty
Summary
Give residents notice of Medicare/Medicaid coverage and potential liability for services not covered was deficient when the facility did not ensure completion of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents reviewed for termination of Medicare Part A services. Review of the facility policy titled Advance Beneficiary Notices showed the facility was to inform Medicare beneficiaries of potential liability for payment, comply with related instructions and regulations, and obtain the beneficiary or representative signature. Review of Medicare Part A beneficiary notices showed Resident #43 was discharged from Medicare Part A on 05/20/26, but the SNFABN did not identify whether the resident or representative chose to continue services, discontinue services, or request a demand bill. Resident #81 was discharged from Medicare Part A on 01/23/26, and the SNFABN did not identify the estimated cost of services, whether the resident or representative chose to continue services, discontinue services, or request a demand bill, and it lacked a beneficiary or representative signature. During interview, an administrative nurse confirmed both SNFABNs were incomplete.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide housekeeping services to maintain a safe, clean, comfortable, and homelike environment for 4 of 4 days of survey. Review of the facility policy titled Safe and Homelike Environment stated that the facility would provide a safe, clean, comfortable, and homelike environment and that housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Observations showed multiple environmental cleanliness concerns throughout the facility, including a water trail extending from the central hallway bathing room down the hallway, alcohol wipe wrappers, food debris, paper, and straw wrappers on the floor outside a resident room, an empty chip bag and used blanket in a common area, sticky substance and clutter in a resident room, crumbs and a dried brown substance on hallway and supply room floors, and candy wrappers and crumbs outside resident rooms. Additional observations found dust-coated fan grates and blades in two resident rooms, with dust blowing toward one resident's bed. In the main dining room, large amounts of scrambled eggs, toast, and other food particles were observed under two tables while the noon meal was being served. An administrative staff member stated that staff were expected to clean wheelchairs, including footrests, and the maintenance supervisor stated all staff were expected to monitor work areas and ensure environmental concerns were promptly addressed.
Failure to Update Care Plans for Current Resident Status
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current status of 2 of 18 sampled residents. For Resident #1, a progress note dated 5/26/26 documented that the resident stated he only wished to see his sister in open areas of the building and that no further information was to be shared with her, but the care plan did not include these choices related to his sister's involvement in his care. For Resident #30, the care plan stated the resident had potential for complications or injury related to smoking cigarettes, but an administrative nurse confirmed on 06/08/26 that the resident was not a smoker, and the resident stated on 06/09/26 that he/she does not smoke. The staff did not review and revise the care plan to reflect the resident's current smoking status.
Failure to Follow Wound Dressing Orders
Penalty
Summary
Failure to provide care and services according to physician orders occurred for Resident #57, who had a skin tear to the right lower extremity. The physician ordered the area to be cleansed, patted dry, steri strips kept intact, and covered with 4x4 gauze secured with tape every day and as needed. Observations on 06/07/26 showed an occlusive dressing to the resident’s right lower calf dated 06/03/26, while observations on 06/09/26 and 06/10/26 showed an undated and uninitialed dressing to the same area. Review of the treatment administration record from 06/02/26 through 06/10/26 lacked documentation that staff changed the dressing on June 2, 3, and 5, 2026. An administrative staff member stated she expected staff to follow physician orders for the type of wound dressing and the frequency of changes.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent during observation of medication administration, with 2 errors identified during administration of 25 medications for an eight percent error rate. During one observation, a nurse prepared an insulin pen by dialing 2 units of insulin but held the pen horizontally with the needle to the side and did not prime the pen with the needle pointing upward as required by facility policy. During another observation, a medication aide administered Fluticasone-Salmeterol inhalation aerosol (Advair) to a resident but did not instruct the resident to rinse their mouth after use, despite the pharmacy label stating to rinse mouth after each use and the manufacturer instructions stating to rinse the mouth with water without swallowing after using Advair Diskus.
Failure to Post Daily Resident Census on Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that resident census was posted on the nurse staffing information on 3 of 4 survey days, from June 7, 2026 through June 9, 2026. Review of the facility policy titled Nurse Staffing Posting Information, dated 05/16/26 and reviewed on 06/10/26, stated that the Nurse Staffing Sheet would be posted daily and include the facility's current resident census. Observation on June 7-9, 2026 identified that the resident census number was not included on the nurse staffing information. During an interview on 06/09/26 at 3:30 p.m., an administrative staff member stated she expected human resource staff to complete and post a daily census/staffing report.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the resident was admitted on 12/10/25, with a comprehensive assessment completed on 12/12/25 indicating the resident required assistance with transfers and toileting, but was independent with eating. However, the baseline care plan created on the admission date did not include interventions for the resident's specific needs related to transfers, eating, or toileting. An administrative staff member confirmed during interview that staff did not develop a baseline care plan for this resident as required by facility policy.
Failure to Follow Contact Precautions and Hand Hygiene for C. diff Resident
Penalty
Summary
A certified nursing assistant (CNA) failed to follow established infection prevention and control protocols for a resident diagnosed with enterocolitis due to Clostridioides difficile (C. diff), who was on contact/enteric precautions. Facility policy required staff to wear gloves and a gown upon entering the resident's room, perform hand hygiene with soap and water before and after glove use, and encourage or assist the resident with hand hygiene. During observation, the CNA entered the resident's room, donned gloves but did not wear a gown, and assisted the resident with a pivot transfer and toileting. The CNA did not perform hand hygiene after glove removal, instead using hand sanitizer, and did not encourage or assist the resident with hand hygiene as required by policy. The resident, who was independently able to complete toileting cares, was assisted by the CNA in transferring and ambulating within the room. The CNA failed to adhere to the facility's infection control policies regarding the use of personal protective equipment (PPE) and proper hand hygiene, specifically in the context of C. diff precautions, which require handwashing with soap and water. These actions were confirmed through observation, record review, and staff interview, indicating a lapse in following infection control standards for residents on contact precautions.
Failure to Monitor and Assist with Nutrition Leading to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with a history of diabetes and malnutrition, resulting in significant weight loss. The resident experienced a 20% weight loss since admission, with documented weights showing a rapid decline over several months. Physician orders included a regular, easy-to-chew diet and scheduled nutritional supplements (Boost) three times daily and as needed for malnutrition. The care plan identified impaired physical functioning, the need for supervision at meals, and interventions such as encouraging food and fluid intake, recording meal percentages, and consulting a dietitian for caloric and nutritional needs. Despite these interventions, staff did not accurately monitor or document the resident's food and supplement intake. Multiple observations revealed discrepancies between actual consumption and what was recorded in the medical record and medication administration record (MAR). Staff frequently left supplements and meals unassisted, failed to provide encouragement, and did not offer alternative menu items when the resident refused food. The resident was often left alone during meals, and staff did not consistently provide the 1:1 assistance indicated by the interdisciplinary team (IDT). The MAR also showed that the resident did not receive any as-needed supplements during the survey period. The facility's records lacked a current dietitian evaluation addressing the significant weight loss and did not update the care plan to reflect the need for 1:1 meal assistance. Staff interviews confirmed expectations for accurate documentation and observation of intake were not met. The combination of inadequate monitoring, lack of assistance, and failure to implement care plan changes contributed to the resident's continued weight loss.
Failure to Provide Adequate Assistance with Personal Hygiene and Dining
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including personal hygiene and dining, for six residents who were dependent on staff support. Observations and record reviews revealed that multiple residents had untrimmed, dirty fingernails and toenails, and some had not received regular oral care. For example, one resident with paraplegia had long, thick, yellow toenails and stated that it had been a while since they were last trimmed. Another resident, dependent on staff for personal hygiene, had toenails approximately one-fourth inch in length and reported that staff only occasionally clipped them. Additional residents were observed with dirty fingernails, debris under their nails, and incomplete or irregular nail care, despite care plans indicating the need for staff assistance. Residents also experienced lapses in oral hygiene and assistance with meals. One resident with hemiplegia and hemiparesis was observed multiple times unable to reach or open items on their meal tray due to physical limitations, with staff failing to provide necessary setup or positioning assistance. This resident also reported inconsistent help with oral care, and was observed with visible debris on their face and mouth. Another resident was found with yellow-brown substance on their teeth and white crust at the corners of their mouth, and staff were observed using an unlabeled or incorrect toothbrush and basin, failing to ensure proper identification and hygiene supplies. Interviews with staff confirmed that CNAs were responsible for providing personal care, including nail and oral hygiene, but observations indicated that these tasks were not consistently performed as required by facility policy and individual care plans. The deficiencies were identified through direct observation, record review, and staff and resident interviews, demonstrating a pattern of inadequate assistance with ADLs for residents dependent on staff support.
Unsanitary Kitchen Conditions and Improper Dishware Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment as required by professional standards. Observations in the main kitchen revealed loose debris and dust on top of the mechanical warewashing machine, visible dry particles and debris on a tray of uncovered bowls located in a high traffic area, dry food and debris on the bottom of a cart used to store clean dishware, and an accumulation of food and dirt debris on the floor between the table legs of a stainless-steel counter and the wall in the dishwashing room. A dietary staff member confirmed that the kitchen environment and floors should remain clean.
Failure to Follow Infection Control Standards During High-Contact Care Activities
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices for several residents requiring enhanced barrier precautions (EBP) due to indwelling medical devices or wounds. In several instances, nursing staff performed high-contact care activities such as flushing Foley catheters and changing wound dressings without donning required gowns, despite clear facility policies and visible indicators (red dot stickers and PPE supplies) at resident rooms. Additionally, staff failed to follow proper glove use and hand hygiene protocols, such as not removing gloves or performing hand hygiene after handling soiled dressings or before obtaining clean supplies, and not changing gloves or performing hand hygiene between different care tasks. Certified nurse aides (CNAs) were observed providing perineal care and assisting with transfers without adhering to hand hygiene requirements. For example, after removing gloves post-perineal care, CNAs did not perform hand hygiene before proceeding to other tasks like adjusting clothing, handling personal items, or bagging linens. In one case, a CNA used soiled gloves to retrieve and apply barrier cream from a resident's nightstand, then continued with other tasks without proper glove change or hand hygiene. These lapses occurred despite the facility's policies and professional standards requiring hand hygiene after glove removal and between resident care activities. Further deficiencies were noted in the technique of perineal care for male residents. Staff failed to retract the foreskin during cleaning, as required to remove smegma and reduce bacterial growth, which was later observed by a nurse during catheterization preparation. Interviews with administrative nursing staff confirmed that the observed practices did not meet the facility's expectations for infection control during high-contact care activities, including the use of appropriate PPE and adherence to hand hygiene protocols.
Failure to Honor Resident Dignity and Respect During Cares
Penalty
Summary
Facility staff failed to provide care in a manner that maintained and respected the dignity and individuality of a resident with intact cognition. During an observed care event, two CNAs and a nurse transferred the resident from a wheelchair to bed in preparation for a bladder scan and toileting. Despite the resident's explicit request to have the bladder scan performed before toileting cares, staff did not honor this request and proceeded with rolling the resident and changing the brief before conducting the scan. Additionally, during the care process, one CNA made an unprofessional and inappropriate comment referencing her own body while rolling the resident. The resident later confirmed hearing the comment and expressed that it was not professional. Facility policy requires staff to treat residents with dignity and respect at all times, and an administrative nurse confirmed that both the failure to honor the resident's request and the CNA's comment were unacceptable.
Failure to Ensure Call Bell Accessibility for Resident with Quadriplegia
Penalty
Summary
Staff failed to ensure that a resident with quadriplegia consistently had access to a call bell that could be activated independently. The resident's care plan specified the use of an easy call universal quadriplegic call bell, which could be activated by turning the head, or a soft touch call bell placed in the resident's hand while in bed. Despite this, multiple observations showed that after staff exited the resident's room, the call bell was left out of reach, either in the seat of the wheelchair or clipped to the pillowcase in a way that the resident could not activate it. The resident, who was cognitively intact, reported that staff often failed to leave the call bell within reach or accessible for activation. Interviews with staff confirmed that the expectation was for the call bell to be placed within the resident's reach and to ensure the resident could activate it. The failure to follow these procedures resulted in the resident being unable to call for assistance as needed.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident with diagnoses including psychosis, schizotypal disorder, and bipolar disorder, the facility did not code the presence of a serious mental illness in Section A1510 of the MDS, despite documentation supporting the diagnosis. Another resident with a suprapubic catheter had their MDS coded for both an indwelling and an external catheter in Section H0100, contrary to the manual's instructions to code only as an indwelling catheter. Additionally, a resident with a documented diagnosis of Parkinson's Disease and a new medication order for carbidopa-levodopa did not have this active diagnosis reflected in Section I of their quarterly MDS. These inaccuracies were confirmed by administrative and corporate staff during interviews, who acknowledged the failures in proper MDS coding. The deficiencies were identified through review of medical records, physician orders, and provider notes, which demonstrated discrepancies between the residents' documented conditions and the information entered into the MDS assessments.
Failure to Provide Timely Skin and Incontinence Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with impaired skin integrity and incontinence. Despite a care plan and physician's orders indicating the need for weekly skin assessments and regular check and change assistance for incontinence, staff did not identify or document multiple areas of skin breakdown on the resident's toes and feet. Observations confirmed the presence of purple and red abrasion-type wounds with open areas on both feet, which were not recorded in the weekly skin assessments, treatment administration record, or physician's orders. The facility's policy required full assessment and documentation of skin breakdown, but this was not followed for the resident in question. Additionally, the facility did not provide a policy on the process or frequency of incontinence care for residents requiring check and change. Documentation showed that the resident often received incontinence care only once or twice in a 24-hour period, with only one day where care was provided four times. The resident reported long intervals between changes, sometimes remaining wet for extended periods, which required full bed changes. The lack of routine incontinence care and failure to monitor and treat skin issues in a timely manner contributed to the deficiency.
Failure to Administer Insulin Timely and Ensure Medication Availability
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering rapid-acting insulin to a resident. The manufacturer's instructions for Humalog insulin specify that it should be administered within 15 minutes before or immediately after a meal. However, a nurse administered 10 units of Humalog to a resident at 11:57 a.m., but the resident did not receive their meal until 12:56 p.m., 53 minutes after the insulin was given. This delay in meal service after insulin administration could potentially lead to a hypoglycemic reaction. An administrative nurse confirmed that the expectation was for meals to be served within 15 minutes of administering rapid-acting insulin. Additionally, the facility failed to ensure the availability of routine, regularly scheduled medication for another resident diagnosed with congestive heart failure (CHF). The resident was prescribed Lasix, a diuretic, to be taken in the morning for CHF management. However, on one occasion, the medication was not available, and the resident did not receive their scheduled dose. The medication was resumed the following day. An administrative nurse verified that the resident did not receive the Lasix as scheduled, which could potentially exacerbate the resident's CHF condition.
Inadequate Toileting and Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide appropriate toileting and incontinence care for Resident A, who required staff assistance with toileting and check and change. According to the resident's care plan, they had a physical functioning deficit related to limited mobility and required assistance with toileting. However, a review of Resident A's check and change record over a 29-day period revealed significant lapses in care. On four days, the resident was not checked and changed for 24 hours, on six days, they were checked and changed only once in 24 hours, on fifteen days, they were checked and changed twice, and on four days, they were checked and changed three times in 24 hours. During an interview, Resident A expressed that their incontinent product was not changed for long periods, which was corroborated by the check and change records. An administrative staff member stated that the expectation was for staff to assist residents with toileting and check and change every 2-3 hours and per resident request. The failure to adhere to these expectations resulted in a deficiency, as it placed the resident at risk for skin breakdown, poor hygiene, and other complications associated with inadequate incontinence care.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to serve foods at palatable temperatures for two sampled residents who received meal trays in their rooms. According to the facility's policy, ready-to-eat foods that require reheating should be cooked to at least 135 degrees Fahrenheit for hot service. However, observations revealed that a CNA delivered a noon meal to a resident, who spit out the fish and refused to eat, stating the food was cold and often received cold meals. The CNA replaced the tray with a new one. Another observation showed a nurse removed a meal tray from a conveyor cart and delayed serving it to a resident, resulting in the fish stick being served at 120.5 degrees Fahrenheit, which the resident described as barely warm. Additionally, a confidential resident reported frequently receiving cold food and needing to request reheating. This failure to serve foods at acceptable temperatures may negatively impact residents' meal consumption.
Infection Control Lapses in Influenza Precautions and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, specifically concerning influenza precautions and hand hygiene. One resident, who tested positive for influenza, was not properly isolated as a staff member entered the room without wearing a mask, despite the physician's orders for contact and droplet precautions. This oversight in following the facility's policy on transmission-based precautions could potentially lead to the spread of infection. Additionally, another resident with a Foley catheter was subject to improper hand hygiene practices by a nurse. After attempting to change the resident's catheter bag, the nurse removed her gown and gloves but did not perform hand hygiene before assisting the resident with their meal. This failure to follow the facility's hand hygiene policy after glove removal and before handling food further exemplifies the lapses in infection control practices within 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 25 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 Fargo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Smp Health - St Catherine South | 0.6 mi | ★★★★★ | 0 | 0 |
| Bethany On University | 0.8 mi | ★★★★★ | 3 | 0 |
| Eventide Lutheran Home | 1.4 mi | ★★★★★ | 4 | 0 |
| Smp Health - St Catherine North | 2.4 mi | ★★★★★ | 4 | 0 |
| Fargo Elim Health Care Center | 2.4 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.