Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Dunklau Gardens during CMS and state inspections, most recent first.
A staff member prepared beef stew by adding unmeasured amounts of meat, vegetables, and spices, rather than following the required recipe with specific ingredient measurements. The Registered Dietician confirmed that the recipe was not followed, which altered the nutritive value of the food served to all residents.
Surveyors found that two residents did not receive pressure-reducing devices as ordered, with staff failing to apply heel boots or offload heels despite care plans and physician orders. Additionally, two residents using insulin pens did not have their pens dated upon opening, contrary to facility policy and manufacturer instructions. These deficiencies were confirmed through observations, record reviews, and staff interviews.
Staff did not perform required hand hygiene when changing gloves during incontinence care and treatment for two residents with impaired skin integrity, despite facility policy and CDC guidelines. Both residents were dependent on staff for care, and staff interviews confirmed that hand hygiene should have been performed during glove changes.
The facility did not ensure that recipes were followed during food preparation, affecting all 72 residents. Observations showed deviations in cooking temperatures and ingredient measurements for Basil & Chive Chicken and Hungarian Goulash. Unapproved ingredients, such as Italian dressing, were used instead of the required marinade. Additionally, the kitchen had multiple sanitation issues, including unclean surfaces, ceiling tiles, ventilation covers, and equipment. There was a buildup of food debris, oily smears, and fuzzy substances, indicating inconsistent completion of scheduled sanitization tasks.
Failure to Measure Ingredients and Follow Recipe in Food Preparation
Penalty
Summary
Staff member A prepared beef stew without measuring any of the ingredients, including precooked beef, celery, onions, frozen peas, frozen carrots, and frozen diced potatoes, instead adding them directly from their containers or bags. Spices were also added by pouring an unmeasured amount into the lid of the spice jar and then into the pan. The recipe for 'Beef Stew Old Fashioned' required specific measured amounts for each ingredient, but these instructions were not followed. The Registered Dietician confirmed that the recipe was not followed and that ingredients were not measured, which would result in a change in the nutritive value of the food. The Admissions Coordinator confirmed that all residents consume food prepared in the kitchen.
Failure to Implement Pressure-Reducing Devices and Insulin Pen Dating
Penalty
Summary
The facility failed to implement pressure-reducing devices as ordered for two residents at risk for skin breakdown. One resident with severe protein-calorie malnutrition, dementia, and a stage 2 pressure ulcer of the sacral region had physician orders and care plans specifying the use of Prevalon heel boots at all times except during care. Despite documentation indicating compliance, multiple observations revealed the resident was not wearing the boots while in a wheelchair, and staff interviews confirmed a misunderstanding of the order, with nursing assistants believing the boots were only required at night. Another resident with diabetes, chronic kidney disease, and lymphedema had orders for heel offloading and off-loading boots when in bed. Observations over several days showed the resident did not have heels offloaded or boots in use, and staff confirmed the interventions were not being implemented as ordered. Additionally, the facility failed to ensure insulin pens were dated when opened for two residents requiring daily insulin injections. Facility policy and manufacturer instructions require insulin pens to be dated upon opening and discarded after 28 days. Observations and interviews confirmed that insulin pens in use for both residents did not have open dates, and staff, including the DON, acknowledged that this practice was not being followed, despite it being outlined in facility policy. These deficiencies were identified through record reviews, direct observations, and staff and resident interviews. The failures involved not following physician orders and facility policies regarding pressure injury prevention and medication management, specifically the use of pressure-reducing devices and proper labeling of insulin pens.
Failure to Perform Hand Hygiene During Glove Changes in Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene during incontinence care and treatment for two residents, as observed and confirmed through interviews and record reviews. For one resident with a stage 2 pressure ulcer and a history of incontinence, a medication aide performed perineal care without changing contaminated gloves before reaching into a wipes container and did not perform hand hygiene after removing gloves before applying barrier cream. Facility policies and CDC guidelines require hand hygiene before donning and after removing gloves, as well as glove changes between tasks from contaminated to clean areas, but these were not followed during the observed care. In a separate incident, another resident with impaired skin integrity and a history of incontinence was assisted by a medication aide who changed gloves without performing hand hygiene before applying barrier cream. Interviews with staff, including the RN, unit leader, and DON, confirmed that hand hygiene should be performed when changing gloves, but this was not done during the observed care. Both residents were cognitively intact and dependent on staff for activities of daily living, and their care plans included interventions for proper hand washing technique before and after care.
Non-Adherence to Recipes and Sanitation Protocols in Food Preparation
Penalty
Summary
The facility failed to ensure recipes were followed during food preparation and maintain proper kitchen sanitation practices, potentially affecting all 72 residents consuming food from the kitchen. During observations, it was noted that the Cook did not follow the specified recipes for Basil & Chive Chicken and Hungarian Goulash, deviating from cooking temperatures and ingredient measurements. The Cook also used unapproved ingredients like Italian dressing instead of the required marinade, indicating a lack of adherence to standardized recipes and procedures. Furthermore, the kitchen was found to have multiple sanitation issues, including unclean surfaces, ceiling tiles, ventilation covers, and equipment. The observations revealed a buildup of food debris, oily smears, and fuzzy substances on various kitchen surfaces, indicating a lack of proper cleaning and maintenance practices. The facility's scheduled sanitization tasks were not being consistently completed, as evidenced by the outdated completion date of the Kitchen, Dishroom, Wall & Cafe Vents log sheet, and the lack of adherence to the Equipment/Areas to Clean log for deliming and cleaning equipment.
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 142 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 Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nye Legacy Health & Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Nye Pointe Health & Rehab Ctr | 1.1 mi | ★★★★★ | 7 | 0 |
| Arbor Care Center-valhaven, Llc | 12.4 mi | ★★★★★ | 29 | 0 |
| Life Care Center Of Elkhorn | 17.6 mi | ★★★★★ | 27 | 0 |
| Crowell Memorial Home | 19 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Dunklau Gardens.
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.