Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Tekakwitha Living Center during CMS and state inspections, most recent first.
Staff failed to follow hand hygiene, glove use, and sanitation practices during meal service. Dietary staff and a CNA repeatedly touched residents, wheelchairs, tables, carts, and their own clothing or hair while wearing the same gloves, then continued serving food and drinks without changing gloves or washing hands. The steam table water was observed dirty with food particles, sanitizer solution used for counters was not tested, and dishmachine wash temperatures and sanitizer levels were frequently not documented.
PBJ staffing data was not accurately completed or submitted to CMS for four fiscal quarters. CASPER review showed failed quarter submission and a one-star staffing rating, while staffing schedules and timecards showed licensed nursing coverage 24 hours per day and 8 continuous hours of RN coverage. The administrator knew the PBJ hours were not being reported, and the regional director confirmed the former HIM had been responsible for the reporting before resigning, with no PBJ reporting policy in the facility.
Residents did not receive mail daily because Saturday mail was not passed out until Monday. Residents reported the issue during a group meeting, while the activities director said the charge nurse received the mail on Saturdays and she delivered it after returning to work. The facility policy required mail and packages to be delivered within 24 hours, including Saturday deliveries.
Expired medications and treatments were found in a medication room and a medication cart. An opened PPD vial had no open date, and the north cart contained expired Novolog for a resident plus expired stock Senna Plus and liquid pain relief. An LPN said opened medications should be dated and discarded when expired, and the DON said medications should be checked for expiration before administration.
Infection control practices were not followed for cleaning an ice maker outside the kitchen and a mini refrigerator in a family room. The ice machine was observed with dirty powder-like residue, heavy water spotting, and rust, and the refrigerator contained melted ice cream spilled across all shelves. Staff interviews showed confusion about whether housekeeping, maintenance, or CNAs were responsible for cleaning these items, despite the facility checklist calling for daily ice machine cleaning and daily refrigerator temperature checks with cleaning and defrosting as needed.
The facility failed to designate a qualified infection preventionist for its infection prevention and control program. The DON stated she was overseeing the program but had not completed an approved IP course, and she confirmed she had also been responsible during the last recertification survey without having completed the course. Review of the infection control binder showed the provider did not have an infection preventionist.
Advance directive code status was not accurately reflected in the records for two residents. One resident’s chart and room signage showed full code even though a living will in the chart indicated DNR and the resident had hospice and DNR/DNI orders; another resident’s chart contained a discharged resident’s CPR directive, while the correct document elsewhere in the chart showed DNR. RN and DON interviews confirmed the records could have led to CPR being performed contrary to the residents’ wishes.
A resident with severe cognitive impairment, dementia, and high fall risk was sent alone to a dental appt via community transit and was left at the clinic by herself for 45 minutes. Her POA said she was notified only minutes before the appt and asked for it to be rescheduled, while the DON verified the resident should not have gone alone and that the appt should have been cancelled unless staff could accompany her. The facility had no policy for transporting residents to appts, and the resident did not have a signed specialty doctor’s appt form.
A resident who was grieving her husband’s death repeatedly expressed sadness and statements about wishing she had died before him during interview and wound care observation. The DON confirmed no Trauma Informed Care assessment had been completed, and the SSD could not locate one, stating she must have missed it. Facility policy identified traumatic loss of a loved one as a trauma survivor situation requiring Trauma Informed Care consideration.
Failure to employ a qualified dietary director. Staff reported there was no dietary manager in place, the restorative supervisor was working as the cook, and a CNA had briefly filled the role after the prior manager left. The administrator handled food ordering and dietary questions despite not being a CDM, while the regular RD was on maternity leave and the consultant RD only visited monthly.
Several cognitively intact residents were not informed of meal options in advance and were not consistently asked about their meal preferences, as menu postings and communication were lacking in one dining area. Additionally, the dietary manager was reported to have yelled and used foul language in front of residents and staff, creating an environment that was not respectful or dignified.
The facility did not maintain a clean and homelike environment, as evidenced by repeated observations of food debris, dirty tables, stained carpets, chipped paint, torn flooring, and a persistent ceiling leak with standing water in a basin. Staff interviews revealed confusion about cleaning responsibilities, especially after evening meals, and maintenance issues were not promptly resolved, leading to ongoing unclean and damaged conditions in resident areas.
The facility did not consistently follow food safety standards, as evidenced by improper storage of food items on the floor, undated and unlabeled open food in the freezer, and incomplete temperature and cleaning logs. Ongoing leaks from the dishwasher and sink were left unresolved for years, with buckets of discolored liquid and sludge found beneath the equipment. Staff interviews confirmed awareness of these issues, and facility policies requiring proper storage, labeling, and equipment monitoring were not followed.
A resident developed facility-acquired pressure ulcers due to inadequate care and failure to adhere to preventive measures. Despite being at high risk, the resident was not consistently repositioned, and necessary interventions like an air mattress and appropriate heel protectors were delayed. Staff acknowledged the ulcers were avoidable, and the facility's policy on regular repositioning and skin monitoring was not followed.
A resident with Alzheimer's disease engaged in woodworking activities in a facility's basement, leading to multiple accidents due to inadequate supervision. Despite a care plan requiring supervision while using an electric saw, the resident was often unsupervised, resulting in injuries. Staff interviews revealed a lack of ongoing assessments and inconsistent implementation of safety measures, contributing to repeated accidents.
The facility failed to have a qualified infection preventionist (IP) for at least two years. The DON had been acting as the IP without proper training or certification. Attempts to train a registered nurse for the role were unsuccessful, and the infection control program's records lacked a qualified IP's signature for annual reviews.
The facility failed to remove expired medications from the medication room, cart, and treatment cart in the north hall. An RN found expired aspirin, hydrogen peroxide, rubbing alcohol, oral glucose gel, Heparin syringes, Prevnar 13 vaccines, hand sanitizer, white petroleum packets, and Vaseline gauze. The DON admitted to not keeping up with removing expired medications, and pharmacy audits did not include checking for expired items, contrary to the facility's policy.
The facility failed to follow food safety guidelines, with incomplete temperature documentation for refrigerators and freezers, and improper food storage and labeling in the main kitchen. Despite staff education, logs were not consistently filled out, and outdated food items were found. The facility's policies on food storage and temperature monitoring were not adhered to.
Two nurses failed to follow appropriate infection control measures during pressure ulcer dressing changes for a resident on enhanced barrier precautions (EBP). LPN G did not perform hand hygiene between glove changes and transported the treatment cart into the resident's room. RN F did not change gloves or wash her hands after removing the resident's boot and sock before applying a new dressing. The DON confirmed the treatment cart should not have been taken into the room, and the facility's policies emphasized the importance of hand hygiene and barrier precautions.
A resident was transferred to the hospital after a fall, but the facility failed to provide a bed-hold notice to the resident or their representative. Staff interviews revealed confusion about who was responsible for notifying the resident, and the facility's policy lacked clarity on the timing of such notifications.
The facility failed to update care plans for two residents, one with a pressure ulcer and another with leisure interests in woodworking and driving a golf cart. Resident 23's care plan lacked documentation of interventions like an air mattress and wound care, while Resident 10's care plan did not address his leisure activities or include his supplemental woodworking plan in the EMR. These omissions led to deficiencies in meeting the residents' current needs.
Food Handling, Hand Hygiene, and Sanitization Lapses During Meal Service
Penalty
Summary
Staff failed to follow proper sanitation and food handling practices during meal service and kitchen operations. During interview, dietary aide/cook I stated that a premixed sanitizer solution was used to clean kitchen counters and tables, but the solution was not tested and no sanitizer testing strips were available to verify the sanitation level. The provider’s dishmachine log also showed repeated failures to document wash temperatures and sanitizer levels after meals across multiple months, and the administrator acknowledged that without documentation it could not be ensured that dishes or counters were being sanitized appropriately. During evening meal service in the north and east dining areas, dietary aide J repeatedly handled food and resident items with the same gloves after touching residents’ arms, wheelchair handles, cart handles, tables, and other surfaces. She used those same gloved hands to grab lettuce, place it in bowls, add dressing, and serve residents throughout the meal service. Restorative supervisor N was observed removing soups from the steam table while the water in the steam table appeared dirty and hazy with food particles floating in it, and both she and dietary aide J stated they were not sure how often the steam table needed to be cleaned. Additional observations during lunch service showed similar lapses. Restorative supervisor N did not wash her hands before putting on clean gloves and then handled food and utensils while serving residents. Dietary aide/cook I served drinks with gloves on, removed the gloves without washing hands, then put on a new pair of gloves and served bread. In the north dining room, dietary aide J and dietary aide/cook I touched residents, wheelchairs, chairs, tables, and resident items while wearing gloves and continued serving food and drinks without changing gloves or performing hand hygiene. CNA H also touched her hair, residents, resident items, and food while serving meals, and cook O removed gloves, did not wash hands, and continued plating food after touching her pants and other surfaces. The steam table in the north kitchenette was again observed with dirty water and food floating in it, and staff stated the steam table cleaning had been done without documentation.
PBJ Staffing Data Not Submitted Accurately
Penalty
Summary
The facility failed to ensure Payroll Based Journal (PBJ) staffing data was accurately completed and submitted to CMS for four federal fiscal quarters in 2025. CASPER data review showed the submitted PBJ data triggered a failed submission for the quarter and a one-star staffing rating, and items such as excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours per day were suppressed because no nursing hours were reported. Review of the facility’s October, November, and December 2025 staffing schedules and timecards showed licensed nursing coverage 24 hours per day and eight continuous hours of RN coverage, which did not match the PBJ data submitted to CMS. During interview, the administrator stated he knew the PBJ hours were not being reported and confirmed the staffing schedules were correct and met PBJ staffing requirements. He reported that the former HIM had been responsible for submitting the staffing data, but that employee stopped working at the facility in October 2024. The regional director stated he was aware the PBJ hours were not being completed, that the former HIM had resigned about a year earlier, and that the former administrator had not completed PBJ education before resigning in December 2025. The regional director also confirmed the PBJ staffing hours had not been submitted as required for the past four quarters, and the administrator stated there was no PBJ reporting policy in the facility.
Failure to Deliver Resident Mail Within Required Timeframe
Penalty
Summary
Residents did not receive their mail daily, and ten residents stated during a resident group meeting that they were not getting mail every day. They reported that mail was not delivered on Saturdays because there was no one available to pass it out, and the activities director usually delivered mail during the weekdays. Social services stated she expected residents to receive mail on Saturdays, while the activities director explained that on Saturdays the charge nurse would get the mail and she would pick it up on Mondays and deliver it because she did not work on Saturdays. A review of the facility’s Mail and Electronic Communication policy stated that mail and packages were to be delivered to residents within 24 hours of delivery on premises or to the facility’s post office box, including Saturday deliveries.
Expired Medications Found in Medication Room and Cart
Penalty
Summary
The facility failed to ensure proper storage and disposal of expired medications and treatments in one medication room and one medication cart. During observation of the medication room with an LPN, an opened Tuberculin PPD solution vial was found with no open date marked on the box or vial, even though it had been ordered from the pharmacy months earlier. The report stated that when the original seal of a manufacturer's container or vial is broken, the nurse is to place a date-opened sticker and enter the date opened and new expiration date. During observation of the north medication cart, expired medications were found in use: Resident 3's Novolog had expired and still had about one-third of the vial remaining, a stock bottle of Senna Plus had expired in November 2025 with approximately half the bottle remaining, and a stock liquid pain relief product had expired in December 2025 with approximately half the bottle remaining. The LPN stated that medications should have expiration dates when opened and should be discarded if expired, and the DON stated that medications were expected to be checked for expiration dates before administration and removed from the cart if expired.
Infection Control Lapses in Ice Maker and Family Room Refrigerator Cleaning
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because proper infection control practices were not followed for cleaning one ice maker located outside the kitchen and one mini refrigerator in the family room. On 1/20/26 at 1:00 p.m., the ice machine was observed to be unclean, with a dirty light green powder-like substance on the outside corners above the ice dispenser that fell off during ice dispensing, heavy water spotting on the splash guard, and visible rust on the metal grate above the water drain. On 1/21/26 at 9:35 a.m., the family room mini refrigerator contained a four-ounce serving of ice cream on the top shelf that had melted and spilled onto all the shelves in the refrigerator. Interviews on 1/22/26 showed that staff were unsure who was responsible for cleaning these items. A housekeeper stated she did not think cleaning the family room refrigerator or ice machine was her responsibility and said her duties were outlined in a notebook. An LPN was not sure whether housekeeping or maintenance was responsible for cleaning the refrigerator or ice machine. The maintenance lead, who said he had been employed less than a year and was the housekeeping supervisor, reported he had not received much training, stated housekeeping staff were responsible for cleaning the family room refrigerator, and said maintenance was only responsible for blowing dust off the top of the ice maker. The DON also stated she was unsure who was responsible for cleaning the ice maker and was not sure whether CNAs or housekeeping were responsible for the family room refrigerator. The facility's undated housekeeping checklist stated to clean the ice machine daily and to check room refrigerator temperatures daily, cleaning and defrosting fridges as needed. The February 2025 Infection Control and Prevention policy stated its purpose was to establish comprehensive guidelines for preventing and controlling infections within the facility and to adhere to evidence-based practices for infection control.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. During an interview on 1/22/26 at 12:25 p.m., the DON stated that she was in charge of the facility's infection prevention program but had not completed an approved infection preventionist course. She reported that she had been working on the course but had not found the time to complete it, and confirmed that she had overseen the facility's infection prevention program during the last recertification survey without having completed the course then as well. Review of the infection control program binder showed that the provider did not have an infection preventionist.
Advance Directive Code Status Not Accurately Reflected in Records
Penalty
Summary
The provider failed to protect residents’ rights and ensure advance directive code status wishes were accurately identified in the medical record for two residents. For one resident, the paper chart and room signage indicated full code status because a heart-with-stethoscope logo was present, and an advance directive in the chart was signed indicating CPR, but a living will behind it stated the resident was DNR. RN E stated she would not have performed CPR because she knew the resident was DNR and had been admitted to hospice, but also stated that someone unfamiliar with the resident could have performed CPR based on the chart and logo because it had not been updated. The resident had moderate cognitive impairment, was admitted to hospice, and had orders for DNR/DNI, along with diagnoses including a left femur fracture, stage four pressure ulcer, osteomyelitis, and CHF. For the second resident, the paper chart did not have the heart-with-stethoscope logo, and RN E initially found an advance directive in the chart indicating CPR should be performed, but it belonged to a discharged resident. The correct advance directive was found on the backside of another page and indicated the resident was DNR. RN E verified that the wrong resident’s advance directive in the chart could have caused an error and CPR could have been performed when it should not have been. This resident had moderate cognitive impairment, an order for DNR, and a diagnosis of CHF. The DON stated that changes to advance directives were sometimes missed and not updated, and confirmed that the first resident’s chart and room logos should have been updated and that the discharged resident’s advance directive should not have been in the second resident’s chart.
Inadequate Supervision for Dental Appointment
Penalty
Summary
The nursing home failed to provide adequate supervision for a resident with severe cognitive impairment and high fall risk when she was sent to a dental appointment alone. The resident had a BIMS score of 3, diagnoses including dementia and a prior left femur fracture, and was documented as needing supervision and assistance with all decision making. Her care plan also noted she could become physically aggressive related to dementia and required intervention before agitation escalated and redirection away from distress. The resident’s granddaughter/power of attorney stated she was called only minutes before the appointment and asked the staff member to reschedule because she could not attend. She later received a call from the dental clinic asking why the resident was there by herself, and the resident had ridden community transportation alone and remained at the clinic alone for 45 minutes. The DON verified the resident was sent to the appointment by herself and stated she should not have gone alone and that the appointment should have been cancelled unless staff could accompany her. The facility also did not have a policy regarding taking residents to appointments, and the resident did not have a signed specialty doctor’s appointments form because she was admitted before the form was implemented.
Missing Trauma Informed Care Assessment After Bereavement
Penalty
Summary
The facility failed to complete a Trauma Informed Care assessment for one sampled resident after the resident experienced the loss of a loved one. During an interview, the resident repeatedly spoke about her husband’s death, stating, “I should have died before him,” identifying his shirt, and saying she had to keep busy so she would not think about him. During observation of wound care, the resident again repeated how sad she was that her husband was not there with her. The DON confirmed the resident did not have a Trauma Informed Care assessment completed and stated the SSD was responsible for completing those assessments. The SSD later could not find a Trauma Informed Care assessment for the resident and stated, “I must have missed that one,” explaining that she completed it on admission and as needed, while the mood assessment was completed quarterly within the MDS. The facility policy stated Trauma Informed Care should address residents’ experiences and preferences and include trauma survivors such as those with traumatic loss of a loved one.
Failure to Employ a Qualified Dietary Director
Penalty
Summary
The facility failed to employ a full-time, qualified registered dietitian or dietary manager to serve as the director of food and nutritional services. During interviews, dietary staff and the restorative supervisor stated that there was no dietary manager in place, and the restorative supervisor was working as the dietary cook after previously serving in that role. Staff reported that after the prior dietary manager quit, a CNA temporarily took over for a few weeks before returning to CNA duties. The administrator was ordering food for the kitchen based on what staff wrote down for him, and when asked who could answer dietary questions, the administrator stated that it would be him, although he was not a CDM. Staff also reported that the regular RD was on maternity leave, with a covering RD and a consultant RD who came monthly, but no full-time qualified dietary leader was identified.
Failure to Promote Resident Self-Determination and Maintain Respectful Environment
Penalty
Summary
The facility failed to promote residents' right to self-determination and maintain a respectful environment, as evidenced by multiple observations and interviews. Four cognitively intact residents who dined in the east dining room reported being unaware of planned meal options or available food choices until meal service began. Observations confirmed that menu choices were not posted in the east dining room, and staff did not consistently ask residents about their meal preferences prior to serving. There was also confusion among staff regarding who was responsible for offering meal choices, and meal identification tray cards were not being used as required. Additionally, the dietary manager (DM) was reported by staff and residents to have yelled and used foul language in front of residents and other staff members. Several staff members described incidents where the DM was verbally aggressive, used profanity, and displayed disruptive behavior such as slamming items. Residents witnessed these outbursts, which made them feel uncomfortable and concerned for the staff involved. Some staff reported these incidents to management, while others did not, and there was a lack of documentation regarding the facility's response to these events. The facility's policies require that all residents be treated with kindness, respect, and dignity, and that staff model effective communication. Despite these requirements, the DM's behavior and the lack of clear communication regarding meal choices resulted in residents not being fully supported in exercising their rights. The events described involved residents who were cognitively intact and able to express their preferences and concerns, yet their rights to self-determination and a respectful environment were not upheld.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as required, with multiple observations of uncleanliness and disrepair in resident common areas. Surveyors observed food crumbs and debris on dining room floors, dirty tables, and persistent coffee-like stains on countertops. A pink foot soak basin with discolored standing water was repeatedly seen on the floor, collecting water from a ceiling leak, and missing ceiling tiles were noted around the leak. Stains and damage were also observed on carpeting throughout hallways and common areas, including large, visible stains and areas with missing or chipped paint, torn flooring, and missing trim. Interviews with dietary and housekeeping staff revealed confusion and lack of clarity regarding cleaning responsibilities, particularly after the evening meal. Dietary staff indicated they were responsible for wiping tables and sweeping floors after supper, while housekeeping staff stated they cleaned tables and floors after breakfast and lunch but were unsure who was responsible in the evenings. Maintenance staff acknowledged awareness of the roof leak and indicated plans to address it, but the issue persisted over several days as evidenced by repeated observations of the basin collecting water. A review of facility policies confirmed the expectation for a clean, orderly, and safe environment, with specific routines for cleaning floors, carpets, and congregate areas, and requirements for prompt attention to spills and damage. Despite these policies, the facility did not ensure that cleaning and maintenance tasks were completed as required, resulting in ongoing environmental deficiencies in areas frequented by residents.
Failure to Follow Food Safety Standards and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to food safety standards regarding the storage, labeling, and monitoring of food and equipment in the kitchen. Observations revealed multiple food items, such as boxes of juice and a dented soup can, stored directly on the floor in the storage room. Several open and undated bags of food, including fish patties, steak patties, cheese omelets, and mini corn dogs, were found in the walk-in freezer. Additionally, a puddle of liquid was observed on the floor inside the walk-in refrigerator, creating a slipping hazard. Temperature logs for refrigeration units and chemical sanitizing dishwashers showed missing documentation on several dates, indicating a lack of consistent monitoring. Further inspection of the dishwashing area revealed ongoing equipment issues, including a leaking dishwasher and a leaking sink drain, both of which had been present for an extended period. Buckets containing discolored liquid and sludge were found under the dishwasher and sink, and hard water stains were noted on the floor. Staff interviews confirmed that the dishwasher and sink had been leaking for up to three years, with maintenance and dietary staff aware of the issues but not resolving them. The dietary manager was responsible for posting and monitoring cleaning and task checklists, but documentation was incomplete or missing for several days, indicating lapses in routine cleaning and maintenance procedures. The facility's policies required that food be stored off the floor, covered, labeled, and dated, and that refrigeration and dishwashing equipment be regularly monitored and documented. However, these standards were not consistently followed, as evidenced by the improper storage of food, lack of labeling and dating, incomplete temperature and cleaning logs, and unresolved equipment leaks. These deficiencies were identified through complaint report review, direct observation, staff interviews, and policy review.
Failure to Prevent Facility-Acquired Pressure Ulcers
Penalty
Summary
The provider failed to prevent a resident from developing facility-acquired pressure ulcers. The resident, identified as having a moderate to high risk for pressure sores, developed a pressure ulcer on the heel and sacrum. Interviews with staff revealed that the resident was not consistently repositioned, which contributed to the development of these ulcers. The Director of Nursing (DON) and other staff acknowledged that the pressure ulcers were avoidable and that interventions such as changing the bed and mattress, and using appropriate heel protectors, were not implemented in a timely manner. Observations and interviews indicated that the resident's care was inadequate, with issues such as the removal of a 'turn and reposition clock' by CNAs and the late implementation of an air mattress. The resident's sacral ulcer worsened significantly over time, indicating a lack of effective preventive measures. The facility's policy required regular repositioning and immediate reporting of skin changes, which were not adhered to, leading to the resident's condition worsening.
Inadequate Supervision of Resident's Woodworking Activities
Penalty
Summary
The provider failed to implement effective precautions and interventions to ensure the safety of a resident with Alzheimer's disease who engaged in woodworking activities in the facility's basement. Despite having a care plan that required supervision while using an electric saw, the resident was often unsupervised, leading to multiple accidents. The resident had a history of cognitive decline and had suffered several injuries, including cuts and bruises, while working with woodworking equipment. Interviews with staff revealed that the resident was assessed for his ability to safely pursue woodworking activities, but ongoing assessments were not conducted despite his Alzheimer's diagnosis. The resident's care plan included interventions such as using a walkie-talkie to communicate with staff and wearing safety gloves, but these measures were not consistently followed. Staff members acknowledged that the resident often worked unsupervised and that there was no video monitoring in place to ensure his safety. The facility's policy on resident safety during leisure tasks was not effectively implemented, as evidenced by the lack of follow-up assessments and incident analyses for the resident's accidents. The resident's electronic medical record documented several incidents of injury, but no incident reports were provided by the facility. The failure to adequately supervise and assess the resident's woodworking activities contributed to repeated accidents and injuries.
Lack of Qualified Infection Preventionist
Penalty
Summary
The provider failed to designate a qualified infection preventionist (IP) for the facility, as revealed through interviews and record reviews. The Director of Nursing (DON) had been acting as the IP for the past two years without the necessary training or certification. Despite attempts to have a registered nurse complete the required program, the facility had not succeeded in appointing a qualified IP. The infection control program's records showed that the annual review signature form had not been signed by a qualified IP for at least two years, indicating a lack of compliance with infection prevention and control requirements.
Expired Medications Not Removed from Storage Areas
Penalty
Summary
The facility failed to ensure that expired medications were removed from the medication room, medication cart, and treatment cart in the north hall. During an observation and interview with a registered nurse, it was found that several expired medications were present, including aspirin, hydrogen peroxide, isopropyl rubbing alcohol, oral glucose gel, Heparin injectable syringes, Prevnar 13 vaccines, hand sanitizer, white petroleum packets, and Vaseline gauze. The registered nurse acknowledged that medication expiration dates should have been checked before administration and that expired medications should have been removed. The director of nursing admitted to not keeping up with the removal of expired medications from the medication rooms and carts, although they should have been removed and destroyed. It was also confirmed that pharmacy audits were conducted, but these audits did not include checking for expired medications. The facility's policy on medication storage stated that no discontinued, outdated, or deteriorated drugs or biologics should be available for use and that all such drugs should be destroyed. However, the pharmacy audits conducted in May and June did not address outdated medications.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The provider failed to adhere to necessary food safety guidelines in the main kitchen, as observed during a survey. The documentation for refrigerator and freezer temperatures was incomplete, with missing entries for several days in April, May, June, and July 2024. Despite regular education provided to staff on the importance of temperature documentation, the logs were not consistently filled out. Interviews with kitchen staff and the dietary manager confirmed the lack of documentation, and verbal warnings had been issued to staff who failed to comply. The facility's policy required daily monitoring and recording of temperatures, but this was not followed. Additionally, food storage and labeling practices were inadequate. Observations revealed improperly stored and labeled food items, including opened packages without use-by dates and outdated food in refrigerators. Uncovered food items were also found, and the dietary manager acknowledged that these items should have been covered, dated, and discarded if outdated. The facility's food storage policy required proper labeling, dating, and covering of food items, but these procedures were not consistently implemented, leading to the presence of outdated and improperly stored food.
Infection Control Deficiency in Wound Care
Penalty
Summary
The provider failed to ensure appropriate infection control measures during pressure ulcer dressing changes for two nurses, LPN G and RN F. During an observation of LPN G's wound care for a resident on enhanced barrier precautions (EBP), it was noted that she prepared wound care materials at the nurses' station without gloves, transported the treatment cart into the resident's room, and did not perform hand hygiene between glove changes. She applied a soaked gauze and a sacral dressing to the resident's wound without washing her hands or using hand sanitizer after cleaning the wound. Similarly, RN F, while changing a heel dressing for the same resident, did not change gloves or wash her hands after removing the resident's boot and sock before applying a new dressing. She also expressed uncertainty about whether the treatment cart should have been taken into the room for a resident on EBP. The Director of Nursing (DON) expressed frustration over the nurses' failure to perform hand hygiene, which is considered standard care, and confirmed that the treatment cart should not have been taken into the resident's room. The facility's undated pressure ulcer prevention and wound care policy emphasized the importance of meticulous handwashing and maintaining a clean environment during dressing changes. The enhanced barrier precautions policy outlined the need for gown and glove use during high-contact resident care activities for residents with wounds, highlighting the risk of transmission of multidrug-resistant organisms (MDROs).
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The provider failed to provide bed-hold notices to a resident and/or their representative during a transfer to the hospital. The deficiency was identified for one of two sampled residents. The resident, who had fallen and sustained a fractured right femoral head, was transferred to the emergency room and subsequently to a local hospital for further evaluation. Despite the transfer, there was no written notification provided to the resident or her representative regarding the bed hold policy. Interviews with staff revealed a lack of clarity and execution in the notification process. RN F admitted to not notifying the resident or their representative about the bed hold notice, and the charge nurse was expected to handle this task. The director of nursing and the administrator confirmed that the charge nurse should have completed the bed hold form at the time of transfer, but this was not done. The facility's bed hold policy, which was undated, did not specify when the notification should be given, contributing to the oversight.
Deficiencies in Care Plan Updates for Residents with Pressure Ulcer and Leisure Interests
Penalty
Summary
The provider failed to ensure that the care plans for two residents were revised to reflect their current needs. Resident 23, who had a pressure ulcer, was observed in bed with interventions such as an air mattress and bunny boots that were not documented in his care plan. Interviews with staff revealed that changes to his bed and mattress were made due to issues with his previous bed, but these changes were not updated in his care plan. Additionally, interventions for his wound care were not noted in the care plan, despite changes being made to improve his condition. Resident 10, who had leisure interests in woodworking and driving a golf cart, did not have these activities addressed in his comprehensive care plan. Although he had a supplemental paper care plan for woodworking, it was not included in the electronic medical record (EMR). Interviews with staff indicated that his ability to safely operate the golf cart and pursue woodworking activities had been assessed, but these assessments were not reflected in his comprehensive care plan. Furthermore, his care plan did not address his goals, preferences, strengths, weaknesses, or needs related to these leisure activities. The facility's policy on care plans requires that they include measurable objectives and timetables to meet the resident's needs and reflect current standards of practice. However, the care plans for both residents 23 and 10 were not updated to include significant changes in their care and activities, leading to deficiencies in meeting their current needs. The interdisciplinary team responsible for reviewing and updating care plans did not ensure that these updates were made, resulting in a failure to provide comprehensive and individualized care for these residents.
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Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sisseton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Browns Valley Health Center | 11.9 mi | ★★★★★ | 7 | 1 |
| Wilmot Care Center Inc | 19.9 mi | ★★★★★ | 0 | 0 |
| Strand-kjorsvig Community Rest Home | 24.5 mi | ★★★★★ | 0 | 0 |
| Traverse Care Center | 28.5 mi | ★★★★★ | 7 | 0 |
| St Gerard's Community Of Care | 28.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.