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 Burnett Medical Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities accused staff of beating them while staff were assisting the resident who was attempting to stand unassisted. Nursing staff documented the resident’s repeated verbal accusations and agitated behaviors and notified the DON during the night shift, and staff completed written statements and continued working. Despite a facility policy requiring that abuse allegations be reported immediately, but no later than 2 hours, to the State Agency and that law enforcement be notified of any reasonable suspicion of a crime, the DON did not report the allegation to the State Agency or police within the required timeframe and did not remove involved staff from resident care during the investigation.
A resident with severe cognitive impairment and multiple medical conditions accused staff of "beating" him during an episode of agitation, but the facility failed to follow its abuse policy requiring a thorough investigation. Although the nurse notified the DON and staff later reported the resident recanted the allegation, there was no documented full body or skin assessment for injuries and no comprehensive investigation, such as interviews with other residents or staff beyond written statements from those directly involved. Surveyor observations and interviews with other residents and staff later showed no visible signs of abuse and no reported concerns, but the required investigative steps were not completed or documented.
The facility failed to monitor resident-specific target behaviors for psychotropic medication use for three residents. One resident with dementia, anxiety, and traumatic brain dysfunction had quetiapine and sertraline orders, but the record lacked documentation of agitation, depression, or sleep concerns and staff said behaviors were not routinely tracked. Another resident with depression, anxiety, PTSD, and mood disorder was on quetiapine, trazodone, bupropion, and duloxetine, yet the chart had no behavior monitoring for sleep, depression, or anxiety. A third resident with vascular dementia, anxiety, and depression had quetiapine for agitation, but no agitation was documented and the DON could not find behavior monitoring.
Missing Code Status and Advance Directive Documentation: The facility failed to document advance directives and code status for two residents. One resident with multiple serious diagnoses had no physician order or advance directive showing DNR status in the EMR, despite staff stating the resident was DNR. Another resident had no code status documented in the EHR or full-code binder, even though outside discharge paperwork showed full code. Staff and the DON acknowledged the documentation was missing.
The facility did not provide complete written transfer or discharge notices for two residents. One resident’s hospital transfer notices lacked the specific reason for transfer, the daily bed hold rate, and appeal rights information, and another resident’s discharge record did not include documentation that the Ombudsman was notified.
Failure to Update Fall Interventions After Repeated Falls: A resident with severe cognitive impairment, dementia, and a history of falls had repeated falls, including falls in her room and dining room. Incident reports documented assessments, VS, and assistance back to bed or chair, but did not identify a root cause or add immediate fall-prevention interventions to the care plan. IDT notes later showed multiple falls in the month, yet no root cause was identified and the active care plan was not updated with specific fall interventions.
Unlocked Medication Cart and Controlled Substance Storage Issue: A medication cart was left unlocked and unattended in a hallway while staff walked by, and liquid lorazepam was found in an unlocked refrigerator in the medication storage room. An LPN stated the cart should have been locked when unattended, and the RN confirmed lorazepam should be double locked as a controlled substance. The DON was unsure whether the current storage setup met the requirement.
The facility failed to maintain infection prevention and control practices during direct care and a glucose sensor change. A CNA provided toileting and peri-care for a resident on EBP without wearing a gown, despite a door sign indicating gown and glove use for direct care. In a separate event, an LPN removed a contaminated Libre sensor and then applied a new sensor without performing hand hygiene and changing gloves between the dirty and clean tasks.
A resident with atrial fibrillation, aortic valve insufficiency, CHF, and moderate cognitive impairment experienced a significant change in condition, including new weakness, confusion, labored respirations, a flaccid left arm, unequal and weak left hand grasp with swelling, and disorientation. Staff documented the event and contacted a family member, who agreed the resident would remain in bed rather than go to the ER, but there was no documentation that the provider was notified. The IDON and an RN confirmed in interviews that the physician should have been called for this change in condition, and facility policy required prompt notification of the attending physician or provider for significant changes in physical, emotional, or cognitive status.
A resident with CHF, chronic kidney disease, and a history of UTIs, and with moderately impaired cognition per BIMS, experienced a change in condition characterized by altered talking and walking ability and incontinence while sitting in a chair. After a family member requested hospital evaluation, the resident was sent to the ER and was admitted with sepsis. The IDON could not locate any transfer notice for this episode, despite acknowledging that a transfer notice including nursing assessment, vital signs, and other pertinent information should have been completed before transfer. Review of facility policy showed that changes in condition and events must be fully and accurately documented, but no such transfer documentation was found for this resident.
Two residents were affected by a failure to maintain complete and accurate medical records when a fall incident was not fully documented. A resident with cardiac conditions and moderate cognitive impairment fell from bed after tripping on blankets, and an incident note recorded the fall, lack of visible injury, and notifications to the physician and family, but omitted vital signs and neuro checks at the time of the event. An RN later reported having performed initial and subsequent neuro checks but did not document them until two days later due to a busy shift, and the IDON confirmed that the record was incomplete and that the assessments should have been recorded at the time of the fall.
A resident with brittle diabetes did not consistently receive insulin and hypoglycemia treatment as ordered, with staff administering alternate doses based on the resident's requests and failing to notify the provider of medication refusals or abnormal blood glucose levels. Documentation was lacking for provider communication and follow-up actions after both hypoglycemic and hyperglycemic events, and interviews confirmed that staff were not adhering to facility policy or physician orders regarding diabetic management.
The facility failed to maintain an effective infection control program, with incomplete infection surveillance logs and improper use of PPE. Staff were observed mishandling medications and neglecting hand hygiene during wound care, compromising infection control standards.
A survey found that a facility failed to label medications with open dates, leading to potential use of expired drugs for several residents. Insulin pens, Timolol drops, and other medications lacked proper labeling, with pharmacy labels covering expiration dates. Staff interviews confirmed the oversight, acknowledging the risk of administering expired medications.
The facility failed to maintain residents' dignity during meal assistance, as staff used clothing protectors instead of napkins to wipe residents' faces. Three residents with cognitive and physical impairments were affected, with staff repeatedly using clothing protectors inappropriately during meal times. The DON acknowledged this practice was not respectful.
A resident's APOA reported a missing personal item, but the facility failed to document, investigate, or resolve the grievance as per its policy. Despite acknowledging the issue, staff did not consider it a grievance, and no documentation was found. The Social Services Manager admitted the practice did not align with the facility's grievance policy.
A resident with an indwelling catheter did not have a comprehensive care plan developed by the facility. Despite the nursing staff being aware and providing care, the care plan lacked documentation of the catheter and necessary care instructions. The oversight was attributed to the catheter's temporary nature.
The facility failed to revise and implement care plans for two residents, leading to deficiencies in fall prevention. One resident's care plan required 30-minute checks after falls, but there was no documentation to confirm these were done. Another resident's care plan required 15-minute checks, but again, no evidence was found to verify completion. The DON acknowledged the lack of documentation for these interventions.
A resident with multiple diagnoses had a pharmacy recommendation to lower their Seroquel dose that was not acknowledged by a physician. The facility's RN and DON could not provide documentation of a provider response, citing delays from the VA hospital and the DON's newness in the role as contributing factors.
A resident was prescribed and administered an antibiotic for a UTI without documented symptoms or lab results to justify its use, contrary to the facility's Antimicrobial Stewardship Program and Loeb criteria. The Infection Preventionist acknowledged that physicians sometimes prescribe antibiotics based on their judgment, even if it conflicts with the policy, posing a potential risk to resident safety.
The facility exceeded the acceptable medication error rate, with errors involving insulin and Morphine administration. An RN failed to hold an insulin injection for the required time, and an LPN did not check the expiration date of Morphine. The DON confirmed expectations for medication labeling and administration, but specific policies were lacking.
Failure to Timely Report Resident’s Allegation of Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse reporting policies and procedures in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours, to the State Agency and local law enforcement. Facility policy titled “Abuse, Neglect, Mistreatment and Misappropriation of Resident Property,” revised 07/10/25, requires that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, be reported immediately, but not later than 2 hours after the allegation is made, to the administrator and the DQA, and that local law enforcement be notified of any reasonable suspicion of a crime against a resident. On 03/22/26, a resident with diagnoses including adult failure to thrive, type 2 DM, emphysema, bipolar disorder, depression, and generalized anxiety, and with a BIMS score of 3/15 indicating severe cognitive impairment and a PHQ-9 score of 5 indicating mild depression, made statements accusing staff of beating them while staff were assisting the resident who was attempting to stand unassisted next to the bed. Progress notes documented that at 0115 the resident was attempting to self-transfer, and staff guided the resident to a safe seated position. The resident then made repeated accusations toward staff, stating, “You’re beating me,” used profane language, and continued yelling, kicking, and making accusations while staff attempted to reassure and de-escalate. The RN notified the DON at 0250 about the incident and the resident’s statements and behavior. In interview, the RN stated that the incident was immediately reported to the DON and that written statements were obtained from staff, and staff continued working the remainder of the shift. In a separate interview, the DON confirmed being notified around 2:30 AM, acknowledged that staff reported the resident had been agitated and was then calm, and stated that the allegation was not reported to the State Agency or police within 2 hours and that staff were not removed from resident care while the investigation was pending. The facility therefore did not report the allegation of physical abuse to the State Agency or local law enforcement within the required 2-hour timeframe.
Failure to Thoroughly Investigate Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff abuse made by one resident. The facility’s abuse policy, revised 07/10/25, requires an immediate and thorough investigation of any reported incident, including collecting and preserving physical and documentary evidence, interviewing the alleged perpetrator, identifying and interviewing other staff or residents who may have witnessed the incident, interviewing staff from previous shifts, and assessing the resident for injuries. The resident involved (R1) had diagnoses including adult failure to thrive, type 2 diabetes mellitus, emphysema, bipolar disorder, depression, and generalized anxiety, with a BIMS score of 3/15 indicating severe cognitive impairment and a PHQ-9 score of 5 indicating mild depression. On 03/22/26 at approximately 1:15 AM, nursing staff documented that R1 was attempting to stand unassisted, became verbally aggressive, and repeatedly accused staff of “beating” him while yelling, kicking, and using profane language. The nurse notified the DON at 2:50 AM of the incident and the resident’s statements. Despite this allegation, record review showed no documentation of a post-incident skin or full body assessment for R1 and no documentation of an investigation in R1’s medical record. The DON later stated that she interviewed R1 on the following Monday and that R1 recanted the allegation and said staff did not hurt him and that he wanted to be left alone. The DON also stated that no additional interviews were conducted with other residents or staff beyond obtaining written statements from the staff involved. Surveyor interviews with other residents and staff on 04/29/26 revealed that they denied knowledge of abuse and reported feeling safe, and observations of R1 that day showed him calm in his wheelchair without visible signs of physical abuse. However, the lack of a documented resident assessment for injuries and the absence of comprehensive interviews with staff and other residents meant the facility did not follow its own policy to conduct a thorough investigation of the abuse allegation.
Failure to Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility did not ensure that 3 of 4 residents reviewed were free from chemical restraints because it did not monitor resident-specific targeted behaviors related to psychotropic medication use for R14, R4, and R1. The report states there was no evidence the facility was tracking targeted behaviors to assess the therapeutic effects of the psychotropic medications or to ensure the residents were receiving the desired benefits and lowest possible dose. Facility policies on depression and antipsychotic medication use required staff to gather, document, observe, and report information about resident behavior, mood, function, and the effectiveness of interventions, including psychotropic medications. R14 was admitted with diagnoses including traumatic brain dysfunction, Alzheimer’s disease with late onset, non-Alzheimer’s dementia, and anxiety disorder. R14’s orders included quetiapine for sleep and sertraline for anxiety, and the care plan addressed behavior management and undesirable behaviors. However, the record reviewed by the surveyor contained no documentation of agitation, depression, or sleep concerns in the TAR, MAR, or orders, and the CNA task list did not include targeted behavior monitoring or nonpharmacological interventions. Staff interviews reflected that they would notify the nurse if R14 seemed different, but they did not routinely track or document behaviors. The Interim DON stated behaviors had not been monitored routinely. R4 was re-admitted with diagnoses including a left femur fracture, diabetes mellitus, depression, anxiety, PTSD, and mood disorder. R4’s care plan stated the resident used psychotropic medications related to insomnia and depression and referenced monitoring behaviors, interventions, and alternate therapies, but the surveyor found no specific behaviors identified for monitoring. R4 was ordered quetiapine, trazodone, bupropion, and duloxetine. The record contained no documentation of agitation, depression, or sleep concerns. During interviews, the DON and Social Services acknowledged uncertainty about the reason for the medications and stated there was no behavior monitoring for sleep, depression, or anxiety in the record. R1 was admitted with vascular dementia, anxiety, and depression. The MDS showed the BIMS could not be completed and the PHQ-9 score was 00, with delusions present but no physical or verbal behaviors, rejection of care, wandering, or restraints. R1’s care plan called for monitoring target behavior symptoms such as violence and aggression and documenting behaviors per facility protocol. R1 was ordered quetiapine for agitation, and the pharmacist recommended dose reduction if behaviors had resolved. The provider response referenced being hard to redirect and disease progression, but the surveyor found no documentation of agitation in the medical record. The DON stated she could not find behavior monitoring for R14, R4, or R1.
Missing Code Status and Advance Directive Documentation
Penalty
Summary
The facility failed to formulate and document advance directives and code status for 2 of 16 residents reviewed. For one resident admitted with metabolic encephalopathy, hepatic encephalopathy, unspecified cirrhosis of the liver, ascites, encounter for palliative care, and CKD stage 3a, the surveyor reviewed the care plan and electronic medical record and found no care area, physician order, or advance directive documenting code status. An LPN stated the resident had DNR status but could not show where it was documented, and stated staff were told this on admission. The DON in-training stated a physician order for code status should be on every resident's EMR and acknowledged there had been uncertainty about the resident's code status. For another resident, the surveyor reviewed the EHR and could not find a code status. Scanned discharge orders from another facility showed the resident was full code, but there were no physician orders or acknowledgement showing the facility addressed the code status in its system upon or after admission. An LPN stated code status should appear in the EHR dashboard and in scanned advance directive documents, but when the resident's record was checked, the code status was not there and the resident was not on the full code binder at the nurse's station. The DON stated staff should address code status on admission and ensure it is documented in the EHR, scanned documents, and, if DNR, by physician order, and stated the resident should have had code status addressed but it was missing on admission.
Incomplete Transfer and Discharge Notifications
Penalty
Summary
The facility did not ensure that two residents reviewed for hospitalization and discharge received complete written transfer or discharge notices. For one resident, who was transferred to the Emergency Department twice, the written bed hold notices did not include the specific reason for transfer to the hospital, the daily bed hold rate, or appeal rights information. The facility’s policy stated that residents and representatives are to be notified in writing of the specific reason for transfer or discharge and of appeal rights information, including how to obtain and submit an appeal hearing request. For the other resident, who was admitted for a short-term rehab stay and later discharged to home without services, the facility did not have documentation that the Office of the State Long-Term Care Ombudsman was notified. Surveyors requested Ombudsman notification documentation from Social Services, but none was provided. The record review also showed that discharge summary and medication reconciliation were completed for this resident.
Failure to Update Fall Interventions After Repeated Falls
Penalty
Summary
The facility failed to ensure adequate supervision and fall prevention interventions for a resident with severe cognitive impairment and a history of falls. The resident was admitted with traumatic brain dysfunction, Alzheimer’s disease with late onset, non-Alzheimer’s dementia, and anxiety disorder. Her MDS showed a BIMS score of 00, indicating severe cognitive impairment, and her care plan identified her as moderate to high risk for falls due to confusion, gait and balance problems, incontinence, poor communication and comprehension, lack of awareness of safety needs, and vision/hearing problems. The care plan included interventions such as use of a front wheeled walker with supervision or touching assistance, prompt response to requests for assistance, and following the fall protocol. After a fall in the resident’s room area, the incident report documented that she was found on the floor by her recliner with blood on the wall socket and the back of her head, and she was incontinent of urine. The report stated immediate assessment, vital signs, and monitoring were completed, but it did not include a root cause or immediate care plan interventions to prevent future falls. The interdisciplinary team meeting notes later documented that the resident had fallen and that the care plan was updated, but no root cause was identified and no specific intervention was implemented at that time. After another fall in the dining room, the incident report documented that the resident was found on the floor near her chair with spilled milk on the table and floor. She was confused at baseline, denied pain or injury, and was assisted back to her chair with a Hoyer lift. The report again did not include a root cause or immediate care plan interventions to prevent future falls, and the reminders and education documented after the fall were not added to the care plan. Later IDT notes stated the resident had five falls in the month, rehab would screen her again, and options such as moving her room and increasing safety checks were discussed, but no root cause was identified and the active care plan was not updated with fall interventions between the falls reviewed.
Unlocked Medication Cart and Improper Controlled Substance Storage
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with currently accepted professional principles, and only authorized personnel did not have consistent access to medication carts and controlled substances. During observation, a medication cart was left unlocked in the hallway on the south wing while unattended and out of view of staff, and two CNAs were seen walking by the cart with no nurse present. When interviewed, the LPN stated the cart should have been locked when walking away from it, and the DON stated the cart should always be locked when unsupervised. A second observation in the medication storage room found liquid lorazepam in the refrigerator unlocked. The RN stated lorazepam should be double locked because it is a controlled substance and confirmed the refrigerator was not locked. The RN then locked the refrigerator with a key from the key set. When interviewed, the DON stated the facility was still looking into the correct process for controlled substance storage and was unsure whether the locked medication storage room with only the nurse on the floor having access met the requirement.
Infection Prevention and Control Failures During Direct Care and Sensor Change
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. One event involved CNA D providing direct care to R7 without using Enhanced Barrier Precautions (EBP) as indicated. R7 was admitted with diagnoses including type 2 diabetes mellitus without complications, unspecified urinary incontinence, and weakness. On observation, R7 had a sign on the room door indicating EBP for direct care activities, and the PPE cart outside the room contained hand sanitizer, gloves, gowns, and face masks. CNA D entered the room without a gown or gloves, then assisted R7 with toileting, peri-care, changing a disposable brief, and redressing while wearing gloves but no gown. A dressing was observed on R7's coccyx, and CNA D later stated that a gown should have been worn during care. A second event involved LPN F changing R4's Libre sensor without performing hand hygiene between removing contaminated equipment and applying the new sensor. During observation, LPN F entered R4's room with short acting insulin and a Libre sensor box, stated the sensor was due to be changed in two hours, and entered without sanitizing hands. LPN F donned gloves, removed the contaminated Libre sensor needle, disposed of it, and then handled the clean sensor and prepared R4's skin while still wearing the same contaminated gloves. LPN F later stated that gloves should have been removed after taking off the contaminated sensor, hands sanitized, and new gloves donned before applying the new sensor. The DON also stated that hand hygiene should have been performed before entering the room and again before applying the new sterile Libre sensor.
Failure to Notify Provider of Significant Change in Resident Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider of a significant change in condition for one resident. The resident was admitted with atrial fibrillation, aortic valve insufficiency, and congestive heart failure, and had a BIMS score of 10/15, indicating moderately impaired cognition. A Plan of Care note documented that around 3:00 AM the resident experienced weakness and confusion, with difficulty walking observed by a CNA. The nurse’s assessment noted labored, puffing respirations, the resident feeling scared but denying pain, a flaccid left arm, unequal and very weak left hand grasp with notable swelling, incorrect responses to orientation questions except for name, and no facial droop with pupils equal and reactive. The resident was assisted via wheelchair to the bathroom and back to bed and was able to swallow water without difficulty. The same Plan of Care note documented that a call was placed to a family member, who agreed with the resident remaining in bed at the facility rather than going to the ER. However, there was no documentation that the provider was notified of this significant change in condition. The Interim DON confirmed in interview that the provider should have been notified as soon as possible. A former DON (now RN) stated that any change in condition should prompt a call to the physician, that she did not recall receiving any call about this event, and that staff should not have called the family and taken direction from them first. Review of the facility’s policy “Change in a Resident’s Condition or Status” stated that the nurse will notify the attending physician or provider when there is a significant change in the resident’s physical, emotional, or cognitive condition or a need to significantly alter medical treatment, which did not occur in this case.
Failure to Provide Required Transfer Documentation to Hospital
Penalty
Summary
The deficiency involves the facility’s failure to provide a transfer form to the hospital at the time of transfer for one resident. The resident was admitted with diagnoses including congestive heart failure, chronic kidney disease, and a history of urinary tract infections. The admission MDS showed a BIMS score of 10/15, indicating moderately impaired cognition. A plan of care note documented that the resident was found sitting in a chair with the light on and was not within normal limits for talking and walking ability, and that she had soiled herself in the chair. A family member was called and requested that the resident be taken to the emergency room for evaluation. The former DON stated that the night nurse alerted her that the resident was not doing well, and the resident was sent to the ER, where she was admitted with sepsis. The Interim DON reported being unable to find any evidence that a transfer notice was completed, despite stating that a transfer notice should have been done prior to going to the ER and should have included a nursing assessment, vital signs, and other pertinent information. Review of the facility’s “Charting and Documentation” policy indicated that all services provided, changes in condition, and events involving the resident must be documented in the medical record, and that documentation must be objective, complete, and accurate. The absence of a transfer notice for this resident at the time of hospital transfer constituted the cited deficiency.
Incomplete and Delayed Documentation of Fall and Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who experienced a fall. The resident was admitted with diagnoses including atrial fibrillation, aortic valve insufficiency, and congestive heart failure, and had a BIMS score of 10/15, indicating moderately impaired cognition. An incident note in the EMR documented that the resident fell out of bed when blankets fell onto the floor and the resident tripped on them, after which the blankets were picked up and the resident was placed back in bed, with no cuts or bruises noted and the physician and son notified. However, this incident note did not include a complete and accurate description of the fall, as it lacked documentation of vital signs and neurological checks at the time of the fall. During interviews, the IDON confirmed that the resident’s medical record was not complete and accurate and that neurological checks should have been documented at the time of the fall rather than two days later. An RN reported being on duty at the time of the fall and described that the resident, who had anxiety at night and transferred independently to the bathroom, was found lying on their stomach near the side of the bed toward the foot of the bed, wrapped in multiple comforters. The RN stated that the resident did not hit their head and that initial and subsequent neurological checks were performed but not documented at the time due to a busy shift, which the RN acknowledged as a mistake. Review of the EMR showed that the neurological checks were not entered into the record until two days after the fall, confirming the incomplete and delayed documentation related to the incident.
Failure to Follow Physician Orders and Notify Provider for Diabetic Care
Penalty
Summary
The facility failed to ensure that a resident with brittle diabetes received care and treatment in accordance with professional standards of practice. The resident had multiple physician orders for blood glucose monitoring, insulin administration, and hypoglycemia management, as well as care plans specifying the need for strict adherence to these orders and prompt provider notification in the event of medication refusal or abnormal blood glucose levels. Despite these directives, the resident frequently refused prescribed doses of insulin, and staff administered alternate doses without provider authorization. There was no documentation that the provider was notified of these refusals or of the administration of doses outside of the ordered parameters. Additionally, the resident experienced multiple episodes of both hypoglycemia and hyperglycemia, with blood glucose readings falling below 70 mg/dL and rising above 400 mg/dL on several occasions. Facility policy required immediate provider notification and specific interventions in these situations, but the medical record lacked evidence that these steps were consistently taken. In several instances, glucose tablets were administered in doses different from those ordered, and there was no documentation of provider notification or follow-up blood glucose checks as required by policy. The MAR also showed that staff did not always document follow-up actions or provider communication after abnormal blood glucose readings or medication refusals. Interviews with nursing staff and facility leadership confirmed that staff were not consistently following provider orders or facility policy regarding medication administration and provider notification. Nurses reported administering insulin and glucose tablets in amounts requested by the resident rather than as ordered, and they did not routinely notify the provider of refusals or abnormal blood glucose levels. The DON and CEO acknowledged that staff were expected to follow provider orders and communicate changes in the resident's condition, but this was not consistently occurring in practice.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies observed during the survey. The infection surveillance log was incomplete, missing documentation for specific dates and lacking critical information such as symptom resolution dates, isolation precaution dates, and antibiotic start and end dates. This oversight was attributed to the absence of the Infection Preventionist (IP) and the lack of data from the previous year. The Minimum Data Set (MDS) Coordinator acknowledged the importance of accurate and complete infection surveillance to prevent potential outbreaks and identify areas of concern. Inappropriate use of personal protective equipment (PPE) was observed, with staff failing to properly don and doff PPE in accordance with facility policy. For instance, a Certified Nursing Assistant (CNA) was seen leaving a resident's room wearing PPE and disposing of it incorrectly, while another CNA entered a different resident's room with contaminated PPE. The Director of Nursing (DON) confirmed that staff should don PPE outside the room and doff it inside, with designated bins for dirty PPE, which was not followed in these instances. Hand hygiene practices were also found lacking, particularly during medication administration and wound care. A Licensed Practical Nurse (LPN) was observed handling medications with bare hands and failing to perform hand hygiene before and after medication preparation. Additionally, during wound care for a resident with a pressure ulcer, the LPN changed gloves without sanitizing or washing hands between changes, contrary to the facility's infection control policy. These actions compromised the facility's infection control standards and posed a risk of infection transmission among residents.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles, specifically regarding the labeling of expiration dates on opened medications. During the survey, it was observed that several medications, including insulin pens and other drugs, lacked open date labels, and pharmacy labels were covering the manufacturing expiration dates. This issue was noted for seven residents, with medications such as Humalog insulin pens, Timolol drops, Levetiracetam, Lantus insulin pens, Tresiba insulin pens, Admelog insulin pens, and Lorazepam being affected. The absence of open date labels on these medications could lead to the administration of expired drugs, as staff members were unable to determine when the medications were opened or when they would expire. Interviews with nursing staff, including an RN, an LPN, and the DON, revealed that there was an expectation for all opened medications to be labeled with the open date to prevent the use of expired medications. However, this practice was not consistently followed, as evidenced by the observations made during the survey. The staff acknowledged the oversight and indicated that the medications had been used without the necessary labeling, which could potentially compromise the effectiveness and safety of the medications administered to the residents.
Residents' Dignity Compromised During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal assistance, as observed by surveyors. Three residents, each with varying degrees of cognitive and physical impairments, were affected by this deficiency. A registered nurse and a licensed practical nurse were observed using clothing protectors to wipe the residents' faces instead of using napkins, which is not in line with maintaining the residents' dignity. This practice was noted during meal times in the dining room, where the staff repeatedly used the clothing protectors for wiping the residents' mouths and faces. Resident 17, who had moderate cognitive impairment and required assistance with eating, was observed being assisted by a registered nurse who used the clothing protector instead of a napkin. Similarly, Resident 22, who was completely dependent on staff for eating due to cerebral palsy, was assisted by both a licensed practical nurse and a certified nursing assistant, both of whom used the clothing protector inappropriately. Resident 7, with moderate cognitive impairment and limited range of motion, was also subjected to the same practice by a certified nursing assistant. The Director of Nursing acknowledged that this practice was not respectful of the residents' dignity.
Failure to Document and Resolve Grievance for Missing Item
Penalty
Summary
The facility failed to investigate, resolve, and document the resolution of a grievance for a resident identified as R28. The resident's Activated Power of Attorney (APOA) reported a missing personal item, specifically a blue luggage bag, shortly after the resident's admission. Despite reporting the missing item to numerous staff members, the APOA did not receive any written documentation to fill out, nor was there any documentation of investigation findings or a resolution offered. The facility's grievance policy, which mandates the oversight of grievances by Social Services and the Director of Nursing (DON), was not followed in this instance. Interviews with facility staff, including the Social Services Manager (SSM) and a Registered Nurse (RN), revealed that the missing item was acknowledged but not documented as a grievance. The SSM, who had been in the role for about three months, stated that missing items were not considered grievances and were not included in the grievance log. The facility's practice was to handle missing items through unit staff, who would complete a missing item form and attempt to resolve the issue. However, no such form was found for R28's missing bag, and the grievance log showed no entries since December 2023. The SSM admitted that the current practice did not align with the facility's grievance policy, acknowledging the negative impact on residents' rights.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling catheter. The resident, who was admitted with diagnoses including syncope, orthostatic hypertension, atrial fibrillation, and repeated falls, had a BIMS score indicating cognitive intactness and was noted to be continent without an indwelling catheter according to the most recent MDS. However, the resident had a 16 French urinary catheter placed for urinary retention during a urology clinic visit, with instructions for continued catheter care until a follow-up appointment. Despite this, the resident's care plan did not reflect the presence of the catheter or the necessary care instructions. Interviews and record reviews revealed that the nursing staff were aware of the catheter and were providing care, but this was not documented in the care plan. The Director of Nursing acknowledged the oversight, attributing it to the temporary nature of the catheter. The resident confirmed the catheter's placement and the nursing staff's involvement in its care, but the lack of documentation in the care plan represents a deficiency in ensuring comprehensive care planning for the resident's needs.
Failure to Implement and Document Care Plan Interventions for Fall Prevention
Penalty
Summary
The facility failed to ensure that care plans were revised and implemented to reflect changes in care for two residents, R12 and R22. R12, who was admitted with diagnoses including syncope, orthostatic hypertension, atrial fibrillation, and repeated falls, had a care plan that included interventions such as room checks every 30 minutes to 1 hour following a series of falls. Despite these interventions being documented in the care plan, there was no evidence that the checks were completed. The Director of Nursing (DON) confirmed that the previous DON did not have these interventions charted, and there was no documentation to verify that the checks were conducted. Similarly, R22, who was admitted with diagnoses including spinal stenosis, repeated falls, and osteoarthritis, had a care plan that required 15-minute checks following falls. Despite the care plan's requirements, there was no documentation to verify that these checks were completed. The DON indicated that although staff were performing the checks, there was no evidence in the charting to confirm this. This lack of documentation and verification of care plan interventions led to the identified deficiencies.
Failure to Acknowledge Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendation reports were acknowledged by a physician for one of the residents reviewed. Resident R12, who was admitted with diagnoses including syncope, orthostatic hypertension, atrial fibrillation, mood disorder, and repeated falls, had a pharmacy recommendation to lower the dose of Quetiapine fumarate (Seroquel) that was not acknowledged or acted upon by a physician. This recommendation, initially made on 06/19/24, remained pending without a response from the provider as of the survey date. During the survey, the Registered Nurse (RN) and the Director of Nursing (DON) were unable to provide documentation of a provider response to the pharmacy's recommendation. The RN indicated that the responsibility for following up on pharmacy recommendations lies with the DON. The DON acknowledged the delay in response from the Veteran Affairs (VA) hospital provider and admitted to being new in the role, which contributed to the oversight in addressing the pharmacist's recommendation.
Unnecessary Antibiotic Use Without Indication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically antibiotics, for a resident reviewed for antibiotic use without adequate indication. The resident, who was admitted with multiple diagnoses including COPD, heart failure, atrial fibrillation, diabetes mellitus, and was under hospice care, was prescribed and administered cefuroxime avetil for a UTI without documented symptoms or laboratory results to justify the antibiotic use. The facility's policy, based on the Antimicrobial Stewardship Program and Loeb criteria, requires that antibiotics be prescribed only when appropriate signs and symptoms are present, and typically after receiving urinalysis results. The surveyor's review of the resident's records revealed that the antibiotic was started before any urinalysis or culture results were available, and no symptoms were documented to indicate a UTI. The Infection Preventionist confirmed that the facility's policy is to wait for urinalysis results before prescribing antibiotics, but acknowledged that physicians sometimes prescribe antibiotics based on their judgment, even if it conflicts with the policy. This practice was recognized as a conflict with the facility's policy and a potential risk to resident safety and health due to the misuse of antibiotics.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in an 11.54% error rate during a medication pass observation. This deficiency involved two residents, R12 and R15, and included 26 opportunities with 3 medication errors. Registered Nurse (RN) D administered insulin to R12 without checking the expiration date and failed to hold the insulin injection in the abdomen for the recommended 10 seconds, leading to insulin dribbling down the resident's abdomen. RN D incorrectly believed that holding the insulin pen was unnecessary for doses under 50 units. Licensed Practical Nurse (LPN) C administered Morphine sulfate to R15 without verifying the expiration date, as the pharmacy label obscured the manufacturing expiration date. LPN C acknowledged the oversight and the importance of checking expiration dates before administering medications. The Director of Nursing (DON) B confirmed the expectation for labeling open medications with an open date and holding insulin injections for at least 10 seconds, although the facility lacked specific policies on these procedures.
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.
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What surveyors actually found near you
We read the 33 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 Grantsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frederic Nursing And Rehab Community | 14 mi | ★★★★★ | 18 | 0 |
| The Estates At Rush City Llc | 14.7 mi | ★★★★★ | 7 | 0 |
| United Pioneer Home | 17.3 mi | ★★★★★ | 8 | 0 |
| Ecumen North Branch | 24 mi | ★★★★★ | 0 | 0 |
| Dove Healthcare - St Croix Falls | 25.2 mi | ★★★★★ | 21 | 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 July 2026) and official state health department websites.