Below 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 Christian Community Home Of Osceola, Inc during CMS and state inspections, most recent first.
Failure to report allegation of neglect: A CNA emailed the DON about a resident found soaked in urine, with urine on the resident’s legs and chest and no documentation that the brief had been changed since the morning. The allegation was not reported to the State Survey Agency or law enforcement within 24 hours, and the facility’s grievance log showed no report of neglect.
Failure to Investigate Alleged Neglect: A CNA reported that a resident was found soaked in urine and described the situation as neglect, but the DON did not complete a thorough investigation after being notified. The record showed no documented allegation, no behavior monitoring, no POA notification, no grievance log entry, and no interviews completed with the resident or staff involved.
A resident at high risk for PI development did not receive consistent turning and repositioning, and skin concerns were not fully assessed or documented. CNA and nursing interviews showed weekly skin checks and repositioning were inconsistently completed and not monitored, while record review showed gaps in skin documentation after buttock and coccyx concerns were noted. When the surveyor requested an assessment, the wound nurse identified a new non-blanchable area on the sacral/gluteal region and stated it was a new stage 1 PI; the PA was not aware of it, and the wound specialty resource had not been contacted.
A resident with Lewy body neurocognitive disorder and severe cognitive impairment had repeated unwitnessed falls, but the facility did not consistently complete thorough fall investigations, document staff education, or show monitoring of ordered interventions. Records showed alarms found off or not in use, missing gripper socks, no documentation of 2-hour checks, and some falls with no new interventions or care plan updates; the DON and CNM could not explain how intervention effectiveness was ensured.
Surveyors found that food items in the kitchen were not consistently labeled with open or use-by dates, and some expired foods were not discarded as required. Additionally, a cook's personal beverages were stored on the food prep table near food being served, contrary to facility policy. Staff interviews confirmed lapses in following food safety and personal hygiene protocols.
The facility did not maintain an effective infection prevention and control program, with incomplete infection surveillance logs and multiple instances of improper hand hygiene by staff. An LPN handled medications with bare hands and failed to sanitize before administering them to two residents, while a CNA provided care to two residents without performing hand hygiene before or after glove use. Residents with indwelling catheters received care without proper glove changes or hand hygiene, increasing the risk of infection transmission.
The facility did not assess or document the appropriate size and fit of mechanical lift slings for residents requiring assistance with transfers, leaving CNAs to select sling sizes without guidance or documented assessments. Multiple residents with significant mobility needs were transferred using slings that may not have been properly fitted, and staff interviews revealed confusion about responsibility for determining sling size. The lack of assessment and documentation led to inconsistent and potentially unsafe transfer practices.
Surveyors found that multiple medications, including Lorazepam, Amoxicillin, and Morphine Sulfate, were stored without proper labeling or were expired, and that prescribed Nystatin powder was left unattended at a bedside without a self-administration assessment. Staff interviews confirmed that required labeling and storage procedures were not consistently followed, and monthly pharmacy reviews had previously identified similar issues.
A resident with multiple complex diagnoses, including diabetes, repeatedly refused prescribed insulin, and the nurse documented the refusals but did not notify the physician as required. The DON confirmed that facility policy requires provider notification for each insulin refusal to allow for medication reassessment.
A contracted RN began working without a completed background check, including BID, DOJ, or IBIS, in violation of facility policy requiring screening for abuse, neglect, and misappropriation history prior to employment. This lapse was identified during a review of staff records and confirmed by the NHA.
A CNA applied prescribed Nystatin powder to a resident's skin folds instead of a nurse, as required by facility policy and physician order. The resident, who had multiple complex medical conditions, received the medication from the CNA after a shower, and both the CNA and RN confirmed this was routine practice. The DON stated that only nurses should administer prescribed medications unless the resident is assessed for self-administration, which had not occurred in this case.
A resident with significant physical limitations and a history of stroke experienced repeated delays in receiving assistance with toileting, waiting up to 36 minutes after requesting help. The resident, who required two staff and a mechanical lift for transfers, was left waiting due to staff breaks and failure to seek additional help, resulting in incontinence and emotional distress. The resident and family reported that such delays were common, and the DON confirmed that staff are expected to respond to requests within five minutes.
A registered nurse did not complete a required pre-treatment lung assessment with a stethoscope before administering a nebulizer treatment to a resident with multiple medical conditions, as mandated by facility policy. The nurse acknowledged the omission, and the DON confirmed that both pre- and post-treatment assessments are expected for respiratory therapy.
The facility did not notify the State Long-Term Care Ombudsman when two residents were either transferred to a hospital or discharged to another care setting. One resident with moderate cognitive impairment was hospitalized, and another with multiple chronic conditions was discharged to assisted living, but neither event was reported to the Ombudsman as required. The facility's process only included hospital readmissions, omitting other transfers and discharges.
The facility failed to prevent foodborne illness by allowing a cook to handle ready-to-eat foods with contaminated gloves, serving food at unsafe temperatures, not ensuring proper dish sanitization, and improperly labeling and storing food items. Personal belongings were also found on the food prep table.
The facility failed to maintain an effective infection prevention and control program, including a water management plan and infection surveillance. Maintenance and flushing records were not documented, and infection surveillance logs for residents and staff were incomplete or missing. The DON/IC admitted to creating logs only after the surveyor's request, and there was a lack of systematic infection control measures and documentation.
The facility failed to develop and implement comprehensive individualized care plans for three residents, leading to deficiencies in fall prevention and pain management. One resident experienced multiple falls without a proper care plan, another had pain and anticoagulant use not initially included in their care plan, and a third had a fall without updated interventions in their care plan.
A resident developed an unavoidable stage 2 pressure injury, and the Director of Nursing did not follow proper infection control procedures during wound care. The DON failed to change gloves and perform hand hygiene between steps, despite acknowledging the need for these practices.
The facility failed to ensure a safe environment for two residents, leading to repeated falls. Despite high fall risk assessments, care plans were not consistently updated with fall prevention interventions. Observations and staff interviews confirmed that fall interventions were not followed, contributing to the residents' repeated falls.
A resident with multiple medical conditions, including recent knee surgery, was repeatedly given a lower dose of Oxycodone than prescribed for higher pain levels. Interviews with staff confirmed the discrepancy, although the resident's pain was reported to be controlled.
A resident did not receive proper pharmaceutical services when an LPN failed to prime an insulin pen before administering insulin. The facility's policy requires priming the pen with 2 units to remove air bubbles, but this step was skipped, as confirmed by the LPN and DON.
The facility failed to ensure that a resident was given psychotropic drugs only when necessary and did not limit PRN orders for these drugs to 14 days. The resident was prescribed antipsychotic medication without a specific condition diagnosed or targeted behavior documentation, and the medication was administered without a stop date ordered. The facility's Behavioral Intervention and Management Program meetings had not been conducted since 2022, leading to a lack of proper monitoring and documentation.
The facility failed to ensure proper storage and labeling of medications, with multiple observations of unlocked medication carts and unlabeled opened medications. Despite clear policies and monthly pharmacy reviews, these deficiencies were not corrected in a timely manner.
The facility failed to establish an effective Antibiotic Stewardship Program, lacking proper documentation and monitoring of antibiotic use and infection surveillance. The DON admitted reliance on PA orders without proper documentation, and policies were outdated.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency or local law enforcement within 24 hours after becoming aware of it for one resident. On 05/10/26 at 10:56 PM, the DON was notified by email from a CNA about a neglect concern involving the resident, who was found in an incontinent brief that was overly saturated with urine, with urine on the resident’s legs and chest. The CNA stated she checked the CNA report sheet and found no documentation that the resident’s brief had been changed since 8:15 AM. The surveyor reviewed the email, which stated the resident was completely soaked in urine that seeped through the pad and down the leg, and that another CNA said there was no time when asked when the resident was last changed. The facility’s complaint/grievance log contained no reported allegations of neglect. During interviews, the NHA stated no allegations of neglect had been reported in the last 3 months, and the DON initially stated no concerns had been brought to her attention. The DON later reviewed emails and acknowledged the CNA’s email, stating she did not initially recognize the word "neglect" and believed the CNA was not credible; the NHA stated the allegation should have been reported within 24 hours regardless of who made it.
Failure to Investigate Alleged Neglect
Penalty
Summary
The facility did not complete a thorough investigation after being notified of a neglect concern involving one resident. On 05/10/26 at 10:56 PM, the DON was emailed by a CNA about the resident being found in an incontinent brief that was overly saturated with urine, with urine on the resident’s legs and chest, and the CNA stated the resident had not been documented as changed since 8:15 AM. The CNA described this as neglect and forwarded the email to the surveyor. The resident’s care plan identified a vulnerability for potential abuse/neglect from self or others, but no goals or interventions were documented. The record review showed no additional care plan interventions after the allegation was reported, no behavior monitoring was implemented, and no documentation of the allegation was found in the resident’s progress notes. There was also no documentation that the resident’s POA was notified, and the facility’s complaint/grievance log did not include the allegation. When interviewed, the DON stated she received the email but did not see the wording alleging neglect, and she reported attempting to interview the CNA staff on multiple occasions; however, as of 05/27/26, no interviews had been completed with the resident, the reporting CNA, the other CNA involved, or any other staff or residents regarding the allegation.
Failure to Prevent and Assess Pressure Injury Development
Penalty
Summary
Facility staff did not implement professional standards of practice to prevent pressure injuries and to ensure treatment and assessment were completed for a resident who was assessed as high risk for pressure injury development. The resident had severe cognitive impairment, required substantial to maximum assistance with rolling and dependent assistance with bed and chair transfers, and had a care plan that included a pressure relieving mattress, pressure relieving cushions in the recliner and wheelchair, and repositioning every 2 to 3 hours. The nursing order for turning and repositioning stated every shift, but it did not specify a frequency during each shift. Record review showed inconsistent documentation of turning and repositioning on the CNA Kardex, including days with no documentation and other days with only one, two, or three documented turns. The resident’s skin documentation also showed gaps. A skin/wound note identified a denuded area on the right buttock related to sheering, but no additional skin assessment documentation was completed until weeks later. Another note documented a red coccyx area cleaned with barrier cream applied, followed by another long gap before the next skin documentation. Weekly bath skin evaluation sheets noted a skin tear on the buttocks, bottom open/red, and concern on the buttock area, but these findings were not followed by additional skin assessment documentation or documentation that the wound nurse was notified. During interviews, CNA staff stated that residents should be rounded on every 2 to 3 hours and incontinent briefs checked, but this was not always done and not everyone documented it. The wound nurse stated the resident’s chronic skin issues were only assessed during weekly bath checks and that the 04/16 skin concern was the only assessment completed for the area because it was considered chronic maceration. The DON and clinical nurse manager stated there was no current process to monitor whether weekly skin checks were documented or whether residents at risk were being turned and repositioned frequently. When the surveyor requested a skin assessment, the resident was observed lying on the left side in bed on a standard mattress, with a gel cushion in the recliner. The wound nurse identified a new dark red, non-blanchable area on the left inner gluteal fold/sacral area and stated it was a new stage 1 PI. The PA was not aware of the new PI at the time, and the wound nurse stated the outside wound specialty resource had not been contacted regarding the resident.
Repeated Falls Not Thoroughly Investigated or Monitored
Penalty
Summary
The facility did not thoroughly investigate repeated falls for a resident with neurocognitive disorder with Lewy bodies and severe cognitive impairment, as shown by a BIMS score of 0/15. The resident had multiple unwitnessed falls, including falls in the room, bathroom, and great room, and the record showed that the facility identified root causes such as self-transfer, confusion, communication deficit, and being up at bedtime. However, the fall investigations did not consistently include review of why the resident’s alarm was off, interviews with staff about how the resident got to the bathroom or the last toileting time, or documentation showing that ordered 2-hour checks were completed. The resident’s care plan included alarm use on the bed and chair, a pressure and laser alarm, a tab alarm, rounding every 2 hours when in bed and overnight, gripper socks, and later a preference for bedtime and assistance with transfers. After the falls, the record did not show staff education following the incidents, and some falls had no new interventions documented. One fall investigation noted the resident’s floor alarm was found on a tray table in the OFF position, another noted the resident had no shoes or gripper socks on, and another noted the care plan was not updated after the fall. When surveyed, the DON and CNM could not explain how they ensured interventions were in place and effective, and the CNM stated there was no documentation of the 2-hour checks.
Improper Food Storage, Labeling, and Personal Item Handling in Kitchen
Penalty
Summary
Surveyors identified that the facility failed to prepare, distribute, and serve food in a manner that prevents foodborne illness for all residents reviewed. During a kitchen inspection, multiple food items in the cooler and refrigerators were found either unlabeled or labeled incorrectly regarding open or use-by dates. Examples included pulled pork, red Jello, crushed pineapple, tomato sauce, and ham salad, some of which were expired or lacked proper labeling. Staff interviews confirmed that the labeling and discarding of expired foods had not been consistently performed, particularly over the weekend. Additionally, personal beverages belonging to a cook were observed on the food preparation table near items being served for lunch. The facility's policies require that personal items and beverages be stored away from food preparation areas, but staff were unclear about appropriate storage locations for personal beverages. The Dietary Manager confirmed that the observed practices did not meet facility expectations for food safety and personal hygiene.
Infection Control Program Deficiencies and Hand Hygiene Failures
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by incomplete infection surveillance and improper hand hygiene practices. Infection surveillance logs were missing critical data, such as the type and location of outbreaks, testing performed, well dates for residents and staff, and details regarding isolation precautions. During an influenza outbreak, the facility did not document essential information needed to monitor and prevent the spread of infection. The Nursing Home Administrator acknowledged that the facility relied on a county-provided spreadsheet and was unaware that additional data was required for adequate infection monitoring. Staff infection tracking was also inconsistent, as staff did not always complete required screening forms. Direct care observations revealed multiple instances of improper hand hygiene and infection control breaches. An LPN was observed handling medications with bare hands, failing to sanitize hands before touching pills, and returning a dropped pill from a contaminated surface to a resident's medication cup. The LPN admitted awareness of proper procedures but did not follow them due to concerns about medication costs. Additionally, a CNA was observed performing resident care without completing hand hygiene before donning gloves, after removing gloves, or between tasks, and used contaminated gloves to touch clean surfaces and equipment. The CNA claimed to use hand gel frequently, but surveyors did not observe any hand hygiene during care. Residents with complex medical needs, such as those with indwelling catheters, were also affected by these lapses. One resident with a suprapubic catheter and nephrostomy tube received care from staff who failed to change gloves or perform hand hygiene when moving between clean and dirty areas during catheter care and dressing changes. During a catheter change, an LPN switched from sterile to non-sterile gloves without hand hygiene and manipulated the catheter, later acknowledging the omission. These failures in infection control practices had the potential to affect all residents in the facility.
Failure to Assess and Document Proper Sling Size for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not assess residents for the safe use of the EZ sit to stand lift for five residents, nor did it have a procedure in place to assess and document the appropriate size and fit of the EZ Way Smart Stand mechanical lift slings for each resident. Certified Nursing Assistants (CNAs) were left to determine sling size based on their own judgment, without guidance from care plans or CNA care guides, and without documented assessments of residents' torso circumference as required by manufacturer guidelines. Multiple residents with significant mobility impairments, including those with a history of stroke, hemiplegia, Parkinson's disease, and other conditions requiring substantial assistance with transfers, were observed being transferred using the EZ sit to stand lift. In all cases, there was no documentation or care plan specifying the correct sling size, and no evidence that an assessment of torso circumference had been completed. During observations, CNAs selected slings based on availability and their perception of resident size, sometimes discussing among themselves which sling to use. In one instance, a resident was observed hanging from her armpits during a transfer, indicating improper fit or use of the sling. Interviews with staff, including CNAs, an Occupational Therapist, an LPN, and the Director of Nursing, revealed a lack of clarity and responsibility regarding who was supposed to determine and document the correct sling size for each resident. The Director of Nursing acknowledged that sling size was not listed on any care guide and was unsure who was responsible for assigning sling sizes. Inventory checks showed limited availability of sling sizes, and staff reported that slings were not kept in residents' rooms and would need to be washed before reuse, potentially delaying care. The lack of assessment, documentation, and clear procedures led to inconsistent and potentially unsafe use of mechanical lift slings for residents requiring assistance with transfers.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices for five residents. In the medication storage room, two opened bottles of Lorazepam for two residents were found without labels indicating the date opened or expiration, making it unclear when they should be discarded. Additionally, an opened and expired bottle of Amoxicillin for another resident was found in the refrigerator, with the expiration date clearly passed. On a medication cart, a bottle of Morphine Sulfate liquid for a resident was opened and unlabeled, with no indication of the date it was first used or when it should expire. Staff interviews confirmed that the expected practice is to label medications with the date opened, but this was not consistently followed. Further observations revealed that prescribed Nystatin powder was left unattended on a resident's bedside table. The resident reported that CNAs applied the powder after showers, but there was no assessment found for self-administration of medications, which is required by facility policy for bedside medication storage. The facility's policies require that all medications be labeled with the date opened and expiration, and that expired medications be promptly removed and destroyed. Monthly pharmacy reviews had previously identified similar issues, including undated and expired medications, but these problems persisted at the time of the survey. Interviews with nursing staff and the Director of Nursing confirmed that the facility's expectations were not met regarding medication labeling and storage. Nurses acknowledged that medications should be labeled upon opening and that expired medications should be discarded immediately. The Director of Nursing stated that nurses on each shift are responsible for monitoring medication refrigerators for expired drugs, and that pharmacy reviews are conducted monthly. However, the ongoing presence of unlabeled and expired medications, as well as improper bedside storage without proper assessment, demonstrated a failure to adhere to established policies and professional standards.
Failure to Notify Physician of Insulin Refusal
Penalty
Summary
A deficiency was identified when a nurse failed to notify the physician on call regarding a resident's repeated refusal of prescribed insulin. The resident, who had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure, had a physician order for 6 units of insulin aspart to be administered subcutaneously before meals, unless blood glucose was below 100. During observation, the nurse checked the resident's blood glucose, found it to be 169, and noted that the resident had been refusing insulin due to previous hypoglycemic episodes. The nurse documented the refusal and monitored the resident but did not notify the physician of the refusal. Upon interview, the nurse acknowledged that physician notification should occur when insulin is refused, as this could prompt a reassessment of the medication order. Review of the resident's progress notes confirmed that the provider was not contacted regarding the refusal. The Director of Nursing confirmed that the facility's expectation is for nurses to notify the provider every time insulin is refused, to allow for potential adjustment or discontinuation of the medication.
Failure to Screen Contracted RN for Abuse and Neglect History
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of employees for a prior history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, a review of eight staff members' Background Information Disclosures (BID) revealed that one registered nurse (RN), who was a contracted staff member, did not have a completed BID, Department of Justice (DOJ) check, or Integrated Background Information System (IBIS) check prior to starting work. The facility's policy requires that all new employees have their background checked before working with residents, but this process was not followed for the contracted RN. The omission was discovered during a surveyor's review and confirmed in an interview with the Nursing Home Administrator, who acknowledged that the background check had not been completed at the time of hire.
CNA Administers Prescribed Medication Instead of Nurse
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) administered a prescribed medication, Nystatin powder, to a resident's skin folds, rather than a licensed nurse as required. The resident, who had multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure, had a physician's order for Nystatin powder to be applied topically three times a day for a candida yeast skin infection. During a survey, the prescribed Nystatin powder was observed on the resident's bedside table, and both the resident and CNA confirmed that the CNA applied the medication after the resident's shower that morning. Further interviews revealed that the CNA routinely applied the Nystatin powder to the resident's groin folds, especially on shower days, due to difficulty locating a nurse. The registered nurse (RN) on the unit acknowledged that CNAs often applied the medication, and the director of nursing (DON) confirmed that it was not acceptable for CNAs to administer prescribed medications, stating that only nurses should do so unless the resident has been assessed and deemed capable of self-administration. The storage of the medication at the bedside was also discussed, with the DON indicating it was only appropriate if the resident could self-administer, which had not been established.
Delayed Assistance with Toileting and Repositioning
Penalty
Summary
A resident with a history of stroke, hemiplegia, hemiparesis, partial digestive tract removal, recurrent urinary tract infections, and vascular dementia required substantial assistance for repositioning and toileting. The resident was cognitively intact and able to communicate needs, as documented in the MDS assessment. On two observed occasions, the resident requested assistance to use the bathroom and experienced significant delays—waiting 36 minutes and 30 minutes, respectively—before being assisted by staff. During the first incident, the resident required a clothing change due to incontinence and expressed feelings of embarrassment and being a burden. The care plan indicated the resident should receive necessary assistance with toileting upon request. Staff interviews revealed that delays occurred because two staff members were required for transfers using a mechanical lift, and one CNA was on break during the incident. The CNA did not seek additional help from other available staff or use the walkie to request assistance, despite this being an available option. The DON stated that the expectation is to respond to resident requests within five minutes and that staff should check on residents' needs before going on break. The resident and family members reported that long waits for assistance were a recurring issue, and the resident was on a waiting list for another facility due to dissatisfaction with care.
Failure to Perform Pre-Respiratory Assessment Prior to Nebulizer Treatment
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to perform a pre-respiratory assessment prior to administering a nebulizer treatment to a resident. According to facility policy, a pre-treatment lung assessment, including auscultation of breath sounds with a stethoscope, is required before administering nebulizer therapy. During the observed administration, the RN applied gloves and began the nebulizer treatment without first listening to the resident's lung sounds. The RN acknowledged this omission when questioned and stated that the assessment would be performed after the treatment. The resident involved had been admitted with diagnoses including iron deficiency anemia secondary to blood loss, bipolar disorder, and major depressive disorder, and had a physician's order for albuterol sulfate nebulizer treatments for cough. The Director of Nursing confirmed that the expectation is for nurses to complete both pre- and post-treatment lung assessments using a stethoscope to monitor the effectiveness of the therapy. The failure to perform the required pre-treatment assessment constituted a deviation from facility policy and standard practice.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers and discharges for two residents out of a sample of twelve. Specifically, one resident with moderate cognitive impairment and an activated Power of Attorney for Health Care was transferred to the hospital due to urinary retention and constipation, but the Ombudsman was not notified of this transfer. Documentation showed that a notice of bed hold and reason for transfer was signed by the POAHC, but the required Ombudsman notification was not completed. Another resident, who had diagnoses including cerebral infarction, chronic headaches, dizziness, and chronic kidney disease, was discharged to an assisted living home without the Ombudsman being notified. Review of the facility's records revealed that the list provided to the Ombudsman only included residents who were readmitted from the hospital and did not account for those who were transferred, discharged, or had passed away. The Nursing Home Administrator confirmed that the Social Worker was responsible for notifications but only sent information about hospital readmissions.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. The cook was observed touching ready-to-eat foods with contaminated gloves while serving meals. Additionally, the facility failed to ensure that foods were served at safe temperatures, as evidenced by the pork tenderloin on the hot steam table being served at 132.6 degrees Fahrenheit, which is below the required 135 degrees Fahrenheit. The dietary manager confirmed that the pork tenderloin should not have been served at this temperature, and temperature logs were not maintained for the point of service checks. The facility also did not ensure proper sanitization of dishes. The surveyor observed that the dishwasher's temperature gauge read below the required 120 degrees Fahrenheit during multiple cycles, and the cook did not check the temperature or use chemical strips for proper sanitization. The dietary manager confirmed that the dishwasher is a low-temperature chemical sanitization system and that the cook should have checked the temperatures and chemical ratios before completing the dishwashing cycles. Furthermore, the kitchen cooler contained various foods in cups that were not labeled with open or use-by dates. Items such as butter, vanilla pudding, leftover meatloaf, and bran muffins were found without proper labeling or past their use-by dates. Additionally, personal belongings of a dietary aide were found on the food prep table, which is against the facility's policy. The dietary manager acknowledged these issues and indicated that personal belongings should be kept in the employee break room and not on the kitchen prep table.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which included a water management program and infection surveillance. The facility did not document maintenance, inspections, or flushing of areas of concern as required by their Water Management Plan. Interviews with the Nursing Home Administrator and Director of Maintenance revealed that while they were aware of the need for flushing, no records were kept, and a documentation sheet had been created but not used. Room occupancy records showed multiple instances of rooms being left vacant for extended periods without proper flushing, increasing the risk of Legionnaires' disease and other waterborne infections. The facility's infection surveillance and treatment program were also found to be inadequate. The Director of Nursing/Infection Control (DON/IC) was unable to provide complete and accurate infection surveillance logs for residents and staff. The DON/IC admitted to creating monthly line lists only after the surveyor's request and acknowledged that infection surveillance had not been properly maintained. The infection logs provided were incomplete and lacked necessary details such as signs and symptoms, testing results, and follow-up care. The DON/IC also indicated that the process for tracking and treating infections was not well-established, and there was a lack of documentation and coordination with the interdisciplinary team. Staff infection surveillance was similarly deficient. The Human Resources Coordinator tracked staff call-ins but did not maintain comprehensive records or a plan of action to prevent the spread of infections. The DON/IC did not document staff infection surveillance or follow-up actions, relying instead on verbal communication and ad-hoc decisions. This lack of systematic infection control measures and documentation put all residents and staff at risk of communicable diseases and infections.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive individualized care plans for three residents, leading to deficiencies in their care. Resident R4, admitted for end-of-life hospice care, had a high fall risk but experienced 25 falls over a two-month period without a comprehensive care plan addressing fall prevention. Despite having interventions listed on a Nursing Assistant Assignment Sheet, these were not observed in practice, and no comprehensive care plan was found in R4's records. Resident R17, with multiple diagnoses including cognitive communication deficit and vascular dementia, had frequent moderate pain and was on anticoagulant therapy. However, R17's care plan did not initially include pain management or anticoagulant use. These care plans were only added after the surveyor requested them. Interviews with R17 and staff confirmed that pain management was being provided, but the care plan was not updated to reflect this until after the surveyor's inquiry. Resident R180 experienced a fall and was sent to the emergency room, but no injury was sustained. Despite an IDT review recommending a perimeter mattress, the comprehensive care plan did not include any interventions related to fall prevention. The updated interventions from the IDT review were not found in the comprehensive care plan, indicating a failure to document and implement necessary care plan updates for fall prevention.
Failure to Follow Proper Infection Control Procedures During Wound Care
Penalty
Summary
The facility did not provide care consistent with professional standards to prevent the development of a pressure injury for a resident. The resident, who had diagnoses including pressure ulcer, dementia, multiple sclerosis, neurogenic bowel, and quadriplegia, developed an unavoidable stage 2 pressure injury while at the facility. The resident's care plan included interventions such as daily skin observation, pressure-relieving cushions and mattresses, and turning and repositioning every 2-3 hours. Despite these measures, the resident developed a stage 2 pressure injury in the ischial area, which was first noted on 03/15/24 and measured 1.5 cm x 1.4 cm x 0.3 cm. The most recent measurement on 04/03/24 indicated the wound was 1 cm x 0.9 cm x 0.5 cm. Weekly assessments and physician notifications were conducted, and wound care orders were updated accordingly. During an observation on 04/04/24, the Director of Nursing (DON) performed wound care on the resident but did not follow proper infection control procedures. The DON did not change gloves or perform hand hygiene between steps of the wound care process. Specifically, the DON removed the old dressing, measured the wound, and cleaned the wound without changing gloves or performing hand hygiene. The DON then used the same contaminated gloves to handle wound care supplies and apply new dressings. When interviewed, the DON acknowledged that hand hygiene should have been performed between glove changes and after cleaning the wound, but it was not done during the observed wound care session.
Failure to Ensure Environment Free from Accident Hazards
Penalty
Summary
The facility did not ensure that the resident's environment remained as free of accident hazards as possible for two residents. Resident R4, who was admitted for end-of-life hospice care, experienced 25 falls between October 12, 2023, and December 23, 2023. Despite multiple fall risk assessments indicating a high risk for falls, the facility failed to consistently document and implement fall prevention interventions in R4's care plan. Observations during the survey revealed that fall interventions were not being followed, and there was no documentation supporting that psychotropic medication was considered a potential cause of falls prior to its discontinuation on November 27, 2023. The Director of Nursing confirmed that fall interventions had not been added to R4's plan of care despite the high number of falls and the use of lorazepam, which increased the fall risk. Resident R5, who had multiple diagnoses including cognitive communication deficit and vascular dementia, also experienced repeated falls without appropriate updates to the care plan. R5's fall risk assessments consistently indicated a high risk for falls, yet the care plan was not revised following falls on November 1, 2023, December 15, 2023, January 16, 2024, January 19, 2024, and February 21, 2024. Post-fall assessments documented the falls and immediate interventions, but the care plan interventions were not updated to reflect these incidents. Interviews with staff revealed that the care plan was not promptly updated with new fall prevention interventions, and the Certified Nursing Assistant care plan did not include specific fall risk information for R5. The Director of Nursing acknowledged that the care plans for both residents should have been updated immediately after determining fall interventions. The failure to update care plans and implement consistent fall prevention measures contributed to the repeated falls experienced by both residents. This deficiency highlights the facility's lack of adherence to its fall prevention policy and the need for improved documentation and communication among staff to ensure resident safety.
Failure to Follow Pain Management Orders
Penalty
Summary
The facility did not ensure that pain management orders were followed for a resident who required such services. The resident, who had a history of left knee joint replacement surgery, migraine, Parkinson's disease, dementia, cognitive communication deficit, diabetes, poly-osteoarthritis, chronic pain, and low back pain, was prescribed Oxycodone with a dosage based on the pain scale. However, the facility repeatedly administered a lower dose of 2.5 mg instead of the prescribed 5 mg for pain levels of 6-10. This occurred on nine out of eleven occasions, as documented in the Medication Administration Record (MAR). Interviews with the resident, an LPN, and the Director of Nursing (DON) confirmed the discrepancy. The resident reported experiencing pain and receiving pain management through medication, ice packs, and elevation of the knee. The LPN acknowledged that the resident should have received the 5 mg dose for pain levels of 6 and 7, and the DON confirmed that the staff should have administered the correct dosage according to the pain scale. Despite the incorrect dosages, the resident's pain was reported to be controlled at the time of the interviews.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility did not ensure that a resident was provided pharmaceutical services to meet their needs, specifically in the administration of insulin. The deficiency was observed when an LPN failed to prime an insulin glargine pen before administering 7 units of insulin to a resident. According to the facility's policy, the insulin pen should be primed with 2 units to ensure no air bubbles are present before drawing the required dosage. However, the LPN did not follow this procedure during the administration observed by the surveyor. The incident was confirmed through interviews with the LPN and the Director of Nursing (DON). The LPN admitted to not priming the insulin pen before administering the insulin to the resident, despite acknowledging that the usual process involves priming the pen with 2 units. The DON also confirmed that the facility's expectation is for all insulin pens to be primed with 2 units before drawing and administering the required dosage. This failure to follow proper procedure led to the deficiency noted in the report.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Additionally, the facility failed to limit PRN orders for psychotropic drugs to 14 days. This deficiency was observed in the case of a resident (R4) who was admitted for end-of-life hospice care with a terminal prognosis of stage 4 chronic kidney disease and multiple sclerosis. R4 was prescribed antipsychotic medication without a specific condition diagnosed or targeted behavior documentation, and the medication was administered without a stop date ordered. R4's orders included Quetiapine Fumarate and lorazepam, which were administered without proper documentation of targeted behaviors or assessments regarding effectiveness and potential adverse consequences. The resident received PRN lorazepam multiple times in September, October, and November, and was later prescribed haloperidol without a stop date or rationale for continued use. The facility's Director of Nursing (DON) confirmed that the PRN use of Haldol without a stop date was inappropriate and that the facility had not been in compliance with psychotropic medication monitoring. The facility's Behavioral Intervention and Management Program (BIMPS) meetings, which are intended to monitor residents receiving psychotropic medications, had not been conducted since 2022 and were only restarted in January 2024. The DON confirmed that there was no documentation supporting the continued use of the antipsychotic medication, including dosage changes, and that the psychotropic medication was not considered a cause of R4's falls prior to the discontinuation of one of the medications. The lack of proper monitoring and documentation led to the deficiency in ensuring the appropriate use of psychotropic medications for R4.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, and did not ensure only authorized personnel had access to medication carts. During the three-day survey, multiple observations were made of medication carts left unlocked when unattended and out of view of staff. Specifically, an LPN was observed multiple times leaving the medication cart unlocked while administering medications and attending to other tasks, despite the facility policy requiring medication carts to be locked when unattended. Additionally, the facility failed to label opened medications with the required open or expiration dates. An open bottle of lorazepam and a vial of Humalog insulin were found without proper labeling in the E-hall medication storage room and medication cart, respectively. The facility's policy and pharmacy recommendations clearly stated that such medications should be labeled with open and use-by dates, but these guidelines were not followed. Interviews with the LPN and DON confirmed that the expectation was for all opened medications to be labeled and for medication carts to be locked when unattended. Despite monthly pharmacy reviews identifying these issues, the deficiencies were not corrected in a timely manner. The DON indicated that it was the responsibility of the nurse on duty to address the pharmacy's recommendations, but this was not consistently done, leading to repeated deficiencies in medication storage and labeling practices.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility did not establish an Infection Prevention and Control Program (IPCP) that includes an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. This deficiency has the potential to affect all 33 residents in the building who may utilize antibiotics. The facility failed to ensure the standard of practice for infection surveillance and treatment, and McGeer's criteria were not utilized in the facility's antibiotic stewardship program. The facility's policy on Nosocomial Infection Surveillance/Antibiotic Stewardship Program was not followed, as evidenced by the lack of documentation and monitoring of antibiotic use and infection surveillance logs from the specified dates. The surveyor reviewed the resident infection surveillance line lists and found that the logs did not include necessary details such as signs and symptoms of infection, start date of infection, start date of isolation, start date of antibiotics, appropriate lab culture results, hospitalizations, or well dates. Additionally, the Director of Nursing (DON) admitted that the facility relies solely on the Physician Assistant's orders without proper documentation or diagnostic tests. The antibiotic stewardship committee only meets annually, and the policies were last updated in 2022, indicating that they were not up to date. No further documentation was provided to address the expired policies or the deficiencies in the antibiotic stewardship process.
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 89 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Osceola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dove Healthcare - St Croix Falls | 8.2 mi | ★★★★★ | 21 | 0 |
| Parmly On The Lake Llc | 9.6 mi | ★★★★★ | 1 | 0 |
| St Croix Health Center | 13.7 mi | ★★★★★ | 10 | 0 |
| Birchwood Health Care Center | 13.8 mi | ★★★★★ | 4 | 1 |
| Meadows On Fairview | 14.5 mi | ★★★★★ | 1 | 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.