Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Age Manor during CMS and state inspections, most recent first.
Food Storage and Labeling Deficiencies: The surveyor observed clean pitchers stored upright instead of inverted, a covered bowl of cereal without contents or date labeling, and an open jug of milk without an opened-on or use-by date. In the cooler, freezer, and dry storage areas, multiple opened or prepared food items lacked dates showing when they were opened or when they should be used by. The DM stated that clean dishes should be inverted and opened food items should be labeled and dated.
Improper hand hygiene, failure to disinfect mechanical lifts between uses, and incorrect PPE use during EBP care were observed during resident care. Staff entered rooms and provided toileting, peri-care, and transfer assistance without consistent hand hygiene, used lifts for multiple residents without wiping them down, and assisted a resident on EBP without wearing a gown during high-contact care. Interviews confirmed staff knew hand hygiene and EBP expectations, and the DON stated lifts were expected to be cleaned after every use.
Infection Preventionist Lacked Required Specialized Training: The facility failed to ensure the RN serving as the IP had completed the required specialized education in infection prevention and control. Survey review found partial CDC training documentation, but the final test certificate had expired and there was no proof the test was taken and passed. The RN stated they were unsure whether a final test was completed and did not have a passing certificate, and the NHA said they had believed the IP course was completed.
Missing Staff COVID-19 Vaccination Documentation: The facility did not maintain required documentation of staff screening, education, offering, and current COVID-19 vaccination status. RN G stated vaccination information was shared at staff meetings and offered yearly, but the facility did not keep records of the education provided or which staff received it. A CNA reported being offered the COVID vaccine through a staff chat platform and had a signed declination in the employee record, while the NHA and DON acknowledged the documentation requirement.
Advance directive and code status documentation was inconsistent for multiple residents. Physician orders listed DNR/DNI for several residents, but charted advance directives, inquiry reports, resident assessments, and hospital transfer documents often showed Full Code or did not address resuscitation wishes at all. In several cases, there was no signed DNR/DNI form and no documentation of a discussion with the resident or representative about code status.
A resident with glaucoma and severe cognitive impairment missed multiple doses of prescribed latanoprost eye drops because the medication was repeatedly documented as unavailable. Staff and the DON acknowledged difficulty obtaining the drops, and pharmacy communication showed a long gap without a refill request before the next dispense. The resident’s family reported the resident was sometimes without the medication for over a week.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility did not have a qualified director of food and nutrition services, as the Dietary Manager's certification did not meet the required standards, and there was no full-time, in-house dietician. The dietician was fully remote, and the facility could not provide evidence of compliance monitoring in the kitchen, potentially affecting all residents.
Surveyors found that opened and prepared foods in the kitchen were not labeled or dated as required, and a staff member responsible for checking food temperatures failed to allow the thermometer probe to air dry after cleaning with isopropyl alcohol before use. These lapses in food safety practices had the potential to affect all residents.
The facility lacked an effective infection prevention and control program, with outdated water management policies, incomplete infection surveillance during outbreaks, and inconsistent hand hygiene practices by staff. Residents with indwelling devices were not always placed on enhanced barrier precautions, and staff failed to follow proper glove use and hand hygiene protocols during personal care, as acknowledged by supervisors.
The facility did not implement an effective antibiotic stewardship program, as required by its own policy, resulting in incomplete documentation of infection surveillance and a lack of standardized monitoring for antibiotic use. The Infection Preventionist relied on delayed pharmacy reports and did not use established criteria, such as McGeer's or Loeb's, to assess the appropriateness of antibiotic therapy.
Several residents reported missing clothing and personal items, but the facility did not consistently document grievances, investigate, or resolve these concerns. Staff interviews and observations revealed a lack of a clear process for labeling and tracking residents' clothing, resulting in many unlabeled items and unresolved losses. The Director of Nursing acknowledged the ongoing issue, and residents often had to keep their own records to track belongings.
Facility staff did not ensure safe, appropriate pain management for several residents with chronic and acute pain, failing to conduct consistent pain assessments, develop individualized pain care plans, or document the effectiveness of pain interventions. Residents with complex medical needs, including those on opioids and palliative care, experienced unmanaged pain, missed medication doses, and lacked monitoring for side effects, with staff often relying on residents to request pain relief rather than proactively assessing and addressing pain.
An LPN left a medication cart in the hallway with the computer screen displaying residents' medical records unattended on multiple occasions while administering medications. This resulted in protected health information being visible to other staff passing by, in violation of facility policy requiring PHI confidentiality.
Two residents with significant mobility limitations did not consistently receive passive range of motion (PROM) exercises as ordered in their care plans. Documentation showed missed or insufficient PROM sessions, and staff interviews revealed that exercises were not routinely performed or reviewed for appropriateness. The lack of regular assessment and monitoring contributed to the ongoing deficiency in restorative care.
A resident with allergic rhinitis received a nasal spray medication from an LPN, who failed to document which nostril was used as required by facility policy. The LPN stated that staff no longer record the site of administration, and the DON was unaware this documentation was not occurring.
Three residents were found to be receiving unnecessary medications, including sleep aids and a prophylactic antibiotic, without adequate clinical indication, assessment, or individualized care planning. Staff did not monitor or document sleep patterns, and there was no evidence of non-pharmacological interventions or rationale for continued medication use, contrary to facility policy.
A resident with multiple chronic conditions was not documented as having been screened or offered the 2024-2025 COVID-19 vaccine. The facility's records lacked evidence of education, consent, or declination for the current vaccination year, and the only immunization policy provided did not address COVID-19. The Infection Preventionist stated the resident was not approached again because they had declined the vaccine the previous year.
Two residents did not have comprehensive care plans developed to address their specific medical and nursing needs. One resident receiving diuretics for edema and chronic kidney disease lacked a care plan for monitoring adverse reactions, while another resident on hospice care did not have a hospice or end-of-life care plan in place. These deficiencies were identified through observation, interviews, and record review.
A resident with Alzheimer's disease and anxiety disorder experienced a marked increase in aggressive and disruptive behaviors, including altercations with other residents. Despite multiple documented incidents and staff interventions, the care plan was not updated to reflect these changes or the new care approaches being provided, such as 1:1 supervision and medication adjustments.
A resident was placed in a private room measuring only 96.5 square feet, which is below the required 100 square feet for single occupancy. The facility administrator acknowledged the deficiency, noting that the room is used for ambulatory residents after informing them and their POA of the size difference. The resident, who has multiple medical conditions and severe cognitive impairment, reported being comfortable in the room.
A facility failed to provide adequate supervision during resident transfers with a Hoyer lift, as a CNA was left alone to transfer three residents due to a staffing shortage. The CNA proceeded with the transfers despite knowing the risk, as another CNA had to leave for a family emergency. The NHA and DON were not informed of the shortage until days later and confirmed that their policy requires two staff members for such transfers.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour with the Dietary Manager, the surveyor observed clean water pitchers on a bottom shelf that were not inverted or covered, and a covered bowl of cereal on a shelf below the serving area that was not labeled with contents or date. In the milk cooler, an open jug of milk did not have an opened-on or use-by date written on it. In the walk-in cooler, the surveyor observed an open bag of whipped topping, an open container of butter, and prepared cinnamon rolls in a baking pan, all without dates showing when they were opened or prepared or when they should be used by. In the walk-in freezer, opened bags of potato wedges, vegetables, and berries were all without dates of when they were opened. In the dry storage area, opened packages of cookies, dried noodles, split peas, powdered pudding, and gelatin mixes were also without dates indicating when they were opened or when they should be used by. The Dietary Manager stated that clean dishes are expected to be inverted when stored and that all opened food items should be labeled and dated with the opened-on date.
Infection Control Failures During Resident Care and Equipment Use
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. Survey observations showed improper hand hygiene during personal care for multiple residents, including residents who were being assisted with toileting, peri-care, transfers, and dressing. Staff were observed entering resident rooms and donning gloves without first performing hand hygiene, and in several instances gloves were removed without hand hygiene afterward. One CNA also washed hands at a kitchen sink after peri-care, touching faucets with hands immediately after completing the care. Surveyors also observed mechanical lifts being used for resident transfers without being disinfected after use. A sit-to-stand lift and a Hoyer lift were observed being moved from one resident’s room to another and parked in common areas without being wiped down. One Hoyer lift that had been used earlier in the day was later observed still not cleaned when brought into another resident’s room and used again for transfer and care. Staff interviews showed differing statements about when lifts were cleaned, including comments that they were cleaned at the end of the shift, whenever possible, or after every person, while the DON stated the expectation was that lifts be cleaned after every use. The facility also failed to ensure proper PPE use for a resident on Enhanced Barrier Precautions. A CNA assisted the resident off the toilet, completed peri-care, removed gloves, and performed hand hygiene, but did not wear a gown during the care even though the resident was on EBP. Interviews with the CNA, an LPN, and the DON confirmed that staff were aware the resident had been placed on EBP and that gowns and gloves were expected for high-contact care activities such as toileting, hygiene, dressing, and transfers. The CNA stated the EBP sign was new to them and acknowledged they should have used it.
Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that RN G, who was acting as the Infection Preventionist, had completed the required specialized education in infection prevention and control. Survey review of the documentation provided for the Infection Preventionist's training found that some modules had certificates of completion from the CDC infection control program, but the CDC training log showed the certificate for the final IP test had expired, indicating the test was not taken within the allowed time after completing the modules. The required IP course did not show that the certification test was taken and passed. When interviewed, RN G stated they were not sure whether they had taken a final test after completing the training modules and did not have a certificate showing they passed the IP test. The Nursing Home Administrator stated they had thought RN G had completed the IP course and that the expectation was for the IP to meet the qualifications required by federal regulations.
Missing Staff COVID-19 Vaccination Documentation
Penalty
Summary
The facility did not maintain documentation of screening, education, offering, and current COVID-19 vaccination status for staff. The facility policy titled, Employee Infection and Vaccination Status, revised January 2024, states employees are to be offered or provided vaccinations per state or local policies, given educational materials for non-mandated vaccinations, and have declinations documented in the employee health record. During interview, RN G stated staff vaccination information was provided at staff meetings and offered yearly, but the facility did not maintain documentation of the education provided or which staff received it, although current vaccination status was kept. During interview and record review, CNA P reported being offered the COVID vaccine and influenza vaccine through a staff chat platform and stated they did not receive the COVID vaccine. CNA P’s employee record showed vaccinations received at hire on 10/12/22 and a signed declination for the COVID vaccine on that date. On 06/24/26, the NHA and DON acknowledged the regulation requiring documentation of screening, education, offering, and current COVID vaccination status for staff. The DON stated they were unaware this was not being done and said the facility used to maintain this information, with the expectation that the Infection Preventionist would maintain the required documentation for all staff.
Advance Directive and Code Status Documentation Not Clearly Identified
Penalty
Summary
The facility did not ensure that advance directive information related to resuscitation status was clearly identified in residents’ medical records for 9 of 18 residents reviewed for advance directives. Across multiple records, physician orders listed code status as DNR/DNI, but the corresponding advance directives either did not address resuscitation wishes, contained conflicting code status information, or lacked a signed DNR/DNI form from the resident or representative. For several residents, the record review showed mismatches between physician orders and other chart documents. One resident’s physician order listed DNR/DNI, but the advance directive did not include resuscitation wishes and no DNR/DNI form was signed. Another resident’s physician order listed DNR/DNI, but the advance directive stated Full Code and the social service assessment stated DNR/DNI. Other records showed physician orders for DNR/DNI while inquiry reports or resident assessments stated Full Code, and some records had no documentation of a discussion with the resident or representative about code status. The survey also found residents whose records reflected changes in code status without supporting documentation of education or discussion. One resident’s electronic record showed DNR, but the signed advance directive indicated the resident wanted CPR attempted unless certain conditions applied, and there was no updated advance directive or DNR/DNI form signed by the resident or representative. Another resident had physician orders for DNR/DNI while hospital transfer orders still indicated Full Code, and no updated advance directive or DNR/DNI document was signed. For another resident, the chart documented a care conference with no change in code status, but no advance directive or DNR/DNI document signed by the resident or representative was present.
Missed Eye Drop Medication Due to Unavailable Supply
Penalty
Summary
The facility did not provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for one resident with glaucoma. The resident was admitted with a diagnosis of glaucoma and had a BIMS score indicating severe cognitive impairment. The physician ordered latanoprost eye drops, 1 drop in both eyes at bedtime, with an open-ended start date. The facility policies titled Administering Medications and Instillation of Eye Drops, both dated 2001, did not address reordering medication or what to do when medication was not available. Record review showed multiple missed administrations of the eye drops because the medication was documented as unavailable on several dates across January through May 2026. The resident’s family member stated they were told the pharmacy was at fault and that the resident was sometimes without the medication for over one week. A pharmacy email stated that a refill request was received on 1/25/26, another on 2/5/26 was too soon, and the next dispense was not until 4/6/26, with no refill request seen between 2/5/26 and 4/6/26. Staff interviews confirmed difficulty obtaining the medication, and the DON stated the resident had missed too many days of the medication and that she later found a bottle of eye drops in the refrigerator.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Unqualified Food and Nutrition Services Director and Lack of Dietician Oversight
Penalty
Summary
The facility failed to designate a director of food and nutrition services who met the minimum qualification requirements for the position. During a kitchen tour, the Dietary Manager (DM) presented certifications, including a Food Protection Manager certificate accredited by ANSI-CFP, but this did not meet the requirements for a Certified Dietary Manager. The facility did not have a full-time, in-house dietician; instead, the dietician was fully remote, and no evidence was provided to show that the remote dietician was monitoring compliance in the kitchen. The Nursing Home Administrator confirmed the absence of an in-house dietician and was unable to provide documentation of oversight or compliance monitoring by the remote dietician. This deficiency potentially affected all 60 residents in the facility.
Improper Food Storage and Unsafe Temperature Probe Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper food storage and handling practices in accordance with professional standards. During a kitchen tour, several opened food items in the walk-in cooler, including sliced tomatoes, repackaged sour cream, shredded cheese, salads, and pre-poured juice, were found to be covered but not labeled or dated with an opened or use-by date. The Dietary Manager confirmed that the expectation was for all opened or prepared foods to be labeled and dated, but this was not done, resulting in the disposal of potentially hazardous foods. Additionally, during food temperature checks, the Head of the kitchen was seen cleaning the thermometer probe with isopropyl alcohol wipes and immediately inserting it into food items without allowing it to air dry as required by FDA Food Code. The Head of the kitchen admitted to not being aware of the need to let the probe air dry between uses and was unsure of when she was last trained on this procedure. These practices were observed to have the potential to affect all residents in the facility.
Infection Control Program Deficiencies and Lapses in Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in policy implementation, surveillance, and staff practices. The water management policy was outdated and lacked specific control measures to prevent the spread of Legionella, particularly in unoccupied rooms and a vacant wing. The infection preventionist and other staff acknowledged that flushing of water lines in these areas was not formally documented in the policy, and there was no clear process for addressing water stagnation. Infection surveillance logs for outbreaks of influenza and COVID-19 were incomplete, missing critical information such as symptom onset dates, staff last worked dates, test types and results, treatment parameters, isolation details, and resolution dates. The facility did not track or document the implementation of isolation precautions, PPE usage, or staff education during outbreaks. Additionally, the process for managing sick staff was informal, with untrained personnel making decisions about staff illness and return-to-work, and no formal tracking of staff testing or work locations during outbreaks. Direct care observations revealed that staff did not consistently follow hand hygiene protocols during personal care activities. In one instance, a CNA failed to perform hand hygiene after removing soiled gloves and before re-gloving while providing care to a resident on enhanced barrier precautions. Another resident with an indwelling catheter did not have enhanced barrier precautions initiated as required by facility policy. In a separate case, a CNA continued care after soiling gloves, wiped them clean instead of changing them, and did not perform hand hygiene after glove removal. These lapses were acknowledged by staff and supervisors as contrary to facility policy and training.
Failure to Monitor and Document Antibiotic Use in Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an Antibiotic Stewardship Program with protocols and a system to monitor antibiotic use. The facility's policy assigned the Infection Preventionist (IP) responsibility for monitoring, investigating, and controlling infections, as well as tracking infection incidence rates and reviewing this information quarterly with the interdisciplinary team and medical director. However, review of infection surveillance logs revealed missing documentation, including incomplete records of symptom onset dates, culture/test types and results, antibiotic treatment parameters (such as antibiotic selection and start/stop dates), and infection resolution dates and times. During an interview, the Infection Preventionist (RN) stated that antibiotic tracking was based on monthly reports received from an external pharmacy provider, which were reviewed approximately two weeks after antibiotics were started. The RN was unable to describe a process for tracking infections, monitoring antibiotic selection, or ensuring appropriate antibiotic use, and deferred these decisions to the prescribing physician. The RN also confirmed that no standardized criteria, such as McGeer's or Loeb's, were being used to determine the need for antibiotics or to monitor their appropriateness, and was unfamiliar with these guidelines until referenced by the surveyor.
Failure to Address and Resolve Resident Grievances Regarding Missing Laundry Items
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal and did not establish or follow an effective grievance policy regarding missing laundry items. Multiple residents reported missing clothing and personal items to staff, but the facility did not consistently document these grievances, conduct thorough investigations, or provide resolutions. Resident council meeting minutes and interviews revealed that several residents experienced ongoing issues with missing clothing, with some items never being found or replaced, and residents often ceased pursuing the matter after initial reports to staff. Surveyor observations and interviews with staff, including the Laundry Director and Nursing Home Administrator, revealed a lack of a clear and consistently implemented process for labeling residents' clothing. Many clothing items remained unlabeled, as evidenced by approximately 80 pieces of clothing on an unlabeled cart in the laundry area. Staff acknowledged that the process for labeling and tracking clothing was not well defined or enforced, and that staff training on this process could not be substantiated with documentation. The facility's grievance logs showed some instances where missing items were found and returned, but other cases were not documented or resolved, and there was no evidence of prompt or systematic efforts to address the broader issue. Interviews with residents and staff further highlighted the facility's inadequate response to grievances about missing laundry. Residents described having to keep personal records to track their belongings, and staff often relied on informal methods or other departments to search for missing items. The Director of Nursing acknowledged the ongoing problem with missing laundry due to improper labeling and confirmed that the facility had not resolved this concern. The lack of a clear, documented process and failure to address residents' grievances led to unresolved losses of personal property for several residents.
Failure to Provide Comprehensive Pain Management and Assessment
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for multiple residents requiring such services, as evidenced by inadequate pain assessments, lack of comprehensive and individualized pain care plans, and insufficient monitoring and documentation of pain interventions. For several residents with chronic and acute pain, including those with complex medical histories such as palliative care, cancer, chronic pain syndromes, and neuropathy, the facility did not consistently assess pain using standardized tools, document pain characteristics, or follow up on the effectiveness of pain medications. In some cases, pain levels were not recorded before or after medication administration, and non-pharmacological interventions were either not offered, not documented, or not included in care plans. One resident with chronic pain and a history of palliative care experienced repeated episodes of severe pain, including a period when a scheduled Fentanyl patch was not administered as ordered, resulting in increased pain and the need for additional PRN opioid medications. Despite these events, there was no comprehensive pain care plan in place, and pain assessments were not consistently performed or documented during periods of increased pain. Staff interviews confirmed that pain management was largely reactive, with staff waiting for residents to request medication and not routinely assessing or documenting pain levels or the effectiveness of interventions. Other residents with chronic pain, cancer, or neuropathy also lacked individualized pain care plans, and their records showed inconsistent or absent documentation of pain assessments, non-pharmacological interventions, and monitoring for opioid side effects such as constipation and sedation. The facility's own policies required comprehensive, multidisciplinary pain management, including regular assessments, care planning, and monitoring for adverse effects, but these standards were not met for the residents reviewed. Staff and leadership interviews acknowledged these deficiencies, noting that pain assessments and care planning were not consistently completed or documented as required.
Failure to Safeguard Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of resident medical records for three out of five sampled and supplemental residents. Facility policy requires that protected health information (PHI) in any form remain confidential and that care be taken to ensure privacy when handling such information. Despite this, observations revealed that an LPN repeatedly left a medication cart in the hallway with the computer screen displaying residents' medical records unattended. This occurred multiple times while the LPN was administering medications to different residents, leaving their PHI visible to staff passing by in the hallway. Specific incidents included the LPN leaving the computer screen open with individual residents' medical records displayed while entering residents' rooms to administer medications. On several occasions, other staff members walked past the unattended cart with the open screen. The Nursing Home Administrator confirmed that employees are expected to safeguard PHI and close or lock computer screens when left unattended, but this expectation was not met during the observed events.
Failure to Provide and Assess Restorative ROM Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to ensure that two residents with limited mobility received appropriate restorative services and assistance to maintain or improve their range of motion (ROM) as ordered. For one resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, hemiplegia, and muscle weakness, the care plan required daily passive range of motion (PROM) exercises for both upper and lower extremities. However, restorative nursing logs showed inconsistent and often minimal completion of PROM, with several days where exercises were not performed at all. Staff interviews confirmed that ROM was only completed during morning care, and there was no evidence of regular review or assessment of the program's appropriateness. Another resident with multiple sclerosis, paraplegia, and a history of contractures had a care plan for a daily stretching program at bedtime. Documentation revealed that PROM was inconsistently performed, with several days missed and no prior tracking available before a certain date. The resident reported that ROM exercises were only done if specifically requested, and staff interviews indicated a lack of program review and assessment. The registered nurse acknowledged that the absence of regular assessments contributed to the failure to identify and address these deficiencies.
Failure to Document Site of Nasal Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its own medication administration policy, specifically regarding the documentation of the route and site of administration for inhaled medication. A resident with a diagnosis of allergic rhinitis had a physician's order for calcitonin nasal spray to be administered in alternating nostrils daily. During a medication pass, an LPN was observed administering the nasal spray into the resident's right nostril and documenting the administration, but did not record which nostril was used. Upon interview, the LPN stated that staff previously documented the nostril used but had stopped doing so, relying instead on memory. The Director of Nursing confirmed that staff are expected to document the site of administration and was unaware that this was not being done.
Failure to Ensure Drug Regimens Are Free from Unnecessary Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' drug regimens were free from unnecessary medications for three out of five residents reviewed. Specifically, residents were prescribed sleep medications such as melatonin and trazodone without adequate clinical indications, assessments, or care plans addressing sleep management. There was no documentation of sleep assessments, monitoring of sleep patterns, or tracking of sleep quality to justify the continued use of these medications. The care plans for these residents did not include individualized interventions or non-pharmacological approaches to promote sleep, as required by facility policy. One resident was also found to be receiving a daily antibiotic for urinary tract infection (UTI) prevention without documented rationale or evidence supporting the need for prophylactic antibiotic use. The infection preventionist and nursing staff were unable to provide criteria or justification for the ongoing antibiotic therapy, and there was no documentation of recurrent UTIs or physician rationale for this regimen. Staff interviews revealed a lack of understanding regarding the appropriateness of the medication orders and an absence of oversight or challenge to the prescriber's decisions. The facility's policy requires comprehensive assessment and individualized care planning for behavioral and psychosocial symptoms, including sleep disturbances. However, the survey found that these processes were not followed. There was no evidence of behavioral assessments, cause identification, or targeted interventions for the affected residents. Staff interviews confirmed that sleep was not routinely monitored or documented, and care plans did not address sleep issues or include non-pharmacological interventions, resulting in the continued use of unnecessary medications.
Failure to Document COVID-19 Vaccination Screening and Offer
Penalty
Summary
The facility failed to maintain documentation of screening, education, and offering of the current COVID-19 vaccination for one of five residents reviewed. Specifically, the electronic medical record for a resident with multiple diagnoses, including Alzheimer's disease, chronic kidney disease, and dementia, did not contain any documentation indicating that the resident had been screened or offered the 2024-2025 COVID-19 immunization. When the surveyor requested documentation, none was available for this resident, and the only policy provided by the facility addressed influenza and pneumococcal vaccinations, with no reference to COVID-19 vaccination procedures. During interviews, the Infection Preventionist (IP) stated that residents and staff are offered immunizations annually, and that education and consent are obtained either directly from the resident or through their Power of Attorney. However, the IP was unable to provide a COVID-19 consent or declination form for the resident in question, explaining that the resident had declined the vaccine in the previous year and was therefore not approached again for the current vaccination year. No further documentation was found after checking with the pharmacy.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing the medical and nursing needs of two residents. For one resident with diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3b, and edema, there was no care plan in place to monitor for adverse reactions or efficacy related to the administration of diuretic medications, despite the resident receiving furosemide and exhibiting significant edema and mobility difficulties. The absence of a care plan was confirmed through record review and interviews, with the Director of Nursing acknowledging the oversight. For another resident with multiple complex diagnoses, including Alzheimer's disease, dementia, and severe cognitive impairment, who was receiving hospice services, the facility did not develop a hospice or end-of-life care plan. This was confirmed through review of the resident's care plans and direct inquiry with the Nursing Home Administrator, who indicated that no hospice care plan had been created. These deficiencies were identified through observation, interview, and record review.
Failure to Update Care Plan Following Escalation of Resident Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect recent changes in behavior and to provide appropriate direction to staff. The resident, who has Alzheimer's disease with late onset, dementia, and an anxiety disorder, exhibited a significant increase in behavioral issues, including physical and verbal aggression, spitting, yelling, throwing objects, and involvement in altercations with other residents. Despite these documented incidents and changes in the resident's condition, the care plan was not updated to include new interventions or reflect the care being provided, such as the initiation of 1:1 supervision and medication adjustments. Documentation reviewed by the surveyor showed multiple behavioral incidents over several days, with staff and LPNs intervening and reporting the events. However, the care plan remained unchanged from its original version, and new interventions were not formally documented until after the survey process began. The facility's own policy requires ongoing assessment and timely revision of care plans as residents' conditions change, but this was not followed in the case of this resident.
Single Resident Room Below Minimum Size Requirement
Penalty
Summary
The facility failed to ensure that a single resident room met the required minimum size of 100 square feet, as specified in the State Operations Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities. During the survey, it was observed that one resident was occupying a room measuring only 96.5 square feet. The Nursing Home Administrator confirmed that the room was smaller than the regulatory requirement and stated that no remodeling had been done to address the deficiency. The administrator also indicated that the facility has limited private rooms and reviews the use of this undersized room annually, placing only smaller, ambulatory residents in it after informing them and their Power of Attorney about the room size. The resident occupying the room was admitted with multiple diagnoses, including atrial fibrillation, anxiety, depression, malnutrition, an unspecified mental disorder, and attention deficit hyperactivity disorder. The resident was assessed as severely cognitively impaired but able to make herself understood and ambulate independently. During an interview, the resident expressed satisfaction with the room, describing it as comfortable and appreciating features such as a large window. The surveyor attempted to contact the resident's Power of Attorney but did not receive a response.
Inadequate Supervision During Resident Transfers
Penalty
Summary
The facility failed to ensure adequate supervision during resident transfers with a mechanical lift, specifically a Hoyer lift, which posed a risk of falling. This deficiency was identified for three residents. On a specific day, a Certified Nurse Assistant (CNA) was left alone to transfer these residents due to a staffing shortage caused by another CNA leaving for a family emergency. The CNA acknowledged the risk of transferring residents alone but felt compelled to proceed due to the lack of available staff. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were not informed of the staffing shortage on the day it occurred and only became aware of the situation days later. Both the NHA and DON confirmed that their policy requires two staff members to operate a Hoyer lift, and they were unaware that the CNA had to perform the transfers alone.
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 82 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 Amery
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Ridge Healthcare | 0.2 mi | ★★★★★ | 0 | 0 |
| Dove Healthcare - St Croix Falls | 15.1 mi | ★★★★★ | 0 | 0 |
| St Croix Health Center | 15.3 mi | ★★★★★ | 10 | 0 |
| Deerfield Care Center, Llc | 15.8 mi | ★★★★★ | 4 | 0 |
| Christian Community Home Of Osceola, Inc | 16.3 mi | ★★★★★ | 4 | 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 October 2026) and official state health department websites.