Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Northern Lights Hcc during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and moderate cognitive impairment required 2-assist transfers with an EZ stand lift per the care plan and PT note. A CNA independently transferred the resident with the lift without checking the care plan, and the resident fell straight down out of the sling, striking the head on the floor and sustaining a scalp laceration that required 7 staples. The resident’s wife witnessed the fall, and the CNA stated she had not reviewed the care plan before the transfer.
Failure to Report Injury of Unknown Origin: A resident with dementia, severe cognitive impairment, osteopenia, falls, and weakness developed a right hip fracture of unknown origin after reporting leg pain during cares. ED imaging showed a displaced proximal femur fracture, and the DON later confirmed the facility did not submit the required self-report to the SA and was unaware it needed to be done.
A resident with severe cognitive impairment and chronic respiratory conditions who tested positive for COVID-19 was not consistently monitored or assessed for changes in condition, and the provider was not notified of new or worsening symptoms as required by facility policy and physician orders. Despite multiple documented changes in vital signs and respiratory status, provider notification did not occur until the resident became minimally responsive and hypoxic, resulting in emergency hospital transfer.
The facility failed to report two incidents of possible neglect to the State Agency as required. In one case, a resident with cognitive and physical impairments suffered a fall with fracture that was not reported. In another, a resident with severe cognitive impairment and respiratory issues experienced a decline in condition and a subsequent complaint of neglect, which was also not reported. Leadership interviews revealed confusion about reporting responsibilities and requirements.
The facility did not thoroughly investigate or report two separate incidents involving potential neglect: one involving a resident with severe cognitive impairment who experienced a significant decline in respiratory status without timely provider notification, and another involving a resident with moderate cognitive impairment who suffered an unwitnessed fall resulting in a fracture. In both cases, required investigations and state reporting were not completed, and the facility's own policies were not followed.
Three residents with cognitive and physical impairments experienced multiple falls, including incidents resulting in head laceration and fracture, without thorough root cause investigations, new safety interventions, or consistent care plan updates. Required post-fall assessments, injury monitoring, and IDT reviews were not documented, and interventions were often not adjusted to address the causes of repeated falls.
Unsafe food handling and hygiene practices were observed in the kitchen. A fan with dust and debris was blowing directly on a rack of clean dishes, a cook wiped a food thermometer probe with alcohol and immediately inserted it into foods without allowing it to air dry, and a dietary aide was observed wearing a beard restraint improperly while entering and working in the kitchen.
Infection prevention practices were not followed during resident care. A CNA emptied a resident’s Foley catheter without the gown required for EBP, another CNA performed incontinence care for a resident with severe cognitive impairment without changing gloves after stool contact and continued care to open skin with the same gloves, staff were observed moving between residents and setting up meals without hand hygiene, and dirty linens were carried through resident areas without being bagged as required by policy.
Dining Assistance and Meal Timing Did Not Preserve Resident Dignity: Survey observations showed staff standing over residents while feeding or assisting them with bites and drinks, and one resident’s meal was set up uncovered before the resident arrived. At shared tables, some residents received meals while others waited, including a resident who had no food in front of him while others were already eating. An RAI interview also indicated meal delivery varied based on staffing in the dining room.
Failure to Report Suspected Physical Abuse: A CNA discovered a 2 cm cut on a resident’s eyelid while providing care, and the resident’s POA, charge nurse, and provider were notified, but the incident was not immediately reported to the administrator or local law enforcement as required. The resident had severe cognitive impairment (BIMS 00), hemiplegia/hemiparesis after CVA, and impaired ROM. The DON stated staff did not follow procedure to notify leadership and investigate the incident.
A resident with hemiplegia, severe cognitive impairment, impaired ROM, and dependence for most ADLs had a CNA task list directing heel pads while in bed every shift, but surveyors observed a foam wedge being used instead and no heel pads in the room. CNAs said the resident had been switched from heel pads to the wedge some time ago, yet the task list still showed heel pads as completed, and the DON stated the nurse should have updated the care plan when the change occurred.
Failure to prevent and treat pressure injuries: Two residents with severe cognitive impairment and dependence for all cares developed stage II pressure injuries while CNA charting repeatedly noted open skin areas that were not reflected in nursing weekly skin checks. Staff reported using barrier cream and powder on the wounds, but there were no timely wound care orders documented, repositioning was inconsistently tracked, and one resident’s care plan was not updated to match current pressure-relief needs.
A resident with hemiplegia and hemiparesis, severe cognitive impairment, and impaired ROM did not receive ordered restorative care. CNA task records showed repeated missed PROM and missed cleansing of the left palm and application of the palm/wrist guard, and a CNA stated staff do not always have time and do not always follow the care plan. The DON stated the cares should have been completed.
A facility did not ensure appropriate care for two residents with feeding tubes. An LPN verified tube placement by auscultation and administered an enteral feeding by pushing formula into the tube even though the order required gravity administration and a different amount. For another resident, an RN also checked G-tube placement by inserting air and listening with a stethoscope, stating this was the facility’s policy, despite current standards cited in the report.
Failure to recognize and manage pain for a resident with severe cognitive impairment, dementia, repeated falls, a right pubis fracture, and chronic pain. Staff observed the resident yelling out, grimacing, guarding the left hip, stiffening, and resisting movement during dressing and transfers, but pain was not consistently identified or treated; charting was mostly 0/10, PRN Tylenol had not been given since admission, and the care plan did not include pain interventions.
Failure to Provide Written Transfer Notices: The facility did not provide written transfer notices for 3 residents who were sent to the hospital by ambulance. The notices did not include the reason for transfer, location of transfer, appeal rights, or Ombudsman contact information. The DON stated the facility was unaware of the requirement and did not have a process in place; bed hold notices were completed and the Ombudsman was notified, but no written transfer notice was documented.
A resident with Alzheimer's and dementia eloped from a facility through an unalarmed door that was known to not shut properly. The resident's care plan included 15-minute checks, which were not consistently completed, and staff were unaware of the requirement. The door, used frequently by staff, was not repaired despite known issues, and staff were not educated on the door's problems or elopement procedures, leading to a finding of immediate jeopardy.
The facility failed to maintain sanitary conditions in food storage and service, affecting all residents. Expired chocolate milk was found, dishwasher temperature logs were incomplete, and test strips were expired. Staff did not wear hairnets properly, and a cook handled food with contaminated gloves. Maintenance work occurred in the kitchen during meal service without proper hair restraints, and the Nursing Home Administrator did not address the issue.
The facility submitted inaccurate staffing data to CMS, affecting all 39 residents. Due to a payroll system change, data for Quarter 3 2023 was inaccessible, leading to reported failures in 24-hour licensed nursing coverage. Quarter 4 2023 data showed issues like low weekend staffing and no RN hours, but reviews confirmed appropriate scheduling. The inaccuracies were due to incorrect staff coding during data submission.
The facility failed to implement restorative and Functional Maintenance Programs (FMP) for residents, leading to missed opportunities for care. A resident was observed without a required palm protector, and staff were unaware of FMPs due to a lack of formal programs and issues with electronic record transitions. The deficiency affected multiple residents, with care plans missing FMPs until surveyor intervention.
The facility failed to provide adequate staffing, resulting in insufficient care for residents. Staffing levels fell short of the facility's assessment, impacting the implementation of Functional Maintenance Programs, meal assistance, and personal hygiene care. Residents with pressure injuries were not repositioned as required, and staff expressed concerns about chronic understaffing affecting their ability to provide necessary care.
The facility failed to provide required written bed hold notices and reasons for transfer to two residents during hospital transfers, as per their policy. Despite the policy's requirement for such documentation, neither resident received the necessary notices, and the Director of Nursing confirmed this oversight.
A long-term care facility failed to provide adequate assistance with activities of daily living for residents dependent on staff. One resident did not receive proper hygiene care, another was left unsupervised during meals, leading to inappropriate behaviors, and a third was not repositioned or offered toileting assistance for several hours, resulting in incontinence. Staff acknowledged the oversights, and the Director of Nursing confirmed the expectations for care.
A resident with multiple medical conditions, including diabetes and an amputation, was not repositioned regularly, leading to inadequate wound care. The resident was left in a wheelchair for long periods without repositioning or toileting assistance, despite having open sores. Additionally, an LPN failed to follow proper infection control practices during wound care, not changing gloves or sanitizing hands between steps, and incorrectly applying Santyl ointment. Staff interviews confirmed the resident should have been repositioned every two hours, but this was not consistently done.
A resident with multiple pressure injuries did not receive adequate care and prevention measures in a facility. The resident was not repositioned as required, leading to prolonged pressure on existing wounds. The wound nurse inaccurately staged the wounds, and the registered nurse failed to follow proper hand hygiene and wound care procedures. Interviews revealed that the resident was concerned about the lack of repositioning and worsening wounds, while staff confirmed the need for repositioning every two hours.
Two residents were prescribed Trazodone for insomnia without comprehensive sleep assessments or monitoring to evaluate the medication's effectiveness. The facility's policy emphasizes non-pharmacological interventions before medication, but the process of conducting sleep monitoring and assessments was not followed, leading to the deficiency.
CNAs failed to perform hand hygiene as required while providing care to a resident dependent on staff for mobility and hygiene. Despite facility policies mandating handwashing before and after resident contact and between glove changes, CNAs did not adhere to these guidelines during peri-care and other tasks, risking infection spread.
Failure to Follow 2-Assist Lift Transfer Care Plan Resulted in Resident Fall
Penalty
Summary
The facility did not ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents when a CNA independently transferred a resident who required 2-person assistance with an EZ stand lift. The resident had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, and the quarterly MDS noted a BIMS score of 08, indicating moderate cognitive impairment. The resident’s care plan and PT discharge note both identified transfers as requiring 2 assist with use of the EZ stand lift. On the day of the incident, the CNA transferred the resident from the bathroom to the recliner using the EZ stand without another staff member present. While positioning the resident, the CNA began moving the lift to accommodate the resident’s wife’s request to move the chair closer to the TV, and the resident suddenly fell straight down out of the sling onto the floor on the left side. The resident’s head struck the floor and began bleeding, and staff provided first aid, notified the provider, and called an ambulance. The resident was transferred to the local hospital and returned the same day. Hospital records showed a 3.5 cm by 4 cm laceration to the left temporal scalp requiring 7 staples, with CT and x-rays showing no fracture or other injuries. During interview, the CNA stated she transferred the resident independently and did not review the care plan before assisting, saying she had gotten into a bad habit of not checking residents’ care plans. The resident’s wife stated she saw the resident fall straight down out of the sling, and the LPN and DON confirmed the transfer did not follow the resident’s care plan.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility did not ensure that an alleged violation involving abuse, neglect, exploitation, or mistreatment was reported immediately, but no later than 2 hours after the allegation was made, when a resident sustained a right hip fracture of unknown origin. The resident had diagnoses including dementia, osteopenia, falls, and weakness, and had a BIMS score of 0, indicating severe cognitive impairment. The resident was transferred to the ED after complaining of right leg pain during cares, and radiology showed a moderately displaced, mildly comminuted proximal right femur fracture along with severe osteopenia. Medical providers determined the resident was not a surgical candidate and the resident returned to the facility on comfort care measures. The DON initiated an investigation into the injury of unknown origin and interviewed nurses and CNAs who worked during the prior 24 hours. Staff reported no complaints of pain before the resident began reporting right leg pain and no witnessed trauma or injury. The investigative report stated the resident's legal representative was aware of the injury and prognosis, but the surveyor found no indication that the facility reported the injury of unknown origin and fracture to the State Agency. When interviewed, the DON confirmed the facility did not submit a self-report for the injury and was not aware that one needed to be done, and confirmed the fracture was considered an injury of unknown origin.
Failure to Notify Provider and Monitor Resident with COVID-19
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory diagnoses, including pneumonia, COPD, and chronic respiratory failure, tested positive for COVID-19 and did not receive consistent monitoring and assessment for changes in condition as required by facility policy and physician orders. The resident, who had severe cognitive impairment and was on continuous oxygen therapy, exhibited several changes in symptoms and vital signs over several days, including new onset of wheezing, productive and non-productive cough, elevated temperatures, increased oxygen requirements, and changes in lung sounds. Despite these changes, there was no documentation that the provider was notified in a timely manner, as required by both facility policy and physician orders. The facility's policy required immediate provider notification for acute illness or significant changes in a resident's physical status, including new or worsening symptoms. Physician orders specifically directed staff to monitor for COVID-19 symptoms every shift and to notify the provider immediately if any symptoms were noted. However, documentation showed that after the resident tested positive for COVID-19, there were multiple instances where new or worsening symptoms were observed—such as changes in lung sounds, increased oxygen needs, and elevated temperatures—but the provider was not notified until the resident became minimally responsive and hypoxic several days later. Interviews with nursing staff and the DON confirmed that any new symptoms or changes from baseline, especially in a COVID-19 positive resident, should have prompted immediate provider notification and documentation. The failure to notify the provider and to document these communications was acknowledged by staff and leadership during interviews. The resident was ultimately transferred to the hospital in acute distress with hypoxia and altered mental status, but there was no evidence of provider assessment or intervention between the initial positive COVID-19 test and the emergency transfer.
Failure to Timely Report Suspected Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act and state law. Specifically, the facility did not report two separate incidents involving possible neglect to the State Agency within the required timeframe. In the first case, a resident with moderate cognitive impairment and significant physical limitations experienced an unwitnessed fall resulting in a left humerus fracture. The incident was not reported to the State Agency as possible neglect, and no Misconduct Report was initiated, despite facility policy requiring immediate reporting of such events. In the second case, another resident with severe cognitive impairment and multiple comorbidities, including respiratory failure and emphysema, experienced a decline in respiratory status after testing positive for COVID-19. The resident developed new and worsening symptoms over several days, but the provider was not notified until the resident was found unresponsive and subsequently hospitalized. Following the hospitalization, the resident's POA filed a complaint alleging neglect due to insufficient monitoring and delayed intervention. This allegation was not reported to the State Agency, and no investigation or Misconduct Report was initiated. Interviews with facility leadership revealed confusion and lack of clarity regarding the responsibility and process for reporting such incidents. The Nursing Home Administrator and Director of Nursing provided inconsistent statements about which incidents should be reported and who was responsible for reporting. Both ultimately acknowledged that the incidents should have been reported to the State Agency prior to completing internal investigations, but this did not occur in either case.
Failure to Investigate and Report Alleged Neglect and Injury
Penalty
Summary
The facility failed to thoroughly investigate potential allegations of neglect for two residents. In the first case, a resident with severe cognitive impairment and multiple respiratory diagnoses tested positive for COVID-19 and subsequently developed new and worsening respiratory symptoms over several days. Despite these changes, the provider was not notified until the resident was found unresponsive and required emergency hospitalization. Following this event, the resident's Power of Attorney (POA) filed a complaint alleging neglect, specifically citing concerns that staff did not act on declining oxygen saturation until the resident became unconscious and that the resident was not adequately monitored. The facility did not initiate a thorough investigation into the allegation of neglect, nor did it report the incident to the State agency as required by policy. In the second case, another resident with moderate cognitive impairment, mobility limitations, and a history of falls experienced an unwitnessed fall resulting in a nondisplaced humerus fracture. The incident was discovered by a nurse, and the resident was transferred to the emergency room for evaluation. Although the interdisciplinary team reviewed the fall and implemented new interventions, the root cause of the fall was not clearly identified, and there was no documentation of staff or resident interviews or staff education to prevent future incidents. The incident was not reported to the State agency, and no misconduct report was initiated. In both cases, the facility's actions did not align with its own policy, which requires immediate reporting and thorough investigation of all alleged violations involving neglect. The Director of Nursing acknowledged during interviews that these incidents should have been considered potential neglect and reported accordingly, but this was not done.
Failure to Investigate and Prevent Resident Falls
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision and interventions to prevent accidents for three residents. Multiple falls occurred among these residents, some resulting in injuries such as a head laceration and a fracture, yet the facility did not conduct thorough root cause investigations or implement new safety interventions after each incident. In several cases, care plans were not updated following falls, and there was a lack of documentation regarding post-fall assessments, monitoring of injuries, and interdisciplinary team (IDT) reviews as required by facility policy. One resident with severe cognitive impairment and significant physical assistance needs experienced an unwitnessed fall resulting in a head laceration and was transferred to the emergency room. There was no documentation of a root cause investigation, no new interventions were implemented, and the care plan was not updated. Additionally, after returning from the hospital, there was no documentation of monitoring the repaired laceration site for infection or status. This resident had a subsequent fall with similar deficiencies in post-fall investigation and intervention. Another resident with moderate cognitive impairment, hemiplegia, and a history of falls experienced multiple unwitnessed falls, often while attempting to self-transfer. Despite repeated incidents, there was no documentation of root cause investigations, new interventions, or care plan updates. In one instance, the intervention provided was not appropriate given the resident's documented behavior. A third resident with moderate cognitive impairment and a history of falls, including one with a major injury, also experienced multiple falls without consistent root cause analysis, new interventions, or care plan updates. In some cases, interventions implemented were already in place, and there was no documentation of family notification or IDT review.
Unsafe Food Handling and Personal Hygiene Practices Observed in Kitchen
Penalty
Summary
Food handling safety was not maintained in accordance with professional standards in the kitchen. During an initial tour of the kitchen on 7/28/25, a surveyor observed a rack of clean dishes drying in the clean dish washing area while an industrial-type fan was blowing directly on the dishes. The fan had a dust-like substance covering the back of it, was loud, and appeared to be on high. The surveyor interviewed the person in charge about the fan blowing on the clean dishes, and he stated there were not usually clean dishes in front of the fan and turned it off. The surveyor also observed a cook taking internal temperatures of foods going from the oven into the warming table for lunch and wiping the thermometer probe with probe wipe before immediately inserting it into the next food item without allowing it to air dry. The cook stated she was not aware she was supposed to wait for the chemical to dry before placing the probe into resident food. In a separate observation, a dietary aide was seen entering the kitchen with a beard net around the neck and not covering the beard, then later wearing it only on the lower part of the chin before finally having it over the lower face including the mouth and mustache. The facility policy required proper cleaning and sanitizing of kitchen equipment and employees to wear hair restraints, including beard restraints, to prevent hair from contacting exposed food.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for all 43 residents. The facility policy on Enhanced Barrier Precautions stated that gown and glove use should be used during high-contact resident care activities, including device care for residents with indwelling urinary catheters. R5 was admitted with obstructive and reflux uropathy and a history of urinary tract infection, and had an order for Foley catheter care every shift. During observation, a CNA emptied R5’s catheter while wearing gloves but no gown, and stated he knew he should be wearing a gown for catheter care but did not always do so. The DON stated her expectation was that a gown and gloves should be worn with care of residents with an indwelling device such as a catheter. The facility also failed to follow its handwashing and linen handling policies during resident care. R40 had severe cognitive impairment, was incontinent of bowel and bladder, and was dependent with all cares and repositioning. During observed incontinence care, a CNA wiped stool from R40’s buttocks, did not change gloves after contact with stool, continued to wipe an open skin area on the upper buttocks, applied barrier cream to open wounds with the same gloves, and dressed the resident before removing them. In another observation, a CNA assisted multiple residents and brought one resident to the dining room without hand hygiene, then set up breakfast after pushing the resident’s wheelchair without performing hand hygiene. Staff were also observed carrying dirty linens in gloved hands down resident hallways and to the soiled linen room without placing them in a bag, despite the facility policy stating soiled linen should be contained and not held close to the body.
Dining Assistance and Meal Timing Did Not Preserve Resident Dignity
Penalty
Summary
The facility did not ensure 8 of 9 residents were treated with respect and dignity during dining and meal assistance. Survey observations showed staff standing over residents while assisting them to eat, including R29, R18, R9, and R16. On 07/28/25, R30 was observed seated at a table with three other residents and had no food in front of him while the others were eating; R30 did not receive a meal until 12:14 PM. During the same meal period, CNA H was observed standing next to residents while placing food on forks and giving bites of food to R29, R18, and R9, and while assisting R16 closer to the table and offering a drink while standing next to him. Survey observations also showed residents at shared tables did not receive meals within a similar time frame as others at the same table. On 07/28/25, CNA K set up R13's meal uncovered on the dining room table while R13 was not present, and R13 was brought to the table three minutes later. On 07/29/25, five residents were observed at a shared table awaiting breakfast; R35 received a meal at 7:43 AM and R2 at 7:48 AM, while R26, R13, and R14 still had no meal when two wing carts of food left the kitchen for resident rooms at 7:49 AM and 7:59 AM. During interview, R21 stated residents do not get their meals at the same time when sharing a table and that meal delivery depends on staffing in the dining room.
Failure to Report Suspected Physical Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting suspected physical abuse in accordance with section 1150B of the Act when an allegation was not reported immediately, and no later than 2 hours, to the administrator and local law enforcement through established procedures for one resident. The facility policy titled, Abuse, Neglect, and Exploitation, Suspected Crimes, states that any person who knows or has reasonable cause to suspect abuse, neglect, or exploitation shall immediately report it to the administrator, and that the administrator, DON, or designee will notify the appropriate regulatory, investigative, or law enforcement agencies immediately in accordance with state regulations. The resident involved was admitted with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The most recent quarterly MDS dated 07/17/25 showed a BIMS score of 00, indicating severely impaired cognition, and impaired ROM in both upper and lower extremities. The EMR showed that on 07/04/25, a CNA reported to an LPN that while providing care in bed, a 2 cm cut on the resident's left eyelid was discovered; the wound was cleaned and gauze applied, and the resident's POA, charge nurse, and provider were notified. The provider later responded to monitor for changes in vision and infection, but no additional documentation of the incident was noted. During interview, the DON stated she was unaware of the incident, that staff did not follow procedure by notifying leadership to investigate, and that the incident would have been investigated and reported if brought to her attention.
Care Plan Not Updated for Heel Offloading Change
Penalty
Summary
The facility did not ensure care plans were revised to reflect residents’ current needs and to provide direction to staff for one resident, R28. R28 was admitted with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and the most recent quarterly MDS dated 07/17/25 showed a BIMS score of 00, impaired ROM in all extremities, substantial to maximum assistance needs for dressing and rolling, and dependent assistance for hygiene and transfers. The assessment also noted R28 was at risk for pressure injuries with no current skin conditions. R28’s CNA task list dated 07/16/24 directed staff to ensure heel pads were on while in bed every shift, and this was documented as completed every shift. However, survey observation found R28 in bed with a foam wedge in place to elevate the heels off the bed, and no heel pads were observed at any time during the survey. CNA F stated heel pads had been used previously but were changed to a wedge because R28 kept pushing the heel pads off, and CNA D stated the resident had been transitioned to the wedge some time ago. Both CNAs indicated the task documentation still showed heel pads because the wedge was being placed instead. The DON stated the nurse should have updated R28’s care plan when the change was made.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure injury care and failed to prevent new pressure injuries for two residents who were reviewed for skin breakdown, resulting in stage II pressure injuries. Both residents were identified as being at risk for pressure injuries and were dependent on staff for care and repositioning. The report states that CNA documentation showed repeated open skin areas for both residents, but nursing staff did not document corresponding weekly skin assessments that reflected those findings, and the open areas were not promptly reported, assessed, or treated in a manner consistent with professional standards of practice. One resident, who had diagnoses including Alzheimer’s disease, heart disease with heart failure, hypotension, weakness, falls, and skin candidiasis, was incontinent of bowel and bladder and dependent for all cares and repositioning. CNA charting repeatedly noted skin tears and open skin areas on the buttocks, while nursing weekly skin checks documented no skin issues or only redness to the groin and buttocks. During observation, the resident had an open area with pink, moist tissue on the right buttock that the surveyor identified as a stage II pressure injury. CNAs reported using barrier cream and baby powder and leaving the area open to air, and staff stated the wound nurse and RN were aware, but the record did not contain wound care orders at the time of review. The resident was also observed repositioned inconsistently, with staff reporting repositioning occurred about every 2 hours but without specific time documentation. The second resident had diagnoses including prior TIA and cerebral infarction, left-sided hemiplegia and hemiparesis, weakness, and spinal stenosis, and was also dependent for all cares and repositioning. Nursing weekly skin checks documented no skin issues, while CNA charting documented open skin areas on multiple days. The surveyor observed an open area with pink, moist tissue on the right upper buttock that met the definition of a stage II pressure injury. The resident had barrier cream and powder caked around the wound edges, was using a pressure reduction mattress, and no cushion was present in the recliner even though the care plan referenced a Broda chair and pressure-relieving interventions. Staff reported the resident was supposed to be repositioned every 2 hours, but the CNA also stated that this was sometimes delayed because staff were busy with other residents. The DON stated CNA skin documentation was not reviewed by nursing staff and that open skin areas should have been reported immediately and documented by nursing, but this did not occur for either resident.
Missed PROM and Palm Guard Care
Penalty
Summary
The facility did not ensure a resident with limited mobility received appropriate restorative services and assistance to maintain or improve mobility with maximum practicable independence. R28 was admitted with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The resident’s most recent quarterly MDS, dated 07/17/25, showed a BIMS score of 00 and impaired ROM in both upper and lower extremities. The care plan directed staff to cleanse the left palm and apply a palm guard, and to provide passive ROM to the upper extremities every shift, focusing on the elbow, fingers, thumb, and shoulder. The CNA care task record for 07/2025 showed multiple missed entries for PROM and for cleansing the left palm and applying the wrist guard. PROM was not completed on 07/01, 07/07, 07/11, 07/12, 07/15, 07/18, 07/23, and 07/28, and cleansing of the left palm and wrist guard placement was not completed on 07/01, 07/11, 07/15, and 07/28. During interview, a CNA stated staff try to complete PROM but do not always have time, and that not all staff follow the care plan for the palm guard. The DON stated a dedicated restorative nurse aide had been established to complete PROM and that these cares should have been completed for R28.
Feeding tube placement was verified by auscultation and one enteral feeding was given contrary to the order
Penalty
Summary
The facility did not ensure that residents with feeding tubes received enteral feeding and tube-placement assessment in accordance with current standards of care. The report states that facility policy required tube placement to be checked, and the National Institute of Health guidance cited in the report says visible tube length should be measured and compared to the x-ray verified length, while older methods such as auscultation are unreliable and should no longer be used. One resident, R28, had diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, gastrostomy status, and mild protein-calorie malnutrition, and had severe cognitive impairment with a BIMS score of 00. During observation, an LPN verified tube placement by placing a stethoscope on the abdomen and pushing air into the tube, stating this was the facility’s current practice. The LPN also prepared 240 ml of formula even though the order was for 200 ml, and began pushing the feeding into the tube even though the order directed that the feeding be given by gravity and not pushed. The LPN stopped after being told the order did not match what was being done, then administered the remaining formula by gravity for a total of 200 ml. A second resident, R5, had dysphagia after stroke with a G-tube for feeding and cognitive impairment on MDS assessment. The care plan and physician orders directed tube placement checks and gravity feedings with specified flushes. During observation, an RN elevated the head of bed and then verified G-tube placement by inserting air into the tube and listening with a stethoscope, stating this was the facility’s policy. The RN also stated she was not aware that auscultation to determine G-tube placement was no longer a standard of practice.
Failure to Recognize and Manage Resident Pain
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services was not met for one resident with dementia, repeated falls, an other specified fracture of the right pubis, and chronic pain. The resident had a BIMS score of 3/15 indicating severe cognitive impairment. Facility policy required residents to be screened for pain regularly, including observing for grimacing, restlessness, moaning, and groaning for residents who have difficulty communicating, and to address identified pain issues on the baseline care plan. However, the resident’s pain assessment on 07/21/25 documented no pain, and charting showed all but one day since admission were marked 0/10 pain, with one day documented as 2/10. Some assessments used a verbal number scale and others used a visual dementia scale. The resident had an order for Tylenol as needed for pain, but it had not been administered since admission. Surveyor observations showed the resident repeatedly yelling out "ow" during care and transfers. On one occasion, a CNA entered the room and immediately requested a Hoyer lift after hearing the resident yell from across the hall. On another occasion, while CNAs were dressing the resident and placing a sling under her, the resident yelled out with each movement, had facial grimacing, guarded her left hip with her left hand, flailed, stiffened her body, and pushed back when rolled with a drawsheet. The CNA stated staff were not entirely sure whether it was pain or fear of movement and said the resident yells out like that during Hoyer transfers. The care sheet in the room listed only impulsive behavior and a history of falls, and the DON stated a pain care plan with interventions should be in place, but the resident’s care plan did not address pain interventions.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility did not provide a written notice of transfer for 3 residents reviewed, including the reason for transfer, the location of transfer, appeal rights, and the name, address, email, and telephone number of the Office of the State Long-Term Care Ombudsman. No written transfer notice was documented for R4, R28, or R32, and the facility did not have a system in place to provide this notice. The deficiency was identified during review of transfers and related records for residents who were sent to the hospital by ambulance and later returned to the facility. R4, who had diagnoses including cerebral infarction, asthma, Todd's Paralysis, diabetes mellitus type 2, and acute embolism and thrombosis of the deep vein of the right lower extremity, was transferred to the hospital with shortness of breath and fever and was admitted. R28, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, atrial fibrillation, and congestive heart failure, was transferred to the hospital for fever, altered level of consciousness, and changes in blood pressure and pulse and was admitted. R32, with diagnoses including diabetes mellitus type 2, COPD, and atrial fibrillation, was transferred to the hospital twice for shortness of breath and once for nosebleed and shortness of breath; each time, bed hold notice was completed and the Ombudsman was notified, but no written transfer notice was documented.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to adequately supervise a resident at risk for elopement, resulting in the resident leaving the building unsupervised. The resident, diagnosed with Alzheimer's disease and dementia, was assessed as having a severe cognitive impairment and was ambulatory without assistance. Despite being identified as an elopement risk and having a WanderGuard, the resident managed to elope through an unalarmed door, A6, which was known to not shut properly unless pulled tightly. This door was used frequently by staff and was not alarmed, allowing the resident to exit the facility unnoticed. The facility's care plan for the resident included 15-minute checks, which were not consistently documented or completed, particularly on the day of the elopement. The staff responsible for these checks was not aware of the requirement, leading to a lapse in supervision. The resident was found by staff from a nearby assisted living facility and returned by law enforcement, having been outside in freezing temperatures without adequate clothing. The facility's failure to repair the door and ensure staff were informed and compliant with the care plan contributed to the resident's unsupervised exit. Additionally, the facility's maintenance department was aware of the door's issues but had not completed necessary repairs or replacements. Despite receiving parts to fix the door, it remained improperly functioning, and daily checks on the door were not consistently performed. Staff were not formally educated on the door's issues or the procedures to follow in the event of an elopement, further exacerbating the risk to residents. This lack of action and communication led to a finding of immediate jeopardy due to the potential for serious harm to the resident.
Removal Plan
- A6 door alarmed.
- A6 door aligned/adjusted door and hinges.
- Aligned ANSI strike plate on door jam.
- Repaired door closer that was not attached to the door.
- Installed bolts on the screws that were stripped.
- Adjusted the preload on the door closer.
- Close/locked off both back hallway doors.
- Reverse locks so they open with a key.
- Education with SNF staff regarding residents being on 15-minute checks, purpose of 15 minute checks and further direction that need to be completed on the form.
- Direct care staff are to complete the form based on the instructions.
- A6 door audits are checked.
- Maintenance staff has been trained regarding door checks on the A6 door.
Sanitation Deficiencies in Food Storage and Service
Penalty
Summary
The facility failed to ensure food was stored and served under sanitary conditions, which had the potential to affect all 39 residents. During an initial tour of the kitchen, a surveyor observed expired chocolate milk containers in the line cooler, which were five days past their expiration date. The Culinary Director acknowledged the oversight and removed the expired milk, stating it was the responsibility of all dietary staff to dispose of expired items. Additionally, the dishwasher temperature logs were incomplete, with no documented temperatures for a specific period, and the Culinary Director could not explain the lapse. Further observations revealed that the facility's internal dishwasher temperatures were not routinely checked, and the test strips used for high-temperature dish machines were expired. New staff members were unsure of the purpose of these strips. During tray line service, a dietary aide was observed wearing a hairnet improperly, with long hair exposed, and the cook was seen touching ready-to-eat food with contaminated gloved hands. The cook used the same gloves to handle various surfaces and food items without changing them or washing hands, which violated the facility's policy on glove use. The surveyor also noted that during meal service, the Plant Operations Director and a roofer entered the kitchen without hairnets, set up a ladder, and removed a ceiling tile, which was not routine practice. The Nursing Home Administrator witnessed this but did not intervene. The Culinary Director later confirmed that maintenance work should not occur during food service and that all individuals entering the kitchen should wear appropriate hair restraints. These observations highlighted significant lapses in maintaining sanitary conditions in the kitchen, as per the facility's policies.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS was complete, accurate, and auditable, potentially affecting all 39 residents residing in the facility. During the review of the facility's Payroll Based Journal (PBJ) Staffing reports for Quarter 3 2023, Quarter 4 2023, and Quarter 1 2024, it was found that the facility could not provide payroll data for Quarter 3 2023 due to a switch in payroll systems. This resulted in a lack of access to the previous system's data. The PBJ data for Quarter 3 2023 indicated a failure to have licensed nursing coverage 24 hours a day, despite schedules showing that licensed nursing staff were scheduled for all shifts on the infraction dates. For Quarter 4 2023, the PBJ data triggered issues such as excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours a day. However, upon review, RN hours were found to be appropriate, and licensed nursing staff were scheduled for all shifts on the infraction dates. The facility's Director of Nursing confirmed that the inaccurate PBJ data was due to existing staff not being coded correctly when data was submitted. The facility's assessment indicated that licensed nurses were scheduled for 40-48 hours per day, and nurse aides for 96-120 hours per day, which was consistent with the facility's census and assessment.
Failure to Implement Restorative and Functional Maintenance Programs
Penalty
Summary
The facility failed to implement restorative and Functional Maintenance Programs (FMP) to maintain or improve the functional abilities of residents, as observed by surveyors. The deficiency was noted in the care of multiple residents, including one resident who was observed without a palm protector device for her contracted left hand, despite having physician orders and an occupational therapy evaluation recommending its use. The resident's care plan and CNA care card did not address the use of the palm protector or FMP for range of motion (ROM), and there was a lack of data collection showing the completion of the resident's FMPs. The surveyor's investigation revealed that the facility did not have a formal restorative program in place, and there was no quality improvement plan developed to address the concerns related to FMPs not being implemented. The Director of Nursing acknowledged the lack of a formal program and the absence of a performance improvement plan. Additionally, the Assistant Director of Nursing noted that when the facility transitioned to a new electronic medical record system, not all residents' programs were transcribed and transferred, leading to a lack of awareness among staff about the residents' FMPs. The deficiency affected several residents, as their care plans did not include their FMPs until brought to the facility's attention by the surveyor. The lack of implementation of FMPs was a chronic issue, exacerbated by a nursing shortage and the absence of a restorative aide. The surveyor observed that residents were not encouraged or engaged in their restorative programs, and staff were unaware of the residents' FMPs, leading to missed opportunities for care and potential decline in residents' functional abilities.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. The facility's assessment indicated a need for 40-48 hours per day of licensed nurse care and 96-120 hours per day of nurse aide care. However, on certain days, the facility scheduled significantly fewer hours than required, with nurse aide staffing falling short by 29.5 hours on one day and 2 hours on another. This deficiency in staffing levels directly impacted the care provided to residents, as evidenced by the lack of implementation of Functional Maintenance Programs (FMPs) for several residents, including those requiring range of motion exercises and other restorative services. The deficiency in staffing also affected meal assistance and personal hygiene care for residents. One resident, who was dependent on staff for meal assistance, was observed multiple times without adequate supervision or encouragement to eat, leading to potential risks of malnutrition and choking. Additionally, the resident was not repositioned or checked for personal hygiene needs for extended periods, highlighting the facility's inability to meet basic care requirements due to insufficient staffing. This lack of care was further corroborated by staff interviews, where CNAs and LPNs expressed concerns about the chronic understaffing and its impact on their ability to provide necessary care. Furthermore, the facility's failure to reposition residents with pressure injuries or other conditions requiring frequent repositioning was evident. One resident with multiple Stage IV and Stage II pressure injuries was left in the same position for hours without staff intervention, despite the facility's policy of repositioning every two hours. Another resident with a perianal abscess was similarly neglected, with no repositioning or toileting care provided for nearly six hours. These observations underscore the facility's inability to adhere to care plans and protocols due to inadequate staffing, resulting in compromised resident care and well-being.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices and reasons for transfer to residents or their representatives during hospital transfers, as required by their policy. The policy, effective since December 28, 2016, mandates that residents or their representatives receive a written notice regarding bed hold options, including duration, financial obligations, and the readmission process, at the time of or prior to a temporary discharge. However, in the cases of two residents, R19 and R33, the facility did not adhere to this policy. Resident R33, who had previously declined a bed hold upon admission, was transferred to the hospital due to an unresponsive episode, but no written notice of bed hold or reason for transfer was found in their medical record. Similarly, Resident R19 was transferred to the hospital following a change in condition, yet there was no documentation of a bed hold notice or reason for transfer. The Director of Nursing confirmed that the facility did not provide such documentation for these residents, indicating a systemic issue in the facility's adherence to its own bed hold policy.
Failure to Provide Adequate ADL Assistance in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for residents who are dependent on staff, affecting three residents. For one resident, identified as R5, the facility did not ensure proper hygiene care during morning routines. Despite being dependent on staff for hygiene due to impairments, the resident's face and hands were not washed, and a palm guard was not applied as required. The CNA involved acknowledged the oversight, and the Director of Nursing confirmed that washing residents' face and hands is a basic expectation, although not explicitly stated in the facility's policy. Another resident, R29, who has Alzheimer's disease and is always incontinent, was not provided with adequate assistance during meals. The resident was left unsupervised with a meal tray, leading to inappropriate behaviors such as placing non-food items in the mouth. Despite the care plan indicating the need for close supervision and assistance with eating, staff failed to provide consistent support, resulting in the resident not consuming the meal and exhibiting signs of distress. Additionally, the resident was not repositioned or checked for incontinence for extended periods, leading to skin integrity issues. The third resident, R16, who has severe cognitive deficits and is dependent on staff for toileting and transfers, was not repositioned or offered toileting assistance for several hours. Observations revealed that the resident was left in a wheelchair without being checked or changed, resulting in incontinence of both urine and feces. Staff interviews confirmed that the resident should have been repositioned and provided with incontinence care every two hours, but this was not adhered to due to staffing challenges and oversight.
Failure to Reposition and Follow Infection Control Practices
Penalty
Summary
The facility failed to ensure that a resident with wounds received necessary treatment and services to promote healing according to current standards of practice. The resident, who has a history of type 2 diabetes mellitus, heart disease, and an above-knee amputation, was not repositioned regularly, which is crucial for preventing further skin breakdown. Observations revealed that the resident was left in a wheelchair for extended periods without being repositioned or offered toileting assistance, despite having open sores on the buttocks. Additionally, the nursing staff did not adhere to proper infection control practices during wound care. A Licensed Practical Nurse (LPN) was observed not changing gloves or sanitizing hands between steps of the wound dressing process, which is against the facility's protocol and standard infection control practices. The LPN applied Santyl ointment incorrectly on intact skin rather than directly into the wound, which could impede the healing process. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), confirmed that the resident should have been repositioned every two hours, but this was not consistently done. The DON and a Registered Nurse (RN) acknowledged the importance of proper hand hygiene and wound care procedures, which were not followed in this case, potentially contributing to the resident's ongoing wound issues.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with multiple pressure injuries. The resident, who has a history of paraplegia, hypertensive heart disease, and other complex medical conditions, was observed not being repositioned or encouraged to offload pressure from the buttocks, which is essential for healing. The resident was found to have three Stage IV and two Stage II pressure injuries, and a new wound developed that was incorrectly documented. The wound nurse inaccurately staged the wounds, and the resident's care plan, which included specific interventions for skin integrity and pressure relief, was not properly followed. During observations, it was noted that the resident was left lying on their back for extended periods without repositioning, contrary to the care plan's directive for repositioning every two hours. The resident's left foot was not properly floated, and the wound nurse failed to identify a wound on the left ankle, which was not documented in the weekly assessments. Additionally, the registered nurse responsible for dressing changes did not practice appropriate hand hygiene, failed to follow the correct wound care procedures, and applied incorrect treatments to the pressure injuries. Interviews with the resident and staff revealed further deficiencies in care. The resident expressed concerns about the lack of repositioning and the worsening of their wounds, while the Director of Nursing confirmed that repositioning should occur every two hours. The wound nurse admitted to incorrectly staging the wounds and acknowledged the risk of worsening pressure injuries due to inadequate repositioning. These observations and interviews highlight significant lapses in the facility's adherence to pressure ulcer care standards, resulting in inadequate treatment and prevention of pressure injuries for the resident.
Inadequate Assessment and Monitoring of Sleep Disturbances
Penalty
Summary
The deficiency involves the inadequate assessment and monitoring of two residents, R11 and R14, for sleep disturbances while using medications to promote sleep. Both residents were prescribed Trazodone for insomnia without comprehensive sleep assessments or monitoring to evaluate the effectiveness of the medication. R11's care plan was developed without a proper assessment of individual needs or monitoring, and there was no sleep assessment or monitoring present in the medical record. Similarly, R14's care plan was created without a comprehensive sleep assessment or monitoring to determine the medication's effectiveness. The facility's policy on psychotropic medication use emphasizes determining the underlying cause of sleep difficulties and utilizing non-pharmacological interventions before resorting to medication. However, the Director of Nursing (DON) acknowledged that the facility's process of conducting a 72-hour sleep monitoring upon admission and completing a sleep assessment for residents with sleep difficulties was not followed for R11 and R14. This oversight led to the development of care plans without proper assessment and monitoring, resulting in the deficiency.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
During a survey, it was observed that Certified Nursing Assistants (CNAs) E and F failed to perform hand hygiene as required while providing morning care to a resident, identified as R5. The facility's policy mandates handwashing before and after resident contact, between glove changes, and after performing any procedure. However, CNA E and F did not adhere to these guidelines. CNA E did not wash hands before donning gloves, after removing gloves, or after performing peri-care. Similarly, CNA F donned gloves without hand hygiene, removed gloves without washing hands, and continued to perform tasks without adhering to hand hygiene protocols. The resident, R5, is dependent on staff for mobility, hygiene, and is incontinent of bowel and bladder, necessitating thorough and consistent hand hygiene to prevent infection. Despite the facility's policies on hand hygiene, both CNAs failed to comply during the care process, including peri-care and transferring the resident using a hoyer lift. The Director of Nursing confirmed the expectation for staff to perform hand hygiene before and after glove use and after peri-care, emphasizing its importance in preventing infection spread.
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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.
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Nursing homes near Washburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Court Manor Health Services | 6.6 mi | ★★★★★ | 0 | 0 |
| Ashland Health Services | 7.3 mi | ★★★★★ | 0 | 0 |
| Westgate Nursing & Rehabilitation Community | 36.9 mi | ★★★★★ | 5 | 0 |
| Villa Maria Health And Rehab Ctr | 37 mi | ★★★★★ | 2 | 0 |
| Sky View Nursing Center | 37 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.