Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Ports Health Services during CMS and state inspections, most recent first.
Infection Control Failures During Hand Hygiene, Glove Use, and Tray Delivery: Staff failed to perform hand hygiene between resident contacts, during meal tray delivery, and after touching contaminated items. A CNA entered and exited rooms on EBP and droplet precautions without hand hygiene, another CNA placed a meal tray on a contaminated garbage can before entering a resident room, and a CNA performing peri care continued using contaminated gloves while handling clean items and repositioning a resident.
A resident with DM2, multiple comorbidities, and total dependence for care did not receive ordered wound care, had an air mattress set at an inappropriate level for the resident’s weight, and missed short-acting insulin when BG was elevated. Staff observed open gluteal fold wounds without the ordered dressings, used wrinkled linens under the resident on the pressure-relieving mattress, and held insulin based on judgment without promptly notifying the provider despite BG readings in the 300s and 500s.
A resident admitted with multiple PIs, including stage 3 wounds and an unstageable ulcer, did not receive a complete admission wound assessment with measurements or descriptions. The admission evaluation listed the wounds but only documented stages, and a later PI tracker back staged two wounds from stage 3 to stage 2. The DON stated a full assessment with measurements was expected on admission, and the RN who completed the admission assessment reportedly used hospital notes for staging.
A resident with moderate cognitive impairment and a history of alcohol abuse was able to access and drive a personal vehicle stored on facility premises, resulting in elopement. The facility lacked policies, procedures, and risk assessments regarding resident vehicle use, and staff only stored the vehicle keys without implementing additional safety measures.
The facility did not adhere to professional standards for food handling, as observed by a surveyor who found opened milk and lettuce in the walk-in cooler without proper labeling. The milk had a received date but no opened date, and the lettuce had no dates at all. The Dietary Manager confirmed that both items should have been labeled with an open date, as per the facility's food storage policy.
The facility failed to notify the State Long Term Care Ombudsman about the hospital transfers of three residents, as required by policy. These residents were transferred due to medical emergencies, but the Social Services Director could not provide documentation of notification to the Ombudsman.
The facility failed to provide written bed hold notices to two residents or their representatives during hospital transfers, as required by policy. One resident with congestive heart failure and diabetes was transferred due to nosebleeds, and another with anemia and a liver transplant history was transferred due to critical lab values. The Social Services Director could not locate the required documentation.
A resident with PTSD did not have a comprehensive care plan addressing their specific triggers, despite facility policy requiring trauma-informed care. Staff interviews revealed unawareness of the resident's PTSD and triggers, indicating a failure to implement the necessary care plan.
Infection Control Failures During Hand Hygiene, Glove Use, and Tray Delivery
Penalty
Summary
The facility did not establish and implement an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveyors observed multiple instances of staff failing to perform hand hygiene and using improper glove practices during resident care and meal tray delivery, affecting 10 of 79 residents observed for infection control practices. During meal tray pass observations, CNA E entered and exited multiple resident rooms without performing hand hygiene, including rooms marked with Enhanced Barrier Precautions and rooms with residents on droplet precautions. CNA E also touched resident items such as a reacher, blankets, and a tray table while in a resident room and then continued tray delivery without hand hygiene. In another observation, CNA D placed a meal tray on top of a contaminated garbage can outside a room before donning PPE and taking the tray into a resident room. The report states the garbage can was used for isolation precaution contaminated waste, and CNA D acknowledged the surface was dirty and that the tray should have been handled differently. During personal care, CNA I provided peri care to a resident and wore the same contaminated gloves after cleaning bowel movement from the resident, rolling the resident side to side, placing a new brief, and then continuing to adjust the resident in bed, including placing a blanket and pillow, without doffing the contaminated gloves. The resident involved in the isolation-related observation, R78, had diagnoses including Alzheimer's disease, dementia, renal insufficiency, high blood pressure, and anemia, and was severely cognitively impaired and dependent or requiring substantial assistance for activities of daily living. R78 was on droplet precautions, and the care plan included hand hygiene prior to entering the room and upon removing PPE.
Wound Care, Mattress Settings, and Insulin Not Managed per Orders
Penalty
Summary
The facility did not provide wound management and diabetic management according to orders and professional standards of practice for one resident with multiple diagnoses including diabetes mellitus type 2, congestive heart failure, cerebral infarction, hypothyroidism, severe sepsis, and absence of the right leg below the knee. The resident’s MDS indicated intact cognition with a BIMS score of 13 out of 15 and total dependence on staff for hygiene, toileting, transferring, and rolling. Physician orders included wound care to the thighs with removal of the old dressing, cleansing, and application of a bordered foam dressing, as well as monitoring of the dressing placement and skin protection measures after incontinent episodes. During observation, a CNA provided incontinent care and no dressings were present on the resident’s coccyx, gluteal fold, and thigh areas as ordered. Open areas on both lower gluteal folds were observed exposed with feces and urine on the wounds. The CNA stated that when the resident was repositioned and changed earlier that morning, there were no dressings in place. The resident’s care plan also directed staff to provide pressure reduction with a pressure-relieving mattress and to inspect skin with care, but the resident’s air mattress was observed highly inflated and set at the highest setting, which did not match the resident’s weight of 218 pounds. Staff stated that nurses were supposed to check the mattress every shift, and the DON stated that the mattress settings should be adjusted to the resident’s weight and checked every shift. The resident also had orders for regular insulin and sliding-scale insulin with instructions to hold only if blood glucose was below 120 and to update the provider for abnormal values. The resident’s glucose readings included values of 353, 393, 276, 500, and 399 mg/dL. A nurse held the short-acting insulin because the resident was sleeping and not eating, stating it was based on her judgment, and did not notify the provider right away. The nurse later acknowledged that the provider should have been called earlier after deciding to hold the insulin. The DON stated that when the Libre monitor alarmed with an upward arrow, staff should assess the resident for symptoms, perform a manual blood glucose check, and notify the physician right away, and also stated that once a blood glucose is 400 or above, all readings should be rechecked manually.
Incomplete admission assessment and back staging of pressure injuries
Penalty
Summary
Facility staff did not implement professional standards of practice to ensure that a resident with pressure injuries received a complete admission assessment and accurate staging of existing wounds. The resident was admitted with severe protein-calorie malnutrition, weakness, adult failure to thrive, mild cognitive impairment, depression, and multiple pressure injuries, including stage 3 pressure injuries to the left trochanter and left buttock, stage 2 pressure injuries to the right hip and right buttock, and an unstageable pressure ulcer to the left hip. The admission evaluation documented skin impairments at the right trochanter, left trochanter, right buttock, and left buttock, but it did not include measurements or wound descriptions. A later pressure injury weekly tracker documented the left trochanter and left gluteal fold as stage 2, which back staged wounds previously documented as stage 3 on admission. During interview, the DON stated the resident should have had a full assessment with measurements on the day of admission, and the RN who completed the admission assessment reportedly took the stage levels from hospital notes and could not recall observing the wounds. The RN who completed the later tracker did not assess the resident on the day of admission.
Failure to Assess and Supervise Resident Use of Personal Vehicle Resulting in Elopement
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment and a history of alcohol abuse. The resident, who had diagnoses including cognitive communication deficit and symptoms following cerebral infarction, was allowed to store a personal vehicle on facility premises. There was no documentation of a risk assessment regarding the resident's ability to safely operate or store a vehicle, nor was there a policy or procedure in place to address such situations. The resident's care plan included interventions for alcohol abuse and potential elopement, but did not address the presence or use of a personal vehicle. The incident occurred when the resident requested access to the keys for the vehicle, which were stored in the business office. Staff accompanied the resident to the vehicle, where the resident stated he would only retrieve paperwork and start the car. Despite assurances, the resident proceeded to drive away from the facility, resulting in elopement. There was no evidence of prior documentation regarding the vehicle or any safety measures beyond key storage. Interviews with the Nursing Home Administrator confirmed the absence of relevant policies, procedures, or risk assessments for residents with personal vehicles on site.
Deficiency in Food Handling and Labeling
Penalty
Summary
The facility failed to ensure the safety of food handling in accordance with professional standards, which had the potential to affect all 78 residents who eat orally. During an inspection, a surveyor observed that a gallon of opened milk and lettuce in a covered container were stored in the walk-in cooler without being labeled with an opened date. The milk had a received date but no opened date, and the lettuce had no dates at all. According to the facility's policy on food storage, all refrigerated foods should be covered, labeled, and dated to ensure they are consumed by their safe use-by dates or appropriately discarded. The Dietary Manager (DM) confirmed that the milk should have been labeled with an open date and expected it to be used within three days, while the lettuce should also have been labeled with an open date when placed back in the fridge.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman about the discharge of three residents who were transferred to hospitals with the expectation of return. The facility's policy requires the Social Services Director (SSD) or designee to provide notice of transfers to the Ombudsman via a monthly list. However, for three residents, this notification was not completed. Resident R7 was transferred to an acute care hospital due to uncontrolled nosebleeds following nasal surgery, and Resident R66 was transferred to a critical access hospital due to critical lab values. Both residents returned to the facility after their hospital stays, but the SSD could not provide documentation of notification to the Ombudsman for these transfers. Similarly, Resident R25 was discharged to a hospital for shortness of breath and low oxygen saturation and was later admitted for rhinovirus and hyperkalemia. The surveyor found that R25 was not included in the August 2024 discharge notifications to the State Ombudsman, and the SSD was unable to locate documentation to support the notification. This lack of notification for these emergency transfers constitutes a deficiency in the facility's compliance with its policy and regulatory requirements.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices and reasons for transfer to residents or their representatives at the time of hospital transfer or within 24 hours, as required by their policy. This deficiency was identified during a survey, which included interviews and record reviews. The facility's policy, last reviewed and revised on July 15, 2022, mandates that a notice of the resident's bed hold policy be given to the resident and their representative at the time of transfer or within 24 hours. Two residents were affected by this deficiency. One resident, with diagnoses including congestive heart failure and diabetes, was transferred to a hospital due to uncontrolled nosebleeds and returned to the facility later. Another resident, with conditions such as anemia and a history of liver transplant, was transferred due to critical lab values and returned the following day. The surveyor requested documentation of the bed hold notices for these residents, but the Social Services Director was unable to locate any such documentation.
Failure to Implement Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as R6, who was diagnosed with PTSD, among other conditions. Despite the facility's policy on trauma-informed care, which emphasizes minimizing triggers and re-traumatization, the care plan for R6 did not address specific PTSD triggers. The resident's admission records indicated a cognitive status of 14 on the BIMS scale, confirming cognitive intactness, and highlighted PTSD as a diagnosis. An assessment conducted by the facility identified loud voices, screaming, and someone approaching from behind as triggers for R6, yet these were not incorporated into the care plan. Interviews with facility staff, including a CNA and two RNs, revealed a lack of awareness regarding R6's PTSD and associated triggers. The CNA and RNs were unaware of any specific triggers that could cause re-traumatization for R6. The Nursing Home Administrator acknowledged that the trauma-informed care assessment should automatically update the care plan with identified triggers, but this process was not completed for R6. This oversight resulted in a deficiency in providing appropriate trauma-informed care for the resident.
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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 Superior
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Marina Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Dove Healthcare - Superior | 2.1 mi | ★★★★★ | 3 | 0 |
| Franciscan Health Center | 3.7 mi | ★★★★★ | 20 | 0 |
| The North Shore Estates Llc | 4.7 mi | ★★★★★ | 16 | 0 |
| Bayshore Residence And Rehabilitation Center | 5.1 mi | ★★★★★ | 2 | 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.