Above average — CMS composite of the measures below.
A standard survey is most likely before 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 United Pioneer Home during CMS and state inspections, most recent first.
Improper Food Labeling and Facial Hair Restraint Use: Surveyors found open food items in cold and frozen storage without opened dates, including milk and frozen vegetables, and observed a dietary staff member serving food with facial hair restraints that did not cover his mustache. The Dietary Director acknowledged the unlabeled items and stated that all facial hair must be restrained when serving food to residents.
Bed hold notices for multiple residents did not include the daily rate to reserve the bed or resident appeal rights. Record review and DON interview showed that some residents received written notices without the required information, while one resident was only told verbally about the bed hold and had no documentation of written notice. The missing details were found on forms for residents with recent hospital transfers and discharge return anticipated MDS assessments.
Staff failed to follow infection control practices during resident care and room entry. A CNA passed water pitchers between residents without sanitizing hands between rooms and entered a resident’s droplet precaution room without PPE. Another CNA performed peri care for a resident, then touched other surfaces and assisted with transfers while still wearing contaminated gloves and without hand hygiene. Maintenance staff also entered a droplet precaution room and cleaned surfaces without donning a gown as required by the isolation signage.
A resident with left knee osteoarthritis, weakness, and other chronic conditions was transferred by a CNA without a gait belt despite care plan directions and facility policy requiring gait belts for assist-of-one transfers. During toileting, the resident’s legs gave out, she plopped back onto the toilet and into the railing, then landed on the edge of the wheelchair seat before being stand-pivot transferred to bed without a gait belt. The CNA acknowledged the gait belt should have been used, and the DON stated the resident needed help in the bathroom and that gait belts were required for non-independent transfers.
A resident with respiratory failure with hypoxia, emphysema, heart failure, and other cardiac conditions had repeated episodes of being found without oxygen or with the NC out of place. Staff notes documented severe drops in O2 saturation, including one episode at 56%, and the resident later required ED transfer after oxygen instability. During a survey observation, a CNA took the resident to a lounge activity without checking the portable O2 tank first, despite the resident’s concern that the tank might be low; the DON later found the tank very low and confirmed the CNA should have checked it.
Significant insulin administration error: An RN gave Humalog to a resident with type 2 DM using a BG result obtained 4 hours earlier. The RN stated night shift sometimes completed BG checks for day shift and used whatever BG was available for insulin prep, while the DON stated BG should be checked around mealtimes and no earlier than an hour before insulin administration.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment lacked proper hazard controls and sufficient monitoring, increasing the risk of accidents for residents.
The facility failed to maintain an effective infection prevention and control program, affecting all residents. Infection control logs lacked documentation of isolation precautions for several residents with respiratory symptoms. Staff did not consistently perform appropriate hand hygiene during care, as observed with two residents. The facility's hand hygiene policy contained conflicting guidelines, contributing to inconsistent practices.
The facility failed to implement an effective antibiotic stewardship program, affecting all residents. Antibiotics were prescribed without proper documentation or adherence to infection criteria, and there was a lack of communication with providers regarding appropriate antibiotic use. The facility's policies on infection prevention were not effectively implemented, and staff education on antibiotic stewardship was insufficient.
The facility failed to accurately document the MDS for two residents, incorrectly indicating they were receiving tube feeding services. Observations and interviews revealed discrepancies between the residents' care plans and their MDS assessments. The DON acknowledged the error, and the LPN responsible for the MDS admitted to a possible mistake during documentation.
A resident with a history of vertebral fracture and muscle weakness was not consistently ambulated as recommended by PT, despite expressing a desire to walk more. Observations showed the resident was often transported in a wheelchair without being offered ambulation, contrary to the care plan. Staff cited pain as a reason, although the resident reported walking reduced her pain.
A facility failed to implement a restorative program for a resident with limited ROM, despite the care plan indicating the need for such care. Observations showed that staff did not perform ROM exercises, and interviews revealed confusion about the resident's restorative care schedule. The DON acknowledged that restorative care was discontinued during palliative care and not resumed, with no clear timeline for restarting it. This lack of communication and documentation led to the deficiency.
A resident was prescribed lorazepam without a documented diagnosis of anxiety and received it PRN beyond the 14-day limit without rationale. The resident's records lacked documentation of non-pharmacological interventions or adequate monitoring of the medication's effects. The care plan did not address the use of anti-anxiety medication, and justification for its continued use was not documented until after the survey began.
A resident with diabetes mellitus II received insulin with a mislabeled dosage during medication administration. The insulin pen label indicated 22 units instead of the prescribed 28 units. The LPN corrected the label with a handwritten sticker, but there was no evidence that the pharmacy was notified of the error, contrary to facility policy.
A resident with cognitive and physical impairments reported an inappropriate comment by a CNA during bathroom assistance. The facility's investigation was insufficient, lacking interviews with other residents and documentation in the medical chart. Additionally, no staff education on abuse and neglect was conducted following the incident, as confirmed by interviews with staff and the NHA.
The facility failed to update care plans with safety interventions for two residents after their call lights were removed, leaving them without reliable methods to request assistance. Staff checks were inconsistent and inadequately documented.
The facility failed to ensure resident safety by not following care plans for three residents. One resident did not have a pressure alarm pad in the recliner, another was transferred without locking the EZ-stand lift brakes, and a third had an elevated leg rest and plugged-in recliner against care plan instructions.
Improper Food Labeling and Facial Hair Restraint Use
Penalty
Summary
Food was not stored and prepared in a sanitary manner to prevent foodborne illness for residents. During an initial kitchen tour, the Dietary Director showed surveyors cold storage items that included an open gallon of milk in the refrigerator without an opened date written on it, as well as an open bag of hashbrowns, frozen peas, and peas and carrots in frozen storage with no opened dates written on them. The Dietary Director stated that these items should have had dates on them and said they would be discarded. Surveyors also observed a dietary staff member obtaining temperatures on hot food items before lunch service on two units while wearing facial hair restraints that did not cover his mustache. The staff member had black facial hair greater than one quarter inch on both the beard and mustache, wore a hair restraint on the top of his head and a beard restraint on his chin, but the restraint did not cover the mustache. A second observation on another unit showed the same staff member with his mustache still not covered. When interviewed, the Dietary Director stated that all facial hair must have a hair restraint when serving food to residents.
Bed Hold Notices Missing Daily Rate and Appeal Rights
Penalty
Summary
The facility did not ensure residents or their representatives were notified in writing of the daily rate to reserve a resident’s bed during a bed hold, and the bed hold notices reviewed also did not include resident appeal rights. Record review and interviews showed this issue affected multiple residents, including R9, R5, R3, R15, and R16. R9 and R5 were both admitted with BIMS scores of 10/15 and had diagnoses including dementia; R9 also had COPD and a history of UTI, while R5 had vascular dementia, Parkinson’s disease, CHF, atrial fibrillation, and a history of UTI. Both residents had hospital transfers after acute changes in condition, and the DON provided bed hold notices that did not list a dollar amount or appeal rights. For R3, record review showed three hospitalizations with discharge return anticipated MDS assessments, and the bed hold notices for those hospitalizations also lacked the daily rate and appeal rights. For R15, the DON stated the resident was told verbally about the bed hold, but there was no documentation that R15 received written notice of the bed hold, the daily rate, or appeal rights. For R16, the facility had a written bed hold form, but it still did not document the daily bed hold rate or resident rights. During interview, the DON acknowledged the missing dollar amount and appeal rights on the bed hold forms.
Infection Control Failures During Resident Care and Room Entry
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. This affected residents R29, R41, R17, R16, R21, and R15. The report identified failures by staff to perform hand hygiene and to use required personal protective equipment during resident care and room entry. During water pitcher rounds, CNA G was observed entering multiple residents’ rooms, placing clean water pitchers on bedside tables, removing dirty pitchers, and then moving to the next resident without sanitizing hands between rooms. CNA G entered R16’s droplet precaution room with contaminated hands and did not wear PPE when entering or sanitizing hands when exiting. CNA G later sanitized hands only after a call light sounded in R21’s room. When interviewed, CNA G stated hand hygiene should have been performed between residents’ rooms and acknowledged it was not done. The DON stated staff were expected to sanitize hands between each resident’s room and before grabbing clean pitchers and delivering them. CNA H was observed providing peri care to R15 while wearing gloves, then continuing to touch other surfaces and assist with transfers while still wearing contaminated gloves. CNA H wiped stool from R15, pulled up the brief and pants, assisted R15 to a walker, handled the wheelchair, adjusted oxygen tubing, placed the nasal cannula in R15’s nose, and put R15’s jacket on before doffing gloves. CNA H then continued pushing R15 into the lounge and touched another resident without sanitizing hands. Maintenance F was also observed entering R16’s droplet precaution room and cleaning surfaces without donning a gown, despite the room’s transmission-based precautions. The DON stated droplet precautions required mask, gloves, and gown when staff were within 6 feet of R16 or near high-contact surfaces.
Failure to Use Gait Belt During Resident Transfers
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible when CNA H transferred R6 without using a gait belt. R6 was admitted with diagnoses including osteoarthritis of the left knee, polymyalgia rheumatica, muscle wasting, bursitis of the left knee, weakness, atrial fibrillation, anemia, and adult failure to thrive. R6’s care plan changed over time from independent transfers and ambulation with a FWW to requiring contact guard assist with a gait belt for ambulation in the facility. Facility policy stated that residents needing minimal assist should use transfer aids and a gait belt, and that direct care staff should avoid manually lifting residents except for medical emergencies. During observation, R6 was assisted off the toilet by CNA H without a gait belt. While CNA H was cleaning R6, R6 screamed that she could not stand long, and her legs gave out as she plopped back onto the toilet seat and fell backward into the toilet railing. CNA H then instructed R6 to try standing again, still without a gait belt, and R6 pivoted into the wheelchair, landing on the edge of the seat and stating she was slipping out. CNA H adjusted the foot plate and later stand-pivot transferred R6 from the wheelchair to the bed without a gait belt. CNA H told the surveyor that a gait belt should have been used but that R6 was sometimes in a rush. The DON stated that R6 was an assist of one and needed help in the bathroom, and that facility policy required gait belts for all transfers except residents who were independent.
Failure to Verify Portable Oxygen and Maintain Oxygen Delivery
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident receiving oxygen therapy. The resident had a history that included respiratory failure with hypoxia, pan lobular emphysema, heart failure, atherosclerosis of coronary artery bypass graft, atrial fibrillation, cardiac pacemaker, and muscle weakness. The resident’s care plan directed oxygen via nasal cannula at 2-4 L, with instructions to keep oxygen saturation above 89% and to ensure the nasal cannula remained properly in the nares throughout the shift because it was known to shift out of place. Survey findings showed repeated episodes in which the resident was found without oxygen or with the nasal cannula out of place. Progress notes documented the resident’s nasal cannula on the ground, oxygen turned off during breakfast with a drop in saturation to 56%, and another episode in which the resident was short of breath, had diminished lung sounds, and required an increase in oxygen flow to restore saturation above 90%. Another note stated the resident was found with oxygen out of the nares after lunch and appeared unaware. The record also included a resident/family concern note and employee coaching form stating the resident had previously been left without oxygen and staff were educated to double check residents with oxygen needs. On 09/22/25, the surveyor observed CNA H assist the resident from the bathroom to a wheelchair and prepare to take the resident to a reading activity in the lounge. The resident asked whether there was enough oxygen in the portable tank because the resident had walked with therapy earlier and was concerned the tank might be low. CNA H told the resident the tank was fine and filled that morning, but did not check the portable oxygen tank before connecting it. When asked by the surveyor, CNA H stated being unsure how much oxygen was in the tank and continued pushing the resident to the lounge. The surveyor then asked the DON to check the tank, and the DON initially reported it appeared empty, then stated it was very low and would need a refill before lunchtime. The DON acknowledged that CNA H should have checked the portable oxygen tank before taking the resident out of the room and stated staff are expected to check oxygen tubing placement and portable tank levels before moving residents off oxygen concentrators.
Significant insulin administration error
Penalty
Summary
A deficiency was cited for failure to ensure that a resident with type 2 diabetes mellitus was free from significant medication errors. For one of 12 residents reviewed for medication errors, the facility administered short acting insulin to R12 four hours after the resident's blood glucose was taken. Surveyor review of the facility's Insulin Administration policy stated that blood glucose should be checked per physician order or facility protocol before insulin administration. On 09/23/25 at 9:34 AM, an RN administered Humalog KwikPen 33 units subcutaneously in R12's left abdomen and stated that R12's blood glucose was 173, taken at 4:12 AM earlier that morning by night shift. The RN reported that the facility sometimes had too many blood glucose checks and that night shift helped complete them for day shift, and that the RN would use whatever blood glucose night shift obtained to prepare insulin administration. The RN also stated that R12 usually fluctuated in the morning and was low, so the RN was not concerned with the 4:12 AM blood glucose. Later, the DON stated that blood glucose should be gathered around mealtimes and no earlier than an hour before insulin administration, and that using a blood glucose from 4 hours earlier was not acceptable practice.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of appropriate hazard controls and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which could potentially affect all 33 residents. The facility's infection control surveillance logs from January to June 2024 lacked documentation of isolation precaution types, start dates, and end dates for several residents with symptoms of respiratory infections, COVID-19, and other conditions. For instance, Resident 30 had multiple instances of respiratory symptoms and treatment with antibiotics, but the logs did not document the necessary isolation details. Similarly, other residents, such as Resident 6 and Resident 21, had incomplete documentation regarding isolation precautions, which is a critical component of infection control. Additionally, the facility's staff did not consistently perform appropriate hand hygiene during resident care, as observed in the cases of Residents 19 and 16. During care for Resident 19, a CNA failed to remove contaminated gloves and perform hand hygiene before continuing care, despite the facility's policy requiring hand hygiene after glove removal. Similarly, during care for Resident 16, CNAs applied gloves without performing hand hygiene, contrary to the facility's hand hygiene policy, which mandates hand hygiene before applying non-sterile gloves. The facility's hand hygiene policy contained conflicting guidelines, contributing to the staff's inconsistent practices. The Director of Nursing acknowledged the discrepancy in the policy, which may have led to confusion among staff regarding the correct procedures for hand hygiene and glove use. This inconsistency in policy and practice highlights a significant deficiency in the facility's infection prevention and control program.
Deficiency in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to establish an effective Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program to monitor and review antibiotic use. This deficiency potentially affects all 33 residents in the facility. The facility did not follow a Standard of Practice (SOP) for antibiotic stewardship, as evidenced by the lack of documentation on antibiotic usage, outcome measures, and antibiotic resistance from January 2024 through June 2024. Additionally, the facility did not implement a SOP for educating prescribing providers and nursing staff on antibiotic use and protocols. The report highlights several instances where antibiotics were prescribed without proper documentation or adherence to updated 2024 Revised McGeer Criteria for infection surveillance. For example, a resident was prescribed Keflex for a wound infection, but culture and sensitivity results did not indicate sensitivity to Keflex. The facility failed to communicate with the resident's provider to ensure the appropriate antibiotic was administered. Other residents were treated with antibiotics without documented symptoms meeting the criteria for infections, and there was no documentation of diagnostic confirmation for some infections. The facility's policies on antibiotic stewardship and infection prevention were not effectively implemented. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) interviews revealed gaps in education and understanding of the criteria used for infection surveillance and antibiotic prescribing. The facility's Quality Assurance and Performance Improvement (QAPI) committee did not review or investigate trends related to antibiotic use, and there was no documentation of education provided to staff on antibiotic stewardship. These deficiencies indicate a lack of oversight and adherence to established guidelines for infection control and antibiotic use.
Inaccurate MDS Documentation for Tube Feeding
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) documentation regarding tube feeding for two residents. For both residents, their care plans, orders, diagnoses, and progress notes did not indicate they were receiving tube feedings while residing in the facility. However, their electronic medical records (EMR) annual MDS comprehensive resident assessments inaccurately documented that they were receiving tube feeding services. These discrepancies were noted during a surveyor's initial tour of the facility, where it was observed that neither resident was receiving tube feeding services. Upon further investigation, the Director of Nursing (DON) acknowledged that the residents were incorrectly labeled for tube feeding on the MDS and stated that a request to correct the error was submitted once the issue was identified. The Licensed Practical Nurse (LPN) responsible for completing the MDS assessment, under the oversight of the DON, admitted to possibly making an error during the documentation process. The DON expressed that such inaccuracies should have been identified and corrected, indicating an expectation for accurate MDS coding.
Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to ensure that a resident, identified as R31, maintained the ability to perform activities of daily living, specifically ambulation, as recommended by Physical Therapy (PT). R31, who was admitted with diagnoses including a compression fracture of the vertebra, low back pain, and generalized muscle weakness, was recommended by PT to ambulate to all destinations with a roller walker and caregiver assistance. Despite this recommendation being included in R31's care plan and CNA Kardex, documentation and observations during the survey period indicated that R31 was not consistently ambulated to and from the dining room for meals. During the survey, R31 expressed a desire to walk more, stating that ambulation helped reduce her pain and was a key part of her recovery in a previous facility. However, surveyors observed that R31 was often transported in a wheelchair without being offered the opportunity to ambulate. Interviews with CNAs revealed inconsistencies in offering ambulation, with some staff citing R31's pain as a reason for not ambulating her, despite R31's own statements that walking alleviated her pain. The Director of Nursing confirmed that it was the facility's expectation for R31 to be offered ambulation and for refusals to be documented, which was not consistently done.
Failure to Implement Restorative Program for Resident with Limited ROM
Penalty
Summary
The facility failed to implement a restorative program to maintain or improve the range of motion (ROM) for a resident with limited mobility. The resident, who was admitted with diagnoses including Alzheimer's, dementia, difficulty in walking, and contractures, was observed not receiving any ROM exercises during care routines. Despite the care plan indicating the need for restorative care, the staff did not perform any exercises aside from basic care activities such as dressing and washing. Interviews with staff revealed a lack of clarity and communication regarding the resident's restorative care schedule. A CNA mentioned that the resident was not on their restorative care list for the month, and the Physical Therapist assumed that the nursing staff was providing the necessary care. However, documentation of a restorative plan was not available, and the last therapy progress note was dated several months prior. The Director of Nursing (DON) acknowledged that the resident's restorative care was discontinued when they were placed on palliative care and was not resumed after the resident was removed from palliative care. The DON admitted to not having a clear timeline or procedure for restarting restorative care after palliative care was discontinued. Despite expectations that CNAs would perform stretching exercises during care, observations indicated that these exercises were not being conducted. The lack of a documented restorative care plan and the absence of communication among staff contributed to the deficiency in maintaining the resident's functional abilities.
Failure to Ensure Resident was Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of lorazepam, an anti-anxiety medication. The resident, who was admitted with chronic obstructive pulmonary disease and heart failure, did not have a documented diagnosis of anxiety, yet was prescribed lorazepam on a PRN basis for anxiety or shortness of breath. The medication was administered frequently over several months without a documented rationale for its continued use beyond the 14-day PRN limit. Additionally, the resident's records lacked documentation of non-pharmacological interventions or adequate monitoring of the medication's effects, including signs or symptoms warranting its administration and potential side effects. The resident's care plan did not address the use of anti-anxiety medication, nor did it include strategies to reduce or eliminate the need for such medication. Despite monthly pharmacy reviews indicating no irregularities, the surveyor found no documentation in the resident's record to justify the ongoing use of lorazepam until a handwritten note was provided during the survey. This note, dated after the survey began, suggested the resident's hospice status and potential need for increased medication as a rationale, but this was not documented in the resident's record prior to the surveyor's review.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, as observed during a medication administration for one of the 26 medications reviewed. A resident, who was admitted with a diagnosis of diabetes mellitus II, had a prescription for insulin Glargine to be administered at 28 units subcutaneously once a day. However, during the medication administration observation, the insulin pen label indicated a dosage of 22 units, which was inconsistent with the physician's order and the Medication Administration Record (MAR). The discrepancy was identified by the surveyor, who confirmed with the LPN that the current order was indeed for 28 units. The LPN acknowledged the error and corrected the dosage on the label with a handwritten sticker. The Director of Nursing (DON) stated that the facility's policy required verification of medication labels upon receipt from the pharmacy and during administration, with immediate correction of any errors. Despite this policy, there was no evidence that the pharmacy had been notified of the labeling error or that it had been corrected when the insulin pen was first received.
Inadequate Investigation and Staff Education Following Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident with moderate cognitive impairment and significant physical limitations. The resident, who had hemiplegia and hemiparesis following a cerebral infarction, reported an incident where a CNA made an inappropriate comment while assisting the resident to the bathroom. The facility's investigation did not include interviews with other residents to determine if similar incidents had occurred, and there was no documentation in the resident's medical chart regarding the abuse allegation. Additionally, the facility did not take adequate steps to protect residents from future incidents, as there was no evidence of staff education on abuse and neglect following the incident. Interviews with staff, including an LPN and several CNAs, revealed that while annual training on abuse and neglect is provided, no additional training had been conducted since the incident. The Nursing Home Administrator confirmed the lack of further documentation or training related to the abuse allegation.
Failure to Update Care Plans After Call Light Removal
Penalty
Summary
The facility failed to revise the care plans with accurate information for safety interventions for two residents, R2 and R3, after their call lights were removed. R2, who has severe cognitive impairment and requires total assistance for most activities of daily living, had his call light removed after an incident where the cord was found draped across his neck. Despite this, the care plan was not updated to include specific safety interventions or a schedule for staff to check on him. Observations showed that R2 had no means to alert staff and had to rely on yelling or waiting for staff to pass by, which was inconsistent and inadequate for his needs. Similarly, R3, who also has severe cognitive impairment and requires moderate assistance for daily activities, had no call light or alternative alert device in place. Staff indicated that they checked on R3 whenever they walked by, but there was no documented schedule or specific safety interventions in the care plan. The lack of a structured plan for checking on R3 was evident during observations, as R3 was seen fidgeting in a recliner without any means to call for help. Interviews with staff, including CNAs, the Social Worker, and the Director of Nursing, confirmed that the care plans for both residents were not updated with necessary safety interventions or specific check schedules after the removal of the call lights. This oversight left both residents without a reliable method to request assistance, compromising their safety and care.
Failure to Ensure Resident Safety and Prevent Falls
Penalty
Summary
The facility did not ensure residents were safe in their environment to prevent the risk of falling. For Resident 1, the staff failed to place a pressure alarm pad under the resident while sitting in a recliner, as specified in the care plan. The surveyor observed the pressure alarm pad lying in the wheelchair instead. Both the CNA and the Director of Nursing confirmed that the pressure alarm pad should have been under the resident in the recliner according to the care plan and physician orders. For Resident 2, the staff did not lock the brakes on the EZ-stand lift during a transfer from a recliner to the bathroom. The surveyor observed the CNAs performing the transfer without locking the brakes, contrary to the care plan's instructions. Both CNAs admitted to not locking the brakes, and the Director of Nursing confirmed that the brakes should be locked before lifting the resident out of the recliner, bed, or wheelchair. For Resident 3, the staff did not follow the care plan instructions to keep the recliner unplugged and the leg rest down. The surveyor observed the resident in a recliner with the leg rest elevated and the recliner plugged in. Both the RN and LPN confirmed that the recliner should not be plugged in and the leg rest should not be elevated, as per the care plan. The Director of Nursing also confirmed these care plan instructions and noted that the resident had a history of falls from the recliner, which necessitated these safety interventions.
What surveyors are citing around you — mapped
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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 90 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Luck
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frederic Nursing And Rehab Community | 5.1 mi | ★★★★★ | 18 | 0 |
| Dove Healthcare - St Croix Falls | 13.2 mi | ★★★★★ | 21 | 0 |
| Burnett Medical Center | 17.3 mi | ★★★★★ | 14 | 0 |
| Willow Ridge Healthcare | 19.3 mi | ★★★★★ | 0 | 0 |
| Golden Age Manor | 19.3 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.