Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Specialty Care Community during CMS and state inspections, most recent first.
The facility failed to complete behavior assessments and implement person-centered care plans for multiple residents with dementia who exhibited wandering, aggression, and other behavioral symptoms. Several residents repeatedly entered others’ rooms, took belongings, and engaged in physical altercations, while staff relied mainly on generic supervision and redirection that they reported as ineffective. Activity and preference assessments documented specific interests such as reading, outdoor time, music, and work-like tasks, but these were not translated into individualized behavioral interventions, and activity staff were rarely present on the unit. Observations showed NAs often seated at the nurse’s station with minimal engagement of residents, and families reported inadequate redirection and lack of meaningful activities, while nurses and NAs described feeling overwhelmed and lacking resident-specific strategies to manage behaviors.
A resident with severe cognitive impairment and dementia-related behaviors was admitted with ample labeled clothing, dentures, a personal radio, and an Army hat. Within about a week, most of the clothing and several personal items were missing from the resident’s room on a locked unit. The family reported the missing items and provided a detailed list to nursing staff and the nurse manager, but a grievance form was not completed, and the required grievance process was not initiated. A NA later reported she had not been informed of the issue, and the RN acknowledged knowing about the missing items for several days without completing a grievance form or involving maintenance. The DON confirmed that, per facility policy, a grievance form and immediate, thorough search should have occurred when the missing items were first reported, but this did not happen.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as evidenced by observations and records showing residents were served meals not aligned with their documented dietary requirements.
The facility failed to ensure residents knew how to file grievances and that grievance forms were accessible in prominent locations. Residents were unaware of the process, and forms were not available in the lobby or nursing stations. The facility's policy outlined the grievance process, but the lack of accessible forms and clear communication led to the deficiency.
The facility failed to monitor and document dishwasher temperatures in four unit kitchenettes, compromising dish sanitation. Logs were incomplete, and dietary staff did not adhere to protocols. Additionally, the coffee machine in the Lakes unit was unsanitary, with mold observed, indicating a lack of daily cleaning. These deficiencies posed potential food-borne illness risks.
A resident with COPD and CHF was found with medications at their bedside without a completed self-administration assessment or physician's order. The facility's policy requires an assessment and a physician's order for self-administration, which were not followed, leading to the deficiency.
The facility failed to maintain clean wheelchairs for two residents with Huntington's disease and dementia, as observed by surveyors. Despite a schedule for cleaning, the wheelchairs had copious amounts of dried food and substances, indicating a lack of regular maintenance. Interviews revealed that the responsibility for cleaning was assigned to overnight staff, but the schedule was not effectively followed, and no specific policy for wheelchair cleaning existed.
A resident with central cord syndrome and obesity experienced an 8.6-pound weight gain in one week, but the facility failed to notify the physician as required. Staff interviews revealed delays in re-weighing and lack of documentation, despite the resident's worsening condition, including edema and shortness of breath, which led to a hospital evaluation recommendation.
A resident at moderate risk for pressure sores did not receive prescribed heel suspension boots as per their care plan. Observations showed the boots were not used, and staff interviews confirmed the care plan was not followed. The resident did not refuse the intervention, indicating a lapse in adherence to pressure ulcer prevention protocols.
A resident with a urinary catheter due to chronic kidney disease and urinary retention had their catheter drainage bag positioned incorrectly at the level of the bladder, contrary to standard practice. The facility's staff failed to document or communicate the resident's preference for using a leg bag, which required deviation from standard catheter care procedures. Observations and interviews revealed a lack of adherence to the facility's catheter care policy, which mandates maintaining a non-obstructed downhill flow of urine.
A resident with severe cognitive impairment and dysphagia was given a regular soda instead of the prescribed thickened liquids, despite orders for a mechanically altered diet. Staff interviews revealed a lack of adherence to dietary requirements, and the facility's policy on documenting refusals and educating on risks was not followed.
A resident with hepatic encephalopathy and alcoholic cirrhosis did not receive rifaximin as ordered due to a delay in cost approval by the facility. The medication was unavailable from the time of the order, and staff failed to notify the medical provider immediately, contrary to facility policy. The delay in communication and action among staff led to the resident not receiving the critical medication for several days.
The facility's assessment failed to specify staffing needs based on resident care requirements, lacking details on staffing levels for different shifts. Interviews with staff revealed uncertainty and insufficient documentation regarding staffing determinations, with the Facility Assessment missing specific staffing requirements.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with complex medical conditions, including stroke-related impairments. The care plan lacked specific goals and interventions for the resident's ADL needs and did not address safety concerns or the need for supervision while eating. Interviews revealed that the care plan was not completed on time, and staff were not adequately informed about the resident's care requirements.
A resident with a swallowing disorder was left unsupervised during meals, leading to aspiration pneumonia. Despite requiring a modified diet and supervision, the care plan was not updated, and staff were unaware of the resident's needs. The resident was found unresponsive and covered in food, resulting in hospitalization. The facility lacked a policy on meal supervision.
The facility failed to ensure call lights were accessible for four residents with cognitive impairments and mobility dependence. Observations showed call lights were not within reach, and staff did not consistently check on the residents. Interviews revealed inconsistencies in staff understanding of residents' abilities and the frequency of checks required, leading to the deficiency.
The facility failed to properly assess, document, and plan the use of physical restraints for several residents, leading to deficiencies in ensuring restraints were used appropriately. Residents with severe cognitive impairments and conditions like Alzheimer's and Huntington's disease were found with restraints without proper documentation or care planning. Interviews with staff revealed a lack of awareness of restraint requirements, contributing to the deficiencies observed.
A nursing assistant in an LTC facility failed to maintain a resident's dignity by speaking in a belittling manner during care. The resident, who has severe cognitive impairment due to Huntington's disease, perceived the comments as verbal abuse. Despite the assistant's claim of joking, the resident expressed discomfort with the communication.
The facility failed to implement and complete person-centered care plans for several residents, leading to deficiencies in meeting their medical and personal care needs. Residents with severe cognitive impairments and various medical conditions were not repositioned or checked on as required by their care plans, resulting in a lack of necessary care and attention. The facility's policy on care plans was not adhered to, and staff interviews revealed a lack of awareness and adherence to the care plans.
A resident with multiple medical conditions, including central cord syndrome, was not provided with adequate personal hygiene care, leading to complaints and a hospitalization for a catheter-related urinary tract infection. Despite being dependent on staff for ADLs, the resident experienced inadequate cleaning, as evidenced by dried blood and feces found during an observation. Staff interviews revealed unresolved complaints and a lack of timely care.
Two residents with cognitive impairments and Huntington's disease were improperly managed by being double briefed, contrary to their care plans. Staff interviews revealed a lack of awareness and adherence to proper incontinence care protocols, and the facility's quality of care policy was not provided.
A resident with dementia and mobility issues developed multiple pressure ulcers due to the facility's failure to implement appropriate preventive measures and interventions. Despite the resident's risk factors, the care plan lacked specific actions to prevent pressure ulcers, and staff did not adequately monitor or report skin changes. This led to the resident's decline and hospital admission with multiple pressure injuries.
The facility failed to serve breakfast at the proper temperature on a unit, affecting 16 residents. Observations revealed scrambled eggs were cold when served, and residents complained about the temperature. A TMA noted challenges in maintaining food temperature due to staggered delivery times and the number of residents needing assistance. The DON was unaware of complaints, and no food temperature policy was obtained.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairments within the required timeframe. A family member's video showed a nursing assistant handling the resident roughly, not using a gait belt, and continuing care despite resistance. The DON acknowledged the mistakes but did not report the incident promptly, believing there was no intent to harm.
Failure to Provide Person-Centered Dementia Care and Behavior Management
Penalty
Summary
The deficiency involves the facility’s failure to assess, develop, and implement person-centered care plans and behavior management interventions for multiple residents with dementia and behavioral symptoms. Six residents with dementia (R1, R2, R3, R5, R7, and R8) lacked individualized behavior assessments identifying triggers and effective interventions, despite documented wandering, aggression, and resident-to-resident altercations. Care plans for these residents contained only generic directions such as cueing, reorienting, supervising PRN, and redirecting, without specific, individualized strategies based on each resident’s known preferences, histories, or observed behavior patterns. Activity assessments and preference evaluations documented that these residents enjoyed specific activities such as reading, outdoor time, music, work tasks, and social engagement, but these interests were not translated into targeted behavioral interventions. For R1, who had dementia with behavioral disturbances, the record showed repeated episodes of wandering into other residents’ rooms, taking belongings, attempting to tilt another resident from a chair, pushing staff, carrying tables, attempting to climb on tables, and trying to hit windows with a chair. R1 was involved in an altercation where another resident stomped on his face after R1 entered that resident’s room, and later engaged in escalating aggression that led to a 911 call and hospital transfer. Progress notes and staff interviews described ongoing exit-seeking, striking out at staff, unplugging cameras, threatening to damage equipment, and urinating in inappropriate places, while staff primarily responded with close supervision and redirection. Despite this pattern, there was no behavior assessment in the medical record to identify triggers or effective interventions, and staff reported that the care-planned approach of “follow and redirect” did not stop R1’s behaviors. R2, who had dementia with agitation and PTSD, was known not to like others in his room, and his care plan included general interventions to protect the rights and safety of others and redirect him. After an altercation in which another resident entered his room, staff attempted to use a mesh barrier with a stop sign across his doorway, but it was placed inside the closed door where it could not serve as a visible cue to others. R2’s record also lacked a behavior assessment to identify triggers or effective interventions, despite family reporting that staff had been informed of his preference to keep others out of his room. R3, who had dementia and a history of physical behaviors toward others, reported multiple incidents of another resident entering his room, attempting to take his pillow, urinating on his floor, and trying to get into his bed. R3’s care plan referenced a history of altercation when another resident walked into his room and included only broad language to protect rights and safety and divert attention PRN, with no documented behavior assessment to guide more specific preventive strategies. R5, with severe cognitive impairment and frequent physical behaviors and wandering, was observed repeatedly entering other residents’ rooms despite staff attempts to redirect him. The care plan again relied on general redirection, offering snacks or diversional activities, and monitoring whereabouts, but staff interviews confirmed that the primary intervention was to follow and redirect, which they stated did not stop his behaviors and required significant staff time. R7, who had severe cognitive impairment and wandering behavior, had no behavior assessment in the record, and family reported that they rarely saw activity staff on the unit and that R7’s interests in motorcycles, fishing, shopping, and being active were not reflected in activities offered; instead, he was usually observed lying in bed. R8, who had dementia and was dependent for ADLs, also had documented interests in social interaction, outings, music, and games, but family reported that some staff were not good at redirecting residents and allowed them to go where they wanted. During one observation, R1 loudly told R8’s visitors it was time to leave, causing them to move to another area, and staff did not intervene. Unit-wide observations showed that activity staff presence was inconsistent and that residents with dementia and wandering or behavioral symptoms were often minimally engaged. During a prolonged observation period, NAs were frequently seated at the nurse’s station with limited interaction with residents, while residents slept at tables, wandered toward exits, or moved around the kitchen area. Staff interviews confirmed that activities on the secured unit were infrequent, often did not occur as scheduled, and that the unit “almost never had activities” except when surveyors were present. Nursing staff, including NAs and nurses, reported feeling overwhelmed by the behavioral needs of residents, described frequent resident-to-resident conflicts related to wandering into rooms, and stated they needed specific, resident-tailored lists of behavioral interventions, which were not available. The DON and medical director acknowledged behavioral challenges and staffing limitations but there was no evidence in the record of completed behavior assessments or individualized, person-centered behavior management plans for the residents reviewed.
Failure to Address Grievance for Missing Personal Belongings
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances and to make prompt efforts to resolve a grievance regarding missing personal possessions. The resident had severe cognitive impairment with documented physical and verbal behaviors related to dementia, including combative actions and wandering that intruded on others’ privacy. The resident’s preferences indicated that having music was very important, and he had a personal radio in his room. Shortly after admission, the resident’s family member observed that the resident had initially arrived with plenty of labeled clothing and a personal radio, but within about a week most of his clothing, his dentures, personal radio, and Army hat were missing from his locked-unit room. The family member reported the missing items and provided a list of the missing belongings to nursing staff and the nurse manager. Despite this report, staff did not initiate the facility’s grievance process as required by policy. A nursing assistant later stated she had not been informed of the missing items until the family member spoke with her during a subsequent visit. The RN involved acknowledged learning of the missing clothing days earlier and admitted she had not completed a grievance form at that time and had not contacted maintenance to search for the items. The DON stated that when family notice missing items, staff are to notify the nurse manager, who should involve the interdisciplinary or clinical team, and that a grievance form should have been completed when the missing items were reported. The DON further acknowledged that the nurse manager had not completed a grievance form when the missing items were first reported, contrary to the facility’s Missing Items policy, which required immediate completion of a grievance form and an immediate, thorough search when an item was reported missing.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified based on observations and records indicating that residents were not always served meals that met their documented dietary needs and stated preferences.
Grievance Process and Form Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that residents were aware of how to file grievances and that grievance forms were accessible in prominent locations throughout the facility. During a resident council meeting, four residents expressed that they were unaware of the grievance filing process and did not know where to find grievance forms. They mentioned that they previously felt comfortable discussing grievances with a former social worker, but since his departure, they did not feel they could approach the current social services director (SSD). The SSD claimed that the grievance process was covered in meetings and that forms were available in the main lobby, but observations revealed no forms were present. Further interviews and observations indicated that the reception desk personnel acknowledged the absence of grievance forms in the lobby due to time constraints. The administrator stated that forms should be available at the front desk and nursing stations, but there was no provision for anonymous submission within the facility. A registered nurse also confirmed the lack of grievance forms at the nursing station, suggesting residents would need to go to the lobby to obtain one. The facility's policy and pamphlet outlined the grievance process, but the lack of accessible forms and clear communication led to the deficiency.
Dishwasher Temperature Monitoring and Coffee Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that dishwasher temperatures were consistently monitored and documented to guarantee proper sanitation of resident dishes in four of the five unit kitchenettes. Observations revealed incomplete temperature logs for the dishwashers in the Lakes, Woodland, Boundary Waters, and Arrowhead units. Dietary staff were responsible for checking and documenting dishwasher temperatures twice daily, but logs were found to be incomplete or not up to date. Interviews with dietary aides and the kitchen manager confirmed the lack of adherence to the expected protocol for monitoring and documenting dishwasher temperatures. Additionally, the facility did not maintain the coffee machine in a sanitary condition, as observed in the Lakes unit kitchenette. The coffee/hot water dispenser was found to be dirty, with a white foamy substance floating in the overflow basin, which was identified as mold by a dietary aide. The kitchen manager confirmed that the coffee maker had not been cleaned in 7-14 days, despite the expectation for daily cleaning. The cleaning logs were not signed off, indicating a failure to complete the required cleaning tasks. Facility policies required employees to ensure cleanliness and sanitation of food preparation equipment, but these were not followed, leading to potential food-borne illness risks for residents.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medication assessment (SAM) was completed for a resident, identified as R140, who was observed with medications at their bedside. R140's admission Minimum Data Set (MDS) indicated intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), requiring partial assistance with most activities of daily living. Despite this, R140's physician's orders did not include an order to self-administer medication, and the medical record lacked an assessment to allow self-administration. During an observation, R140 was found with three inhalers on their nightstand, including two Breo Ellipta inhalers and one albuterol inhaler. A registered nurse (RN-C) confirmed that R140 was not assessed to self-administer medications and should not have medications at the bedside without a proper assessment and physician's order. The RN-C explained to R140 the importance of not keeping medications in the room without a lock box to prevent other residents from accessing them. The director of nursing (DON) stated that a resident must be assessed for safety and obtain a physician's order to self-administer medications. Medications should not be kept at the bedside, even if the resident is deemed safe to self-administer, and must be stored in a lock box to prevent access by other residents. The facility's policy outlined the procedure for determining if a resident could self-administer medications, which includes completing a Resident Self-Administration of Medications UDA, obtaining a physician's order, and documenting the process in the care plan. However, these steps were not followed for R140, leading to the deficiency.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to maintain a clean and safe environment for two residents who were dependent on wheelchairs for mobility. Both residents had moderately impaired cognition and were diagnosed with Huntington's disease and dementia. During observations, it was noted that the wheelchairs of both residents had copious amounts of dried food and other substances on the wheels, indicating a lack of regular cleaning and maintenance. The care plans for these residents highlighted their dependence on wheelchairs and the need for assistance with mobility, yet their wheelchairs were not kept in a clean condition. Interviews with the nursing staff and the Director of Nursing revealed that the responsibility for cleaning the wheelchairs fell on the overnight shift staff, with a schedule in place to determine which wheelchairs should be cleaned each night. However, the schedule was not effectively followed, as evidenced by the unclean state of the wheelchairs. The facility did not have a specific policy for wheelchair cleaning, and the existing schedule indicated that the wheelchairs were to be cleaned once a week, with additional cleaning by maintenance if needed. Despite these arrangements, the wheelchairs of the two residents remained unclean, demonstrating a failure in maintaining a homelike and safe environment.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who experienced a substantial weight gain. The resident, who had intact cognition and diagnoses including central cord syndrome, spinal stenosis, and chronic pain syndrome, required substantial assistance with activities of daily living and mobility. According to the physician's orders, the resident was to be weighed weekly, and the physician was to be notified if there was a weight gain of more than 5 pounds in a week. On February 5th, the resident weighed 397.5 pounds, and by February 12th, the weight had increased to 406.1 pounds, indicating an 8.6-pound gain. However, there was no documentation of the physician being notified of this change. Interviews with various nursing staff revealed that the resident was not re-weighed immediately due to the unavailability of the appropriate staff and equipment, and the physician was not informed of the weight gain. The resident's progress notes later indicated a change in condition, including edema and shortness of breath, leading to a recommendation for hospital evaluation. Despite the facility's policy on weighing residents, the staff did not adhere to the protocol of re-weighing immediately, notifying the physician, and documenting the incident, which contributed to the deficiency.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure pressure ulcer prevention interventions were in place for a resident identified as R66, who was at moderate risk for developing pressure sores. R66's care plan and physician orders required the use of heel suspension boots to elevate and protect the heels at all times. However, multiple observations revealed that the boots were not being used as prescribed. During several instances, R66 was found with heels resting directly on the mattress or footrest without the protective boots, despite the care plan's instructions and the resident's acknowledgment that she did not refuse the use of the boots. Interviews with staff, including registered nurses and nursing assistants, confirmed that the care plan was not being followed, and the boots were not consistently applied. The staff acknowledged the importance of following care plans and documenting any refusals, which were not evident in this case. The wound doctor and the director of nursing reiterated the necessity of using the boots to prevent further pressure ulcer development, highlighting a lapse in adherence to the facility's policy on pressure ulcer management.
Improper Catheter Care and Positioning for a Resident
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, identified as R68, who had a urinary catheter due to chronic kidney disease and urinary retention. The resident's care plan and physician's orders did not specify that the catheter drainage bag should be positioned below the bladder, which is necessary to facilitate proper urine flow and prevent complications. Observations revealed that the resident's leg catheter bag was attached at the level of the bladder, contrary to standard practice, and was over halfway full of urine. Nursing staff, including nursing assistants and registered nurses, confirmed that the drainage bag was not positioned correctly and acknowledged that the physician should have been notified if the resident's preference for using a leg bag all the time required deviation from standard practice. Interviews with various nursing staff, including registered nurses and the director of nursing, highlighted a lack of communication and documentation regarding the resident's catheter care preferences and the necessity of positioning the drainage bag below the bladder. The facility's policy on catheter care emphasized the importance of maintaining a non-obstructed downhill flow of urine, which was not adhered to in this case. The director of nursing confirmed that any changes in catheter use should be communicated with the provider, especially when deviating from the physician's orders, to ensure proper care and documentation.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to ensure that beverages were served in the appropriate consistency for a resident who required a mechanically altered diet with thickened liquids due to dysphagia. The resident, who had severe cognitive impairment and a history of pneumonitis due to inhalation of food, was observed receiving a can of soda that was not thickened, contrary to her dietary requirements. The resident's care plan and physician orders specified a pureed diet with mildly thick liquids, yet the administrator provided the resident with a regular soda without thickening it, indicating a lapse in following the prescribed dietary orders. Interviews with staff, including registered nurses and the administrator, revealed a lack of adherence to the resident's dietary needs, with staff acknowledging that all liquids should be thickened and that the resident's family was aware of this requirement. The facility's policy required documentation of any refusal of the prescribed diet and education on the risks and benefits, which was not evident in the resident's medical record. The speech-language pathologist confirmed the need for thickened liquids due to silent aspiration risks, and the director of nursing emphasized the expectation for residents to receive diets as ordered.
Failure to Administer Critical Medication Due to Cost Approval Delay
Penalty
Summary
The facility failed to provide medication as ordered by the physician for a resident diagnosed with hepatic encephalopathy and alcoholic cirrhosis of the liver. The physician had ordered rifaximin, a critical medication for preventing liver failure, to be administered twice daily. However, the medication was not available at the facility from the time of the order on January 14th until January 16th. The delay was due to the need for price approval by the facility, which was not promptly addressed. The nursing staff did not notify the medical provider immediately about the unavailability of the medication, contrary to the facility's policy. The delay in medication administration was compounded by a lack of communication and action among the facility staff. The LPN did not call the medical provider because the medication was awaiting management approval due to its cost. The DON was informed of the high-cost medication on January 16th and sought an alternative from the NP, who was not updated about the missed doses until two days later. The consultant pharmacist emphasized the importance of the medication for the resident's condition, and the facility's failure to administer it could have led to an exacerbation of symptoms. The facility's policy required immediate notification to the physician if a medication was unavailable, which was not followed in this case.
Facility Assessment Lacks Specific Staffing Information
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately identified staffing needs based on the care requirements of its resident population. The assessment, which was organized into six parts, was intended to guide staffing and resource decisions, including the operating budget necessary for facility functions. However, it lacked specific information on staffing levels required for different shifts, such as day, evening, and night, and did not adjust for changes in the resident population. Interviews with facility staff revealed a lack of clarity and documentation regarding staffing determinations. A registered nurse indicated that staffing was based on resident care needs and managed by the DON and administrator. The interim DON, temporarily filling the position, stated that staffing was determined by resident acuity levels. The senior director, assisting during the administrator's leave, acknowledged that staffing was based on resident census and needs but was unsure of specific staffing numbers. The Facility Assessment did not include specific staffing requirements, and there were no additional attachments providing this information.
Failure to Develop Timely Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who had multiple complex medical conditions, including hemiplegia, hemiparesis, dysarthria, type 2 diabetes, dysphagia, aphasia, and a history of stroke. The resident was admitted from the hospital following an ischemic cerebrovascular accident and required skilled services such as medication administration, therapy, and assistance with activities of daily living (ADLs). However, the care plan did not include specific goals and interventions for the resident's ADL needs, such as bathing, bed mobility, dressing, eating, oral care, toileting, and transfers. Additionally, the care plan lacked safety concerns and did not address the resident's need for supervision and assistance with eating. Interviews with nursing assistants and the registered nurse responsible for care planning revealed that the care plan was not completed within the required 48-hour timeframe. The interim director of nursing confirmed that the care plan should have been updated within 48 hours, but it was not. The facility's procedure for new admission care plans was not followed, and the unit manager did not review the resident's care plan the day after admission. The director of nursing acknowledged that the care plan was incomplete and that staff were not adequately informed about the resident's care requirements during the resident's stay. The facility was unable to provide a policy related to new admissions and baseline care plans when requested.
Failure to Supervise Resident with Swallowing Disorder During Meals
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with a swallowing disorder, leading to a serious incident. The resident, who had a history of hemiplegia, dysphagia, and other conditions following strokes, required a regular diet with soft and bite-sized textures and moderately thick liquids. Despite these needs, the resident's care plan was not updated to reflect the requirement for supervision during meals, and staff were not adequately informed of the resident's dietary needs and supervision requirements. On one occasion, a family member found the resident slumped over in a chair, unresponsive, and covered in food, indicating a lack of supervision during a meal. The family member reported that staff had left the resident unattended with a meal tray in the room, despite the resident's known swallowing difficulties. This incident resulted in the resident being admitted to the hospital with aspiration pneumonia. Interviews with staff revealed a lack of awareness regarding the resident's dietary modifications and supervision needs, and the care plan did not reflect the necessary supervision during meals. The facility's interim DON confirmed that the resident's functional assessment indicated a need for supervision while eating, but this was not communicated in the care plan. The DON also noted that staff were expected to supervise residents with dysphagia during meals, whether in the dining room or in their rooms, but this expectation was not met. The facility was unable to provide a policy on supervision during meals when requested, highlighting a gap in procedural guidance for staff.
Failure to Ensure Call Lights Accessible for Residents
Penalty
Summary
The facility failed to ensure that call lights or another means to request assistance were accessible for four residents who were dependent on staff for mobility. These residents, identified as R5, R6, R7, and R8, had varying degrees of cognitive impairment and were reliant on staff for activities of daily living. Observations revealed that call lights were not within reach for these residents, and staff did not consistently check on them to ensure their needs were met. R5, who had severe cognitive impairment and was totally dependent on staff, was observed without a call light within reach while in her Broda wheelchair. Despite being checked on by staff, the call light was not placed within her reach. Similarly, R6, who had cognitive impairment and was dependent on staff, was left in her room without a call light accessible, and staff did not check on her for over two hours. R7, with severe cognitive impairment, was also left without a call light within reach, and staff did not check on him for an extended period. R8, who had moderate cognitive impairment, was found in his room with the call light on the floor, out of reach. Staff checked on him but did not ensure the call light was accessible. Interviews with staff revealed inconsistencies in their understanding of the residents' ability to use call lights and the frequency of checks required. The facility's policy required call lights to be within easy reach, but this was not adhered to, leading to the deficiency.
Deficiencies in Restraint Use and Documentation
Penalty
Summary
The facility failed to properly assess, care plan, and re-evaluate the use of physical restraints for five residents, leading to deficiencies in ensuring that restraints were used appropriately and only when necessary for medical treatment. The report highlights that the facility did not document the need for restraints, did not provide interventions for freedom of movement, and did not ensure that the restraints were the least restrictive alternative. For instance, Resident R4, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease and hallucinations, was using a Broda chair with a back latching belt without proper documentation or care planning to address the restraint's use and necessity. The report further details that Resident R5, who had Huntington's disease and severe cognitive impairment, was observed with a thigh belt restraint instead of the pommel cushion as indicated in the physician's orders. The care plan for R5 did not include interventions for freedom of movement or specify the medical symptoms the restraint was intended to treat. Similarly, Residents R6, R7, and R8 were also found to have restraints without proper documentation, care planning, or assessment of the need for such restraints, and there was a lack of documentation of family or resident education regarding the use of these restraints. Interviews with facility staff, including the Medical Director and registered nurses, revealed a lack of awareness and understanding of the requirements for restraint use, including the need for signed physician orders, documentation of symptoms being treated, and regular assessments. The facility's policy on physical restraints and psychotropic medications outlined the risks associated with restraint use but did not provide specific guidance on the use of restraints, contributing to the deficiencies observed during the survey.
Failure to Maintain Resident Dignity and Respectful Communication
Penalty
Summary
The facility failed to uphold the resident's right to dignity and respectful communication, as evidenced by the interaction between a nursing assistant (NA-C) and a resident (R7). During an observation, NA-C was seen speaking to R7 in a belittling manner while providing care. R7, who has severe cognitive impairment due to Huntington's disease, was dependent on staff for various activities of daily living. During the care process, NA-C made inappropriate comments about R7's movements and bodily functions, which R7 perceived as verbal abuse. R7's medical condition includes unclear speech and severe cognitive impairment, making him reliant on staff for communication and care. Despite NA-C's claim that her comments were made in jest, R7 expressed that he did not feel NA-C spoke kindly to him and identified the comments as verbal abuse. The incident highlights a failure in maintaining the resident's dignity and respectful communication, as required by resident rights regulations.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement and complete person-centered care plans for several residents, leading to deficiencies in meeting their medical and personal care needs. Resident R4, who has severe cognitive impairment and multiple diagnoses including Alzheimer's disease and pulmonary fibrosis, did not have a care plan that included necessary assessments and interventions for the use of a Broda chair with a thigh strap. Similarly, Resident R5, who is severely cognitively impaired and diagnosed with Huntington's disease, was not repositioned or checked on as required by her care plan, which included specific instructions for the use of a Broda chair and incontinence care. Resident R6, with cognitive impairment and dependent on staff for daily activities, was not checked on by facility staff for over two hours, contrary to the care plan's requirements for regular checks and repositioning. Additionally, Resident R7, who is severely cognitively impaired and diagnosed with Huntington's disease, was not repositioned or offered a position change as indicated in his care plan, which was designed to prevent pressure ulcers. The care plans for these residents were not followed, resulting in a lack of necessary care and attention. The facility's policy on care plans, which requires comprehensive and measurable objectives to meet residents' needs, was not adhered to. Interviews with staff revealed a lack of awareness and adherence to the care plans, with one nursing assistant stating that the care plan for R7 was not appropriate. The Director of Nursing acknowledged that the care plans should be person-centered and up to date, indicating a gap between policy and practice in the facility.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain proper personal hygiene for a resident who was unable to perform activities of daily living (ADLs) independently. The resident, who had a history of central cord syndrome, post-traumatic stress disorder, and other medical conditions, was dependent on staff for personal hygiene and toileting. Despite physician orders to keep the peri-area clean and dry every shift, the resident experienced inadequate care, as evidenced by multiple complaints about improper cleaning and a recent hospitalization for a catheter-related urinary tract infection. The facility's grievance logs indicated unresolved complaints regarding care, and there was no documentation provided to show how these complaints were addressed. During an observation, it was noted that the resident's peri-care was not completed in the morning, and the catheter bag had not been emptied until the resident requested it. When staff eventually attended to the resident, dried blood and feces were found, indicating a lack of timely and adequate cleaning. Interviews with staff revealed that the resident had made multiple complaints, and there was an acknowledgment that the resident should have been cleaned earlier. However, the staff failed to report the issue or seek assistance, and the facility's policy on ADLs for dependent residents was not provided upon request.
Improper Incontinence Care Management
Penalty
Summary
The facility failed to adhere to professional standards of practice by improperly managing the incontinence care of two residents, identified as R6 and R9. Both residents were observed wearing two incontinence briefs simultaneously, which was not in accordance with their care plans. R6, who has cognitive impairment and is always incontinent of bowel and bladder due to Huntington's disease, was found with two saturated briefs during a bed bath. The hospice nursing assistant noted that double briefing was a common practice on the unit. Similarly, R9, who also suffers from severe cognitive impairment and Huntington's disease, was observed seated in a wheelchair with two briefs. Both residents' care plans specified that their briefs should be checked and changed every two hours, with no mention of double briefing. Interviews with staff, including a hospice RN, a nursing assistant, a trained medication assistant, and the director of nursing, revealed a lack of awareness and adherence to proper incontinence care protocols. The director of nursing confirmed that double briefing was inappropriate and that staff should follow the care plan instructions, which did not include double briefing. Despite the facility's policy on quality of care being requested, it was not provided, indicating a potential gap in policy enforcement or availability.
Failure to Prevent and Address Pressure Ulcers
Penalty
Summary
The facility failed to appropriately assess and initiate interventions to minimize the risk for pressure ulcer development for a resident with dementia, incontinence, and mobility issues. The resident's care plan identified a potential for pressure ulcer development but did not incorporate specific interventions to prevent them. Despite the resident's significant weight loss and inadequate protein intake, which increased the risk for pressure ulcers, the care plan lacked necessary preventive measures. The resident developed a stage 1 pressure ulcer on the right hip, which was not adequately addressed in the care plan. The nursing staff failed to implement frequent turning, maximal remobilization, and other interventions recommended for residents at mild risk for pressure ulcers. The resident's skin assessments and Braden scores indicated a need for more intensive monitoring and care, but these were not provided, leading to the development of additional pressure injuries. Interviews with staff revealed a lack of communication and follow-up regarding the resident's skin condition. Nursing assistants and registered nurses did not consistently report or address skin changes, and there was a delay in obtaining treatment orders from the nurse practitioner. The facility's policy on skin assessment and pressure ulcer prevention was not effectively implemented, resulting in the resident's decline and subsequent hospital admission with multiple pressure injuries.
Failure to Serve Breakfast at Proper Temperature
Penalty
Summary
The facility failed to ensure that breakfast was served at the proper temperature on the 2nd floor WL unit, potentially affecting all 16 residents. During an observation, scrambled eggs were noted to be cold when served to residents. A resident was heard complaining about the cold eggs, and another resident confirmed that their breakfast was cold. The food was not covered while waiting to be served, contributing to the temperature issue. A trained medication assistant acknowledged the difficulty in serving breakfast at the correct temperature due to the staggered delivery times and the number of residents needing assistance. The director of nursing was unaware of any complaints about cold food, and no policy regarding food temperatures was obtained.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the state agency within the required two-hour timeframe after the allegation was made. This deficiency involved a resident with severe cognitive impairments, including dementia and delirium, who required extensive assistance for daily activities. A family member provided a video showing a nursing assistant (NA) handling the resident roughly during care, including exposing the resident, not using a gait belt during transfer, and continuing care despite the resident's resistance. The director of nursing (DON) reviewed the video and acknowledged the NA's mistakes but did not report the incident promptly, believing there was no intent to harm. The resident's care plan indicated the need for two staff members to assist with care and recommended specific dementia care tactics, which were not followed by the NA. The NA's actions included pulling the resident's clothing, leaving the resident in an unsafe position, and failing to communicate effectively. Despite recognizing these issues, the DON did not report the incident to the state agency within the mandated timeframe, as required by the facility's policy on abuse and neglect. The NA was suspended and later terminated, but the delay in reporting the incident constituted a failure to comply with regulatory requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 794 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Robbinsdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villas At Robbinsdale | 0.8 mi | — | 5 | 1 |
| The Terrace At Crystal Llc | 0.9 mi | — | 38 | 3 |
| Courage Kenny Rehabilitation Institutes Trp | 1.7 mi | — | 7 | 1 |
| Covenant Living Of Golden Valley Care & Rehab Ctr | 2.2 mi | — | 2 | 0 |
| Victory Health & Rehabilitation Center | 2.6 mi | — | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Good Samaritan Society - Specialty Care Community.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.