Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Tlc Nursing Center during CMS and state inspections, most recent first.
An LPN falsified controlled substance records by signing other nurses’ names as witnesses to dropped narcotic disposal and signed out Oxycodone for a resident without MAR evidence of administration. The investigation found forged signatures on multiple controlled drug records, and staff interviews confirmed the witness signatures were not authentic and that the required dual-signature disposal process was not followed.
Failure to Timely Report Misappropriation Allegation: The ADM failed to ensure an allegation of misappropriation involving an LPN’s falsification of controlled drug records was reported to the SA within the required 24-hour timeframe. The LPN forged witness signatures on controlled medication disposal records and signed out controlled meds without documenting administration on the MARs, affecting multiple residents.
A resident who returned after hemiarthroplasty for a right femoral neck fracture did not receive ordered anticoagulant therapy for 20 days. The hospital had recommended aspirin 81 mg BID for DVT prevention, but the order was discontinued because of an aspirin allergy, and no alternate therapy was ordered or documented until Eliquis was later prescribed. The MD said he expected the nurse to contact the surgeon, while the surgeon said he was never told about the allergy and would have recommended Eliquis.
A resident returned after hip surgery with an order for aspirin prophylaxis, but staff identified an aspirin allergy and discontinued the medication. An LPN notified the attending MD, yet no alternate anticoagulant was ordered and the surgeon was not contacted, leaving the resident without aspirin or other anticoagulant therapy for 20 days despite the post-op recommendation for 6 weeks of treatment.
A resident was readmitted with a fracture diagnosis and had an order for aspirin 81 mg BID for DVT prevention, but the order was discontinued because of an aspirin allergy. An LPN said she notified the attending physician of the allergy but did not document that communication in the chart, and the record did not show what would be given instead of aspirin. Staff interviews confirmed that physician communication should be documented in the nurses' or progress notes.
Falsified controlled substance records and missing MAR documentation
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money when an LPN falsified controlled substance documentation and did not follow required procedures for handling, storage, disposal, and documentation of controlled medications. The investigation found that the LPN fabricated other nurses’ signatures on controlled drug records for residents receiving Tramadol and Hydrocodone, indicating that those nurses had witnessed disposal of dropped medications when they had not. The facility’s policies required controlled medication waste or disposal to occur in the presence of a nurse witness, with both nurses signing the disposition record, and the LPN did not follow that process. For one resident with diagnoses including vascular dementia and pain, the controlled drug record for Tramadol showed an RN’s signature next to an entry stating the medication had been dropped. The RN stated she never signed as a witness for that disposal and explained that the proper procedure was to have another nurse witness the waste and sign the record. For two other residents, controlled drug records for Hydrocodone showed signatures of two different LPNs as witnesses to dropped medication disposal, but one LPN stated the signature was not hers and the other nurse could not be reached for interview. The Interim DON and the consultant pharmacist both stated that a nurse should never sign another nurse’s signature on a controlled medication record and that doing so would be considered diversion or misappropriation. The facility also found that the same LPN signed out Oxycodone for another resident on multiple occasions in August and September, but the resident’s MAR did not contain initials or documentation showing the medication had been administered for those doses. That resident had diagnoses including fractures and chronic pain, and had a BIMS score of 13 indicating intact cognition. The resident did not recall requesting the medication on most occasions, and the consultant pharmacist stated that when a controlled medication is signed out without evidence it was administered, it is misappropriation of the resident’s property. The report identified these actions as misappropriation of resident property involving four residents and one medication cart.
Failure to Timely Report Misappropriation Allegation
Penalty
Summary
The Administrator failed to ensure an allegation of misappropriation of resident property was reported to the State Agency within the required 24-hour timeframe after becoming aware on 09/11/2025 that an LPN was falsifying residents’ Controlled Drug Records. The report states the LPN forged other nurses’ signatures as witnesses to dropped medication disposal on Controlled Drug Records and signed out controlled medications on a Controlled Drug Record without documenting them as administered on the Medication Administration Records, contrary to facility procedures for handling, storage, disposal, and documentation of controlled substances. The incident involved residents identified in the report as RI #99, RI #104, RI #105, and RI #85. The facility’s policy required immediate reporting of allegations of theft or misappropriation, defined as within 24 hours for allegations not involving abuse or serious bodily injury. The State Agency received the Facility Reported Incident on 10/01/2025, and the Administrator acknowledged that the incident was not reported in a timely manner.
Failure to Provide Ordered Anticoagulant Therapy After Hip Surgery
Penalty
Summary
The facility failed to provide RI #81 with care and treatment according to hospital discharge orders, the plan of care, and medication needs after a right femoral neck fracture with hemiarthroplasty. The hospital discharge summary recommended aspirin 81 mg twice daily for six weeks for DVT prevention, but RI #81’s facility medication orders later showed the aspirin was discontinued because of an aspirin allergy. There was no evidence in the medical record that RI #81 received the ordered anticoagulant therapy after readmission until Eliquis was ordered on 03/12/2026. LPN #9 stated she notified the MD that RI #81 was allergic to aspirin, and the MD told her to discontinue the aspirin order, but no alternate therapy was ordered at that time. The record contained no documentation of that conversation and no evidence showing who was responsible for contacting the surgeon for an alternate medication. RI #81’s care plan included anticoagulant therapy interventions, but the February and March 2026 MARs showed no administration of aspirin or any other anticoagulant from readmission until 03/12/2026. During interviews, the MD stated he knew RI #81 had been readmitted with the surgeon’s aspirin order, but he did not provide a new anticoagulant order because he wanted to speak with the surgeon and believed the nurse was doing that. The orthopedic surgeon stated he was never informed of the aspirin allergy and would have recommended Eliquis if he had been told. The Interim DON stated the facility failed to ensure continuity of care and that everyone had "dropped the ball," and the CRNP and clinical pharmacist both confirmed the resident should have received anticoagulant therapy after surgery.
Failure to Provide Anticoagulant Orders After Hip Surgery
Penalty
Summary
The facility failed to ensure that a resident discharged from the hospital after arthroplasty with partial hip replacement had attending physician orders in place to meet medical needs on return to the facility. The resident’s orthopedic surgeon had recommended aspirin 81 mg twice daily for six weeks, but when the resident returned to the facility, staff identified that the resident was allergic to aspirin and the aspirin order was discontinued on 02/20/2026. An LPN notified the attending physician of the allergy, but no alternate anticoagulant order was provided at that time. The attending physician stated he did not order a replacement anticoagulant because he wanted to speak with the surgeon about what to use instead, but he never contacted the surgeon because he believed the nurse would do so. The orthopedic surgeon later stated he was never notified of the aspirin allergy and said he likely would have ordered Eliquis. As a result, the resident did not receive aspirin or any anticoagulant therapy for 20 days after readmission, despite the surgeon’s recommendation for six weeks of anticoagulant therapy.
Failure to Document Physician Notification and Medication Discontinuation
Penalty
Summary
The facility failed to maintain Resident Identifier #81's medical record in a way that was complete and accurately reflected the resident's condition and physician consultation. Resident Identifier #81 was admitted on 02/12/2025 and later readmitted with a diagnosis of displaced fracture of the base of the neck of the right femur, subsequent encounter for closed fracture with routine healing. A review of the February 2026 physician orders showed aspirin 81 mg twice daily had been ordered for DVT prevention, but the order was discontinued because the resident was allergic to aspirin. During interview, LPN #9 stated she notified the attending physician that Resident Identifier #81 was allergic to aspirin when the resident was readmitted, but she did not document that communication in the medical chart. She also stated she had given report to another nurse. The record did not identify what would be provided in place of the aspirin. Facility staff interviewed stated that communication with the physician would be documented in the chart or progress notes and that such documentation was important for other nurses to see changes made and to support continuity of care.
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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 Oneonta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Oneonta | 1 mi | ★★★★★ | 0 | 0 |
| Altoona Health & Rehab | 9.2 mi | ★★★★★ | 0 | 0 |
| Health Care Inc | 10.9 mi | ★★★★★ | 0 | 0 |
| Hanceville Nursing & Rehab Center, Inc | 19.3 mi | ★★★★★ | 9 | 0 |
| Attalla Rehabilitation And Nursing Center | 20 mi | ★★★★★ | 0 | 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.