Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Sandridge Post Acute during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment had diclofenac sodium topical gel 1% left on the bedside table without a physician order or self-administration evaluation. The resident said he got the cream from his roommate and used it for knee pain. Staff, including an RN and the DON, confirmed the medication should not have been in the room and that the resident was not authorized to self-administer medications.
A resident with multiple chronic conditions and intact cognition alleged that a CNA told him to "shut the f**k up." The nurse manager and Administrator responded promptly, but the allegation was never documented in the resident’s medical record or in the facility’s risk management system, despite facility policy and a Charting and Documentation policy requiring that all incidents and events involving residents be recorded. The Administrator and DON both confirmed that no entry was made in risk management or in psychosocial/progress notes for this incident, resulting in an incomplete and inaccurate clinical record.
The facility did not follow its own policies for investigating and documenting allegations of abuse, neglect, and misappropriation involving several residents. Required 5-day investigation reports were missing or incomplete, interviews with staff and residents were not documented, and clinical records were not updated with relevant incident details. In some cases, families were not notified as required, and there was inconsistent documentation regarding the causes of injuries and incidents.
The facility did not conduct or document thorough investigations into allegations of abuse and misappropriation for two residents, including missing property and a fall resulting in injury. Required interviews and documentation were not completed, and investigation records were unavailable when requested, contrary to facility policy.
Surveyors found that medication carts containing resident medications, controlled substances, and diabetic supplies were left unattended and unlocked in multiple units. Staff interviews confirmed that this practice was not in line with facility policy, which requires all medication storage areas to be locked when not in use.
Staff left medication carts unattended with laptops displaying resident records on two separate units. Both LPNs involved acknowledged that this was not in line with facility policy and could result in unauthorized exposure of resident information. The DON and LPN Manager confirmed that such actions violate HIPAA and residents' rights to privacy, as outlined in facility policy.
A resident with severe cognitive impairment and behavioral issues, including substance use and hallucinations, physically struck another resident in the head with a metal brace following a verbal altercation. Staff initially separated the residents after the verbal exchange but did not report the incident or remove the aggressor immediately, allowing the situation to escalate to physical abuse.
A resident with a history of dementia, agitation, and poor impulse control repeatedly engaged in physical and sexual abuse toward several cognitively impaired peers, including inappropriate touching, aggression, and attempts to bring female residents into his room. Staff and housekeepers observed and reported these behaviors, but there was inconsistent escalation to the DON or Abuse Coordinator, incomplete documentation, and a lack of effective interventions, resulting in continued harm to multiple residents.
A resident with dementia and behavioral disturbances repeatedly engaged in sexually inappropriate and aggressive behaviors toward several female peers, including touching and attempting to lead them to his room. Multiple staff members observed and reported these incidents to their supervisors, but the events were not escalated to the DON or Abuse Coordinator, and no report was made to the State Agency as required by policy. The facility failed to follow its abuse reporting procedures, resulting in unaddressed allegations of abuse and ongoing risk to cognitively impaired residents.
The facility did not report multiple allegations of sexual abuse and inappropriate behaviors involving several cognitively impaired residents to the State Agency as required. Staff observed and documented incidents such as inappropriate touching and sexualized behaviors, but these were not consistently escalated to the DON or Abuse Coordinator, resulting in a failure to follow the facility's abuse reporting policy.
A facility failed to thoroughly investigate and document multiple incidents of alleged sexual and physical abuse involving several cognitively impaired residents. Staff observed inappropriate behaviors, including touching and attempts to isolate female residents, but did not consistently report these incidents to supervisory staff or follow facility policy for abuse investigations. As a result, required notifications and investigations were not completed, and the facility lacked evidence of appropriate response to all alleged violations.
A facility failed to implement its abuse policy by not promptly reporting and investigating an abuse allegation involving a resident with dementia and major depressive disorder under hospice care. A hospice CNA reported the resident's claim of being raped and visible bruises to a nurse and social worker, but the facility delayed notifying the appropriate authorities. The operation manager received the allegation from APS and reported it to the State Agency later that day. Interviews revealed a lack of awareness and delayed action among staff, indicating a breakdown in communication and reporting. The facility's policy requires immediate reporting to several entities, but law enforcement and the ombudsman were notified late, constituting a failure to adhere to the policy.
A resident under hospice care with severe cognitive impairment alleged rape, but the LTC facility delayed reporting the abuse to the State Agency. Despite the facility's policy requiring immediate reporting, the incident was only reported after APS intervention. Staff interviews revealed a lack of awareness and communication about the abuse allegation, leading to a delayed response and potential risk to the resident's safety.
A resident under hospice care in a facility alleged she was raped, with visible bruising observed by a CNA. Despite the facility's policy requiring immediate reporting of abuse allegations, there was a delay in notifying law enforcement and a lack of timely investigation, leading to a deficiency. The resident, with severe cognitive impairment, was able to articulate the allegations during an interview.
A resident with multiple chronic conditions and a history of leg fractures was injured during a Hoyer lift transfer when only one trained staff member and an untrained dietary director were present. The resident fell when a strap became unhooked, highlighting a breach in the facility's safety protocols requiring two trained staff members for such transfers.
A resident with dementia and other conditions eloped from a facility due to inadequate supervision and lack of a care plan despite being identified as an elopement risk. The resident expressed a desire to leave, but this was not documented, and door alarms were not functioning properly. The resident was found two days later in a hospital, and the facility's investigation could not determine how the elopement occurred.
A resident's code status was inaccurately documented in the facility's records, leading to a potential risk of not receiving care aligned with their advance directive. Despite having a full-code status in their advanced directive, the electronic health record indicated a DNR order. Staff interviews revealed confusion and lack of awareness about the resident's true code status.
A cognitively intact resident with multiple diagnoses was involved in an altercation with a staff member, where the resident hit the staff member with a broom, leading to the staff member retaliating by hitting the resident. The incident was witnessed by other staff, who intervened. Despite training on abuse prevention, the staff member's actions violated the resident's right to be free from abuse.
A resident with chronic respiratory conditions was found with an oxygen cylinder stored directly on the floor in their room, contrary to facility policy requiring cylinders to be in carriers. Multiple staff members acknowledged the risk of explosion from improper storage, yet the cylinder remained on the floor until removed during an observation.
The facility did not ensure the safety of a resident with quadriplegia, bipolar disorder, anxiety disorder, and PTSD, who was involved in physical altercations with another resident diagnosed with osteomyelitis of vertebra, depression, hypertension, and psychoactive substance abuse in remission. Incidents included the resident ramming a motorized wheelchair into the other resident, leading to physical confrontations. Witnesses reported multiple altercations, indicating insufficient safety measures to prevent resident abuse.
A resident with schizoaffective disorder, alcohol abuse, and opioid abuse, assessed with a high elopement risk score of 18, managed to leave the facility multiple times. Staff noted the resident's pacing and expressed desire to leave, but inconsistent monitoring and documentation of room checks allowed the resident to escape through open windows. Despite securing windows with sliding locks after the initial incident, the resident was able to remove a window and leave again, highlighting gaps in supervision and environmental safety measures.
Unsecured Medication Left at Resident Bedside Without Order
Penalty
Summary
The facility failed to ensure that medications were properly stored and not left at the bedside for 1 of 1 sampled residents, Resident #160. Resident #160 was admitted with diagnoses including metabolic encephalopathy, unspecified dementia, and other abnormalities of gait and mobility. The care plan addressed cognitive loss related to Alzheimer's disease or other dementias and included interventions to explain care before providing it and monitor for changes in cognitive status. The modified admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and the resident required moderate to maximum assistance with ADLs. There was no evidence in the electronic clinical record that Resident #160 was authorized or able to self-administer medications. During an observation of the resident's room, an orange tube of diclofenac sodium topical gel 1% was found on the bedside table. The resident stated he obtained the medication from his roommate, who had an extra tube, and that he used it on his knees for pain. Review of the electronic record showed no medication self-administration evaluation and no physician's order for diclofenac sodium topical gel 1%. An RN stated the medication should have been confiscated and that all medications require a physician's order before administration. The RN also stated the resident should not have had the cream and that the practice did not meet the facility's expectations. The CNA stated he watches for medications left in residents' rooms and reports anything dangerous to the nurse, and that medications left in a room could pose harm to anyone entering that room. The DON stated the facility needs a physician's order for all medications and treatments, that staff are expected to confiscate medications found in a resident's possession, and that if a resident wishes to self-administer, an evaluation and physician order are required and should be reflected in the care plan. The DON confirmed there was no physician's order for diclofenac sodium topical gel 1%, no self-administration evaluation, and no care plan evidence that the resident could self-administer medications. Facility policies also stated that self-administered medications must be documented and stored securely, and medications found at the bedside without authorization are to be turned over to the nurse in charge.
Failure to Document Verbal Abuse Allegation in Resident Medical Record and Risk Management System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record and risk management documentation for a resident who alleged verbal abuse by a CNA. The resident, who had multiple diagnoses including atherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction, dysphagia, paraplegia, hypertension, hyperlipidemia, a history of recurrent pneumonia and falls, and gastrostomy status, was cognitively intact with a BIMS score of 13/15. On a specified date, the resident reported that a CNA told him to "shut the f**k up." The nurse manager responded to the scene, ensured the resident was safe, and immediately reported the allegation to the Administrator, who then went to the resident’s room. Despite these actions, the allegation of verbal abuse was not entered into the resident’s medical record and was not documented in the facility’s risk management system, contrary to facility policy and the Charting and Documentation policy, which required that any events, incidents, or accidents involving a resident be recorded in the medical record. The Administrator acknowledged that all incidents were required to be entered into the risk management system and that this did not occur for this resident. The DON confirmed that incidents, including verbal abuse, should have been documented in risk management and somewhere in the resident’s clinical chart, such as psychosocial progress notes, but no such documentation was found for this incident.
Failure to Investigate and Document Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The facility failed to implement its own policies and procedures requiring thorough investigations of abuse, neglect, and misappropriation allegations for four residents. In multiple cases, the facility did not complete or retain required 5-day investigation reports, did not document interviews with staff or residents, and failed to update clinical records with relevant information about incidents. For example, one resident experienced an unwitnessed fall resulting in a hematoma, but the facility could not provide the mandated 5-day investigation report, and the resident's family reported not being notified of the incident on the day it occurred. Attempts to contact staff involved at the time were unsuccessful, and documentation was incomplete. Another resident reported rough treatment by a CNA, resulting in a bruise, but the facility's 5-day report was incomplete and lacked staff or resident interview accounts. There was also no documentation of disciplinary action taken against the staff member involved. Interviews with current staff revealed inconsistent practices regarding documentation and investigation, with some staff unaware of the incidents or unable to recall details. The facility's policies required interviews with witnesses, residents, and staff, as well as immediate family notification, but these steps were not consistently followed or documented. Additional deficiencies included a failure to investigate a resident's report of a missing wallet, which involved potential misappropriation of funds. The facility did not document interviews or complete a 5-day investigation report, and the administrator confirmed that such incidents are reportable and should be investigated with written records. In another case, a resident sustained a hip fracture after a fall, with conflicting documentation about whether a resident-to-resident altercation occurred. The incident report did not address the altercation as a probable cause, and required documentation and interviews were missing. Facility policies clearly outlined the steps for investigating and documenting such incidents, but these were not adhered to in the cases reviewed.
Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and misappropriation of property for two residents. For one resident with multiple psychiatric and medical diagnoses, documentation showed that the resident reported a missing wallet containing important identification cards following a hospital stay. Although the resident did not suspect theft or want police involvement, there was no evidence that the facility conducted or documented interviews with staff, the resident, or other potential witnesses. Additionally, when requested, the facility was unable to provide a five-day investigation report or related grievance logs, and the administrator confirmed that such documentation was not available. For another resident with dementia and a history of falls, the facility reported a witnessed fall that resulted in a hip fracture. The clinical record indicated a change in the resident's condition prior to the fall, and a physician's note later stated the injury was due to a resident-to-resident altercation. However, there was no documentation in the clinical record to support the occurrence of an altercation, and required interviews with staff and residents were not completed. Attempts to interview staff were unsuccessful due to lack of recollection or staff no longer being employed. Facility policies required comprehensive investigations of all incidents, including interviews with witnesses, staff, and residents, as well as detailed documentation of the circumstances and follow-up. In both cases, the facility did not follow its own policies and procedures for investigating and documenting incidents of potential abuse, misappropriation, or altercations, resulting in incomplete investigations and insufficient records.
Medication Carts Left Unattended and Unlocked
Penalty
Summary
Surveyors observed that three medication carts were left unattended and unlocked in multiple units of the facility. On several occasions, medication carts containing resident medications, over-the-counter drugs, diabetic supplies, lancets, narcotic medications, medicated patches, and alcohol pads were accessible while nursing staff were not present or were inside resident rooms. These observations were confirmed by staff interviews, where nurses acknowledged that leaving carts unlocked and unattended was not consistent with facility policy or their usual practice. The fill-in Director of Nursing and LPN Manager also confirmed that medication carts should not be left unlocked when unattended. A review of the facility's policy on Medication Labeling and Storage, revised in December 2025, indicated that all compartments containing medications and biologicals must be locked when not in use, and carts used to transport such items should not be left unattended if open or accessible. Despite this policy, surveyors were able to access medication carts without restriction, and staff confirmed the presence of controlled substances and diabetic supplies in these carts at the time of the observations.
Failure to Maintain Confidentiality of Resident Records
Penalty
Summary
Staff failed to maintain the confidentiality of resident-identifiable information by leaving laptops with open resident records unattended on medication carts in two separate units. On two occasions, surveyors observed medication carts left unattended with laptops displaying resident records while the assigned nurses were inside resident rooms. Both nurses acknowledged during interviews that leaving the laptops open and unattended was not consistent with their process or facility policy, and recognized that this practice could result in unauthorized exposure of resident information. The fill-in Director of Nursing and LPN Manager confirmed that staff are expected to ensure computer screens are not left open and unattended, as this would violate HIPAA and residents' rights to privacy. Facility policy reviewed by surveyors stated that unauthorized release, access, or disclosure of resident information is prohibited, and all such actions must comply with current privacy laws. No specific resident medical history or condition was mentioned in relation to the deficiency.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident, with a history of major depressive disorder, PTSD, bipolar disorder, and severe cognitive impairment, exhibited behavioral problems including hallucinations, delusions, and a history of substance use. This resident left the facility unsupervised, returned after several hours, and reported using methamphetamine. The resident continued to display nonsensical speech, delusions, and hallucinations upon return. On the morning following the resident's return, a verbal altercation occurred between this resident and another resident with mild cognitive impairment and a history of schizoaffective disorder. The altercation escalated when the first resident swung a metal ankle foot orthosis (AFO) brace at the other resident, striking him in the head. Staff initially separated the residents after the verbal exchange but did not report the incident immediately. The situation escalated again, resulting in physical contact before staff intervened and removed the aggressor from the area. Facility documentation and staff interviews confirmed that the incident was not promptly reported after the initial verbal altercation, and the resident who committed the abuse was not immediately removed from the situation. The facility's policy states that residents have the right to be free from abuse, including physical and verbal abuse, and that staff are responsible for protecting residents from abuse by others. The failure to intervene effectively and promptly report the incident led to a resident being physically abused by another resident.
Failure to Protect Residents from Sexual and Physical Abuse by a Peer
Penalty
Summary
The facility failed to protect six residents from sexual and physical abuse by another resident, resulting in multiple incidents of inappropriate touching, physical aggression, and sexualized behaviors. The resident responsible for the abuse had a history of dementia, agitation, schizophrenia, and poor impulse control, with documented behavioral issues including aggression toward other residents and staff, as well as repeated sexualized behaviors toward female peers. Despite these ongoing behaviors, interventions such as 1:1 supervision were not consistently implemented, and staff responses were often limited to redirection, which proved ineffective in preventing further incidents. Several incidents were documented in clinical records and staff interviews, including the resident physically assaulting another resident over a chair, resulting in a hairline rib fracture, and multiple episodes of inappropriate sexual contact, such as touching, kissing, and attempting to bring female residents into his room. Staff and housekeepers observed these behaviors and reported them to supervisors, but there was a lack of consistent escalation to the Director of Nursing or Abuse Coordinator. In some cases, staff did not recognize the need to report incidents as abuse, and documentation of these events was incomplete or missing from resident records. The facility's failure to ensure timely and appropriate reporting, documentation, and intervention allowed the abusive behaviors to continue, exposing vulnerable residents with severe cognitive impairments to further harm. Interviews revealed that staff were aware of the resident's unpredictable aggression and sexualized behaviors, but did not consistently implement or escalate protective measures. The facility's policies required immediate reporting and intervention for abuse, but these procedures were not followed, resulting in ongoing risk and actual harm to multiple residents.
Failure to Report and Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not reporting multiple allegations of sexual abuse and inappropriate behaviors involving several residents to the State Agency. The report details repeated incidents where one resident, with a history of dementia, agitation, and behavioral disturbances, engaged in sexually inappropriate and aggressive behaviors towards female peers, including touching, kissing, rubbing, and attempting to lead them to his room. These behaviors were observed and documented by various staff members, including CNAs, LPNs, and housekeeping staff, and were sometimes witnessed by other residents' family members. Despite these observations, there was a lack of consistent documentation in the residents' records and no evidence that these incidents were reported as required by facility policy. Interviews with staff revealed a breakdown in communication and reporting procedures. Several staff members, including CNAs and housekeeping, reported incidents to their immediate supervisors or unit managers, but these reports were not escalated to the Director of Nursing (DON) or the Abuse Coordinator as required. The Abuse Coordinator stated he did not file a report with the state agency because he was not fully informed of the details, and the unit manager indicated she did not feel the incidents warranted further reporting since no one was visibly hurt or in distress. This resulted in the DON and Abuse Coordinator being unaware of the full extent of the resident's behaviors and the ongoing risk to other residents. The facility's policy clearly states that all allegations of abuse, neglect, or exploitation must be reported immediately to the appropriate authorities, including the state agency, within two hours. However, the report demonstrates that this policy was not followed, as multiple incidents involving inappropriate sexual contact and aggression were not reported or investigated according to protocol. The lack of timely and appropriate reporting could result in continued resident-to-resident abuse and a failure to protect vulnerable residents with severe cognitive impairments and behavioral issues.
Failure to Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to ensure that allegations of sexual abuse involving five residents were reported to the State Agency as required. Multiple incidents were documented in clinical records and staff interviews, including inappropriate touching, sexualized behaviors, and physical aggression by one resident towards several female residents, all of whom had varying degrees of cognitive impairment. Staff observed and documented these behaviors, such as a resident rubbing another's legs, attempting to take female residents to his room, and grabbing buttocks, but these incidents were not consistently reported to the appropriate authorities. Interviews with staff revealed a lack of clarity and consistency in reporting procedures. Some staff members, including CNAs and housekeepers, witnessed or were informed of inappropriate behaviors and reported them to their immediate supervisors or unit managers. However, these reports were not always escalated to the Director of Nursing or the Abuse Coordinator, as required by facility policy. In several cases, staff made subjective decisions about whether incidents were reportable, often based on whether physical harm was observed, rather than following the policy to report all allegations of abuse immediately. Facility documentation and policy review confirmed that the policy required immediate reporting of all abuse allegations to local, state, and federal agencies, as well as internal leadership. Despite this, the Abuse Coordinator and DON were not informed of several incidents, and no reports were filed with the State Agency for the sexual abuse allegations involving the five residents. The deficiency was further evidenced by interviews with the DON and Abuse Coordinator, who were unaware of the full extent of the incidents until informed by surveyors.
Failure to Investigate and Report Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to provide evidence that alleged violations involving sexual abuse among five residents were thoroughly investigated. Multiple clinical record reviews, staff interviews, and policy reviews revealed that incidents of inappropriate sexual and physical behaviors by one resident towards several female residents were either not documented, not reported to appropriate supervisory staff, or not investigated according to facility policy. Staff interviews indicated that several incidents, such as inappropriate touching, attempts to take female residents to the perpetrator's room, and physical aggression, were observed by various staff members, including CNAs, housekeepers, and LPNs. However, these incidents were not consistently reported to the Director of Nursing (DON) or the Abuse Coordinator, and in some cases, staff made unilateral decisions not to escalate the reports, believing the incidents did not warrant further action if no physical harm was observed. Clinical documentation showed repeated behavioral issues, including sexualized behaviors and aggression, by a resident with moderate cognitive impairment and a history of psychiatric diagnoses. Despite multiple behavioral notes and staff observations of inappropriate contact with other residents—many of whom had severe cognitive impairment and were unable to protect themselves—there was a lack of thorough investigation or documentation of these incidents in the affected residents' records. Interviews with staff revealed a lack of clarity and consistency in reporting procedures, with some staff assuming others had reported incidents or believing that redirection was sufficient if no injury occurred. The DON and Abuse Coordinator were not made aware of several incidents, and the facility's policy requiring immediate reporting and investigation of abuse allegations was not followed. Additionally, the review of facility records and interviews highlighted that the required notifications to state agencies and thorough investigations were not completed for several incidents. The facility's own policy mandates immediate reporting of all abuse allegations to supervisory staff and external agencies, but this was not adhered to. The lack of documentation and investigation could result in further incidents not being addressed, and the facility did not have evidence that it responded appropriately to all alleged violations as required.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy by not reporting and investigating an allegation of abuse involving a resident to the State Agency. The resident, who was admitted to the facility with diagnoses of senile degeneration of the brain, unspecified dementia, and major depressive disorder, was under hospice care. During an interview, a hospice CNA reported that the resident had expressed being raped and had visible bruises, which were communicated to a nurse and a social worker. However, the facility did not report the allegation to the appropriate authorities immediately as required by their policy. The facility's operation manager received an allegation of abuse from adult protective services and submitted a report to the State Agency later that day. Interviews with various staff members, including a CNA, LPN, RN, and the social service director, revealed a lack of awareness or delayed action regarding the abuse allegation. The social service director and other staff members were not aware of the allegation until informed by APS, indicating a breakdown in communication and reporting within the facility. The facility's policy requires immediate reporting of abuse allegations to several entities, including the state licensing agency, ombudsman, resident's representative, APS, law enforcement, and the resident's attending physician. Despite this, the facility did not notify law enforcement until later in the day, and the ombudsman and case manager were informed the following day. This delay in reporting and investigating the abuse allegation constitutes a failure to adhere to the facility's abuse policy, potentially resulting in further incidents of abuse.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency in a timely manner. The resident, who was admitted to the facility with diagnoses including senile degeneration of the brain, unspecified dementia, and major depressive disorder, was under hospice care. On January 6, a hospice CNA observed bruising on the resident and heard the resident claim she had been raped. The CNA reported these observations to a hospice nurse and a social worker, but the facility did not report the allegation to the State Agency until January 13, after being contacted by Adult Protective Services (APS). Interviews with facility staff revealed a lack of awareness and communication regarding the abuse allegation. A licensed practical nurse and a social service director both stated they were unaware of any abuse allegations until APS intervened. The Director of Nursing (DON) confirmed that the facility has a policy requiring abuse allegations to be reported within two hours, but this protocol was not followed. The DON only reported the incident to the Department of Health after being informed by APS, and there was confusion among staff about who was responsible for notifying law enforcement and other required parties. The facility's policy on reporting abuse, neglect, and exploitation was not adhered to, as the report to the State Agency was delayed, and there was uncertainty about whether law enforcement had been notified. The resident's account of the alleged abuse was detailed and consistent, yet the facility's response was inadequate and delayed, potentially compromising the resident's safety and well-being.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and correct alleged violations of abuse for a resident, leading to a deficiency that could result in psychosocial harm and further abuse. The resident, who was admitted to the facility with diagnoses of senile degeneration of the brain, unspecified dementia, and major depressive disorder, was under hospice care. During an interview, a CNA reported that the resident had repeatedly stated she was raped and wanted to press charges. The CNA observed bruising on the resident's body, which she reported to a nurse and a social worker, but was told there was no sheet available to document the skin assessment. The nurse, upon being informed of the allegations, conducted a head-to-toe assessment and found bruising on the resident's wrists. Despite the resident's severe cognitive impairment, she was able to articulate allegations of rape during an interview with surveyors. The facility's operation manager reported receiving an allegation of abuse from adult protective services and submitted a facility report. However, the social service director claimed to have no knowledge of the allegations until informed by APS, indicating a lack of communication and timely reporting within the facility. The facility's policy requires immediate reporting of abuse allegations to various authorities, including law enforcement, within two hours. However, there was a delay in notifying law enforcement, as the LPN/unit manager only contacted them later in the evening. The facility's failure to adhere to its policy and promptly investigate and report the allegations of abuse contributed to the deficiency identified by the surveyors.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the proper protocol for using a Hoyer lift, resulting in a major injury to a resident. The resident, who had multiple chronic conditions including COPD, heart failure, and a history of leg fractures, required extensive assistance for mobility and was at risk for falls. Despite the care plan indicating the need for two staff members during transfers, the resident was transferred using a Hoyer lift with only one trained staff member and a dietary director who was not trained in Hoyer lift operations. During the transfer, the resident fell when one of the straps of the Hoyer lift became unhooked, causing the resident to slide out of the sling and onto the floor. The incident report and interviews revealed that the dietary director was acting as a spotter from the hallway and did not enter the room, contrary to the facility's policy that required two caregivers to be present during such transfers. The CNA involved in the transfer admitted uncertainty about whether the sling was properly secured, and the dietary director acknowledged a lack of training in Hoyer lift operations. The facility's policies and the Hoyer lift manual both emphasized the necessity of having two trained staff members present during transfers to ensure safety. However, the facility allowed untrained staff to act as spotters, which contributed to the incident. The Director of Nursing and other staff interviews confirmed that the dietary director was not trained in Hoyer lift operations, and the facility's policy did not explicitly require the second person to be trained, leading to a breach in safety protocols and resulting in the resident's injury.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with dementia, diastolic congestive heart failure, adjustment disorder, and anxiety disorders. The resident was identified as being at risk for elopement, with assessments indicating a high risk score and verbal expressions of a desire to leave the facility. Despite these indicators, there was no evidence of a care plan or interventions implemented to address the resident's elopement risk until after the incident occurred. On the evening of the incident, the resident was reported missing by a CNA during routine checks. The resident had been expressing a desire to leave the facility for the past week, but this was not documented in the clinical records. The facility initiated an elopement procedure, but the resident was not found until two days later when a hospital case manager informed the facility that the resident was in the emergency department. The facility's investigation could not determine how the resident eloped, as there were no cameras in the secure unit, and the door alarms were not functioning properly. Interviews with staff revealed that the resident had been moved to a locked unit due to wandering behavior and a decrease in BIMS score. However, the door to the smoking area was found to be unlocked and the alarm did not sound, which may have facilitated the resident's elopement. The facility's policy required risk assessments and care plans for residents at risk of elopement, but these were not adequately implemented for the resident in question.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that the code status for a resident was accurate and consistent in the medical record, which could result in the resident not receiving care consistent with their signed advance directive. The resident, who was cognitively intact, had a documented advanced directive indicating they were to be resuscitated and hospitalized. However, discrepancies were found in the electronic health record, where a DNR order was noted, conflicting with the resident's full-code status as per the advanced directive. This inconsistency was not updated in the physician's order until a later date. Interviews with staff revealed a lack of awareness and understanding of the resident's true code status. A CNA and an RN both believed the resident was a DNR based on the profile page in the electronic health record, which did not match the advanced directive. The DON acknowledged the mismatch and stated that the code status should always align with the most current advanced directive form. The facility's policy required that advanced directives be communicated to direct care staff and physicians, but this was not effectively implemented, leading to the deficiency.
Resident Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure that a resident was free from staff abuse, as evidenced by an incident involving a cognitively intact resident with a BIMS score of 15. The resident, who had diagnoses including chronic obstructive pulmonary disease, hypertension, paraplegia, muscle weakness, and idiopathic neuropathy, was involved in an altercation with a staff member. On the day of the incident, the resident was observed hitting a staff member with a broom, which led to the staff member, identified as staff #121, retaliating by hitting the resident. This incident was witnessed by other staff members, who intervened to separate the resident and the staff member. The facility's investigative report confirmed that staff #121 was terminated following the incident. Interviews with various staff members revealed that they were aware of the facility's policies on abuse and had received training on the subject. Despite this, staff #121 was observed willfully hitting the resident, which constitutes a violation of the resident's right to be free from abuse. The facility's policy on abuse prevention, as well as the resident's rights policy, clearly state that residents should be protected from abuse by facility staff or others.
Improper Storage of Oxygen Cylinder in Resident's Room
Penalty
Summary
The facility failed to ensure the safe storage of oxygen cylinders for a resident diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The resident was observed with an oxygen cylinder placed directly on the floor in their room, without a carrier or stabilizing support mechanism. This was noted during multiple observations on the same day, indicating a lack of adherence to safety protocols regarding the storage of oxygen cylinders. Interviews with various staff members, including a licensed practical nurse, a certified nursing assistant, a registered nurse, and the director of nursing, confirmed that the facility's policy requires oxygen cylinders to be stored in carriers and not directly on the floor. The staff acknowledged the potential risks associated with improper storage, such as the cylinder tipping over and potentially exploding. Despite this understanding, the oxygen cylinder remained improperly stored until it was eventually removed by a staff member after being pointed out during an observation.
Resident Safety and Abuse Prevention Deficiency
Penalty
Summary
The facility failed to ensure that resident #14 was free from abuse by resident #21, leading to a deficiency in protecting residents from abuse. Resident #14, admitted with quadriplegia, bipolar disorder, anxiety disorder, and post-traumatic disorder, was involved in altercations with resident #21, resulting in physical harm. Resident #21, admitted with osteomyelitis of vertebra, depression, hypertension, and psychoactive substance abuse in remission, was also engaged in altercations with resident #14, indicating a lack of safety measures in place to prevent such incidents. Additionally, resident #40 witnessed resident #14 ramming his motorized wheelchair into resident #21, leading to a physical altercation between the two residents. Resident #6 reported an incident where resident #14 ran over resident #21 with his wheelchair, escalating into a physical confrontation.
Elopement Risk Management and Monitoring Deficiency
Penalty
Summary
The facility failed to prevent elopement of Resident #1, who was admitted with diagnoses including schizoaffective disorder, alcohol abuse, and opioid abuse. Despite a high elopement risk assessment score of 18, the resident was able to leave the facility on multiple occasions. Staff observations noted the resident pacing the unit, expressing a desire to leave, and ultimately escaping through open windows. Interviews with staff members revealed a lack of consistent monitoring and documentation of room checks, with instances where the resident was missing for days before being located at his mother's house. The facility's policy emphasizes resident safety supervision and the prevention of accidents as a priority, targeting interventions to reduce individual risks related to environmental hazards. Despite efforts to secure windows with sliding locks after the initial elopement incident, Resident #1 was still able to remove a window and leave the facility again.
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 259 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
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 Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village Of Tempe | 3.7 mi | ★★★★★ | 2 | 0 |
| Plaza Healthcare | 4 mi | ★★★★★ | 4 | 0 |
| Citrus Heights Respiratory And Rehabilitation | 5 mi | ★★★★★ | 12 | 0 |
| Haven Of Scottsdale | 5.8 mi | ★★★★★ | 13 | 0 |
| Osborn Health And Rehabilitation | 5.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.