Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franklin County Transitional Care during CMS and state inspections, most recent first.
Failure to prevent abuse and neglect involved a resident with chronic pain who did not receive a timely response when staff were asked to help him to bed, another incident where a CNA snatched a washcloth from the same resident’s hand, a resident with a painful leg wound whose pain and tight wrappings were not promptly followed up, and a resident who felt fearful after a CNA made threatening-sounding comments. The DON acknowledged one event should have been reported as neglect, and the investigation found verbal abuse toward the resident who felt afraid.
Kitchen equipment was not cleaned and sanitized in accordance with professional standards. Cooking saute pans and baking sheets were observed with a black encrusted residue that did not scrape off without effort, and the Dietitian stated the pans and sheets should not have that residue. The deficient practice had the potential to affect the 33 residents who consumed food prepared by the facility.
Failure to implement the antibiotic stewardship program affected all residents. The facility’s protocol required infection assessment using standardized criteria, use of LOBES minimum criteria before starting antibiotics, staff education, and antibiotic orders with indication, dose, and duration, but records showed no defined diagnostic algorithm, charting not aligned with McGeer's or LOBES criteria, reflex urine cultures without indication, and inconsistent 72-hour reassessment of UTI antibiotic courses. Two residents were reviewed: one had fatigue with labs and UA ordered without meeting criteria, and another had a change in mental status, no infection signs, a UA, and a Cipro order despite not meeting criteria.
Incomplete and inconsistent restorative nursing documentation was found for several residents with care plans for restorative services. Records for residents with conditions including MS, chronic pain, anxiety, polyneuropathy, venous disease, DM, and failure to thrive lacked physician orders for restorative services, and the restorative logs did not consistently show exercises or refusals. Staff also used handwritten calendars that did not match the clinical record, and an MDS coordinator confirmed treatments were being tracked on calendars instead of documented in the resident record.
Failure to Implement Enhanced Barrier Precautions: The facility failed to ensure EBP were implemented and maintained for 7 of 32 residents with chronic wounds or indwelling medical devices. Surveyors observed no EBP in use during multiple facility observations, and no EBP policy was provided. The IP stated the facility had stopped using EBP after an update was received, and the DON said she misunderstood CMS guidance and believed EBP was no longer required.
A resident’s urinary catheter drainage bag was observed hanging from his waistband and fully visible during restorative ambulation with a CNA. The CNA acknowledged the bag should have been covered to maintain the resident’s dignity and privacy, but said a privacy cover was too bulky.
Failure to Monitor Psychotropic Medication Side Effects: The facility did not document required monitoring for psychotropic medication side effects for multiple residents receiving antipsychotic, antidepressant, and anti-anxiety drugs. Care plans directed staff to watch for adverse reactions such as falls, confusion, drowsiness, appetite loss, and movement changes, but the records lacked the required monitoring. One resident had repeated unwitnessed falls and significant weight loss, and the DON stated the facility did not monitor side effects for antipsychotic, antidepressant, or anti-anxiety medications.
Failure to timely report abuse and neglect allegations: The facility did not submit multiple abuse/neglect allegations to the SA within required LTC reporting timeframes. Concerns involved a resident with chronic pain and failure to thrive, a resident with an open leg wound and diabetes whose pain and tight wrap were not promptly addressed, and a resident with visual loss and depression who reported fearful comments from a CNA. The DON stated some concerns were handled as grievances or were not identified as abuse/neglect at the time.
Incomplete abuse and neglect reporting and investigation: The facility failed to accurately report and fully investigate multiple abuse/neglect concerns involving residents with significant medical needs. One resident with a leg wound and chronic conditions reported pain and tight wrappings, another resident with visual loss and depression was left fearful by a CNA’s comments that the DON identified as verbal abuse, and a third resident’s allegation of demeaning treatment was investigated without interviewing nearby residents or witnesses.
A resident with thyroid cancer, dysphagia, and weakness was transferred out of the facility for a scheduled procedure, but the discharge record did not show that the required written bed-hold notice was provided. The discharge file included contact information and a POST form, and the DON stated the facility did not formally issue the bed-hold documentation.
A resident admitted with multiple sclerosis and anxiety disorder was later diagnosed with MDD and PTSD, but the record did not show that a PASRR level II was submitted to the state mental health authority for either diagnosis. The Social Services Director stated that a new PASSR should have been completed and submitted after the new mental health diagnoses, but it was not.
The facility failed to follow its bowel protocol for two residents with constipation-related orders and bowel management needs. One resident with constipation, chronic pain, and adult failure to thrive had repeated MAR and bowel record deviations, including incorrect sequencing of juice, oral laxatives, and suppositories, while another resident with dementia, diabetes, and anxiety had missed or inconsistent bowel interventions and no bowel management protocol included in the care plan. The DON confirmed the protocol was not being followed and that MAR blanks showed medications were not being offered appropriately.
Failure to Prevent Accidents: Two residents experienced falls tied to unsafe conditions and care-plan issues. One blind resident fell after his recliner and garbage can were moved, and another resident with a history of falls and weakness fell while self-transferring from a recliner to the restroom while wearing a pressure-relieving boot that was intended only for use in bed.
A resident with anxiety, chronic pain, and psychotropic medication use had a significant 14.1% weight loss that was not identified in a timely manner. The care plan called for weekly weights and nutritional supplements, but weights were missed for extended periods, intake was often poor, supplement refusals were frequent, and the dietitian was not notified of the reduced appetite or weight-loss pattern.
A resident with diabetes, visual loss, muscle weakness, and depression did not receive ordered insulin glargine at the prescribed 8:00 AM time. An incident report showed the morning dose was still in the drawer when evening meds were being prepared, and the DON stated an LPN documented the insulin as given before entering the room, then returned it to the cart when the resident was in the bathroom without correcting the MAR.
Surveyors identified deficiencies in food storage and labeling, including unsealed and undated food items in the walk-in freezer and nourishment room refrigerator. Both the Dietary Coordinator and assistant acknowledged that food items were not properly sealed, dated, or labeled with resident names as required by facility policy and the Idaho Food Code.
The facility did not ensure that residents and their representatives received assistance to exercise their right to formulate Advance Directives, as required by policy. For six residents with various medical conditions, there was no documentation of Advance Directives or evidence that assistance was offered, with the process limited to documenting CPR status. Both the DON and Social Worker confirmed that discussions or confirmations of Advance Directives were not documented during annual reviews.
A resident with multiple diagnoses, including diabetes and stroke, had inconsistent height measurements recorded in the MDS assessments, with entries alternating between 66 inches and 63 inches on different occasions. The administrator could not explain the discrepancies in the documentation.
The facility did not update care plans for two residents after multiple falls and wandering incidents. Despite documented investigations and recommendations by the Fall Committee and staff, interventions were not added to the care plans, and episodes of wandering were not addressed in care planning. The DON and Social Worker confirmed that care plans were not revised as required.
Surveyors found that two resident rooms had sink water temperatures above 120°F, with one resident reporting the water was very hot. Affected individuals included a resident with pneumonia and hemiplegia/hemiparesis after a stroke. These unsafe temperatures were confirmed by direct measurement and placed residents at risk for harm.
Licensed nurses failed to document interventions when a resident's oxygen saturation repeatedly fell below the physician-ordered threshold while on oxygen therapy. Despite multiple low SpO2 readings, nursing staff did not consistently take or record appropriate actions, as confirmed by the DON.
Controlled medications were not properly tracked or secured when a narcotic accountability record for a medication cart was found missing required signatures from two nurses during a review. Both an LPN and the DON confirmed that two nurses should have signed the record when accepting or releasing the cart, but this was not done.
Surveyors observed that a box of lorazepam, a controlled medication, was stored in a medication refrigerator without a separately locked compartment, contrary to requirements. Additionally, glucose test solutions were found undated after opening, and staff confirmed these should have been labeled.
The facility's abuse policy failed to include staff screening and training requirements, and protection measures for residents during investigations. The Administrator confirmed these deficiencies, despite annual abuse training covering required topics.
The facility failed to ensure residents received gradual dose reductions (GDRs) of psychotropic medications or a stop date for as-needed psychotropic medication unless clinically contraindicated. This deficiency was identified for three residents, who were on various psychotropic medications without GDR attempts or stop dates, despite stable moods and lack of identified problem behaviors. The consulting pharmacist did not make GDR recommendations, and the Medical Director confirmed the lack of GDRs and stop dates.
The facility failed to implement an antibiotic stewardship program, leading to the prolonged use of antibiotics without documented rationale for two residents. One resident received Bactrim DS for an undocumented infected hip wound, and another received Ciprodex Otic Suspension for an undocumented tympanic membrane perforation. The Infection Preventionist confirmed the lack of necessary documentation.
Failure to Prevent Abuse and Neglect
Penalty
Summary
The facility failed to ensure residents remained free from abuse and neglect for 3 of 6 residents reviewed for abuse-prevention practices. The facility’s policy stated residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the facility will actively prevent, identify, and report such situations. Survey findings showed the facility did not timely recognize or respond to events involving resident complaints, staff interactions, and resident distress, and the investigations did not consistently include interviews with residents or other potential witnesses in proximity to the incidents. One resident with constipation, chronic pain, and adult failure to thrive complained of severe right leg pain after being transferred to bed. A CNA reported that multiple CNAs at the nurses’ station did not respond when she asked for help because the resident was in a lot of pain, and she attempted to comfort the resident while waiting for assistance. The LPN documented giving pain medication, assessing the resident, and proceeding with catheter care, but the investigation did not include an interview with the resident or other residents nearby. In a separate incident involving the same resident, a CNA reported that another CNA snatched a dry washcloth from the resident’s hand while she was washing her face, hung it back on the rack, and made a comment to the resident; the resident then dried her face with her shirt. The facility concluded the behavior was inappropriate and terminated the CNA. A second resident with an open right lower leg wound, polyneuropathy, chronic venous hypertension, hypertension, diabetes, and anxiety complained that leg wrappings were too tight and that she was in pain. The RN acknowledged she did not check back to see whether pain medication had helped and was unclear when the wrappings were changed, while the DON stated the resident could have been checked sooner and that the incident should have been reported as neglect. A third resident with visual loss in both eyes, muscle weakness, diabetes, and depression reported feeling fearful after a CNA told him, “I know where you live,” and responded to his question about stalking with, “That’s something for me to know and you to find out.” The investigation found the resident experienced verbal abuse and documented that he felt fearful and had decreased self-esteem.
Kitchen Equipment Not Properly Cleaned
Penalty
Summary
Kitchen equipment was not cleaned and sanitized in accordance with professional standards. Based on observation, FDA Food Code, and staff interview, cooking saute pans and baking sheets were found with a black encrusted residue that did not scrape off without effort. The FDA Food Code Section 4-602.12 states that food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer needed to adequately cook food, and the Dietitian stated that the baking sheets and saute pans should not have the black encrusted residue. This deficient practice had the potential to affect the 33 residents who consumed food prepared by the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for all residents in the facility. Its Antimicrobial Stewardship Protocol required assessment for infection using standardized tools and criteria, use of LOBES minimum criteria before starting antibiotics, education for prescribing practitioners and nursing staff, and antibiotic orders that included indication, dose, and duration. However, stewardship documents identified that the facility lacked a defined diagnostic algorithm, Point Click Care charting was not aligned with McGeer's or LOBES criteria, reflex urine cultures were being performed without indication, and UTI antibiotic courses were not consistently reassessed at 72 hours. Record review showed that on 4/1/26, a resident reported increased fatigue and the provider ordered a CBC, CMP, and UA, but the IP determined the resident did not meet McGeer's or LOBES criteria when the labs and UA were ordered. On 6/30/26, another resident had a change in mental status, was assessed with no signs or symptoms of infection identified, had a UA performed, and was prescribed Cipro 500 mg twice daily for 7 days even though the IP determined the resident did not meet criteria. The report also stated that staff would contact the provider to discontinue the order because the resident did not have urinary symptoms and the altered mental status resolved prior to antibiotic therapy initiation. On 7/22/26, the IP confirmed infection control screening was not conducted for either resident and stated there was no real process in place, while also confirming the expectation was to use McGeer's and LOBES criteria before reporting symptoms, sending cultures, and initiating antibiotics.
Incomplete and inconsistent restorative nursing documentation
Penalty
Summary
The facility failed to ensure resident medical records were complete, accurately documented, readily accessible, and systemically organized for restorative nursing services. Record review, policy review, and staff interview showed that for 4 of 6 residents reviewed for RNA services, the clinical record did not consistently show physician-ordered restorative services being completed, and the facility also used external handwritten calendars that did not match the documentation in the residents’ records. Resident #3, who had multiple sclerosis and anxiety disorders, had a care plan directing continued restorative involvement to maintain functional ability, but the record did not include a physician order for the restorative nursing program. Her record listed restorative programs for NUTSTEP use and active ROM, yet the restorative nursing documentation for May and June 2026 did not document exercise or refusals for most days reviewed. The facility provided handwritten calendars for May through July 2026 that documented restorative opportunities, but those entries did not match the restorative nursing documentation in the resident’s clinical record, and the calendars showed only one of the two restorative programs. Resident #4, with anxiety, chronic pain syndrome, and a history of UTIs, also had a care plan directing continued restorative involvement, but no physician order was located in the record. Her record listed NUTSTEP use, yet the restorative nursing program did not document exercise or refusals for many days in May, June, and July 2026. Resident #14, who had an open wound on the right lower leg, polyneuropathy, chronic venous hypertension, HTN, DM, and anxiety, likewise had no physician order for restorative services, and the restorative nursing program did not document exercise or refusals for many days across May through July 2026. Resident #2, with constipation, chronic pain, and adult failure to thrive, had a care plan for restorative nursing to improve strength and mobility, but no physician order was present; the record listed bed mobility, eating, and ROM programs, with multiple missed opportunities documented, and the calendars provided for May through July 2026 did not include a last name or DOB and showed only 2 of the 3 restorative programs. The MDS Coordinator confirmed that staff were documenting restorative treatments on a calendar rather than in the resident record, and the RNA RN stated documentation should be completed within 24 hours of the activity.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and maintained for 7 of 32 residents who lived in the facility. The report states that EBP were not in use for residents with chronic wounds or indwelling medical devices during multiple observations conducted throughout the facility, despite CDC guidance that EBP should be used for residents with unhealed wounds, chronic skin breakdown, or indwelling medical devices during high-contact care activities such as dressing, bathing, transferring, hygiene, changing linens, toileting, wound care, and device care. The facility’s Infection Control Plan identified the Infection Preventionist as responsible for overseeing the infection prevention and control program, but no EBP policy was provided when requested. The Infection Preventionist stated the facility had previously followed EBP practices but stopped in [DATE] after the Administrator and DON received an update that EBP was no longer necessary. The DON later provided documentation showing CMS QSO-24-08-NH stated EBP recommendations include use for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of MDRO status, and then stated she had misunderstood the memo and believed that because the memo expired the facility no longer had to implement EBP.
Failure to Maintain Resident Dignity During Ambulation
Penalty
Summary
The facility failed to provide care in a manner that supported and promoted dignity and respect for Resident #17 during a restorative nursing ambulation activity. The facility’s Resident Rights Policy stated that each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. On 7/22/26 at 9:29 AM, Resident #17 was observed ambulating in the hallway with a CNA as part of his restorative nursing ambulation program, and his urinary catheter drainage bag was hanging from his waistband, fully visible, with approximately 100 mL of bright yellow urine in the bag. At 9:30 AM, CNA #4 stated the resident participated in the ambulation program six times per week and acknowledged that the catheter bag should have been covered to maintain the resident’s dignity and privacy during ambulation.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to prevent harm by not adequately monitoring side effects of psychotropic medications for 5 residents whose records were reviewed. The deficiency involved residents receiving antipsychotic, antidepressant, and anti-anxiety medications, while the facility did not have a policy for psychotropic use available when requested and the DON stated the facility did not monitor side effects of antipsychotic medications. The record review and staff interviews showed that required monitoring was not documented for these residents despite care plans directing staff to observe and report adverse reactions. Resident #19 had diagnoses including anxiety, chronic pain syndrome, and a history of UTIs, and was ordered clonazepam 1 mg at bedtime and 0.5 mg in the morning for anxiety. The care plan directed staff to monitor for adverse reactions such as drowsiness, clumsiness, confusion, dizziness, impaired thinking, and aggressive or impulsive behaviors. The record also showed multiple unwitnessed falls, including falls with head injury and staples, along with a 17.8-pound weight loss; the dietitian stated the resident’s 14% weight loss had not been identified prior to interview and staff had not notified her of reduced appetite. The DON stated the facility did not monitor side effects of antipsychotic medications. Resident #4 had dementia and anxiety and was receiving brexpiprazole for dementia, but the DON stated there was no side effect monitoring for the resident’s dementia medication. Resident #29 had dementia, anxiety, insomnia, and opioid dependence and was receiving escitalopram, clonazepam, trazodone, and brexpiprazole, yet the record did not include monitoring documentation for anti-anxiety and antidepressant side effects. Resident #6 had depression, anxiety, and dementia and was receiving sertraline, but no antidepressant side effect monitoring was documented as required by the care plan. Resident #9 had dementia, anxiety, and chronic pain and was receiving lorazepam and escitalopram, but the record did not include monitoring documentation for anti-anxiety medication side effects; the DON confirmed the facility did not have official documentation of the required monitoring.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse and neglect were reported to the State Agency within required timeframes for 3 of 6 residents reviewed. The facility’s policy stated it would actively prevent, identify, and report abuse, neglect, misappropriation of resident property, and exploitation, but the record showed multiple allegations were handled internally without timely reporting to the State Agency through the Long-Term-Care Reporting Portal. For Resident #2, who was admitted with diagnoses including constipation, chronic pain, and adult failure to thrive, a CNA texted that another CNA forcibly removed a washcloth from the resident’s hand and spoke to her in a demeaning manner. The allegation was investigated, but the portal record showed it was not reported within the required timeframe. A separate text message from another CNA alleged Resident #2’s needs were not met, suggesting possible neglect; staff statements were collected and the concern was forwarded internally, but the allegation was also not reported to the State Agency. The DON stated she was unsure when the allegation should have been reported and later stated the facility did not identify the incident as abuse or neglect at the time. For Resident #14, who had diagnoses including an open wound on the right lower leg, polyneuropathy, chronic venous hypertension, hypertension, diabetes, and anxiety, the resident and her daughter reported that the leg wrapping was too tight and that the resident was in pain, with the daughter also reporting that an RN had been abrupt. The RN delayed changing the wrapping and did not check whether pain medication relieved the pain. The DON stated the concern was handled as a grievance because it resolved and was not considered neglect, and no neglect report was submitted. For Resident #28, who had diagnoses including visual loss in both eyes, muscle weakness, diabetes, and depression, the facility investigated a report that a CNA made comments that left the resident fearful. The investigation documented the resident perceived the comments as threatening, but the incident was not reported within the appropriate timeframe, and the DON stated abuse and neglect reports should be submitted within 2 to 24 hours depending on severity.
Incomplete Abuse and Neglect Reporting and Investigation
Penalty
Summary
The facility failed to provide an accurate and thorough report to the Long-Term Care Reporting Portal for 3 of 6 residents reviewed for abuse and neglect. The facility’s policy stated it would actively prevent, identify, and report abuse, neglect, and exploitation. Survey findings showed that the facility did not upload a neglect report for a resident who had concerns about staff after reporting that her leg wrappings were too tight and that her daughter complained to the DON about the resident’s pain and an RN being abrupt with her. The resident had multiple diagnoses including an open wound on the right lower leg, polyneuropathy, chronic venous hypertension, hypertension, diabetes, and anxiety. For another resident, the facility submitted an abuse/neglect report describing an encounter with staff that left him fearful after a CNA made comments including, “I know where you live,” and “That’s something for me to know and you to find out.” The investigation documented that the CNA had spoken before thinking and that the resident did not interpret the comments as intended, but the DON stated the incident was verbal abuse as written. The report also documented that the CNA had prior warnings related to work ethic and following directions, and that the resident had visual loss in both eyes, muscle weakness, diabetes, and depression. For a third resident, the facility’s abuse investigation documented an allegation that a CNA forcibly removed a washcloth from the resident’s hand and spoke to her in a demeaning manner. The investigation concluded the CNA displayed inappropriate behavior and was terminated, but it did not include interviews with other residents or witnesses identified during the investigation process. The resident had diagnoses including constipation, chronic pain, and adult failure to thrive. The DON confirmed the investigation should have included statements from residents in proximity to the incident.
Missing Bed-Hold Notice at Transfer
Penalty
Summary
The facility failed to ensure that a resident was provided the required written bed-hold notification upon transfer out of the facility. Resident #8 was readmitted with diagnoses including thyroid cancer, dysphagia, and weakness, and a debulking procedure was scheduled. On the day of transfer, a progress note documented that the resident left the facility at 10:00 AM with his representative in a private vehicle. The discharge record included practitioner contact information, resident representative information, and a POST form, but it did not include documentation that a bed-hold notice was provided at the time of transfer. The facility’s Transfer and Discharge Notification policy also did not describe when the bed-hold notice must be issued. The DON stated that the facility did not provide a bed-hold notice and acknowledged that the required documentation was not formally issued.
PASRR Level II Not Submitted After New Mental Health Diagnoses
Penalty
Summary
The facility failed to provide a PASRR level II to the designated state agency for Resident #3, who was admitted with multiple diagnoses including multiple sclerosis and anxiety disorder. The facility policy, dated 12/20/24, stated the Social Services Director was responsible for tracking each resident's assessment, care planning, and transitions of care, and that any resident with a newly evident or possible serious mental disorder would be referred to the state mental health authority for a level II resident review. Resident #3 was diagnosed with Major Depression (MDD) on 5/7/25 and Post-Traumatic Stress Disorder (PTSD) on 7/24/25, but the record did not document that a PASRR level II was sent to the state mental health authority on either date. During interview on 7/23/26 at 9:21 AM, the Social Services Director stated a new PASSR should have been completed and submitted for Resident #3 with the new diagnoses of MDD and PTSD, and it was not.
Bowel protocol not followed for two residents
Penalty
Summary
The facility failed to ensure bowel management was carried out according to its bowel protocol and the residents’ individualized plans of care for 2 residents. The facility’s bowel care policy required the night nurse to review each resident’s chart nightly, identify residents with more than 24 hours without a bowel movement or a small bowel movement in 48 hours, identify residents with loose stools, and add residents to the Laxative List accordingly. The bowel protocol directed staff to follow a stepwise sequence of interventions: Day 1 fluids and juice, Day 2 juice plus oral medication, Day 3 juice plus oral medication and a suppository if no bowel movement, and Day 4 provider notification. One resident had diagnoses including constipation, chronic pain, and adult failure to thrive, and had physician orders for multiple bowel interventions including Senokot S, juice, bisacodyl suppository, bisacodyl tablets, Enemeez enema, Milk of Magnesia, MiraLax, and Senokot tablets. The bowel record showed repeated deviations from the protocol, including MiraLax being given before Day 1, bisacodyl tablets being given on Days 3 and 4, juice being given on Day 3 instead of Day 1, MiraLax being given for 5 consecutive days, and other instances where the sequence was not followed or steps were skipped. On 7/24/26 at 12:08 PM, the DON confirmed the record showed improper administration and documentation of the bowel protocol. The other resident had diagnoses including dementia, diabetes, and anxiety, and had physician orders for juice, bisacodyl tablet, Enemeez enema, Milk of Magnesia, MiraLax, and Senokot for constipation. The resident’s care plan did not include bowel management protocol. The MAR documented multiple periods without bowel movements and inconsistent administration of ordered bowel medications and juice, including missed doses and days when no medication was administered despite no bowel movement being documented. The DON stated the facility was not following the protocol because there were blanks in the MAR indicating medication was not being offered appropriately, and clarified that Day 1 of bowel management begins 24 hours after a resident does not have a bowel movement.
Failure to Prevent Accidents
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards and to provide adequate supervision to prevent accidents for 2 of 4 residents reviewed. The facility’s Risk Assessment for Accidents, Falls, and Care Planning stated the resident environment should remain as free of accident hazards as possible and that residents should receive adequate supervision and assistive devices to prevent accidents through identifying hazards, evaluating risks, implementing interventions, and monitoring effectiveness. The deficiency involved Resident #28 and Resident #5, both of whom experienced falls in circumstances tied to environmental or care-plan issues. Resident #28 was admitted with diagnoses including visual loss in both eyes, muscle weakness, diabetes, and depression, and his care plan directed staff to keep a safe environment with even floors free from spills and clutter because of his limited mobility due to blindness. The I&A report documented that he was found on the floor while trying to get into his recliner after his garbage can and recliner had been moved, and he fell when attempting to sit down. Resident #5 had diagnoses including a history of falling, muscle weakness, and dizziness and giddiness. His care plan directed staff to use a pressure-relieving boot on his right foot only when in bed and to remove shoes when he was in his recliner or bed, yet the fall report documented that he fell while attempting to self-transfer from his recliner to the restroom without assistance while wearing the boot on his right foot and a non-skid sock on his left foot.
Failure to Monitor Weight and Intake
Penalty
Summary
The facility failed to monitor weight for a resident with anxiety, chronic pain syndrome, a history of urinary tract infections, and psychotropic medication use. The resident’s care plan directed weekly weights and nutritional supplements, and physician orders included clonazepam, fluoxetine, regular diet, Ensure Clear twice daily, and LiquaCel. Record review showed weights of 126.4 pounds on 6/27/26 and 108.6 pounds on 7/20/26, reflecting a 17.8-pound, 14.1% loss. No weights were recorded between 5/29/26 and 6/26/26, or between 6/28/26 and 7/19/26, and the record did not document psychotropic medication monitoring for weight loss or appetite changes. The resident’s intake records showed frequent poor intake and refusal of supplements. Nursing documentation noted the resident ate 50% or less for 2 or more meals in a day, was encouraged to eat, and later was documented as sleeping most of the day and not eating much. The Nutrition - Amount Eaten Task Report showed multiple meals at 0-25% and 26-50% intake across May, June, and July, and the Nutrition Supplement Record showed repeated refusals of Ensure. The dietitian stated the significant weight loss had not been identified prior to 7/23/26 and that staff had not notified her of the resident’s reduced appetite. She also stated residents are normally weighed weekly and that the resident was care planned for weekly weights, but the weekly weights were not completed as expected.
Missed insulin administration and inaccurate MAR documentation
Penalty
Summary
The facility failed to ensure that Resident #28 received insulin glargine at the physician-ordered time of 8:00 AM. Resident #28 was admitted with diagnoses including visual loss in both eyes, muscle weakness, diabetes, and depression. The physician’s order dated 2/10/26 directed staff to administer insulin glargine 15 units subcutaneously once daily at 8:00 AM, and the care plan directed staff to provide diabetes medication as ordered by the provider. An incident and accident report dated 2/28/26 documented that staff were preparing to give Resident #28 evening medication and found the morning medication still in the drawer, showing the resident had not received the morning dose. The report stated the resident, physician, and DON were notified. On 7/21/26, Resident #28 stated he had missed an insulin dose but did not recall which day. On 7/24/26, the DON stated a nurse documented the medication as administered before entering the resident’s room, then found the resident in the bathroom and returned the medication to the cart without correcting the MAR. The DON stated the nurse did not follow the required process of documenting medication as completed only after the resident had actually received it.
Deficient Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and labeling practices. In the walk-in freezer, a bag of biscuits was found unsealed and exposed to room air, and a large Ziploc bag of sandwiches was not dated. Additionally, there was significant ice buildup on the floor and fans of the walk-in freezer unit. The Dietary Coordinator confirmed that these issues, including improper sealing and dating of food items, needed to be addressed. Further inspection of the nourishment room refrigerator revealed an opened relish container without an open date or resident name, an opened container of homemade jelly/jam with only a year marked on the lid and no resident name, and a Ziploc bag of sliced cheese with no date. The assistant Dietary Coordinator acknowledged that all refrigerated resident food items must be dated and labeled with resident names or be disposed of, which was not done in these instances.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an Advance Directive, as required by facility policy. Record review, policy review, document review, and staff interviews revealed that for six residents, there was no documentation of Advance Directives in their medical records, nor evidence that the facility had offered assistance in formulating such directives. The facility's policy outlined specific procedures for providing information about medical treatment decisions, obtaining signatures, and referring residents to social services for assistance with Advance Directives, but these steps were not documented as completed for the affected residents. For each of the six residents reviewed, including individuals with diagnoses such as dementia, depression, chronic kidney disease, chronic respiratory disease, chronic obstructive pulmonary disease, anoxic brain damage, diabetes, and chronic viral hepatitis, there was a lack of documentation regarding Advance Directives. The only documentation present was related to CPR status, which the DON confirmed was the extent of the facility's process for Advance Directives. The Social Worker also confirmed that during annual admission reviews, there was no documentation that Advance Directives were discussed or confirmed with these residents. Additionally, the facility's document provided to residents, "Your Rights As A Patient To Make Medical Treatment Decisions," only contained information about living wills and durable power of attorney for health care, and did not include documentation declaring the status of an Advance Directive. This incomplete process and lack of documentation were consistent across all six residents reviewed, indicating a systemic failure to follow the facility's own policy and federal requirements regarding Advance Directives.
Inaccurate MDS Assessment Due to Inconsistent Height Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident's status, as evidenced by inconsistent documentation of a resident's height across multiple assessment dates. Specifically, the resident's height was alternately recorded as 66 inches and 63 inches on different MDS assessments, with no explanation for the discrepancies. The issue was identified through observation, interview, and record review, and the facility administrator was unable to provide a reason for the inconsistent height entries. The resident involved had multiple diagnoses, including diabetes and stroke.
Failure to Update Care Plans After Falls and Wandering Incidents
Penalty
Summary
The facility failed to ensure that care plans were revised and updated for residents following significant events, as required by facility policy. For one resident with chronic obstructive pulmonary disease and depression, multiple falls were documented over several months. Although the facility's Fall Committee investigated each incident and recommended specific interventions—such as moving the resident's room, providing a urinal at bedside, adjusting oxygen tubing, and ensuring non-skid footwear—these interventions were not incorporated into the resident's care plan after each fall. The Director of Nursing confirmed that the care plans should have been updated to reflect these interventions but were not. Another resident with dementia and hypertension experienced several wandering incidents, including one where the resident wandered outside the facility. Progress notes documented multiple episodes of wandering, and the admission assessment indicated a history of wandering. However, the resident's care plan did not include documentation of these incidents or interventions to address wandering. Both the Social Worker and Director of Nursing acknowledged that the care plan had not been updated to reflect these issues.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure safe water temperatures in resident rooms, as observed in two out of five rooms checked. Specifically, water temperatures in two resident rooms were found to be above 120 degrees Fahrenheit, with one room measuring 125 degrees F and another at 126 degrees F. A resident with multiple diagnoses, including pneumonia and hemiplegia/hemiparesis following a stroke, reported that the water in his room was very hot. These findings were confirmed through direct measurement of the sink water temperatures during the survey. The State Operations Manual Appendix PP, 483.25d, Table 1, was referenced to illustrate the risk of burns at various water temperatures and exposure times, highlighting that the temperatures found in the resident rooms exceeded safe levels for bathing and could cause harm.
Failure to Document and Intervene for Low Oxygen Saturation
Penalty
Summary
Licensed nurses at the facility failed to demonstrate appropriate competencies in managing oxygen therapy for a resident with multiple diagnoses, including anxiety disorder and dementia. The resident had a physician's order for oxygen via nasal cannula at 2-3L to maintain oxygen saturation (SpO2) above 90%. Despite this order, there were multiple documented instances where the resident's SpO2 levels fell below the prescribed threshold while on oxygen, and no nursing interventions were documented in response to these low readings. The report details several occasions over a period of months where SpO2 values ranged from 84% to 89% while the resident was receiving oxygen, with no evidence that licensed nurses took action or documented any interventions, except for one instance where a nurse instructed the resident to take deep breaths. The Director of Nursing confirmed that staff should have documented interventions for each low SpO2 reading but did not. This deficiency was identified for four out of fifteen licensed nurses and had the potential to affect all residents assessed for oxygen therapy.
Failure to Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing signatures on the narcotic accountability record for one of two medication carts reviewed. During an audit of the Hall B medication cart, it was observed that the narcotic accountability record covering a ten-day period did not have the required two licensed nurse signatures to document acceptance or release of the medication cart. Both an LPN and the Director of Nursing confirmed that two nurses should have signed the record when the cart was accepted or released. This lapse in documentation was identified through record review and staff interviews.
Controlled Medications Not Properly Secured; Biologicals Not Labeled When Opened
Penalty
Summary
Surveyors found that controlled medications, specifically a box of lorazepam (a Schedule IV controlled substance), were stored on a medication refrigerator shelf that did not have a separately locked compartment for controlled drugs, as required. Although both the medication refrigerator and cabinet were locked, there was no additional locked compartment inside the refrigerator for controlled substances. Additionally, biologicals such as glucose test solutions were observed to be undated when opened. Staff interviews confirmed that the glucose test solution bottles should have been dated upon opening, but this was not done.
Deficient Abuse Policy
Penalty
Summary
The facility failed to ensure their abuse policy included screening and training of employees, and protection for residents during an investigation. The policy, dated 5/18/20, did not include screening requirements of staff to prevent abuse, nor did it specify to whom, how, and when to report incidents of abuse and neglect. Additionally, the policy lacked details on how the facility would protect a resident during an investigation of an allegation of abuse. During an interview, the Administrator confirmed that the abuse policy was lacking in these areas, although annual abuse training for employees covered all required topics.
Failure to Implement Gradual Dose Reductions and Stop Dates for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents received gradual dose reductions (GDRs) of psychotropic medications or a stop date ordered for as-needed psychotropic medication unless clinically contraindicated. This deficiency was identified for three residents. Resident #8, who was admitted with anxiety and depression, had been on escitalopram for over two years without any GDR recommendations or attempts, despite not displaying the identified problem behaviors. Resident #13, also with anxiety and depression, had no GDRs for Seroquel and no stop date or reevaluation for as-needed Ativan after 14 days of use. Additionally, Resident #18, with depression, was on multiple psychotropic medications without GDR attempts and had no diagnosis justifying the use of Risperdal for a movement disorder or psychotic disorder. The records showed that the consulting pharmacist did not make GDR recommendations for these residents, and the Medical Director confirmed the lack of GDRs and stop dates for the medications in question. Resident #8's care plan included monitoring for depressive symptoms and behaviors, but no changes were recommended in the psychotropic medication review forms over multiple months. Resident #13's psychotropic medication review forms also showed no changes recommended, and the resident's moods were stable. However, the resident's record did not include GDRs for Seroquel or a stop date for Ativan. Resident #18's care plan documented a behavior management plan for depressive and anxiety symptoms, but the resident had not demonstrated these symptoms since November 2023. Despite this, the resident's record did not include GDRs for Risperdal, Bupropion, and Venlafaxine. The Medical Director and Director of Nursing confirmed the consulting pharmacist did not make GDR recommendations for these residents, and there was no stop date for the as-needed Ativan ordered for Resident #13.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program, resulting in the continued use of antibiotics without a documented rationale for two residents. Resident #8, who was admitted with multiple diagnoses including dementia and anxiety, received Bactrim DS for an infected hip wound for over two years without any documentation of an infected hip wound in his record. Similarly, Resident #13, admitted with diagnoses including anxiety and chronic kidney disease, was prescribed Ciprodex Otic Suspension for a tympanic membrane perforation, despite no documentation of a ruptured eardrum in his record. The Infection Preventionist confirmed the lack of documentation for both residents, indicating a failure to ensure appropriate use of antibiotics.
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 56 citations issued within 25 miles in the last 12 months — including the 1 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 Preston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oneida County Hospital & Long Term Care Facility | 20.5 mi | ★★★★★ | 12 | 0 |
| Maple Springs Senior Living | 22.6 mi | ★★★★★ | 12 | 0 |
| Rocky Mountain Care - Logan | 23.5 mi | ★★★★★ | 14 | 0 |
| Logan Regional Hospital Transitional Care Unit | 23.7 mi | ★★★★★ | 2 | 0 |
| Sunshine Terrace Skilled Nursing | 24.9 mi | ★★★★★ | 16 | 1 |
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 October 2026) and official state health department websites.