Above 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 Oneida County Hospital & Long Term Care Facility during CMS and state inspections, most recent first.
Advance directive documentation was not ensured for two residents. One resident’s record noted a DPAHC existed, but the copy was missing from the chart, and another resident’s record showed a POA form that did not authorize healthcare decisions even though the questionnaire indicated a healthcare DPA existed. The DON stated the facility did not realize the second form was financial rather than healthcare POA.
A resident with dementia and Parkinsonism was discharged after developing a fever, but the chart lacked a documented discharge plan, discharge goals, and evidence that discharge planning was discussed with the resident or family. The wife picked him up, signed discharge paperwork, and took his belongings and meds, but no discharge summary was completed and the DON stated the record did not contain the proper discharge documentation.
A resident with alcohol dependence and alcohol-induced persisting dementia had completed PASRR Level I and Level II screenings, but the facility did not refer the resident for the recommended substance use evaluation or document why it was not obtained. The LCSW confirmed the evaluation was missing, and the DON stated the resident should have been referred as recommended by the PASRR Level II.
A resident with dementia and PTSD was admitted and readmitted to the facility, and the record showed PTSD in the care plan, MDS, and medical record. However, the PASRR Level I did not document the PTSD diagnosis, and there was no documentation of a PASRR Level II. The LCSW stated the facility should have completed the PASRR Level I with the PTSD diagnosis and submitted the Level II to the state-designated authority, but had not.
Failure to assess and document bed rail use for a resident with schizophrenia and depression. The resident was observed with one upper bed rail in the up position, but the chart lacked documentation of a resident assessment, alternatives tried, the purpose for the bed rail, a physician order, and a discussion of risks and benefits with signed consent. The DON stated the resident had not been assessed for bed rail use and should not have had the rail in use.
The facility failed to ensure annual performance reviews were completed for 2 CNAs whose personnel files were reviewed. One CNA had an initial hire date of 10/18/23 and the other 4/24/09, but neither file contained documentation of an annual performance review. The HR Director stated the reviews had not been provided for the files, and the DON stated the reviews had not been completed but should have been.
Incomplete Daily Nurse Staffing Postings: The facility failed to post accurate nurse staffing information daily and for each shift. Review of the staffing sheets showed no resident census, no weekend staffing sheets, and no actual licensed or unlicensed staff hours documented for the months reviewed. The DON stated these omissions had been occurring before her arrival and had continued.
A resident with COPD, heart failure, and an order for nightly CPAP use had the CPAP mask and tubing observed placed in the bed on top of the linen on two occasions. The facility’s policy required delivery devices to be kept covered in a plastic bag when not in use, but the equipment was not bagged. The DON stated the CPAP equipment should not have been in the bed and should have been stored appropriately and placed in a plastic bag when not in use.
The facility failed to accurately complete a PASARR for a resident with PTSD and did not update PASARRs for two residents with new mental health diagnoses. The LCSW admitted to overlooking the PTSD diagnosis and was unaware of the need to update PASARRs for new diagnoses, potentially impacting the provision of necessary mental health services.
Advance Directive Documentation Not Ensured
Penalty
Summary
The facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advance directive for 2 of 12 residents reviewed, Resident #4 and Resident #19. The facility policy stated that on admission it would determine whether a resident had executed an advance directive and, if not, whether the resident would like to formulate one, and that copies of any advance directive would be made and placed on the chart and communicated to staff. Resident #4 was admitted with diagnoses including stroke and malignant melanoma of the skin. Her Idaho Physician Order for Scope of Treatment form documented that advance directive documents existed, including a Durable Power of Attorney for Healthcare, but the medical record did not contain a copy of that document. The DON stated the paper chart had a form showing she had an advance directive, but the medical record did not have a copy and should have had one. Resident #19 was admitted with diagnoses including atrial fibrillation and major depression. His advance directive questionnaire stated that he had an advance directive and Durable Power of Attorney for Health Care, but the record contained an Idaho Statutory Form Power of Attorney that stated it did not authorize the agent to make healthcare decisions. The DON stated the facility did not realize the form was for financial rather than healthcare power of attorney and was not sure whether the resident realized he did not have a healthcare POA.
Incomplete discharge documentation and communication
Penalty
Summary
The facility failed to ensure appropriate discharge planning was documented in the medical record and failed to ensure appropriate resident information was communicated to the resident's representative for Resident #27. The facility's Discharge Summary policy, approved 4/22/25, stated that a discharge summary should be provided upon discharge and address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. Resident #27 was admitted with multiple diagnoses including dementia and Parkinsonism. On 3/31/26, staff documented that Resident #27 had a fever of 101.4 F without other associated symptoms, with a plan to obtain a urinalysis and urine culture and monitor for additional symptoms. Later that day, the resident was picked up by his wife, who took his belongings and medications, and signed discharge paperwork before walking him out. The discharge instruction form signed by family listed a regular diet, activity as normal, showering allowed, no driving restrictions, disposition to home with home care nurse, no wound care, special instructions to follow HH, and medications as prescribed. The resident's care plan did not document his discharge plan or goals, the medical record did not document that discharge planning was discussed with the resident or family, and no discharge summary was completed. The DON stated she was not sure if a discharge summary or charting had been done and later stated the resident did not have the proper discharge documentation in the medical record.
Failure to Follow PASRR Level II Recommendation for Substance Use Evaluation
Penalty
Summary
The facility failed to refer a resident for recommended further evaluation after a PASRR Level II determination identified the need for a substance use evaluation. The facility’s policy stated that recommendations from a PASRR Level II determination and/or evaluation report would be incorporated into the resident’s assessment, care plan, and transitions of care, but the resident’s record did not document follow-up on the recommended evaluation or a reason why it was not obtained. Resident #2 was admitted with diagnoses including alcohol dependence with alcohol-induced persisting dementia and diabetes. The resident’s comprehensive care plan documented antipsychotic medication and thiamine related to the dementia diagnosis. The medical record showed completed PASRR Level I and Level II screening evaluations from the state-designated authority, but the recommended substance use evaluation was not completed. The LCSW stated the facility did not have a substance use evaluation for the resident or documentation explaining why it had not been obtained, and the DON stated the resident had not been referred for the evaluation as recommended on the PASRR Level II.
PASRR Screening Not Completed for Resident with PTSD
Penalty
Summary
The facility failed to refer a resident for further evaluation after the resident was diagnosed with a major mental illness. The facility’s Resident Assessment - Coordination with PASRR Program policy, dated 8/18/25, states that all applicants will be screened for serious mental disorders or intellectual disabilities and that the facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined are appropriate for admission. Resident #1 was initially admitted and later readmitted to the facility with diagnoses including dementia and PTSD. The resident’s care plan, created on 12/5/23, documented dementia and PTSD, and the admission MDS completed on 12/13/23 also documented PTSD. The medical record documented PTSD as a major mental illness, but the resident’s PASRR Level I did not document PTSD, and the record did not show completion of a PASRR Level II. The LCSW stated on 5/12/26 that the facility should have completed the PASRR Level I with the PTSD diagnosis and submitted a PASRR Level II to the state-designated authority, but had not.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that, before a bed rail was placed in use, Resident #3 had a documented assessment that included alternatives attempted and how those alternatives failed to meet the resident’s assessed needs. The facility’s Proper Use of Bed Rails policy, reviewed on 6/5/25, required the resident assessment to evaluate alternatives tried before installation or use of a bed rail, assess the resident’s risk from using bed rails, obtain informed consent after alternatives were attempted, and then obtain a physician’s order for the specified bed rail and the medical reason for its use. Resident #3 was initially admitted and later readmitted to the facility with diagnoses including schizophrenia and depression. On 5/11/26 and 5/12/26, the resident was observed with one upper bed rail on the bed in the up position. On 5/12/26 at 10:05 AM, the medical record did not document a resident assessment, evaluation of alternatives attempted, the purpose for the bed rail, a physician order for the bed rail, or a documented discussion of risks and benefits with signed consent. At 1:42 PM, the DON stated the resident had not been assessed for the use of bed rails and should not have had the bed rail in use, but did.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that each CNA's annual performance review was completed at least once every 12 months for 2 of 2 CNAs whose personnel records were reviewed. Review of CNA #1's employee file showed an initial hire date of 10/18/23, but there was no documentation of an annual performance review in the file. Review of CNA #2's employee file showed an initial hire date of 4/24/09, but there was no documentation of an annual performance review in the file. During interview, the HR Director stated the CNAs' annual performance reviews had not been provided to her to include in the personnel files, and the DON stated the annual performance reviews had not been completed but should have been.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure nurse staffing information was accurate, posted daily for each shift, and included scheduled and actual hours. During review of the daily posted staffing sheets for November 2025 through May 2026, surveyors observed that the sheets did not include the resident census for any of the 7 months reviewed, no weekend (Saturday and Sunday) staffing sheets were completed for the 7 months reviewed, and no actual licensed or unlicensed staff hours were documented for the 7 months reviewed. The DON stated that the facility had not documented the resident census or the actual licensed and unlicensed staff hours on the daily posted staffing sheets prior to her arrival and that the practice had continued, and also stated that weekend daily posted staffing sheets had not been completed prior to her arrival and that the practice had continued.
Improper Storage of CPAP Equipment
Penalty
Summary
The facility failed to maintain infection control prevention practices for Resident #15, who had diagnoses including COPD and heart failure and a physician order to wear a CPAP machine every night for obstructive sleep apnea. The facility’s Oxygen Administration and Monitoring policy stated that delivery devices should be kept covered in a plastic bag when not in use. On 5/11/26 and again on 5/12/26, Resident #15’s CPAP mask and tubing were observed placed in the resident’s bed on top of the bed linen, and the equipment was not bagged. During interview on 5/12/26, the DON stated the CPAP equipment should not have been in the bed and should have been stored appropriately and placed in a plastic bag when not in use.
Failure to Accurately Complete and Update PASARRs
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) was accurately completed for one resident prior to admission and did not update the PASARR for two residents when new mental health diagnoses were identified. Resident #15 was admitted with multiple diagnoses, including PTSD, but the Level 1 PASARR completed by the Licensed Clinical Social Worker (LCSW) did not reflect this diagnosis. The LCSW admitted to possibly overlooking the diagnosis by focusing on the medication list rather than the diagnoses list, resulting in an inaccurate PASARR. Additionally, Resident #10, who had a new diagnosis of delusional disorder, and Resident #11, who had new diagnoses of major depressive disorder and paranoid schizophrenia, did not have updated Level 1 PASARRs to reflect these serious mental disorders. The LCSW confirmed that he was unaware of the requirement to update the PASARRs for these new diagnoses. These oversights created the potential for harm if the residents required specialized mental health services that were not provided.
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 citations issued around you in the last 12 months — including the 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 Malad
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franklin County Transitional Care | 20.5 mi | ★★★★★ | 0 | 0 |
| Maple Springs Senior Living | 36.3 mi | ★★★★★ | 12 | 0 |
| Rocky Mountain Care - Logan | 37 mi | ★★★★★ | 14 | 0 |
| Logan Regional Hospital Transitional Care Unit | 37.1 mi | ★★★★★ | 2 | 0 |
| Sunshine Terrace Skilled Nursing | 37.7 mi | ★★★★★ | 16 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oneida County Hospital & Long Term Care Facility.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.