Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Good Samaritan Society - Liberal during CMS and state inspections, most recent first.
A resident with DM2, prior stroke with hemiparesis/hemiplegia, malignant brain neoplasm, impaired cognition, and total dependence for transfers was being moved from bed to wheelchair using a full-body mechanical lift with two staff. After the resident was lifted off the bed and the lift was pulled away to position the wheelchair, one staff briefly released physical contact to retrieve the wheelchair, during which the resident rolled to the side, sling loops became partially detached from the lift hooks, and the resident fell, striking the back of the head and developing two hematomas. Facility lifts had hook assemblies without mechanisms to prevent sling loops from unintentionally coming loose, and although facility policy required a "TIME OUT" safety stop to verify secure straps before moving away from the surface, the incident occurred after the lift was moved from the bed. The fall documentation lacked evidence of a completed investigation or identified root cause for the sling detachment.
A resident with dementia and behavioral disturbances was able to access multiple lighters and started a fire in her room, leading to the evacuation of all residents. Staff discovered the fire and extinguished it, but inspection revealed the resident had accumulated hazardous items, including lighters and medical equipment belonging to others, due to inadequate supervision and lack of effective monitoring of personal belongings.
The facility failed to ensure the proper functioning of the call light system, leading to significant delays in response times to residents' needs. Additionally, the facility did not appropriately respond to allegations of abuse, including a large bruise on a resident and a reported sexual assault. These failures placed residents at risk for neglect and abuse, impacting their well-being.
A resident reported a sexual assault by two male perpetrators within the facility, but the staff failed to assess her for injuries or report the incident to authorities. Despite the resident's report to hospital staff and subsequent notifications to the facility, no investigation was initiated, and law enforcement was not contacted until much later. This failure placed the resident in immediate jeopardy and at risk for further harm.
A resident reported being sexually assaulted by two male perpetrators, but the facility failed to investigate or notify law enforcement until a surveyor intervened. Despite the resident's cognitive intactness and medical vulnerabilities, the facility did not act on the allegations, leading to a significant oversight in resident safety and well-being.
A resident with a history of trauma and anxiety disorder reported sexual assault multiple times, but the facility failed to investigate or report the allegations to law enforcement. Despite the resident's symptoms of fear and aggression, consistent with a trauma response, the facility did not document the allegations or initiate an investigation until months later, placing the resident in immediate jeopardy.
The facility failed to maintain sanitary conditions in food storage and preparation, risking food-borne illness. Observations revealed undated and improperly stored food items, scratched kitchenware, and burnt substances in ovens. Dietary staff confirmed these issues, which violated the facility's policy requiring proper labeling and storage of opened food.
The facility failed to submit accurate staffing data to CMS, with discrepancies in the Payroll Base Journal (PBJ) showing a lack of 24/7 licensed nurse coverage and low weekend staffing. Despite daily staffing sheets indicating equal staffing levels, the facility lacked a policy to ensure PBJ accuracy, affecting the reported care for 37 residents.
The facility was cited for multiple deficiencies, including four Immediate Jeopardy citations, indicating substandard quality of care. Issues included unreported and uninvestigated abuse allegations, failure to recognize changes in residents' conditions, and lack of comprehensive care plans. The facility also failed to provide necessary care, maintain a safe environment, and serve food under sanitary conditions. Additionally, the administration was ineffective in addressing quality deficiencies, leading to continued substandard care for all residents.
The facility failed to manage its resources effectively, leading to multiple deficiencies in care and administration. Key issues included inadequate response to abuse allegations, failure to perform timely assessments, and inaccurate staffing reports. These deficiencies compromised residents' well-being and quality of care.
A resident with a history of hemiplegia, hemiparesis, and traumatic brain injury experienced a decline in ADLs and increased behavioral issues, which the facility failed to document as a significant change in condition. The resident's functional abilities deteriorated, requiring total dependence on staff for most ADLs, and exhibited increased behaviors such as yelling and hitting. The facility lacked a policy for MDS completion, relying instead on the RAI manual, leading to the oversight.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated care needs. One resident's MDS did not reflect the use of a chair alarm despite its documented necessity due to frequent falls. Another resident's MDS inaccurately documented the absence of a personal alarm, despite its confirmed use. Additional inaccuracies included incorrect documentation of urinary catheter use, restraint use, and medication classification, highlighting a pattern of incomplete MDS documentation.
The facility failed to provide restorative nursing programs for several residents, including those with severe cognitive impairment, contractures, and functional limitations. Observations revealed that residents did not receive necessary range of motion exercises or splints, despite recommendations from the therapy department. Staff were unaware of any restorative programs, and the facility lacked a system for routine screening to identify residents who would benefit from such programs.
A resident with a history of falls and intact cognition experienced multiple falls without the care plan being updated for specific incidents. Despite having interventions like a chair alarm and physical therapy consults, the care plan lacked updates for falls on two occasions. Staff interviews confirmed that fall investigations and care plan updates were required but not completed, leading to a deficiency in care planning.
The facility failed to ensure resident safety by not placing a fall mat as required for a resident with severe cognitive impairment and by allowing a single staff member to transfer another resident with a mechanical lift, contrary to policy. These actions led to deficiencies in care and potential safety risks.
A facility failed to follow a Consultant Pharmacist's recommendation to conduct an AIMS assessment for a resident on Risperidone, an antipsychotic medication. Despite the resident's history of traumatic brain injury and behaviors like yelling and hitting, the required assessment was not completed in a timely manner, contrary to facility policy. This oversight was confirmed by the Administrative Nurse, highlighting a lapse in adherence to established procedures.
The facility failed to administer medications as ordered for two residents. One resident did not receive Tramadol for seven days due to unavailability, and the facility did not notify the physician or use the emergency kit. Another resident missed a dose of Aspart insulin because it was not available, and the facility did not follow its policy to notify the physician. These failures placed residents at risk for additional medical problems.
A cognitively impaired resident with a history of elopement risk was able to leave the facility unsupervised due to malfunctioning door locks and a failed WanderGuard system. The resident, who was upset and voicing a desire to go home, was found and returned by a neighbor 14 minutes later. Staff were unaware of the elopement until the resident's return.
Resident Fall From Mechanical Lift Due to Inadequate Sling Security and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from accident hazards and received adequate supervision during a mechanical lift transfer, resulting in a fall and head injury. The resident had significant medical conditions including DM2, prior stroke with hemiparesis and hemiplegia affecting the right dominant side, and a malignant brain neoplasm. The resident’s MDS documented moderately impaired cognition, dependence on staff for all care and transfers, and use of a wheelchair for locomotion. The care plan identified the resident as at risk for falls due to stroke-related deficits and required staff assistance with all transfers, specifying use of a total mechanical lift with two staff and a large sling, with staff ensuring proper positioning in the sling before bearing weight. On the morning of the incident, two staff (a CNA and a CMA) were transferring the resident from bed to wheelchair using a full-body mechanical lift. The CNA reported standing close to the resident while the CMA operated the lift controls. After the resident was lifted off the bed, the lift was pulled away from the bed to make room for the wheelchair. The CNA turned away to get the wheelchair and then heard the CMA scream; when she turned back, the resident was partially hanging from the lift with feet in the air and head on the ground, with only two sling loops still attached. The CMA reported that when the CNA let go of the resident and turned to get the wheelchair, the resident rolled to the side in the sling, the sling became partially undone, and the resident fell, striking the back of the head on a leg of the lift. The CMA recalled that three of the four sling loops remained connected after the fall. The nurse who responded found the resident on the floor between the legs of the lift and documented two hematomas on the back of the resident’s head. The facility’s equipment and documentation further contributed to the deficiency. Observation of the full-body lifts in service showed that the hook assemblies used to attach sling loops lacked any mechanism to prevent sling loops from unintentionally coming loose during transfers. The facility’s Safe Resident Handling Program policy required caregivers to perform a “TIME OUT” safety stop while the resident was still over the bed or chair surface, with straps taut, to ensure the straps were secure before moving away from the surface. Administrative staff stated that staff were expected to pause for approximately 30 seconds after lifting the resident free of the surface to double-check that sling loops had not come undone before proceeding with the transfer. The fall report and Fall Scene Huddle Worksheet for this incident did not contain evidence that an investigation was performed or that a root cause of the fall was identified, and there was no documented determination of why the sling loops became detached during the transfer.
Failure to Prevent Resident Access to Hazardous Items Resulting in Fire
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment free from accident hazards, resulting in a cognitively impaired resident starting a fire in her room using a cigarette lighter. The resident, who had a history of dementia with behavioral disturbances, confusion, and impaired cognitive function, was able to access and retain multiple lighters in her room. Despite care plans indicating the need for supervision and the use of a WanderGuard due to elopement risk, the resident was left unsupervised in her room, where she ignited her recliner, triggering the facility's smoke alarm. Staff discovered the fire after noticing a glare from the resident's room. Upon entering, they found the resident in her wheelchair next to the burning recliner. The fire was extinguished by CNAs with the assistance of a resident's representative, and all residents were evacuated from the building. Subsequent inspection of the resident's room revealed not only multiple lighters but also various items belonging to other residents, including medical equipment and scissors, indicating a lack of effective monitoring of potentially hazardous items. Interviews and documentation confirmed that the resident had a history of confusion, hallucinations, and delusions, and her cognitive assessments fluctuated from intact to severely impaired. Staff and administrative interviews indicated that the facility was unaware of how the resident obtained the lighters and that there was no effective system in place to prevent unsafe items from entering resident rooms. The failure to supervise the resident and control access to hazardous items directly led to the fire and placed all residents in immediate jeopardy.
Deficiencies in Call Light Response and Abuse Allegation Handling
Penalty
Summary
The facility failed to ensure the proper functioning of the call light system, which resulted in significant delays in response times to residents' needs. Multiple residents reported issues with call light response times, and observations confirmed extended delays, such as a 42-minute response time for one resident. The facility had been aware of the call light system issues for months but did not have adequate measures in place to monitor and address the problem, as evidenced by the absence of staff at the nurses' station to watch the call light system. Additionally, the facility did not appropriately respond to allegations of abuse. One resident had a large bruise across her chest, which was reported to be caused by improper use of a gait belt. However, there was no investigation or documentation of the incident, and the facility failed to educate staff on proper handling to prevent such occurrences. Another resident reported a sexual assault by two men in the facility, but the facility did not investigate the allegation, notify law enforcement, or take steps to protect the resident from further abuse. The facility's failure to address these issues placed residents at risk for neglect and abuse, impacting their physical, mental, and psychosocial well-being. The lack of timely response to call lights and inadequate handling of abuse allegations demonstrated a significant deficiency in the facility's ability to provide a safe and responsive environment for its residents.
Failure to Report and Investigate Sexual Assault Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of sexual assault made by a resident, identified as R17, who was cognitively intact but dependent on care. R17 reported being sexually assaulted by two male perpetrators within the facility on a specific date. Despite the resident's report of bruises and bite marks, the nursing staff did not respond appropriately, failing to assess her for injuries or report the incident to the necessary authorities. The resident later reported the assault to hospital staff during a visit for chest pain, and the hospital notified the facility of the allegation, but the facility still did not take action. The facility's records, including the Electronic Medical Record (EMR) Progress Notes, indicated that R17 had reported the assault to the facility staff, but no investigation was initiated, and law enforcement was not notified until much later when the resident reported the incident to a surveyor. The facility's grievance log did not document any allegations of abuse or neglect regarding R17, and interviews with staff revealed a lack of awareness and education on handling such allegations. The facility's policy required immediate reporting and investigation of abuse allegations, but this was not followed. The failure to act on R17's allegations of sexual assault placed her in immediate jeopardy and at risk for further harm. The facility did not protect the resident or ensure her safety, as required by their policy. The lack of response and investigation into the allegations of abuse was a significant deficiency, as it compromised the resident's physical, mental, and psychosocial well-being.
Failure to Investigate and Report Sexual Assault Allegations
Penalty
Summary
The facility failed to thoroughly investigate and respond to allegations of sexual assault made by a resident, identified as R17. R17, who was cognitively intact but dependent, reported being sexually assaulted by two male perpetrators on multiple occasions. Despite the resident's report of bruises and bite marks, the facility did not conduct a proper investigation or notify law enforcement until the issue was brought to light by a surveyor. The resident's allegations were initially reported to the facility on 05/16/24, and again during a hospital visit on 05/24/24, but the facility did not take appropriate action. R17's medical records indicated a history of traumatic subdural hemorrhage, anxiety disorder, and other conditions requiring assistance with personal care. The resident had a BIMS score indicating intact cognition and had reported feelings of depression and social isolation. Despite these vulnerabilities, the facility did not adequately protect R17 from potential further abuse or investigate the claims. The facility's failure to act on the resident's allegations was compounded by a lack of documentation in the grievance log and a breakdown in communication among staff members. Interviews with facility staff revealed a lack of awareness and education regarding the handling of abuse allegations. The facility's policy required immediate reporting and investigation of such allegations, but this was not followed. The Director of Nursing, Social Services Designee, and other staff members failed to take necessary steps to ensure the resident's safety and well-being, resulting in a significant oversight that placed the resident in immediate jeopardy.
Failure to Respond to Resident's Allegations of Sexual Assault
Penalty
Summary
The facility failed to appropriately respond to a resident's allegations of sexual assault, which were reported on multiple occasions. The resident, who had a history of traumatic subdural hemorrhage and anxiety disorder, reported feeling down, depressed, and isolated. She also experienced hallucinations and delusions. Despite these symptoms and her report of sexual assault, the facility did not take immediate action to investigate or report the allegations to law enforcement. The resident expressed feelings of fear, anger, and aggressiveness, which were consistent with a trauma response. The resident first reported the assault to facility staff on May 16, 2024, stating that two men had sexually assaulted her in the facility. She described having bruises and bite marks, but the facility's nurse did not find any injuries during a skin assessment. The facility's records show that the resident reported the assault again during a hospital visit on May 24, 2024, and upon her return to the facility on May 29, 2024. Despite these reports, the facility did not document the allegations in their grievance log, nor did they initiate an investigation or notify law enforcement until July 16, 2024, when the resident reported the incident to a state agency surveyor. Interviews with facility staff revealed a lack of awareness and action regarding the resident's allegations. The new administrator, who started on June 10, 2024, was not informed of the allegations until July 17, 2024. The facility's policy required immediate reporting and investigation of abuse allegations, but this was not followed. The facility's failure to respond to the resident's allegations of abuse on three different occasions placed the resident in immediate jeopardy and at risk for untreated trauma.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illness among residents. During observations of the kitchen and food storage areas, several issues were identified. A sealed 5-pound bag of cake mix was found without an open date, and a bag of corn bread mix was unsealed. The refrigerator outside the kitchen contained opened containers of orange juice, milk, and chocolate milk, all lacking open dates. Additionally, three frying pans and six cutting boards were found with scratches, and both kitchen ovens had burnt substances on the bottom. The chest freezer contained ice cream with removed lids and freezer-burned cups, as well as an open, undated bag of barbecued pork and a ten-pound bag of frozen vegetables. Dietary Staff BB confirmed these concerns and acknowledged that the undated items were unacceptable. The facility's policy required opened or prepared food to be placed in enclosed containers, dated, labeled, and stored properly, which was not adhered to in this instance.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility's Payroll Base Journal (PBJ) Staffing Data Report for fiscal year Quarter 3, 2023, showed a lack of licensed nurse coverage for 24 hours a day, seven days a week on several specific dates. Additionally, the PBJ reports for subsequent quarters indicated excessively low weekend staffing, despite daily staffing sheets showing equal staffing levels on weekends and weekdays. This discrepancy was confirmed by Administrative Nurse D, who reported that the Administrator compiles and transmits the staff hours to CMS. The facility did not have a policy in place to ensure the accuracy of the PBJ submissions. The report highlights that the facility's failure to provide accurate staffing data included information for agency and contract staff, which should be based on payroll and other verifiable and auditable data in a uniform format as specified by CMS. The facility reported a census of 37 residents at the time of the survey, but the inaccurate staffing data submission could potentially impact the quality of care provided to these residents.
Multiple Deficiencies and Immediate Jeopardy in Facility Care
Penalty
Summary
The facility was found to have multiple deficiencies during the recertification survey, including four Immediate Jeopardy (IJ) citations, which indicated substandard quality of care. These deficiencies were not identified by the facility's Quality Assurance and Performance Improvement (QAPI) program, affecting all 37 residents. The surveyors discovered issues such as abuse, lack of reporting and investigating abuse allegations, and failure to protect residents from further abuse. Additionally, the facility did not recognize significant changes in residents' conditions, failed to complete required assessments, and did not develop comprehensive care plans. The survey revealed that the facility failed to provide necessary care and services to maintain residents' well-being. Specific incidents included the failure to revise fall care plans, provide scheduled pain medication, and respond to pharmacist recommendations. The facility also did not ensure a safe environment, as evidenced by improper use of mechanical lifts and failure to document fall prevention measures. Furthermore, the facility did not serve food under sanitary conditions, potentially leading to foodborne illnesses. The facility's administration was ineffective in identifying and addressing quality deficiencies, as evidenced by inaccurate reporting of staffing information and failure to maintain corrective measures from previous surveys. The lack of an effective QAPI program resulted in continued substandard care, placing all residents at risk for decreased quality of life and well-being.
Ineffective Administration and Resource Management
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, compromising the quality of care and well-being of its residents. Key deficiencies included the lack of an effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by multiple deficient practices and substandard quality of care. The facility did not ensure staff appropriately identified and responded to allegations of abuse, including a resident's report of sexual assault, and failed to report these allegations to the State Agency or local law enforcement as required. Additionally, the facility did not investigate all allegations of resident-to-resident abuse or protect residents from further incidents. There was also a failure to recognize significant changes in residents' conditions and perform timely assessments, which could lead to uncommunicated needs and further deterioration of residents' well-being. The facility's administration was ineffective in developing comprehensive, person-centered care plans and revising fall care plans with necessary interventions. It failed to provide necessary care and services to maintain residents' highest practicable well-being, including issues related to the Restorative Nursing Program and safe transfer procedures. The facility did not provide scheduled pain medication as ordered, respond to pharmacist recommendations, or serve food under sanitary conditions. Furthermore, the facility failed to accurately report staffing information to CMS, which included incorrect reporting of RN coverage. These deficiencies placed residents at risk for decreased quality of care, treatment, and overall well-being.
Failure to Capture Significant Change in Resident's Condition
Penalty
Summary
The facility failed to identify and document a significant change in condition for a resident, who experienced a decline in activities of daily living (ADLs) and an increase in behavioral issues. The resident, who had a history of hemiplegia, hemiparesis, traumatic brain injury, and severely impaired cognition, showed a marked decline in functional abilities between assessments. Initially, the resident required supervision for eating and oral care, moderate assistance with ADLs, and maximal assistance with transfers and personal hygiene. However, by the next assessment, the resident required total dependence on staff for most ADLs and exhibited increased behaviors such as yelling and hitting. Despite these changes, the facility did not capture this significant change in the resident's condition, as evidenced by the lack of a policy for Minimum Data Set (MDS) completion and reliance on the Resident Assessment Instrument (RAI) manual. The resident's behaviors were documented in progress notes, indicating frequent mood behaviors and difficulty in redirection by staff. The failure to recognize and document these changes had the potential to negatively impact the resident's physical, mental, and psychosocial well-being.
Inaccurate MDS Documentation Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated care needs. For one resident, the MDS did not reflect the use of a chair alarm, despite documentation in the care plan and physician orders indicating its necessity due to frequent falls. The resident had a history of falls and was found on the floor on multiple occasions, yet the MDS section for alarms was not completed correctly. Interviews with staff confirmed the presence of the alarm, but the facility lacked a specific policy for MDS completion, relying instead on the Resident Assessment Instrument (RAI) manual. Another resident's MDS inaccurately documented the absence of a personal alarm, despite observations and staff interviews confirming its use for several months. The resident had severe cognitive impairment and required significant assistance with activities of daily living. The care plan, physician orders, and progress notes did not mention the alarm, and the MDS was not updated to reflect its use. This oversight was acknowledged by administrative staff, who again cited reliance on the RAI manual for MDS completion. Additional inaccuracies were found in the MDS for other residents, including incorrect documentation of urinary catheter use and restraint use. One resident's MDS inaccurately indicated the use of multiple types of catheters, while another resident's MDS incorrectly noted the use of physical restraints, which the resident denied. Furthermore, a resident receiving antipsychotic medication was not accurately documented in the MDS, with the medication being misclassified. These errors highlight a pattern of incomplete and inaccurate MDS documentation, which could lead to unmet care needs for the residents.
Failure to Provide Restorative Nursing Programs
Penalty
Summary
The facility failed to provide appropriate restorative nursing programs for several residents, leading to deficiencies in maintaining or improving their range of motion and mobility. Resident 4, who had severe cognitive impairment and functional limitations due to hemiplegia and osteoporosis, did not receive therapy or restorative nursing programs. Observations revealed that the resident was not provided with passive range of motion exercises or the necessary splints to prevent contractures, despite recommendations from the therapy department. The restorative aide confirmed that no routine restorative nursing programs were being provided due to time constraints and lack of assessments. Similarly, Resident 11, who had severe cognitive impairment and a stage four pressure ulcer, did not receive the necessary restorative nursing care to prevent worsening contractures. The resident's care plan included interventions for contractures, but observations showed that no range of motion exercises or splints were applied during care. Staff members were unaware of any restorative nursing programs, and the facility lacked a system for routine screening to identify residents who would benefit from such programs. Resident 29, with a history of cerebral infarction and traumatic brain injury, also did not receive restorative nursing programs despite having functional limitations in range of motion. Observations indicated that the resident did not receive exercises or assistance with range of motion during meals. The facility's policy on restorative nursing care was not implemented, and the therapy department's recommendations for continued restorative services were not followed. Additionally, Resident 8, who had dementia and contractures in both lower extremities, did not receive a restorative nursing program to prevent further decline, as recommended by the therapy department. The facility's failure to provide these services placed residents at risk for further decline and discomfort.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to accurately update the care plan for a resident, identified as R7, following multiple falls. R7's electronic health record indicated a history of falls, along with diagnoses of metabolic encephalopathy, muscle weakness, anxiety disorder, and intact cognition. Despite these conditions, the care plan lacked interventions for falls that occurred on January 26, 2024, and April 15, 2024. The care plan did include some interventions, such as the use of a chair alarm and physical therapy consults, but these were not updated following the aforementioned falls. The facility's policy required documentation for any necessary updates to the care plan, which was not adhered to in this case. The report detailed several incidents where R7 was found on the floor, including falls in the bathroom, room, and whirlpool room, with varying degrees of injury. Interviews with staff revealed that a fall investigation should be conducted after each incident, and the care plan should be updated accordingly. However, it was confirmed that the care plan lacked interventions for specific falls, placing the resident at risk for uncommunicated care needs. The facility's failure to update the care plan as required by their policy and state regulations led to this deficiency.
Deficiencies in Resident Safety and Transfer Protocols
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for two residents, leading to deficiencies in care. For one resident, who had severe cognitive impairment and required maximal assistance with activities of daily living, the facility did not consistently place a fall mat next to the resident's bed as per the care plan. On one occasion, the resident was found on the floor next to the bed, with the fall mat improperly placed by the window. A Certified Nurse Aide admitted to forgetting to place the mat, which was a required safety intervention documented in the care plan. Another deficiency involved the unsafe transfer of a resident with severe cognitive impairment and a cerebral aneurysm. The resident's care plan required a total lift transfer with two-person assistance. However, a Certified Nurse Aide transferred the resident alone using a full body mechanical lift, contrary to the facility's policy that mandates two staff members for such transfers. The aide acknowledged the breach, citing the unavailability of other aides at the time. These incidents highlight the facility's failure to adhere to established care plans and policies, potentially compromising resident safety. The lack of proper execution of safety interventions and adherence to transfer protocols were directly observed and reported by staff, indicating lapses in following prescribed procedures for resident care.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to adhere to the Consultant Pharmacist's recommendations regarding the completion of an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving Risperidone, an antipsychotic medication. The resident, who had a history of traumatic brain injury and exhibited behaviors such as yelling and hitting, was prescribed Risperidone to manage these behaviors. Despite the Consultant Pharmacist's recommendations on multiple occasions to conduct an AIMS assessment to monitor for tardive dyskinesia, a potential side effect of Risperidone, the facility did not complete the assessment in a timely manner. The resident's medical records indicated severely impaired cognition and a history of behaviors that warranted the use of antipsychotic medication. The facility's policy required an AIMS assessment to be conducted every six months, but the assessments were overlooked, as confirmed by the Administrative Nurse. This oversight was contrary to the facility's policy and the Consultant Pharmacist's recommendations, potentially impacting the resident's well-being.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure that two residents received their medications as ordered by their physicians. Resident 8, who has diagnoses including dementia and osteoarthritis, did not receive their prescribed Tramadol for seven days. The medication was not available, and the facility staff failed to notify the physician or obtain the medication from the emergency kit. The resident's electronic health record and medication administration record indicated that the medication was unavailable on multiple occasions, and the facility was unable to locate the narcotic sign-off record for the missing dates. Resident 16, diagnosed with diabetes mellitus and altered mental status, did not receive their prescribed Aspart insulin on one occasion. The facility staff documented that the medication was not available, and the insulin was not administered as per the sliding scale orders. The facility's policy required that if a medication is not available for 24 hours, the physician must be notified, but this was not done in a timely manner. The facility's failure to administer medications as ordered placed both residents at risk for additional medical problems. The facility's policies on medication administration and ordering from the pharmacy were not followed, leading to these deficiencies. The lack of communication and failure to utilize the emergency kit contributed to the residents not receiving their necessary medications.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease, altered mental status, restlessness, agitation, and dementia, was left unsupervised near the front entrance despite being upset and voicing a desire to go home. The front doors, which were known to be malfunctioning and did not require a code to open, allowed the resident to exit the facility without staff awareness. Additionally, the WanderGuard system, which was supposed to alert staff when the resident approached the exit, failed to alarm. The resident was found and returned to the facility by a neighbor 14 minutes later, uninjured but without staff knowledge of her elopement until her return. The resident's medical records and care plan indicated that she had severe cognitive impairment, used a wheelchair for mobility, and was at risk for elopement. The care plan included the use of a WanderGuard bracelet to alert staff to her movements near exit doors and required staff to check the WanderGuard daily. Despite these measures, the resident was able to leave the facility due to the malfunctioning door lock and the failure of the WanderGuard system. Staff interviews revealed that the resident had been upset and crying throughout the day, asking to go home, and was last seen by staff shortly before her elopement. Maintenance staff confirmed that the WanderGuard system and door locks had been checked and were reported to be functioning properly prior to the incident. Observations and interviews with staff indicated that the resident had been left unsupervised near the front entrance, and staff were unaware of her elopement until she was brought back by a neighbor. The facility's policy on elopement required measures to minimize the risk of elopement, but these measures were not effectively implemented in this case. The failure to provide adequate supervision and a safe environment for the resident, who was known to be an elopement risk, resulted in her leaving the facility without staff knowledge and placed her in immediate jeopardy.
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 19 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 Liberal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southwest Medical Center Snf | 0.9 mi | ★★★★★ | 18 | 0 |
| Wheatridge Park Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Stevens County Hospital Ltcu Dba Pioneer Manor | 24.6 mi | ★★★★★ | 1 | 0 |
| Satanta District Hospital Ltcu | 26.1 mi | — | 0 | 0 |
| Beaver County Nursing Home | 28.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.