Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southwest Medical Center Snf during CMS and state inspections, most recent first.
The facility failed to provide the required 8 consecutive hours of RN coverage daily. The nursing schedule showed no scheduled RN coverage on multiple days, and an Administrative Nurse confirmed there was no auditable evidence that he worked as the RN on duty for 8 consecutive hours. He also stated that a house coordinator would have covered on one day, but that person was not on the Skilled Nursing Unit for 8 consecutive hours. The facility policy required RN coverage 12 hours a day, 7 days a week, with an RN or LPN on each shift.
Failure to use EBP and maintain clean technique during med pass occurred when an LN provided hands-on care to a resident with a Stage 2 pressure ulcer, then used the same gloves to prepare and administer meds in the room. The LN also touched the computer keyboard and handled meds with gloved hands for another resident, while the IP stated staff were expected to use appropriate PPE for EBP and clean gloves with hand hygiene between care and med administration.
Failure to Provide Written Baseline Care Plans: The facility did not provide written baseline care plans to multiple residents after admission, and EMRs lacked documentation that the plans were reviewed with the residents or family members. Residents reported they did not receive care plan paperwork, and staff stated the baseline care plan was entered in the EMR on admission but not given out or documented as reviewed.
A resident's Lantus pen was observed without an open date or discard date. An LPN and an administrative nurse stated insulin pens should be labeled with the date opened and a discard date, and the facility policy stated insulin should be dated when opened and is outdated 28 days later.
Failure to Invite Resident or RP to Care Plan Meetings: A resident with DM, a right hip fracture, and intact cognition was not invited to participate in care plan meetings or discharge planning. Staff documented an interdisciplinary meeting with only facility personnel present, while the resident later reported she had not been invited or attended any care plan meeting since admission. Facility policy required the resident and/or family to receive an invitation to the next interdisciplinary care meeting.
The facility failed to notify the LTCO of facility-initiated transfers/discharges for two residents. EMR review showed both residents were discharged home, but the facility could not provide evidence of LTCO notification, and an Administrative Nurse stated the facility did not notify the LTCO when a resident was transferred or discharged.
Failure to assess and treat a present-on-admission pressure ulcer: A resident with weakness, frailty, and CHF was admitted with a Stage 2 sacral pressure ulcer, but the wound was not measured or fully assessed on admission, no photo was completed, and no wound treatment order was obtained. Nursing documentation later varied between sacrum and right buttock, and staff observed that the foam dressing was not covering the open area, with the wound showing drainage and macerated peri-wound skin.
Inaccurate PBJ staffing submission: The facility failed to submit complete and accurate PBJ staffing data based on payroll and other auditable records. The PBJ report showed no RN hours on multiple days within identified quarters and indicated a lack of 24-hour licensed nursing coverage on multiple days, even though the nursing schedule showed 24-hour licensed coverage when the Skilled Nursing Unit was open. Administrative nurses confirmed the PBJ inaccuracies and stated they had not reviewed the reports before submission.
A dietary staff member failed to sanitize a thermometer before measuring the temperature of a steak product, as observed during a meal service. The thermometer was stored in a sheath with a hole, raising cleanliness concerns. The dietary manager confirmed that sanitization should occur before each use, as per facility policy.
The facility failed to properly maintain and dispose of garbage, as observed with multiple dumpster lids left open, which were shared with an attached hospital. The Dietary Manager acknowledged the ongoing issue of lids being left open by the hospital's staff. The facility did not provide a policy on garbage handling and disposal, and observations confirmed the continued presence of open dumpster lids, potentially leading to pest issues.
The facility failed to submit accurate staffing data to CMS, missing 24-hour LN coverage on 59 dates in 2023. A review of PBJ reports showed discrepancies, and the facility lacked a policy for accurate PBJ completion.
The facility failed to provide required in-service education for five CNAs, including training on abuse, neglect, and exploitation (ANE), and dementia care for one CNA. This deficiency was confirmed by administrative staff and was not addressed in the facility's Employee Annual Education policy, placing residents at risk for inadequate care.
A facility failed to complete a timely comprehensive assessment on the MDS for a resident with diabetes and a foot ulcer. The resident's EHR lacked an Admission MDS, despite policy requiring completion within 14 days. Staff interviews revealed a lack of awareness about MDS requirements, with an Administrative Nurse citing private insurance as a reason for non-completion and a Licensed Nurse noting the absence of EHR alerts. This oversight could lead to negative psychosocial effects.
A facility failed to maintain effective infection control due to inadequate hand hygiene during a PICC line procedure. A nurse handled a wound vac with gloves, applied a gown without changing gloves, and did not perform hand hygiene before or after changing gloves during the PICC line dressing removal. Administrative staff confirmed the breach in protocol, and the nurse acknowledged the oversight.
A resident requested a pneumococcal vaccine, but the LTC facility failed to administer it before discharge. The EHR lacked documentation of the vaccine, although a signed consent was present in the paper chart. An immunization assessment noted the need for physician notification, but the vaccine was not given. Staff acknowledged the oversight, and the facility lacked a policy for pneumococcal vaccination.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of RN staff daily for residents. The 08/05/25 Facility Assessment stated that staffing was based on resident population and needs, with a nurse-to-resident ratio of six residents to one RN and one CNA, and that an additional LPN could be used if resident numbers increased. The nursing schedule for 10/01/25 through 12/31/25 showed no scheduled RN coverage on Thursday 11/13/25, Sunday 11/20/25, and Saturday 12/20/25. During interviews, Administrative Nurse E confirmed the lack of scheduled RN coverage and stated there was no auditable or verifiable evidence that he worked as the RN on duty for eight consecutive hours on the weekend days, and he was not listed or identified on the schedule or staff postings for RN coverage. He also stated he was off on 11/13/25 and that the house coordinator for the hospital would have covered, but that person was not on the Skilled Nursing Unit for eight consecutive hours. Administrative Nurse D stated she expected the Skilled Nursing Unit to have a scheduled RN for the required eight consecutive hours daily. The facility policy dated 05/2025 stated the minimal staffing required was RN coverage for 12 hours a day, 7 days a week, and that on any shift there would be either an RN or LPN.
Failure to Use EBP and Maintain Clean Technique During Medication Administration
Penalty
Summary
The facility failed to use Enhanced Barrier Precautions (EBP) when providing direct care to a resident with a Stage 2 pressure ulcer. On 04/21/26 at 08:53 AM, an LN sanitized her hands and put on gloves, but did not apply any other PPE before entering the resident’s room with medications in blister packs. She placed the medications on the counter, assisted the resident to sit up and move toward the head of the bed, assessed him, covered him, and elevated the head of the bed. She then returned to the computer, scanned the resident’s bracelet and medications, opened the packets, and dropped the pills into a medication cup while still wearing the same gloves used for hands-on care. She removed pills from the cup with her gloved hand and administered them directly into the resident’s mouth. The facility also failed to ensure adequate hand hygiene and clean technique during medication administration for two residents. On 04/21/26 at 09:40 AM, the same LN sanitized her hands and applied gloves and a gown before entering another resident’s room, then prepared medications with the same gloved hands used to touch the computer keyboard, opened blister packets, administered the medications, and applied a topical medication patch. During interview, the LN stated she did not realize she had worn gloves while providing hands-on care before preparing medications and did not think touching objects in the resident’s room with gloved hands and then preparing and administering medications in the room was a concern. The Infection Preventionist stated staff were expected to wear appropriate PPE for residents on EBP and to use clean gloves for medication administration, removing gloves after hands-on care, performing hand hygiene, and applying new gloves. The facility policy stated medication administration was to maintain clean technique throughout, and the EBP policy stated residents with qualifying screening responses required an EBP order, with high-contact care activities such as dressing, transferring, and wound care requiring gown and glove use.
Failure to Provide Written Baseline Care Plans
Penalty
Summary
The facility failed to provide a written baseline care plan to Resident 1, Resident 2, Resident 11, and Resident 4 after admission. During interviews, Resident 1 reported she had not received a copy of a baseline care plan and stated she had not attended a care plan meeting or any discharge planning since admission. Resident 2 reported she was never provided a written copy of the care plan while she was a resident in the facility. Resident 11 reported he was uncertain about a baseline care plan and said he did not receive any paperwork about a care plan. Resident 4 reported that neither she nor her family member received a copy of the care plan. Record review showed each resident’s EMR lacked documentation that a written baseline care plan was given to or reviewed with the resident or a family member after admission. On interview, a licensed nurse reported the charge nurse would start the baseline care plan in the EMR on the day of admission and would not review or give a written copy to the resident or family. An administrative nurse reported the baseline care plan was completed in the EMR on the first day of admission as a basic skilled care plan and would later be developed into a personalized care plan, but the facility did not give a copy to the resident or family and had no area in the EMR teaching section to document that the care plan was reviewed. Another administrative nurse reported the baseline care plan was completed after the initial assessments were completed and stated it should be documented when reviewed with the resident or family member. The facility’s Care Plans policy dated 07/2011 lacked documentation regarding a baseline care plan.
Insulin Pen Not Dated After Opening
Penalty
Summary
The facility failed to store and label biologicals adequately when staff did not date an insulin pen after it was opened. During observation on 04/21/26 at 09:50 AM, R1's Lantus pen was found without an open date or discard date. At 09:51 AM, LN G stated that all insulin pens should be labeled with an opened date and a discard date. On 04/22/26 at 01:15 PM, Administrative Nurse E stated he expected all insulin pens to be labeled with the date they were opened and a discard date. The facility policy, Medication Administration, dated 08/23, stated insulin vials may be kept at room temperature in the patient's medication drawer and should be dated when opened; insulin is outdated 28 days after being opened.
Failure to Invite Resident or Responsible Party to Care Plan Meetings
Penalty
Summary
The facility failed to ensure Resident 1 was given the opportunity to participate in the development and implementation of the person-centered plan of care when staff did not invite the resident or the responsible party to care plan meetings. Resident 1’s EMR documented diagnoses of DM and a displaced intertrochanteric fracture of the right femur. The admission MDS documented a BIMS score of 15, indicating intact cognition, and also showed the resident required moderate assistance with ADLs and touching assistance with bed mobility and transfers. The resident’s CAA documented a left arm sling, right hip fracture, and falls. Resident 1’s care plan documented a goal of returning to care of her husband once therapy goals were met and she was safe to go home. A progress note documented a care team meeting attended by administrative nurses and a consultant staff member, with discharge planning discussed, but the resident later reported she had not been invited or attended a care plan meeting about her care or discharge plan since admission. Administrative Nurse F stated the care plan meeting would include staff members only, and also stated that if a resident or family member was invited but refused to attend, it would not be documented. Administrative Nurse D stated she expected staff to invite the resident and/or responsible party to a care plan meeting. The facility policy required the resident and/or family to receive a letter inviting them to the next interdisciplinary care meeting and stated resident-centered interdisciplinary conferences would be held weekly.
Failure to Notify LTCO of Resident Discharges
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for two residents. Record review showed that one resident was discharged home and another resident was also discharged home, but the facility was unable to provide evidence that the LTCO was notified of either transfer/discharge. During an interview, the Administrative Nurse reported that the facility did not notify the LTCO when a resident was transferred or discharged, and the facility did not provide an Ombudsman Notification policy.
Failure to Assess and Treat Present-on-Admission Pressure Ulcer
Penalty
Summary
The facility failed to adequately assess a resident’s present-on-admission pressure ulcer at the time of admission and failed to ensure wound treatment orders were obtained and treatments were provided. The resident had diagnoses including weakness, frailty, and CHF, and the admission physical assessment documented a Stage 2 pressure ulcer on the sacrum without assessment or measurement. The resident’s EMR also showed no admission MDS completed, and the physician orders did not include a treatment order for the Stage 2 pressure ulcer, only lanolin ointment as needed for skin irritation. The Braden Scale dated on admission documented a score of 19, indicating low risk. Subsequent documentation was inconsistent regarding the wound location and stage, with the hospitalist history and physical documenting a sacral pressure ulcer as Stage 1, while nursing shift assessments documented a Stage 2 pressure injury on the sacrum and later on the right buttock. Nursing documentation noted provider awareness and use of a sacral adhesive foam, but the wound was not measured on admission, no picture was completed, and no treatment order was in place for the wound on the right inner buttock. A nurse reported the wound should have been measured and documented on admission and that an order should have been obtained from the provider. On later observation, the dressing on the sacrum did not cover the open area on the right inner buttock, and the wound was observed with serosanguinous drainage, red wound bed, and macerated peri-wound skin.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information through Payroll-Based Journaling (PBJ) based on payroll and other verifiable and auditable data. The PBJ Staffing Date Report showed no RN hours triggered four or more days within the quarter with no RN hours, and it also showed the facility failed to have licensed nursing coverage 24 hours per day for four or more days within the identified quarters of FY 2026 Quarter 1 and FY 2025 Quarter 3. Review of the nursing schedule for 04/01/25 through 06/30/25 and 10/01/25 through 12/31/25 showed the facility had 24 hours per day of licensed nursing coverage when the Skilled Nursing Unit was open. On 04/22/26, Administrative Nurse D and Administrative Nurse E confirmed the PBJ data inaccuracies for the identified quarters and stated that neither had reviewed the PBJ reports before that day and were unsure why the reports were submitted inaccurately. Later that day, Administrative Nurse D stated she expected the PBJ reports to be submitted accurately. The facility policy stated that staffing data submitted through PBJ must be based on payroll and other auditable data and that the system is used to collect staffing information, turnover, and tenure data.
Failure to Sanitize Thermometer Before Food Temperature Measurement
Penalty
Summary
The facility failed to maintain sanitary conditions during food service, which could potentially lead to foodborne illness among residents. During an observation of the noon meal service, a dietary staff member used a thermometer probe to measure the temperature of a steak product without sanitizing it first. The thermometer was stored in a sheath in the staff member's sleeve pocket, which was not fully enclosed and had a pre-manufactured hole, raising concerns about its cleanliness. The dietary staff member acknowledged that the thermometer should have been sanitized before use, as per the facility's policy. The dietary manager confirmed that all thermometers should be sanitized with a commercially available sanitizer solution or isopropyl alcohol wipe before each use. The facility's policy, dated 2022, requires that food temperatures be taken at the beginning of tray service using a sanitized stem thermometer. This oversight in following proper sanitization procedures had the potential to negatively affect all residents in the facility.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain and dispose of garbage and refuse properly, which was observed during a survey. The initial tour of the kitchen facilities revealed that the outside dumpster area contained eight double-lidded dumpsters, with four of the lids left open. The Dietary Manager stated that the dumpsters were shared with an attached hospital, and the hospital's environmental services staff routinely left the lids open, which was an ongoing problem. The facility did not provide a policy related to garbage and refuse handling and disposal when requested. Observations on subsequent occasions showed that some dumpster lids remained open, indicating a failure to maintain sanitary conditions and prevent the harborage and feeding of pests.
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 did not accurately report 24-hour per day Licensed Nurse (LN) coverage on 59 different dates throughout the year 2023. This deficiency was identified through a review of the Payroll Base Journal (PBJ) Staffing Data Report, which revealed multiple instances where the facility lacked LN coverage for 24 hours a day, seven days a week, as mandated by CMS specifications. The report highlights that the facility did not have a policy in place for the accurate completion of PBJ reports, which contributed to the inaccurate reporting. Despite the facility's claim that they had the required 24-hour nurse staff on the mentioned days, the lack of a formal policy and the discrepancies in the PBJ reports indicate a failure to comply with CMS requirements for staffing data submission.
Deficiency in CNA Training on ANE and Dementia Care
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) had the required in-service education, including training on abuse, neglect, and exploitation (ANE). Additionally, one CNA lacked training in dementia management. This deficiency was identified through a review of five staff personnel files and in-service training records, which revealed that none of the CNAs had received the necessary ANE training, and one CNA was missing dementia care training. Administrative Staff M and Administrative Nurse B confirmed the lack of required training. The facility's Employee Annual Education policy, dated May 2024, required ongoing annual in-service training on ANE but did not include documentation for dementia care training. This oversight placed residents at risk for inadequate care.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to accurately complete a comprehensive assessment on the Minimum Data Set (MDS) for a resident within the required 14-day timeframe. The resident, who was admitted with a diagnosis of diabetes mellitus type two, a diabetic left foot ulcer, and pain, did not have an Admission MDS completed. The resident's Electronic Health Record (EHR) lacked this crucial assessment, despite being admitted on a specified date. The facility's policy mandates that the MDS coordinator complete an admission MDS no later than 14 days after admission, which was not adhered to in this case. Interviews with facility staff revealed a lack of awareness and understanding regarding the necessity of completing the MDS for this resident. An Administrative Nurse acknowledged that the admission MDS was not completed because the resident was covered by private insurance and typically, patients do not stay longer than two weeks. A Licensed Nurse also admitted to not being aware of the requirement for an MDS due to the Patient Driven Payment Model (PDPM) and noted the absence of alerts in the EHR to prompt MDS completion. This oversight had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs.
Inadequate Hand Hygiene During PICC Line Care
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in relation to hand hygiene during the care of a resident with a peripherally inserted central catheter (PICC). On the observed date, a licensed nurse (LN) was seen handling a wound vac and its bag with gloves on, then proceeded to apply a personal protective gown without changing gloves. The nurse then removed the dressing from the PICC line site, changed gloves, but did not perform hand hygiene before or after the glove change. This lack of hand hygiene was noted during the procedure of removing the PICC line dressing. Interviews with administrative nurses revealed that the expected protocol was not followed. Hand hygiene should have been performed before any care was delivered, after handling potentially contaminated equipment like the wound vac, and between glove changes. The facility's policy on PICC line care, dated May 2022, also emphasized the importance of washing hands and using non-sterile gloves. The nurse involved acknowledged the oversight, admitting that she should have washed her hands before and after glove changes during the procedure.
Failure to Administer Requested Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a requested pneumococcal vaccine to a resident, identified as R6, before discharge. The Electronic Health Record (EHR) for R6 lacked documentation of the pneumococcal vaccine being administered, despite a signed consent form being present in the resident's paper chart. An immunization assessment indicated that the physician should be informed of the patient's need for the vaccine before discharge. However, Administrative Nurse C acknowledged that the vaccine administration 'slipped through the cracks,' and Administrative Nurse O confirmed that R6 was eligible for the vaccine upon admission and expected it to be administered before discharge. The facility did not have a policy in place for pneumococcal vaccination, contributing to the oversight.
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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 2 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
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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) |
|---|---|---|---|---|
| Wheatridge Park Care Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Liberal | 0.9 mi | ★★★★★ | 1 | 0 |
| Stevens County Hospital Ltcu Dba Pioneer Manor | 24.3 mi | ★★★★★ | 1 | 0 |
| Satanta District Hospital Ltcu | 26.7 mi | — | 0 | 0 |
| Beaver County Nursing Home | 28.7 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.