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 Stevens County Hospital Ltcu Dba Pioneer Manor during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete or document required pre-employment criminal background checks for two CNAs before they were hired and allowed resident contact. Personnel file reviews showed no evidence of background screenings for these staff, and administrative staff confirmed they could not locate any such records or explain why the checks were not done, despite a written abuse, neglect, and exploitation policy requiring screening and documentation for all potential employees.
A facility failed to provide necessary ADL care for a resident, leading to prolonged exposure to soiled briefs and skin damage. Another resident experienced a significant weight loss of 10.75% over four months due to inadequate assistance with meals. Both residents had cognitive impairments and required substantial assistance, but the facility's care practices were insufficient, resulting in deficiencies in personal hygiene and nutritional management.
Two residents developed preventable pressure ulcers due to the facility's failure to implement effective prevention and treatment measures. One resident, with multiple medical conditions, developed a stage 3 ulcer due to inconsistent skin assessments and lack of treatment orders. Another resident, at risk for pressure ulcers, developed stage 2 injuries due to an inappropriate air mattress and inadequate skin monitoring. Staff interviews revealed a lack of wound care training and understanding of equipment use.
A resident with dementia experienced a 10.75% weight loss over four months without appropriate interventions. Despite being at high risk for weight loss, the care plan only included monitoring, and no dietary interventions were initiated. Observations showed inconsistencies in meal assistance, and staff interviews confirmed the weight loss was discussed but not addressed with new orders. The facility's weight policy requiring notification and referral for significant weight loss was not followed.
The facility failed to maintain an effective infection prevention and control program, with staff not consistently performing hand hygiene and failing to implement enhanced barrier precautions (EBP) for residents with open wounds. Additionally, the infection control surveillance program was ineffective, with incomplete and inaccurate documentation. These practices had the potential to affect all residents.
The facility failed to implement an effective antibiotic stewardship program, impacting their Infection Prevention and Control Program. The Infection Preventionist admitted the program was ineffective, with untrained staff completing incomplete Infection Control Surveillance Logs. Despite attempts to enforce McGeer criteria, more staff education was needed. The facility's policy outlined a mission for optimal antimicrobial therapy, but practices like prescribing prophylactic antibiotics after two UTIs did not align with guidelines, potentially affecting all 73 residents.
The facility failed to ensure the Infection Preventionist (IP) effectively managed the Infection Prevention and Control Program (IPCP), affecting 73 residents. Administrative Staff B, the designated IP, admitted the IPCP was ineffective, with floor nurses completing incomplete Infection Control Surveillance Logs. These logs lacked critical information and mapping for tracking infections. The nurses were not trained in infection control or Antibiotic Stewardship, contrary to the facility's policy requiring the IP to oversee infection surveillance and management.
The facility failed to provide the required annual in-service training for CNAs, including dementia care and abuse prevention. A review showed one CNA had less than the required 12 hours of training, and two CNAs lacked dementia care training. Administrative Staff A confirmed the absence of additional training records and the facility did not provide a policy on CNA continuing education.
The facility failed to verify valid advanced directives for three residents, leading to potential uncommunicated needs regarding end-of-life care. Despite indications of valid DNR orders in the EHR, necessary documentation was missing or incomplete, including lack of signatures from residents, representatives, or physicians. Staff interviews confirmed the deficiency, and the facility did not provide a policy on advanced directives when requested.
The facility failed to accurately complete MDS assessments for three residents, resulting in uncommunicated care needs. One resident's behaviors were not documented, another's oxygen use was omitted, and a third's need for total assistance with ADLs was inaccurately recorded. Staff interviews confirmed these discrepancies, highlighting lapses in the facility's assessment process.
The facility failed to update care plans for four residents after changes in psychotropic medications and the development of pressure ulcers. One resident's care plan was delayed by four months for a pressure ulcer update, and medication changes were not reflected. Another resident's care plan lacked updates for an open area on the back. Two other residents' care plans did not accurately reflect medication changes. Staff interviews indicated a lack of comfort in updating electronic health records, and no policy on care plan revisions was provided.
The facility failed to provide safe respiratory care for several residents, with observations showing improper handling and storage of oxygen equipment. Oxygen tubing was found on the floor, in baskets, and improperly stored, contrary to facility policy. Staff interviews revealed a lack of adherence to storage protocols, contributing to the deficiency.
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 35.71%. Errors included incorrect water flush for a PEG tube, mixing medications without physician orders, and leaving medications unsupervised. Additionally, a resident's Prednisone was unavailable, and Metoprolol Succinate was not administered as extended-release. These actions violated facility policies and placed residents at risk.
The facility failed to ensure proper labeling and secure storage of medications, with observations of expired drugs in residents' rooms, unsecured medication drawers, and improper handling of narcotics by staff. Interviews confirmed non-compliance with policies requiring secure storage and proper administration of medications.
The facility failed to provide pneumococcal and influenza vaccines or obtain consent/declination forms for several residents, and did not document a required assessment before administering the influenza vaccine to another resident. The facility's Immunization Policy was not followed, as confirmed by an administrative nurse.
A resident with multiple health issues and intact cognition was discharged without active discharge planning. Despite being dependent on staff for most ADLs and having no initial plans for discharge, the resident was sent home with a spouse after the family notified the facility. The EHR lacked evidence of discharge planning, and administrative nurses confirmed its absence. The facility did not provide a discharge planning policy when requested.
The facility failed to remove accident hazards for a resident with impaired cognition, leaving a disposable razor within reach and the call light out of reach. Additionally, staff incorrectly used a mechanical lift for another resident, not following the facility's policy, which led to unsafe transfer practices.
A resident with dementia and depression was not provided with adequate behavioral health care, as the facility failed to monitor and document targeted behaviors and delayed referring the resident to a behavioral health provider. Despite being on antianxiety and antidepressant medications, the resident remained tearful and sad, with staff interviews revealing a lack of awareness and communication regarding the resident's mental health needs.
The facility failed to complete AIMS assessments for two residents receiving Seroquel and did not provide a rationale for not following pharmacy recommendations for a GDR. One resident received Seroquel for several months without an AIMS assessment, and another had incomplete assessments and unaddressed pharmacy recommendations. Staff interviews confirmed these deficiencies, which were identified during an onsite survey.
Failure to Complete and Document Required Pre-Employment Background Checks
Penalty
Summary
The facility failed to develop and implement a process to ensure required pre-employment criminal background checks were completed and documented for all staff prior to hire and resident contact. Review of personnel records for two certified nurse aides (one CMA and one CNA) showed hire dates in late 2023 and mid-2024, respectively, with no evidence that pre-employment criminal background checks had been completed. When surveyors requested documentation of these checks, the facility was unable to provide any proof that the screenings had been performed for either employee. Administrative staff confirmed they could not locate criminal background checks for these two employees and could not explain why the tasks were not completed. The facility’s written Abuse, Neglect and Exploitation policy, dated 06/25/24, stated that all potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property and that the facility would maintain documentation proving that such screening occurred. Despite this policy, the facility’s records and staff interviews demonstrated that the required background checks and corresponding documentation were not in place for these two staff members, resulting in noncompliance with the facility’s own procedures and regulatory expectations for preventing abuse, neglect, exploitation, and misappropriation.
Deficiencies in ADL Care and Weight Management
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for Resident 20, who was at risk for poor personal hygiene and related complications. Resident 20 had multiple diagnoses, including idiopathic peripheral neuropathy, pressure ulcer, venous hypertension with ulceration, dementia, and other conditions. The resident was dependent on staff for assistance with activities of daily living (ADLs) and required substantial assistance with all cares except eating. On a specific day, Resident 20 was observed in a geri-recliner in the dining area, calling out for assistance to use the bathroom, which was ignored by staff for over an hour. This delay in care resulted in the resident soiling his brief and developing moisture-associated skin damage. The facility also failed to assist Resident 72 with meals, contributing to a significant weight loss of 10.75% over four months. Resident 72 had moderately impaired cognition and required maximum assistance with ADLs, including eating. Despite being at high risk for weight loss, the facility did not ensure that Resident 72 was assisted to the dining area for meals or provided assistance with meals in her room. Observations showed that Resident 72 was not consistently assisted to the dining room for meals, and there was a lack of documentation and intervention regarding her weight loss. The facility's policies on pressure ulcer treatment and prevention, as well as weight management, were not effectively implemented. The failure to provide prompt ADL care to Resident 20 and to initiate weight loss interventions for Resident 72 demonstrated deficiencies in the facility's care practices. These deficiencies placed both residents at risk for negative health outcomes, including skin breakdown and further weight loss.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and provide adequate treatment for two residents, leading to deficiencies in care. Resident 24, who had multiple medical conditions including fractures, lymphoma, and dementia, developed a stage 3 pressure ulcer on her back. Despite having a care plan that included interventions for pressure ulcer prevention, such as repositioning and the use of pressure-reducing devices, the facility did not document or implement effective measures to prevent the worsening of her condition. The resident's skin assessments were inconsistent, and there were no treatment orders for her wounds, indicating a lack of proper wound care management. Resident 14, diagnosed with diabetes and muscle weakness, was identified as at risk for pressure ulcers but developed multiple stage 2 pressure injuries. The facility's failure to provide an appropriate weight-based intervention, such as a suitable air mattress, contributed to the development of these injuries. The resident's air mattress was not functioning properly, and staff were unaware of the weight limit and settings required for effective use. Additionally, the facility did not consistently monitor, measure, or assess the resident's skin condition, leading to inadequate care and management of his pressure injuries. Interviews with staff revealed a lack of wound care training and understanding of equipment use, further contributing to the deficiencies. The facility did not have a dedicated wound nurse, and the household nurse was responsible for weekly skin assessments, which were not consistently performed. The facility's policies on pressure ulcer treatment and prevention were not effectively implemented, resulting in preventable pressure injuries for both residents.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to initiate weight loss interventions for a cognitively impaired resident, identified as R72, who experienced a significant weight loss of 10.75% over four months. R72, diagnosed with dementia and vitamin deficiency, required maximum assistance with activities of daily living, including eating. Despite being at high risk for weight loss due to a new admission and lifestyle changes, the care plan only included monitoring nutritional status and weight, without implementing specific interventions to address the weight loss. The resident's weight fluctuated significantly, with records showing a decrease from 93 pounds to 83 pounds over the specified period. Observations revealed inconsistencies in the resident's meal assistance, with R72 sometimes not being assisted to the dining room for meals and reporting thirst. Despite these fluctuations and the resident's decreased food intake, no dietary interventions or supplements were initiated following the risk meeting on December 5, 2024, where the weight loss was discussed. Interviews with facility staff, including a registered dietician and administrative nurses, confirmed that the weight loss was acknowledged but not addressed with new orders or interventions. The facility's weight policy required notification and referral to a registered dietitian for significant weight loss, which was not followed in this case. The lack of timely intervention and documentation of progress notes or orders for supplements contributed to the deficiency in care for R72.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. Staff did not consistently perform hand hygiene before and during care for multiple residents, including R20, R27, and R14. For instance, CNA S applied medicated creams to R14's buttock and groin area without changing gloves or washing hands between tasks. Similarly, LN H and CNA I did not wash their hands when applying PPE or handling dressing change supplies for R27, and LN H used the same gloves to perform multiple tasks without hand hygiene. The facility also failed to implement enhanced barrier precautions (EBP) for residents with open wounds, such as R24, R14, R27, and R20. During a dressing change for R24, LN BB did not wear a gown and was unaware of the need for EBP for open wounds. Interviews revealed that staff were not consistently applying EBP, and some were unaware of the policy requirements. Administrative Nurse B confirmed that residents with open areas should be on EBP, but this was not consistently practiced. Additionally, the infection control surveillance program was ineffective, as demonstrated by incomplete and inaccurate documentation. Surveillance logs for R12 and R48 lacked necessary details, such as culture results and causative organisms. Administrative Nurse B acknowledged the deficiencies in the infection control program, including the lack of proper tracking and trending of infections. These practices had the potential to affect all residents in the facility.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, which is a critical component of their Infection Prevention and Control Program (IPCP). During an interview, Administrative Staff B, who was identified as the Infection Preventionist, admitted that the facility did not have an effective infection control program, including an Antibiotic Stewardship Program. The staff responsible for completing the Infection Control Surveillance Logs were not trained in infection control or antibiotic stewardship. The logs were found to be incomplete, lacking information such as the causative organism, site of infection, and further documentation after a culture was documented. Additionally, there was no mapping of infections within the facility. Administrative Nurse B attempted to enforce the McGeer criteria for documenting the appropriateness of antibiotics but acknowledged that more education was needed for the staff. The facility's policy, dated 12/28/17, outlined the mission to provide the best antimicrobial therapy and establish an Antibiotic Stewardship Program team to review infections and monitor antibiotic usage patterns. However, the facility did not adhere to these guidelines, as evidenced by the resident physician's practice of prescribing prophylactic antibiotics after a resident had two urinary tract infections, which did not align with the Antibiotic Stewardship Guidelines. This failure had the potential to affect all 73 residents in the facility.
Inadequate Infection Control Program Management
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) effectively assessed, implemented, and monitored the Infection Prevention and Control Program (IPCP), potentially affecting all 73 residents. During an interview, Administrative Staff B, who was designated as the IP, admitted that the facility did not have an effective IPCP. The floor nurses, rather than the IP, completed the Infection Control Surveillance Logs, which were found to be lacking critical information such as causative organisms, sites of infection, and documentation of cultures. Additionally, the logs did not include mapping for tracking and trending infections. Administrative Staff B acknowledged that the nurses were not trained in infection control or Antibiotic Stewardship, which was necessary for the effective management of the IPCP. The facility's Infection Control Policy required the IP Nurse to oversee the program, including surveillance, tracking, and trending of infections, but these responsibilities were not adequately fulfilled.
Deficiency in CNA In-Service Training Program
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required annual in-service training, including specific topics such as dementia care and abuse prevention. A review of training records for five CNAs employed for over a year revealed deficiencies in the training program. One CNA had less than the mandated 12 hours of documented in-service training, with only eight hours and twelve minutes recorded. Additionally, two CNAs did not receive training on required topics, specifically lacking dementia care education. Administrative Staff A acknowledged the deficiencies, confirming the absence of additional training records for the CNAs in question. The facility did not provide a policy related to CNA continuing education and in-service training when requested. This lack of documentation and adherence to training requirements indicates a failure to develop, implement, and maintain a comprehensive in-service training program for CNAs, as mandated.
Failure to Verify Valid Advanced Directives
Penalty
Summary
The facility failed to verify valid advanced directives for three residents, which could lead to uncommunicated needs regarding end-of-life care. Resident 20 had a severely impaired cognition with a BIMS score of six, and although the EHR indicated a valid DNR order, the Physician's Orders tab and Resident Documents tab lacked a DNR order. A prescription pad signed by a physician was provided, but it was not valid as it lacked the resident's or representative's signature and a witness signature. Resident 62 also had severely impaired cognition, and while the EHR indicated a valid DNR order, the necessary documentation was missing in both the Physician's Orders tab and Resident Documents tab. Resident 72, with a BIMS score indicating severely impaired cognition, had a DNR form in the Resident Documents tab, but it was not signed by a physician, rendering it invalid. Interviews with staff revealed that the determination of full code versus DNR should be performed on admission, and the DNR paperwork should be signed by the resident or representative and witnessed by a physician. The facility did not provide a policy regarding advanced directives or DNR when requested, further highlighting the deficiency in verifying valid advanced directives for these residents.
Inaccurate MDS Assessments Lead to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in capturing essential care needs. For one resident, behaviors were not documented in the MDS despite being recorded in the medication administration record (MAR) during the look-back period. The administrative nurse admitted to not reviewing the targeted behaviors documented on the MAR, resulting in the omission. Another resident's use of oxygen was not captured in the annual MDS, which was confirmed by the administrative nurse during an interview. Additionally, a third resident's MDS inaccurately reflected their need for assistance with activities of daily living (ADLs). The admission MDS indicated substantial to maximal assistance, while the quarterly MDS showed total assistance was required. The administrative nurse acknowledged the error, stating she did not realize the need to capture the correct level of assistance. Interviews with staff confirmed that the resident had consistently required total assistance since admission. The facility's policy mandates accurate and comprehensive assessments, but these lapses placed residents at risk for uncommunicated care needs.
Failure to Update Care Plans Following Medication Changes and Pressure Ulcers
Penalty
Summary
The facility failed to accurately revise care plans for four residents following changes in psychotropic medications and the development of pressure ulcers. Specifically, the care plan for one resident was not updated in a timely manner after a pressure ulcer was discovered, with a delay of four months before the care plan was revised. Additionally, this resident's care plan did not reflect changes in psychotropic medications, including the addition of Seroquel and Buspirone. Another resident's care plan was not revised to include an open area on the back upon readmission to the facility. Further deficiencies were noted in the care plans of two other residents, where changes in psychotropic medications were not accurately reflected. One resident's care plan did not include updates for multiple medication orders and discontinuations, such as Prozac, Lorazepam, Seroquel, and Trazodone. Another resident's care plan failed to remove discontinued medications and did not include a new order for Lexapro. Interviews with facility staff revealed that care plan updates were expected to be completed within a few days, but there was a lack of comfort among household nurses in updating electronic health records. The facility did not provide a policy regarding care plan revisions.
Deficiency in Respiratory Care and Oxygen Handling
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for five residents, as observed during a survey. The deficiencies included improper handling, storage, and dispensing of oxygen equipment. For instance, one resident's oxygen tubing was found connected to the concentrator with the nasal cannula hanging off the humidifier bottle. Another resident's oxygen tubing was observed coiled on the floor behind the concentrator. Additionally, a resident's oxygen tubing was placed in a basket on the bedside table, and another unused tubing was shoved in a basket beside a recliner. Furthermore, a nonrebreather mask was draped over a concentrator, unplugged, with the mask touching the floor. Interviews with staff revealed inconsistencies in the handling of oxygen equipment. A CNA mentioned that oxygen tubing and nasal cannulas should be placed in a bag and off the ground when not in use. However, the facility had recently removed plastic bags used for storage, citing a non-home-like environment, without providing an alternative solution. The facility's policy required nasal cannulas and nebulizer masks to be stored in plastic bags when not in use and changed weekly, but this was not adhered to. These actions and inactions led to the deficiency in providing respiratory care consistent with professional standards of practice.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 35.71% during the survey. This was observed in two of the four households reviewed during the medication administration pass. A total of 42 medication opportunities were observed, with 15 medication errors identified. These errors placed residents at risk for adverse reactions from the medications. One specific incident involved a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, where the physician's orders required the tube to be flushed with 150 milliliters of water before and after medication administration. However, a licensed nurse administered only 90 milliliters of water, citing the resident's tendency to become nauseous. Additionally, the nurse mixed the resident's medications together in water, contrary to the physician's orders and facility policy, which required medications to be administered separately unless otherwise directed by a physician. Another incident involved a resident whose medications were not administered correctly. The resident's Prednisone was unavailable, and the Metoprolol Succinate administered did not match the extended-release order. Furthermore, the nurse left the resident's medications unsupervised in the room, which was against facility policy. The resident's care plan and electronic health record lacked documentation regarding self-administration of medications, and the nurse was unsure if the resident's request to have medications left in the room was documented. These actions were contrary to the facility's policies on medication administration and security.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled and stored in locked compartments, allowing only authorized personnel access to the keys. During observations, it was noted that a resident had a medication cup with pills left unattended in her room, which she took without staff supervision. Additionally, expired medications were found in multiple residents' rooms, including Nystatin powders and saline nasal gel, which were not removed or disposed of as per policy. Further observations revealed that a licensed nurse left a medication drawer unlocked and unattended while preparing a resident's medication, and another nurse carried narcotic medications for multiple residents in a pill container in her pocket without proper labeling or documentation of administration times. The medication room contained expired and undated medications, including Novolog insulin and Miralax, which were not disposed of or labeled correctly. Interviews with staff confirmed that medications were sometimes left unsecured in residents' rooms, and there was a lack of adherence to the facility's policies regarding medication storage and administration. The facility's policies required that medications be stored securely, outdated medications be disposed of immediately, and that staff observe residents taking their medications, none of which were consistently followed, leading to the identified deficiencies.
Deficiencies in Vaccine Administration and Documentation
Penalty
Summary
The facility failed to provide the pneumococcal vaccine or obtain consent/declination forms for two residents, and similarly failed to provide the influenza vaccine or obtain consent/declination forms for three residents. Additionally, the facility did not complete and document a required assessment prior to administering the influenza vaccine to another resident. These deficiencies were identified through interviews and record reviews, which revealed a lack of documentation in the Electronic Health Records (EHR) for the involved residents. The facility's existing Immunization Policy, dated August 2017, mandates that all residents be offered the influenza vaccine annually and that new admissions be offered the pneumonia vaccine. The policy also requires that a resident's temperature be taken prior to vaccine administration. However, the facility did not adhere to these protocols, as confirmed by an administrative nurse during an interview, who acknowledged the absence of necessary documentation and assessments in the residents' EHRs.
Lack of Active Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure active discharge planning for a resident, identified as R75, who was admitted with multiple diagnoses including abnormal weight loss, urinary tract infection, urosepsis, osteoarthritis, and chronic obstructive pulmonary disease. The resident had intact cognition, as indicated by a BIMS score of 15, and was dependent on staff for most activities of daily living (ADLs), using a wheelchair and having an indwelling urinary catheter. Despite these needs, the care plan did not include plans for discharge, and the family did not expect the resident to return home. However, on a later date, the family notified the facility that the resident would be going home, and the physician provided discharge orders. The resident was discharged home with a spouse, and a packet for community resources was provided. Despite this, the electronic health record lacked evidence of active discharge planning prior to the discharge, and during an interview, administrative nurses confirmed that no discharge planning had occurred. The facility also failed to provide a policy related to discharge planning when requested, indicating a deficiency in the discharge planning process.
Failure to Remove Accident Hazards and Incorrect Use of Mechanical Lift
Penalty
Summary
The facility failed to identify and remove accident hazards for three residents, leading to potential risks to their physical and psychosocial well-being. Resident 60, who had severely impaired cognition and was dependent on staff for assistance, was left unattended with a disposable razor within reach and his emergency call light out of reach. Despite his mental health conditions, including anxiety disorder, Alzheimer's disease, and dementia, staff did not ensure the removal of the razor or the accessibility of the call light, which was observed on multiple occasions. Resident 20, who had moderately to severely impaired cognition and was dependent on staff for most activities of daily living, was subjected to incorrect use of a mechanical lift. During a transfer from a geri-recliner to a bed, staff used the lift at an angle rather than directly in front of the resident, contrary to the facility's policy. This practice was observed during a transfer, where one staff member let go of the resident, allowing them to swing independently, which was not in line with the correct procedure. The facility's failure to adhere to its own policies and procedures regarding accident hazards and mechanical lift usage was evident in these incidents. The staff did not follow the correct protocols for ensuring resident safety, as outlined in the facility's policies, which contributed to the deficiencies observed during the survey.
Failure to Provide Adequate Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as R5, who had been sad and tearful since admission. R5 had diagnoses of dementia and depression, and was on routine antianxiety and antidepressant medications. Despite these medications, R5 continued to exhibit signs of sadness and tearfulness, which were not adequately addressed by the facility. The resident's care plan included monitoring for mood symptoms and providing one-on-one support, but these interventions were not effectively implemented. The facility's records revealed several deficiencies in the management of R5's mental health needs. There was a lack of targeted behavior monitoring and documentation, as the physician orders did not include instructions to monitor and document specific behaviors. Additionally, there was a delay in referring R5 to a behavioral health provider, despite a request made by the resident to see a therapist. The social service designee was unaware of the order for behavioral therapy, and the administrative nurse was not aware of the resident's ongoing tearfulness and the need for targeted behavior charting. Interviews with staff indicated a lack of awareness and communication regarding R5's mental health needs. The social service designee did not document the new behavioral health services in the resident's electronic health record, and the administrative nurse was unaware of the resident's request for therapy. The facility also lacked a policy for treatment and services for mental and psychosocial concerns, contributing to the inadequate care provided to R5, who remained tearful and sad since admission.
Failure to Complete AIMS Assessments and Address GDR Recommendations
Penalty
Summary
The facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments for two residents, R62 and R20, who were receiving Seroquel, an antipsychotic medication. R62's electronic health record (EHR) showed that they received Seroquel for several months without an AIMS assessment being completed. Additionally, the facility did not provide a rationale for not following the pharmacy's recommendation for a gradual dose reduction (GDR) of R20's Seroquel. The lack of AIMS assessments and failure to address the pharmacy's recommendations were identified during an onsite annual survey. R62's EHR indicated that they received Seroquel for a diagnosis of dementia, which was later changed to restlessness and agitation. Despite receiving Seroquel routinely, no AIMS assessments were completed during the seven months of administration. The pharmacist did not make any recommendations regarding the Seroquel administration for R62 until later, when a GDR was suggested for other medications. Eventually, R62's medication regimen was adjusted following a behavioral health consult. R20's EHR revealed that they received Seroquel for dementia and had AIMS assessments completed earlier in the year, but none were done from August to December. The pharmacist recommended a GDR for Buspirone, another medication R20 was taking, but the provider disagreed without providing a rationale. Interviews with facility staff confirmed the lack of appropriate responses to pharmacy recommendations and the failure to complete required AIMS assessments. The facility's policy on psychotropic medication use emphasized the need for adequate indication and monitoring, which was not adhered to in these cases.
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 Hugoton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wheatridge Park Care Center | 23.6 mi | ★★★★★ | 0 | 0 |
| Southwest Medical Center Snf | 24.3 mi | ★★★★★ | 18 | 0 |
| Good Samaritan Society - Liberal | 24.6 mi | ★★★★★ | 1 | 0 |
| Satanta District Hospital Ltcu | 27.5 mi | — | 0 | 0 |
| Western Prairie Senior Living Llc | 29.3 mi | ★★★★★ | 20 | 0 |
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