Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Sam Swope Care Center during CMS and state inspections, most recent first.
A facility failed to honor a resident's advance directive, mistakenly entering a DNR order instead of the resident's chosen Full Code status. The error was compounded by allowing the POA to sign DNR documents, despite the resident's capability to make his own decisions. Staff interviews revealed a lack of awareness of the resident's true code status, with the LPNUM admitting to selecting DNR in error. This miscommunication placed the resident at risk, as staff were prepared to follow the incorrect DNR order.
The facility failed to implement comprehensive care plans for four residents, leading to discrepancies in care. A resident's care plan conflicted with their full code status, risking emergency response errors. Another resident's Foley catheter use was not addressed in their care plan, despite physician orders. A third resident's dialysis access site was not monitored due to a discontinued order, and a fourth resident on warfarin lacked a care plan for monitoring side effects. These oversights were confirmed by staff and highlighted a lack of adherence to care protocols.
The facility failed to ensure that supplies in medication rooms and crash carts were not expired, affecting three out of six medication rooms and crash carts. Observations revealed expired medical supplies, including test kits and securement devices. Interviews with LPNs and the central supply worker indicated a lack of clarity in responsibility for checking expiration dates. The DON and Administrator confirmed the need for regular audits to prevent the use of expired supplies.
A resident with severe cognitive impairment due to dementia was inadequately supervised, leading to repeated wandering into other residents' rooms, causing privacy intrusions and safety concerns. Despite staff attempts to redirect and occupy the resident with activities, these measures were ineffective. The facility's policy did not adequately address privacy intrusions, and staff acknowledged the ongoing issue and resident complaints.
A facility failed to monitor a resident's tunnel catheter post-dialysis, potentially impacting the quality of hemodialysis care. The resident's care plan included monitoring for infection, but records showed no documentation of catheter monitoring. Staff interviews revealed the treatment order was discontinued due to changes in the access site, and the order was not reinstated. The DON confirmed the oversight, and the Executive Director emphasized the need to follow protocols.
A resident receiving warfarin for conditions such as coronary artery disease and atrial fibrillation was not monitored for side effects, including bleeding, as required. Despite the expectation from the DON and Executive Director for such monitoring, there was no documentation of it being performed, and the facility lacked a policy for anticoagulant monitoring.
A resident reported an allegation of sexual abuse, but the facility failed to document this in the resident's medical record. Staff interviews revealed a practice of not documenting potentially reportable incidents unless approved by the Administrator or DON, leading to incomplete and inaccurate medical records.
A resident reported an allegation of sexual abuse to a PTA, who informed the SW. The SW interviewed the resident and reported the allegation to the DON. However, the Administrator was not informed until later, and the report to the SSA was delayed beyond the required two-hour timeframe. The resident's medical record lacked documentation of the allegation and immediate assessments, compromising the investigation.
The facility failed to thoroughly investigate abuse allegations for two residents. One resident with dementia reported sexual abuse, but the investigation lacked documentation of key interviews and assessments. Another resident, moderately cognitively impaired, was involved in a verbal altercation with CNAs, but the investigation did not include video footage review. The Administrator's responses indicated gaps in the investigation process.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor a resident's right to formulate an advance directive, resulting in a significant discrepancy between the resident's wishes and the documented code status. Resident 85, who was cognitively intact and capable of making his own decisions, had clearly expressed and signed a directive to be a Full Code upon admission. However, the facility erroneously entered a Do Not Resuscitate (DNR) order into the electronic medical record, contradicting the resident's explicit wishes. The error was compounded when the facility allowed the resident's Power of Attorney (POA) to sign DNR documents, despite the resident's capability to make his own decisions. Interviews with staff revealed a lack of awareness and understanding of the resident's true code status, with multiple staff members incorrectly identifying the resident as a DNR based on the erroneous documentation. The Licensed Practical Nurse Unit Manager (LPNUM) responsible for entering the order admitted to mistakenly selecting DNR from a drop-down menu, further highlighting the procedural oversight. The situation was exacerbated by a lack of communication and verification between the facility staff, the resident, and the POA. The POA, who had previously signed DNR paperwork, was not aware of the resident's current wishes to be a Full Code. This miscommunication and procedural error placed the resident at risk, as staff were prepared to follow the incorrect DNR order in the event of a cardiac or respiratory emergency.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for four residents, leading to significant discrepancies in their care. Resident 85, who was cognitively intact, had chosen to be a full code, meaning he wanted resuscitation efforts in case of cardiac or respiratory failure. However, his care plan contained conflicting information, indicating both a full code and a Do Not Resuscitate (DNR) status. This contradiction arose from a physician's verbal order entered by an LPN, which was not aligned with the resident's documented wishes. The care plan's inconsistency placed the resident at risk during a potential emergency. Resident 117, also cognitively intact, was admitted with a diagnosis of prostate cancer and had an indwelling Foley catheter. Despite the presence of physician orders for catheter care, the resident's care plan did not address the use of the Foley catheter. This omission was confirmed by the MDS Coordinator, who acknowledged that the care plan should have included specific interventions for the catheter. The Director of Nursing also confirmed that the care plan should have been updated to reflect the resident's needs, as the care plan serves as a guide for staff in providing appropriate care. Resident 90, who had chronic renal failure and received dialysis, had a care plan that included monitoring the access site for complications. However, the treatment order for monitoring the resident's chest tunnel catheter was inadvertently discontinued, and there was no documentation of monitoring in the resident's records. The Director of Nursing confirmed the oversight, and the resident reported that the nurse did not check the access site after dialysis. Additionally, Resident 59, who was on anticoagulant therapy with warfarin, did not have a care plan addressing the medication or monitoring for potential side effects. The lack of a care plan for the anticoagulant was confirmed by an LPN and the Director of Nursing, highlighting a failure to ensure the resident was monitored for bleeding and other side effects.
Expired Supplies in Medication Rooms and Crash Carts
Penalty
Summary
The facility failed to ensure that all supplies in the medication rooms and crash carts were not expired, which was observed in three out of six medication rooms and three out of six crash carts. During an observation and interview with an LPN on the [NAME] unit, it was revealed that a tuberculin purified serum was not dated when opened, and several test kits and medical supplies were expired. The LPN acknowledged that expired test kits could lead to inaccurate assessments and that nursing staff should have been checking for expiration dates. Further observations on the [NAME] unit and [NAME] House hall revealed additional expired medical supplies, including securement devices, test kits, and suction tubing. Interviews with LPNs indicated that while the crash carts were checked nightly by nursing staff, the responsibility for checking expiration dates was unclear. The central supply was supposed to restock the crash carts if opened, but they only checked if the cart was sealed and did not verify expiration dates. Interviews with the Central Supply Worker and the Director of Nursing (DON) confirmed that the central supply was responsible for stocking and auditing the crash carts weekly. However, the central supply worker admitted to not checking inside the crash carts for expired supplies. The DON acknowledged that expired supplies might not function properly and expressed uncertainty about why expired supplies were present. The facility's Administrator confirmed that both crash carts and medication rooms should be audited for expired supplies.
Inadequate Supervision of Wandering Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as R68, from wandering into other residents' rooms, which led to privacy intrusions and potential safety hazards. R68, who has a severely impaired cognitive status due to unspecified dementia, was observed repeatedly entering other residents' rooms, taking items, and lying in their beds. Despite attempts by staff to redirect and educate R68, these efforts were ineffective due to the resident's confusion and agitation. The facility's policy on wander/elopement precautions did not address the intrusion of privacy for other residents, which was a significant oversight given R68's behavior. The resident's care plan noted behavioral symptoms such as aggression towards staff and wandering, but the interventions in place, including redirection and the use of a fidget apron, were not successful in mitigating these behaviors. Observations and interviews with staff and other residents highlighted ongoing issues with R68's wandering, which caused distress among other residents and led to complaints. Staff interviews revealed that while they were aware of R68's behaviors, the interventions employed were not effective in preventing the resident from entering other rooms. The Director of Nursing and the Executive Director acknowledged the problem and were aware of the complaints from other residents. Despite efforts to keep R68 occupied with activities and redirection, the facility's measures were insufficient to prevent the resident from wandering and intruding on the privacy of others.
Failure to Monitor Dialysis Catheter Post-Dialysis
Penalty
Summary
The facility failed to monitor a resident's tunnel catheter post-dialysis for complications, which could potentially impact the quality of the resident's hemodialysis care. The resident, who had chronic renal failure and received dialysis, had a care plan that included monitoring the access area for signs of infection. However, the facility's records, including the treatment administration record and dialysis communication forms, showed no documentation of monitoring the resident's right chest tunnel catheter. Interviews with staff revealed that the treatment order for monitoring the catheter was discontinued due to changes in the access site from the arm to the chest, and the order was not reinstated. The Director of Nursing confirmed that there was no specific treatment order for monitoring the catheter, only a general one for infection, and acknowledged that the order had been inadvertently discontinued. The Executive Director stated that the expectation was for staff to follow protocols, physician orders, and the care plan related to the resident's tunnel catheter. This oversight in monitoring the catheter post-dialysis represents a deficiency in the facility's care for the resident.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to monitor a resident's drug regimen for side effects of an anticoagulant medication, specifically warfarin. The resident, identified as R59, had a history of coronary artery disease, atrial fibrillation, and deep venous thrombosis, and was receiving warfarin as part of their treatment. Despite the medication notes indicating the need to monitor for serious bleeding and other side effects, there was no documentation in the resident's Treatment Administration Record or notes indicating that such monitoring was conducted. Interviews with the Director of Nursing (DON) and the Executive Director revealed that there was an expectation for monitoring the resident for bleeding and other side effects, but this was not carried out. Additionally, the facility lacked a policy for monitoring anticoagulant medications like warfarin, which contributed to the oversight. The deficiency was identified during a survey, highlighting the facility's failure to adhere to proper monitoring protocols for residents on anticoagulant therapy.
Failure to Document Allegation of Abuse in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurately documented, particularly in the case of a resident who reported an allegation of sexual abuse. The resident, identified as R88, was admitted to the facility on May 30, 2024, and later made an allegation of sexual abuse on July 4, 2024. However, a review of the resident's medical records revealed no documentation of this allegation or any related assessments and notes. This lack of documentation was contrary to the facility's policy, which mandates that medical records should reflect the resident's healthcare and care needs. Interviews with facility staff, including a social worker and the Social Services Director, revealed that it was the facility's practice not to document any potentially reportable incidents in the resident's medical records unless approved by the Administrator or the Director of Nursing. The social worker admitted to documenting the interview with the resident on a scrap piece of paper, which was discarded after verbally reporting the incident. The Administrator stated that it was his expectation for residents' medical records to be complete and accurate, indicating a disconnect between the facility's documented policies and the actual practices followed by the staff.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse within the required two-hour timeframe for a resident identified as R88. On July 4, 2024, at approximately 9:00 AM, R88 reported to a Physical Therapy Assistant (PTA) that she had been raped by two black women. The PTA immediately informed the Social Worker (SW), who then interviewed R88 and reported the allegation to the Director of Nursing (DON) at around 9:30 AM. However, the Administrator was not informed until 11:30 AM, and the report to the State Survey Agency (SSA) was made at 12:41 PM, exceeding the two-hour reporting requirement. The facility's investigation revealed inconsistencies in the timeline of when the staff became aware of the allegation. The DON stated that the SW reported the allegation during a clinical meeting that started at 10:00 AM and ended at 11:00 AM, but could not provide an exact time. The Administrator, when interviewed, was unaware of the issue with the timeliness of the report and stated that he was informed at 11:30 AM. The facility's policy mandates that allegations of sexual abuse be reported immediately, but not later than two hours after the allegation is made. R88's medical record lacked documentation of the allegation and any immediate assessments related to the reported sexual abuse. The resident, who was admitted with diagnoses including dementia and generalized anxiety disorder, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The facility's failure to document and report the allegation in a timely manner compromised the investigation of the incident, as noted in the survey findings.
Failure to Investigate Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents, R88 and R103, as identified in the survey. R88, who has dementia, psychotic disorder, and generalized anxiety disorder, reported an allegation of sexual abuse on July 4, 2024. The Physical Therapy Assistant (PTA) was informed by R88 about the incident and immediately notified the Social Worker (SW). However, the facility's internal investigation lacked documentation of an interview with the SW, who was the first to interview R88 after the allegation. Additionally, there was no evidence in the medical record that R88 was assessed by nursing staff following the allegation. In the case of R103, who was moderately cognitively impaired, an allegation of verbal abuse was reported on August 17, 2023. The report indicated that two CNAs were involved in a verbal altercation with R103 in the dining room. The facility's investigation included verbal statements from the involved staff but did not document the time of interviews or review video surveillance footage from the dining room, which could have validated or invalidated the event. Despite the lack of substantiation, one CNA was terminated for unprofessional behavior. The Administrator's responses during interviews revealed gaps in the investigation process, such as not interviewing key staff members or reviewing available evidence like video footage. These deficiencies highlight the facility's failure to adhere to its own policies and procedures for investigating abuse allegations, as well as ensuring thorough documentation and assessment of residents involved in such incidents.
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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.
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Nursing homes near Masonic Home
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westport Place Health Campus | 1.5 mi | ★★★★★ | 5 | 0 |
| Seneca Place | 2.1 mi | ★★★★★ | 0 | 0 |
| Clifton Heights | 2.3 mi | ★★★★★ | 11 | 1 |
| Cherokee Park Rehabilitation | 2.4 mi | ★★★★★ | 0 | 0 |
| Sycamore Heights Health And Rehabilitation | 2.4 mi | ★★★★★ | 9 | 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.