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 Buffalo Prairie Center For Rehab And Healthcare during CMS and state inspections, most recent first.
Staff failed to honor a full-code resident’s wishes for CPR when an LPN discontinued resuscitation efforts before EMS arrived. The resident, who had COPD, prior intracerebral hemorrhage, and kidney cancer, was documented as full code on the face sheet, care plan, and physician orders. When the resident was found unresponsive with fluid from the nose and mouth and no pulse, the LPN verified full-code status, directed staff to call 911, and began chest compressions. As fluid and vomit were observed, the LPN rolled the resident to the side, then stopped CPR, stating the resident had aspirated and could not be resuscitated, and did not proceed with suction. Other staff and later-arriving EMS and the coroner confirmed that CPR had been stopped prior to EMS arrival, despite facility expectations that CPR for a full-code resident be continued until EMS assumes care.
Staff failed to ensure accurate administration and documentation of an antibiotic and steroid regimen for a resident with COPD and pneumonia. The physician ordered cefdinir for a defined seven-day course and a tapering prednisone schedule, but the MAR showed cefdinir documented for ten days while a medication card still contained unused doses, and progress notes indicated the drug was unavailable on some of the days it was charted as given. Prednisone doses for two ordered periods were not documented as administered, and an unopened prednisone card was found despite active orders. Multiple CMTs, LPNs, the DON, and the Medical Director acknowledged that medications should be given and documented as ordered, that blanks on the MAR indicate doses were not given, and that unavailability should be recorded, yet there were unexplained discrepancies between orders, MAR entries, and actual medication availability.
A resident with a history of spina bifida, UTIs, pyelonephritis, sepsis, urostomy, and a brain shunt was not care planned for shunt monitoring, and no shunt-related orders or staff training were documented. The resident experienced frequent headaches and neck/shoulder pain, with repeated PRN Tramadol and Acetaminophen use and several episodes of unrelieved pain, yet progress notes often lacked pain characteristics and there was no consistent evidence of MD notification when pain persisted. The resident’s WBCs were elevated, but follow-up CBC orders and timely MD notification were not documented, and urine output records were inconsistent despite reports from CNAs of decreasing output and dark, tea-colored urine. Staff interviews described the resident’s worsening pain, confusion, hallucinations, low BP, puffy face, distended abdomen, and dark urine, while management initially discussed treating in-house before the resident was eventually sent to the hospital, where hydrocephalus requiring shunt replacement and urosepsis with septic shock were diagnosed.
A resident with paralysis and high risk for skin breakdown developed extensive pressure-related wounds to the coccyx, sacrum, and bilateral buttocks after staff failed to consistently assess, document, and obtain MD orders for a new coccyx wound, did not update the care plan, and did not ensure use of pressure-reducing devices despite MDS-identified need. Initial documentation lacked wound measurements, detailed descriptions, and timely MD notification, and subsequent worsening with open, weeping, foul-smelling areas was reported by staff as resembling “hamburger meat” with odor and blackened areas. Wound orders were inconsistently entered on the POS, weekly skin and wound assessments were missed or incompletely documented, and staff interviews revealed confusion about responsibility and frequency for wound monitoring and documentation after the ADON who previously managed wound assessments was no longer in that role.
Surveyors identified a failure to maintain a sanitary, orderly, and comfortable environment, with multiple halls and rooms containing dried stains, accumulated debris, overflowing trashcans, strong urine and bowel odors, and trash and food crumbs on floors and under beds. A resident reported routinely cleaning their own room and having soiled bedding left on the floor for days, while another resident noted delays in trash removal and better cleanliness on weekdays when housekeeping was present. Staff, including CNAs, a COTA, and a housekeeper, described the building as dirty at the start of shifts, especially after weekends, with trash left by night and weekend staff, shower rooms cluttered with linens and clothing, frequent overflowing trashcans, and uncertainty about housekeeping coverage and leadership, despite existing policies requiring routine and cycle cleaning of all resident-use areas.
A resident with neuromuscular bladder dysfunction and an indwelling catheter did not have catheter care addressed in the care plan or physician orders, despite facility policy requiring catheter care every shift. During observed care, CNAs used a single washcloth on the inner thighs, did not change gloves or perform hand hygiene between perineal and bowel care tasks, failed to retract the foreskin, and cleansed the catheter tubing from the distal end toward the meatus instead of away from the body. Staff interviews, including with the CNA, another CNA, the DON, and the Administrator, confirmed that catheter tubing was expected to be cleansed away from the body to prevent infections, which was not followed in this instance.
Surveyors identified that staff failed to follow the facility’s infection control policies during peri-care for a resident with an indwelling catheter and during wound care for a resident with lower extremity ulcers. During catheter and peri-care, CNAs moved from cleaning bowel incontinence to handling clean briefs, the catheter, the drainage bag, the toilet, and the sink without changing gloves or performing hand hygiene, and did not disinfect surfaces touched with soiled gloves. In a separate wound treatment, an LPN began care without hand hygiene, placed soiled scissors on a clean barrier next to sterile supplies, repeatedly reached into bulk gauze and handled clean supplies with contaminated gloves, then later used those previously contaminated supplies to dress the wound and returned contaminated bulk items to the treatment cart. Interviews with CNAs, the DON, and the Administrator confirmed that these actions were inconsistent with facility expectations for hand hygiene, glove changes, and cleaning of reusable items.
Failure to Pay Fire and Safety Service Bills Timely: The facility failed to manage its operating budget effectively when bills were not paid in a timely manner, resulting in a credit hold with the fire and safety vendor. Marmic reported outstanding balances, delayed sprinkler repairs, and overdue kitchen exhaust and alarm inspections/testing, while the BOM and Administrator were unaware of the credit hold and related service delays.
Kitchen walls and hidden areas behind splash guards and paneling had black and green powdery, fuzzy discoloration, with one area appearing wet and an air unit vent also showing black powdery substance. Staff said they believed the substance was mold or mildew, had discussed it with management before, and that the issue had been present for a long time.
A resident with HF, DM, HTN, and paranoid schizophrenia had repeated changes in condition, including refusing care, meds, insulin, and glucose checks; self-isolating; poor intake; agitation; paranoia; delusions; and altered behavior. The chart showed multiple progress and behavior notes documenting these changes, but physician and guardian notifications were not documented for several episodes. Staff interviews confirmed that notifications were expected, while an RN stated the guardian was not notified of the refusals and self-isolation. The resident later collapsed, CPR was started, EMS was called, and the guardian was notified at that time.
Failure to provide and document showers for a resident who needed substantial to maximum assistance with bathing. The resident had DM, dementia, HTN, and CKD, but the care plan did not address bathing preferences or a bathing schedule, and no shower sheets or shower record were found. Staff said residents were expected to receive two showers per week, showers and refusals were to be documented, and the shower aide was often pulled to the floor because of short staffing. Multiple staff reported they could not locate documentation showing the resident received a shower, and one RN said he/she had been told the resident had not received one.
Failure to Notify Physician and Family and Update Care Plan After a Resident Fall: A resident with dementia, CKD, HTN, and diabetes was identified as high risk for falls due to prior falls, confusion, and balance problems. After the resident fell while trying to use the restroom, the nurse documented normal VS and neuro checks but did not document physician or family notification, complete a new fall risk assessment, or update the care plan. Staff interviews showed fall protocol was expected to include assessment, incident reporting, notifications, and care plan review.
A resident with kidney cancer and moderate cognitive impairment had an order for daily Lenvima for cancer treatment, but the medication was repeatedly not administered because it was not available or pending delivery. The MAR and progress notes showed multiple missed doses, and several entries did not document a reason for the omission. Staff interviews confirmed that when a medication was unavailable, the pharmacy and physician were expected to be notified and documented, but those notifications were not consistently made or recorded.
The facility failed to maintain an effective pest control program when multiple flies were repeatedly observed on and around several residents and in their rooms, despite an existing pest control policy and contracted services. One cognitively impaired resident was seen in bed with numerous flies crawling on their hands, legs, body, and linens, while other cognitively intact residents reported that flies were always present, were bothersome, and required them or family to swat and kill multiple flies during visits. Staff, including an RN, reported that flies had recently become widespread after warmer weather, that the issue had been reported to the Administrator and DON, and that flies posed infection control concerns, while the DON, Maintenance Supervisor, and Administrator each described expectations that staff report fly problems to maintenance and rely on pest control monitoring and bug lights.
A resident with severe cognitive impairment and behavioral symptoms was slapped by a staff member during care, and the incident was not reported to facility management or the state agency within the required two-hour timeframe. Staff interviews confirmed knowledge of immediate reporting requirements, but the delay in reporting resulted in noncompliance with abuse prevention and reporting policies.
A facility failed to conduct a timely and thorough investigation into an allegation of physical abuse involving a resident with severe cognitive impairment and behavioral symptoms. The investigation relied only on statements from the two nurse aides involved, without interviewing other staff or residents, and lacked documentation of immediate protective measures for all residents during the investigation.
Staff failed to consistently document and administer physician-ordered medications for multiple residents, resulting in numerous undocumented doses of critical medications such as insulin, antipsychotics, pain relievers, and antibiotics. Residents with complex medical needs reported missed or late medications, and staff interviews revealed that documentation was often incomplete due to workload. Leadership was unaware of the extent of these lapses, and required documentation and notification procedures were not followed.
Three cognitively intact residents with chronic conditions, including diabetes and GERD, consistently received meals that were not served at appropriate temperatures, with food items measured below the required 135°F. Staff and dietary personnel acknowledged receiving complaints about cold food, and a test tray confirmed substandard temperatures. There was inconsistent understanding and application of the facility's food temperature policy among staff.
Facility staff did not complete an admission MDS assessment within the required timeframe for a resident with multiple complex diagnoses, and there was no documented policy on MDS assessments. Interviews with staff confirmed the assessment was not completed as required.
A resident with multiple complex diagnoses was moved to a locked memory care unit after several behavioral incidents involving theft of food and beverages. Staff did not complete a significant change MDS assessment following the transfer, and the care plan was not updated to address the behaviors that led to the move. Facility staff confirmed the required assessment was not completed.
A resident was transferred to the hospital after experiencing chest tightness, tachycardia, and fever, but staff did not complete the required discharge with return anticipated MDS or the readmission MDS within the mandated timeframe. Interviews revealed that the MDS Coordinator was new to the role and the facility lacked a policy for MDS assessments, resulting in the deficiency.
Staff did not complete a baseline care plan within 48 hours for a newly admitted resident with multiple complex diagnoses, contrary to facility policy. Documentation was missing, and staff interviews revealed confusion about the required timeframe for baseline care plan completion.
Staff failed to complete a comprehensive care plan for a resident with multiple complex diagnoses after admission, and did not update another resident's care plan to address repeated behavioral incidents and a subsequent move to a locked unit. Interviews with the SSD, MDS Coordinator, Administrator, and DON confirmed that care plans were not completed or updated as required by facility policy.
The facility did not pay overdue invoices for a portable generator, leading to the removal of the generator after repeated warnings from the service provider. Observations confirmed the absence of an operational generator on site, and interviews revealed that facility leadership was unaware of the outstanding debt due to invoices being sent directly to ownership. The facility lacked a policy on timely payments to service providers.
Two nurse aides provided direct care without completing required CNA training and certification within the mandated 120-day period. Personnel files lacked documentation of certification, and facility leadership acknowledged lapses in oversight and compliance with CNA training requirements.
A resident with Alzheimer's disease, chronic kidney disease, and BPH was left in a Broda chair for over two hours with visible urine incontinence, despite staff passing by and facility policy requiring checks every two hours and as needed. The resident was not checked or changed until prompted by a surveyor, resulting in saturated clothing and chair. Staff interviews revealed uncertainty about care routines and acknowledged the resident should have been attended to sooner.
The facility was cited for ineffective and inefficient use of resources, as identified in a survey. The citation pertains to the overall management and resource utilization practices, without specific details on actions or individuals involved.
The facility failed to maintain adequate RN and DON staffing, leading to the DON working as a charge nurse or CNA, which hindered her ability to perform essential duties. This resulted in a lack of effective antibiotic stewardship and significant medication errors, including missed warfarin doses and unavailable medications.
The facility failed to employ a qualified dietary manager for its food and nutrition services department. The current dietary manager lacked necessary certifications and training, such as being a certified dietary manager or having an associate's degree in food service management. The administrator was unaware of these requirements, leading to a deficiency in staffing qualifications.
The facility failed to maintain an effective infection control program, particularly in preventing Legionella growth and ensuring proper hand hygiene. The facility lacked a Legionella risk assessment and did not monitor water conditions. Staff, including the DON and CMTs, were observed not performing hand hygiene during medication passes, despite being aware of its importance.
The facility failed to maintain an effective antibiotic stewardship program, lacking a current and ongoing log for residents with active infections. Despite having a policy in place, the facility only provided a printout of antibiotic prescriptions for September, with no further tracking documentation. Interviews with the DON revealed no residents on antibiotics, no documented tracking measures, and no outcome surveillance related to antibiotic use. The Administrator expected adherence to guidelines, but the deficiency indicates a lack of proper implementation.
The facility failed to provide adequate pressure ulcer care and documentation for two residents, leading to deficiencies in wound management. Staff did not consistently assess and document pressure ulcers, and treatment orders were not entered into the system. Interviews revealed that the former wound nurse did not enter treatment orders, resulting in a lack of documented care.
The facility failed to manage oxygen equipment per standards for two residents with COPD, resulting in undated or outdated nasal cannulas and tubing. Despite orders for weekly changes, observations showed equipment unchanged since mid-month. Staff interviews revealed confusion over responsibilities, contributing to the deficiency.
Two residents experienced inadequate pain management due to the facility's failure to administer prescribed medications and document substitute orders. One resident with multiple fractures did not receive morphine or Percocet due to pharmacy delays, while another resident with COPD and cancer faced similar issues with Tylenol and oxycodone. Staff interviews revealed systemic problems with medication procurement and documentation, leading to prolonged pain for the residents.
A LTC facility failed to maintain a medication error rate below 5%, resulting in a 12.82% error rate. Errors included administering incorrect medication forms and dosages, and improper techniques for g-tube medication administration. A resident received a tablet instead of liquid medication, another received incorrect dosages, and a third had medications improperly combined for g-tube administration.
The facility failed to store controlled substances securely and left medication carts unlocked and unattended. Controlled substances for two residents were not stored under two locks, and medication carts containing narcotics were left unlocked in areas accessible to residents. Staff interviews confirmed the expectation for secure storage, but observations showed non-compliance with these protocols.
A resident with chronic conditions was found without accessible water on multiple occasions, despite care plan requirements for thickened liquids. Observations showed the resident was visibly thirsty, and staff interviews revealed confusion about hydration protocols. The facility failed to ensure water was accessible during regular rounds.
A facility failed to conduct the required PASARR Level 1 screening for a resident with mental disorders before admission. The resident, diagnosed with major depressive disorder, bipolar disorder, and psychosis, exhibited symptoms such as delusions and socially inappropriate behavior. Despite these indicators, the PASARR was not completed, as confirmed by the Central Office Medical Review Unit. The Social Services Designee was responsible for the PASARR but only completed it if the hospital had not done so.
A resident with schizophrenia and major depressive disorder did not receive their prescribed escitalopram oxalate on multiple occasions due to the medication's unavailability. Despite facility policies requiring timely reordering and follow-up with the pharmacy, staff failed to ensure the medication was available, leading to missed doses. The DON and other staff were not consistently aware of the medication's status, and the facility's tracking system was not reviewed daily, contributing to the deficiency.
A resident with thrombophilia missed three doses of warfarin sodium due to unavailability, as documented by a CMT. The medication was on hold but should have been restarted, and staff failed to notify the DON or physician about the missed doses. The facility's policy required immediate reporting of such discrepancies, which was not followed, resulting in a significant medication error.
The facility failed to maintain complete medical records for two residents transferred to the hospital and later returned. Documentation lacked details such as the reason for transfer, time, and physician notifications. Interviews with staff revealed expectations for obtaining physician orders and documenting all relevant details, which were not followed.
CPR Discontinued Early for Full-Code Resident Prior to EMS Arrival
Penalty
Summary
Facility staff failed to ensure a full-code resident’s wishes regarding cardiopulmonary resuscitation (CPR) were honored when CPR was discontinued prior to EMS arrival. The resident had diagnoses including COPD with acute exacerbation, nontraumatic intracerebral hemorrhage, and malignant neoplasm of the kidney, and was documented as a full code on the face sheet, care plan, and physician orders. The care plan and facility CPR policy required that staff provide basic life support, including CPR, in accordance with the resident’s advance directives and continue CPR prior to EMS arrival if the resident did not show obvious signs of clinical death. On the morning of the incident, an LPN entered the resident’s room and observed the resident sitting on the side of the bed with a cup in hand, appearing as if preparing to get a drink. After tending to the roommate and returning, the LPN noted the resident was unresponsive, with fluid coming from the nose and mouth, and no palpable pulse. The LPN asked another staff member to verify the resident’s code status, was informed the resident was full code, and directed staff to call 911. The LPN initiated chest compressions, during which fluid continued to come from the resident’s mouth and nose. The LPN rolled the resident to the side to allow more fluid to drain, observed vomit on the bedding, and then rolled the resident back and continued compressions. The LPN reported the resident felt room temperature and that the chest felt soft and mushy during compressions. According to written statements and interviews, the LPN stopped CPR after determining the resident had aspirated and believing resuscitation was not possible, despite the resident’s full-code status and without EMS on scene. CNA and CMT staff present confirmed that CPR was started and then discontinued, and that the LPN declined to continue compressions or use suction, stating the resident had aspirated too much and that nothing more could be done. EMS personnel and the county coroner later arrived and found the resident with dependent back lividity and no CPR in progress; both stated that CPR should have been continued until EMS arrival. Multiple staff interviews, including CNAs, CMTs, LPNs, the DON, the Administrator, and the Medical Director, consistently described that facility practice and expectations were to initiate CPR for full-code residents and continue until EMS arrival or a physician pronouncement, indicating that in this case staff actions did not follow the resident’s documented wishes or the facility’s stated process.
Failure to Accurately Administer and Document Antibiotic and Steroid Therapy
Penalty
Summary
Facility staff failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident with COPD, nontraumatic intracerebral hemorrhage, and kidney cancer. The resident had moderate cognitive impairment, shortness of breath with exertion, at rest, and when lying flat, and was receiving oxygen therapy. On one occasion, the resident was found with an oxygen saturation of 78% on six liters via nasal cannula, with bilateral wheezing and rhonchi and diminished lung sounds at the bases. Staff documented that the resident was on prednisone until a specified date and had completed a course of cefdinir for pneumonia, and the physician was notified for further recommendations. Subsequent physician documentation showed that, due to non-resolving pneumonia, the resident was to continue cefdinir 300 mg PO BID for seven days and start prednisone 40 mg PO daily for five days, then decrease by 5 mg every five days until discontinued. The February Physician Order Sheet reflected an order for cefdinir 300 mg PO BID for seven days, and prednisone 40 mg PO daily for five days followed by prednisone 35 mg PO daily for five days. However, the February MAR showed cefdinir documented as administered twice daily for ten days, three days longer than ordered, and staff progress notes later documented that cefdinir was not available on two of those days. The MAR also showed no documentation of prednisone administration for the ordered periods, with only a single prednisone dose documented on a later date. Observation of the medication storage revealed an unopened package of prednisone 35 mg, ordered once daily for five days, and a cefdinir medication card dated earlier in the month with three of fourteen capsules remaining, despite MAR documentation indicating administration beyond the seven-day order. Interviews with the Medical Director confirmed that all medications should be administered and documented as prescribed, and that he would presume medications were not given if not documented. Multiple CMTs and LPNs stated that medications should be administered as ordered, that blanks on the MAR indicate medications were not administered, and that unavailability or refusals should be documented on the MAR and in progress notes. Staff also reported issues with medication availability related to a pharmacy change. The DON and Administrator both stated that medications should be administered as prescribed, that there should be no blanks on the MAR, and that medications should not remain on the MAR past the stop date, but they were unaware of why cefdinir was documented past the stop date, why doses remained, or why prednisone doses were not documented or administered as ordered.
Failure to Monitor Brain Shunt, Manage Pain, and Respond to UTI/Sepsis Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, resident preferences, and goals for a resident with complex medical needs, including a brain shunt, urostomy, history of UTIs, acute pyelonephritis, and sepsis. The resident’s face sheet and care plan did not include a diagnosis of a brain shunt, and there were no physician orders or care plan interventions for monitoring the shunt. Staff were not documented as being trained or informed about shunt care, and there was no systematic monitoring of head, neck, or shunt-related symptoms despite frequent complaints of headaches and pain. The facility’s pain management policy required evaluation of pain upon admission and with changes in condition, use of appropriate pain assessment tools, and development and revision of interventions, but documentation repeatedly lacked characteristics of the pain, including location and quality, and did not reflect consistent reassessment or escalation when pain was not relieved. The facility also failed to effectively address increasing pain in the resident’s head, neck, and shoulder areas and did not consistently notify the physician of unrelieved or escalating pain. MAR and progress note reviews showed numerous PRN administrations of Tramadol and Acetaminophen for pain scores ranging from 3 to 9 out of 10, including generalized body aching, back pain, and neck and shoulder pain, with multiple instances where pain remained at 5–7 out of 10 after medication. Progress notes frequently omitted the characteristics or location of the pain, and when pain was not relieved, there was no documentation that the physician was notified. Interviews with CNAs indicated the resident complained of daily headaches, described the head as "blowing up or exploding," cried from pain, and reported pain at the shunt site, yet these complaints were only reported verbally to nurses and not reflected in detailed clinical documentation or care plan revisions. A roommate reported the resident’s head appeared swollen and that the resident became confused several days before hospital transfer. In addition, the facility failed to timely recognize and respond to signs of possible UTI and sepsis, and did not complete or follow up on ordered labs for elevated WBCs. The resident had a history of UTIs, kidney infections, and sepsis, and a WBC of 14.4 was documented in December, followed by a WBC of 16.8 on 01/06/26. There was no prompt physician notification documented for the increasing WBC, and although a physician note later referenced leukocytosis with a plan to recheck the CBC, no new lab orders appeared on the POS and no follow-up lab documentation was found. The care plan required monitoring and reporting of signs of kidney infection and sepsis, including no output, deepening urine color, and other symptoms, but MARs showed inconsistent urine output documentation, with multiple days lacking any recorded output. CNAs reported decreasing urine output from several bag drainings per shift to sometimes once per day, and described dark, tea-colored, and burnt orange urine, as well as the resident’s decreased eating, confusion, hallucinations, low blood pressure, puffy face, and distended abdomen. Although these findings were eventually reported to nursing staff, there was a delay in sending the resident to the hospital, and management initially discussed treating the resident in-house and attributing confusion to new medication. The resident was ultimately transferred to the hospital, where documentation showed diagnoses of hydrocephalus requiring shunt removal/replacement and urosepsis with septic shock, with the resident intubated and sedated in the ICU and a WBC of 43.7.
Failure to Assess, Treat, and Document Pressure Ulcers and Prevent Worsening Wounds
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive services consistent with professional standards for a resident who was at risk for skin breakdown and later developed extensive pressure-related wounds. The resident had spina bifida with paralysis, neuromuscular bladder dysfunction, a history of UTIs and sepsis, and required substantial to maximum assistance with ADLs and mobility. The resident’s MDS indicated intact cognition, no existing pressure ulcers, risk for pressure ulcers, and a need for pressure-reducing devices for bed and chair. The care plan directed staff to assess, record, and monitor wound healing as ordered, measure wounds, document wound bed and perimeter, report changes to the MD, and follow facility policies for prevention and treatment of skin breakdown. On a weekly skin assessment dated early in the month, staff documented no open areas and no pressure-reducing devices in use, with only skin discoloration on the left buttock. A few days later, the DON documented being called to the resident’s room for an open coccyx area and applied a foam dressing, but there was no documented full wound description, no measurements, and no documentation of MD notification or treatment orders for this new area. The POS for that month did not contain orders for pressure-reducing devices or for treatment of the new coccyx wound, and no new skin assessment was completed after the earlier weekly assessment. The care plan was not updated to reflect the new coccyx wound, and progress notes for the following week contained no wound assessments or documentation related to the open area. Later in the month, a nurse documented that the resident’s coccyx, sacrum, and bilateral buttocks were open, red, irritated, and weeping serous drainage, and that the MD was notified and wound care orders were received and applied. However, this note still lacked wound measurements and a detailed wound description, and the new wound orders were not entered on the POS. A physician progress note documented ulcerations to the coccyx, sacrum, and bilateral buttocks and the need for a wheelchair cushion for pressure reduction, but no order for a pressure-reducing cushion was documented on the POS. A subsequent wound assessment recorded multiple open areas on both buttocks with specific measurements and daily dressing changes, but again without detailed descriptive characteristics. Shortly thereafter, the resident was hospitalized, and a surgery consult described excoriated sacral skin, necrotic-appearing tissue near the anus, and foul-smelling purulent drainage. Interviews with CNAs, nurses, and other staff showed inconsistent understanding and implementation of wound assessment and documentation practices. CNAs and other staff described the buttock wounds as looking like “hamburger meat,” oozing, bleeding, with odor and blackened areas, while RNs and LPNs acknowledged that nurses were responsible for wound care, assessments, and documentation. Staff reported that an ADON had previously completed weekly wound assessments and that after the ADON’s departure, expectations for who would perform and document weekly wound measurements were unclear. One LPN who completed a weekly wound assessment stated that measurements were documented on paper and should have been entered into the EMR but was unsure how regularly wounds should be monitored or documented. The DON stated she expected weekly skin and wound assessments with measurements, MD notification for new open areas, and documentation of assessments, but indicated she did not become aware of the wounds opening until around the middle of the month. The Administrator stated an expectation that wounds and skin be assessed, monitored, measured, documented, and that care plans be individualized, which did not occur in this case.
Failure to Maintain Sanitary and Clean Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior environment in resident-use areas, despite written policies requiring routine and cycle cleaning. Surveyors observed multiple instances of unclean conditions throughout several halls and rooms. On Buffalo Blvd. Hall, there was a large dried splatter stain with a white crust on the floor, a large pile of dried leaves accumulated at an exit door, and a resident room with a pillow on the floor amid food crumbs, napkins, tissues, a clear cup, and an empty food box. Between two rooms, an orange medication cart cap and a single blue plastic glove were on the floor. On Memory Lane Hall/Unit, surveyors noted a strong urine odor upon entering. The dining room trash can at the end of the serving counter was overflowing, with trash and napkins on the surrounding floor. In the TV/visiting area, a resident was reclined in a chair next to a wheeled side-table cart heaped with trash, including soda cans, rolled tissues, and wrappers, with food crumbs, tissues, and an elastic hair band on the floor under the recliner. Multiple rooms on this unit had tissue and food crumbs on the floor, large stained discolorations on the floor, popcorn and wadded trash items on the floor, overflowing trashcans, splatter-like stains across the floors, and various discarded items such as straws, wrappers, tissues, Q-tip wrappers, and bottle caps under beds. On a later observation date, one room had a strong urine odor, wadded trash under the bed, and dried, hardened wads of paper splattered onto the floor. On Prairie Lane Hall, a wadded-up piece of paper was observed on the floor outside a room and appeared to remain in the same location several days later. A cognitively intact resident reported usually cleaning the room independently because it took too long for staff to do it, stating that housekeeping staff were good but too few, and that other staff did not help with cleaning. This resident’s room had a strong bowel odor, and the resident pointed out a pile of soiled bedding under the sink counter that had been removed from the bed two days earlier and not picked up, causing embarrassment. Another cognitively intact resident stated that staff would empty trash but took a long time to do so, and that weekdays were better because housekeeping came to help clean rooms. Staff interviews further described ongoing cleanliness issues. A COTA reported noticing the facility in disarray at times and personally cleaning gum wrappers from under a resident’s bed because they had been there so long. A CNA stated the facility was dirty at the start of shifts, that night shift staff were the worst about throwing trash around, and that there was no current housekeeping department head after the prior Maintenance Director left. This CNA also reported that some residents were incontinent and that urine-containing items in trash contributed to odors, and that plumbing issues caused sewer smells, especially after showers. Another CNA reported the facility was filthy on Monday mornings and after weekends, with weekend staff leaving trash in rooms instead of disposing of it. A housekeeper stated it was normal to arrive each day to find trash all over floors, shower rooms with clothes, bedding, and towels scattered, and overflowing trashcans. Another CNA said housekeeping tasks completed depended on who was working, that housekeepers were supposed to clean every room daily and deep clean monthly, and that they always carried trash bags because someone’s room was always dirty. The DON reported there were three or four housekeeping staff, was unsure if housekeeping worked weekends, and stated housekeeping should empty trash, sweep, and wipe surfaces daily, with aides also able to perform these tasks. The Administrator stated an expectation that all staff pick up after any mess they make and that staff try to clean when they notice cleanliness or odor issues.
Failure to Provide Proper Catheter Care and Care Planning for Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate catheter care and related services for a resident with an indwelling urinary catheter, as required by facility policy and the resident’s needs. The resident was cognitively intact, dependent on staff for toileting, and had a diagnosis of neuromuscular dysfunction of the bladder with an indwelling catheter in use. The resident’s care plan addressed monitoring intake and output, catheter tubing kinks, pain or discomfort related to the catheter, and signs and symptoms of urinary tract infections, but did not include any interventions for catheter care. Review of the physician orders for the month showed there were no orders related to catheter care, despite the facility’s written policy requiring catheter care every shift and as needed. During an observed catheter care episode, two CNAs entered the resident’s room, performed hand hygiene, and donned PPE. One CNA removed the resident’s brief while the other cleansed the resident’s inner thighs with a single wet washcloth, folding it over between swipes but not obtaining a new washcloth. The CNA did not remove soiled gloves, perform hand hygiene, or apply new gloves before proceeding. The CNA did not retract the foreskin and cleansed the catheter tubing from the distal end toward the proximal end at the meatus, contrary to the facility policy that required cleansing from the meatus outward. The CNA then provided care to the resident’s backside after bowel incontinence without changing gloves or performing hand hygiene before placing a clean brief under the resident, adjusted the catheter, and hung the catheter bag on the bed. Interviews with the CNA, another CNA, the DON, and the Administrator confirmed that catheter tubing was expected to be cleansed away from the body to prevent infections, which did not occur during the observed care, and that catheter care was not ordered or care-planned for this resident.
Failure to Follow Hand Hygiene and Aseptic Technique During Peri-Care and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, specifically related to hand hygiene, glove use, and prevention of cross-contamination during resident care. For one resident with multiple sclerosis, neuromuscular bladder dysfunction, quadriplegia, and an indwelling catheter, two CNAs entered the room to perform catheter and peri-care. Both CNAs initially performed hand hygiene and donned PPE. One CNA removed the resident’s brief while the other provided catheter care and then cleaned the resident’s backside after bowel incontinence. After providing this care, the CNA obtained a clean brief and placed it under the resident without performing hand hygiene or changing gloves. The same CNA then adjusted the resident’s urinary catheter and hung the catheter bag on the side of the bed, again without performing hand hygiene or changing gloves. The CNA obtained a graduate, drained the catheter bag, emptied the graduate into the toilet, flushed the toilet, touched the resident’s sink, and turned on the water to rinse the graduate, all while wearing the same soiled gloves. Only after these tasks did the CNA remove gloves and perform hand hygiene. The CNA did not sanitize any of the room surfaces that had been touched with soiled gloves. Staff interviews, including with CNAs, the DON, and the Administrator, confirmed that the facility’s expectation was that staff perform hand hygiene and change gloves when moving from dirty to clean surfaces to prevent cross-contamination. A second deficiency occurred during wound care for another resident with cellulitis of the left lower limb, non-pressure chronic ulcers of both lower legs, and open foot lesions. An LPN entered the room to perform wound care on a left leg wound that had an odor, visible brownish-yellow drainage through the gauze wrap, and drainage on a bed pad under the leg. The LPN placed clean dressing supplies on a clean barrier, then applied gloves without hand hygiene, removed the resident’s shoe and sock, used scissors from a pocket to cut off the soiled dressing, and then placed the soiled scissors on the clean barrier next to clean supplies. The LPN removed gloves, did not perform hand hygiene, donned new gloves, and began cleansing the wounds, repeatedly reaching into a bulk bag of gauze and handling clean supplies without changing gloves or performing hand hygiene. The LPN placed the used wound cleanser bottle and clean gauze roll back on the designated clean barrier after touching them with contaminated gloves, briefly acknowledged not remembering all the steps, then removed gloves, performed hand hygiene, donned new gloves, and used the previously contaminated gauze roll to wrap the wound. The LPN then handled the resident’s sock and shoe, placed the leg back on the soiled bed pad, exited the room, removed gloves, used hand sanitizer, and left the contaminated bulk gauze bag, scissors, and wound cleanser on top of the treatment cart. Interviews with CNAs, the DON, and the Administrator confirmed expectations that reusable items used for multiple residents be sanitized before and after use and that soiled hands not be placed into bulk supplies.
Failure to Pay Fire and Safety Service Bills Timely
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its operating budget effectively and efficiently when it did not ensure bills were paid in a timely manner. During record review and interviews, the facility was found to have no policy or procedure regarding bill payment, and the census was 44. The Maintenance Director stated that the fire and safety system, including sprinklers, was serviced by Marmic Fire and Rescue and that Marmic provided quarterly inspection and maintenance services, with the only current concern being an air pressure leak. Marmic Fire and Safety staff reported that the facility was on credit hold, that the last quarterly sprinkler review had been completed, and that there was a deficiency in the sprinkler system involving multiple leaks causing the system to trip. They stated this would not be fixed until the facility was no longer on credit hold. Marmic also reported the facility was past due for kitchen exhaust inspection, annual alarm testing, and alarm inspection, with several outstanding bills. The Business Office Manager said she was not aware of any credit holds and that invoices were sent to accounts payable by the Maintenance Director, while the Administrator said she had just become aware of a past due bill and was not aware of any services not being provided due to unpaid bills.
Kitchen Walls Had Visible Mold-Like Discoloration
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment when black and green spotted discoloration with a powdery, fuzzy appearance was observed in the kitchen. During observation, the cleaning side of the kitchen showed discoloration in the corner from the top of the sink area to the ceiling, behind pulled-back splash guards, and on drywall beneath protective paneling near a window. The air unit under the window also appeared to have a black powdery substance on the vents, and the area behind the paneling appeared wet in one section. Staff interviews confirmed the concern had been present for some time and had been discussed with management before the survey. Dietary staff stated they believed mold could be behind the splash guards on the dishwasher side of the kitchen and said the Maintenance Director had previously pulled back the splash guard, took a picture, and left after saying he was allergic to it. The Dietary Manager said she believed the substance was mildew, that the issue had just come to her attention a couple of days earlier, and that staff had been cleaning the areas with vinegar. The Maintenance Director said he was aware of the discoloration, had removed paneling and washed the area, and was working on scraping old caulk, but he was not aware the affected areas were on drywall. The DON said she had heard about mold concerns, and the Administrator said she was informed of a mildew or mold concern and asked Maintenance to obtain quotes.
Failure to Notify Physician and Guardian of Resident’s Change in Condition
Penalty
Summary
The facility failed to ensure that the resident’s physician and resident representative were notified in a timely manner when the resident experienced a documented change in condition. The resident had diagnoses including heart failure, diabetes, high blood pressure, and paranoid schizophrenia, and the care plan noted a potential for decline in mood, a history of care and medication refusals, a history of self-harm, and a history of heart disease and diabetes. The resident’s admission MDS indicated the resident was cognitively intact. Progress notes and behavior notes documented a series of changes in the resident’s condition, including refusing care and all medications, believing staff and other residents were trying to kill him/her by poisoning him/her, self-isolating more, loss of appetite, not eating dinner, refusing insulin, swatting at a nurse, no longer attending activities, smoking, or eating, giving only one-word answers, taking off clothing and refusing to put it back on, and continuing to refuse medications, insulin, and glucose checks while stating that everything was poison and staff were trying to kill him/her. The physician later documented seeing the resident for hypoglycemia and delusions, with staff reporting increased agitation, paranoia, confusion, refusal of medications, insulin, and blood glucose monitoring, and isolation from activities. Additional physician documentation noted continued delusions, refusal of ordered labs, reports of animals on the resident’s body, variable oral intake, and new orders for labs, chest x-ray, and urinalysis. The record did not document physician and resident representative notifications for multiple episodes of the resident’s decline and behavioral changes. Staff interviews showed that nurses and CNAs expected changes in condition to be assessed, documented, and reported to the physician and guardian, but RN B stated the guardian was not notified of the resident’s refusals and self-isolation and believed notifications were typically not made unless there were new orders. The resident’s case manager stated the facility had not communicated much about the resident’s concerns and that the guardian expected to be contacted about resident concerns. The resident later collapsed, CPR was initiated, EMS was called, and the guardian was notified at that time.
Failure to Provide and Document Resident Showers
Penalty
Summary
The facility failed to ensure a resident who required substantial to maximum assistance with bathing received the necessary bathing services to maintain grooming. The resident had diagnoses including diabetes, dementia, high blood pressure, and chronic kidney disease, and the admission MDS showed moderate cognitive impairment with partial to moderate assistance needed for mobility and substantial to maximum assistance needed for bathing. The resident’s care plan did not address bathing preferences or a bathing schedule, and the facility record did not contain documentation of a shower record or shower sheets during the resident’s stay. The facility policy stated residents would be provided showers according to their preferences, care plan, safety needs, and the facility’s bathing protocol. Multiple staff members stated the expectation was for residents to receive two showers per week, that showers and refusals were to be documented on shower sheets, and that the shower aide was responsible for completing the schedule and documentation. Staff also stated the shower aide was often pulled to the floor because of short staffing, which could cause residents to go without showers. The former ADON and DON both stated they could not locate shower sheets for the resident, and the DON stated the resident should have had at least one shower during the short stay. During interviews, staff reported the resident had not received a shower and that they were unaware of any shower refusal or completed shower documentation. The shower aide stated there was no set schedule and that other aides could shower residents, but no one had communicated that the resident had been showered. The RN also stated he/she had been told the resident had not received a shower. The facility census was 44, and the deficiency was identified during survey review of records and staff interviews.
Failure to Notify Physician and Family and Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure residents were free from accidents when it did not notify the physician and family after a fall and did not review or update the care plan for one resident who fell. The resident had diagnoses including diabetes, dementia, high blood pressure, and chronic kidney disease. On admission, the resident was identified as at risk for falls due to a history of one to two falls in the prior three months, intermittent confusion, and being ambulatory with a balance problem requiring an assistive device. After the resident was found on the bathroom floor area, the nurse documented that the resident had been attempting to use the restroom and fell against the bathroom door. The note stated there were no observed injuries, vital signs and neurological checks were within normal limits, and a small bruise on the lower back appeared older in nature. The nurse documented continued monitoring and reminded the resident to use the call light, but did not document physician or family notification, any additional interventions, or a reason for no additional interventions. The resident's care plan was not updated to reflect the fall, and a new fall risk assessment was not completed. During interviews, staff described that proper fall protocol included assessment, neurological checks, incident reporting, physician and family notification, and care plan updates. The nurse who found the resident said he or she was unsure of any other documentation needed and assumed the next shift would make any necessary notifications. Other staff, including the former ADON, RNs, CNA, MDS/Medical Records Nurse, DON, and Administrator, stated that falls should be fully documented, notifications completed, and the care plan updated, and the DON stated the incident report should prompt a fall risk evaluation, skin assessment, and care plan update. The former ADON was not aware the resident had fallen.
Missed Chemotherapy Medication and Lack of Follow-Up
Penalty
Summary
The facility failed to ensure a resident with kidney cancer received prescribed chemotherapy medication and failed to follow up when the medication was not administered. The resident was admitted with diagnoses including malignant neoplasm of the kidney, COPD, and benign intracranial hypertension. The resident’s MDS indicated moderate cognitive impairment, receipt of chemotherapy medication, and a need for supervision with mobility. The care plan identified the kidney neoplasm diagnosis, but did not address management of the condition. The January 2026 MAR showed an order for Lenvima 10 mg by mouth daily for cancer treatment, but the medication was repeatedly not administered. On multiple days, the MAR documented the dose as not given, with progress notes stating the medication was not available, was on order, or was pending delivery. Several entries also lacked any documented reason for the missed dose. The record showed no documentation that the physician or pharmacy was notified on those occasions when the medication was unavailable. During interviews, the former ADON, LPN, RN, DON, Medical Director, and Administrator all described that medications were expected to be given as ordered and that staff should notify the pharmacy and physician when a medication was unavailable. The former ADON stated the resident had been without the chemotherapy medication for at least a couple of weeks and that nurses had not been following up as expected. RN B stated he/she had notified the resident’s oncologist, while other leaders stated they were not aware the resident was without the medication. The documentation and interviews showed the resident’s chemotherapy medication was not administered as ordered and that follow-up notifications were not consistently documented.
Failure to Maintain Effective Pest Control for Fly Infestation in Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to control a significant fly population in resident care areas, despite having a written Pest Control Program policy and contracted pest control services. Pest control inspection documentation showed fly activity on an interior bug light in early December, with no detailed findings documented on a subsequent December visit. On the day of survey, multiple observations revealed numerous flies in and around several residents and their rooms. One cognitively impaired resident was observed in bed with flies buzzing around and crawling on the resident’s hand, legs, body, and bed linens, including five to six flies on the resident’s legs and body during an observation with the DON. Another resident with intact cognition was observed in bed with flies on the forehead and neck, several flies buzzing around the resident, and approximately six flies on the floor beside the bed; later the same day, additional flies were observed around the bed and on the floor in that room. A third cognitively intact resident, seated in a wheelchair in their room, had a fly land on their head and reported that flies were always present in the room and were bothersome, keeping a fly swatter at the end of the bed and keeping the door closed to try to keep flies out. A fourth resident, also in a wheelchair in their room, reported that flies had been bad and had bothered them the previous night while in bed, and a family member present stated they had killed about eight flies during that visit while swatting at flies on the floor. Staff interviews showed that housekeeping expected staff to report flies to a supervisor, and an RN reported that flies had been “everywhere and bad” after a recent warm spell, that they had informed the Administrator and DON about the fly problem, and that flies put residents at risk for skin infections and contamination of food. The DON stated that pest control monitored flies, that staff should report flies to maintenance, that she had not heard recent complaints, and that flies caused infection control issues and a non-homelike environment. The Maintenance Supervisor acknowledged ongoing issues with flies, reliance on bug lights and pest control guidance, and the expectation that staff report flies to him, while the Administrator stated that pest control visited monthly, staff were expected to report flies to maintenance, and staff were expected to kill flies as needed.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to facility management and within two hours to the state licensing agency, as required by both facility policy and federal regulations. Specifically, a nurse aide (NA C) witnessed another aide (NA D) slap a resident during care after the resident, who has severe cognitive impairment and behavioral symptoms related to dementia, became physically aggressive. Instead of reporting the incident immediately, NA C waited until the following day to inform management, citing discomfort with reporting while still on shift with the involved staff member. The resident involved had a history of vascular dementia, polyneuropathy, and required assistance with personal care, exhibiting frequent behavioral challenges such as yelling, physical aggression, and refusal of care. The care plan for this resident included specific interventions for managing behavioral symptoms, but during the incident, the staff response escalated to physical abuse. The delay in reporting meant that the incident was not brought to the attention of the Administrator until the afternoon of the following day, and the state agency was not notified within the required two-hour window. Interviews with multiple staff members, including CNAs, RNs, the Social Services Director, the DON, and the Administrator, confirmed that facility policy and their training require immediate reporting of abuse allegations to management and notification to the state agency within two hours. Despite this, the actual practice in this case did not align with policy, resulting in a failure to protect the resident and comply with regulatory requirements for timely reporting of abuse.
Failure to Conduct Timely and Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of possible physical abuse involving a resident with severe cognitive impairment and behavioral symptoms related to dementia. The incident occurred when two nurse aides entered the resident's room to provide care, and the resident began hitting one of the aides. In response, the aide allegedly slapped the resident. The incident was not reported immediately; instead, it was reported the following day by the other aide present during the event. Upon review, it was found that the facility's investigation was insufficient. The investigation relied solely on written statements from the two nurse aides involved and did not include interviews with other staff or residents who might have had relevant information. The facility's own policy requires a comprehensive investigation, including interviews with multiple staff and residents, but this was not followed. Additionally, the investigation summary was undated and lacked documentation of immediate protective measures for all residents during the investigation period. The resident involved had a history of severe cognitive impairment, required assistance with activities of daily living, and exhibited behavioral symptoms such as physical aggression toward staff. Despite these vulnerabilities, the facility did not document a full assessment or protective interventions immediately following the allegation. The failure to follow established abuse prevention and investigation protocols resulted in a deficiency related to the facility's response to alleged abuse.
Failure to Document and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate administration and documentation of physician-ordered medications for six residents. Staff did not consistently document medication administration in the Medication Administration Record (MAR) as required by facility policy, resulting in multiple undocumented doses across a range of medications, including insulin, antipsychotics, pain medications, antibiotics, and medications for chronic conditions such as hypertension, COPD, and diabetes. The facility's policy required staff to document all administered medications, note refusals, and provide reasons for any missed doses, but these procedures were not followed. Residents affected had complex medical histories, including diagnoses such as chronic obstructive pulmonary disease, schizophrenia, diabetes, hypertension, depression, and recent acute medical events like peptic ulcer with hemorrhage and perforation. For example, one resident with diabetes and chronic pain did not have documentation for several doses of insulin, pain medication, and other prescribed drugs. Another resident with hypertension, COPD, and a history of fractures had multiple undocumented doses of blood pressure medication, pain medication, and antibiotics. In several cases, there was no documentation in the nurses' progress notes to explain the missed or undocumented doses. Interviews with residents revealed that some experienced increased pain, missed doses, and inconsistent medication administration, which affected their comfort and ability to sleep. Staff interviews confirmed that documentation was sometimes omitted due to being busy, and blank areas on the MAR were not in accordance with policy. The Director of Nursing and Administrator were unaware of the extent of the documentation lapses and missing doses, despite policies requiring staff to notify them if medications were unavailable or not administered.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and appetizing temperatures for three residents who frequently ate in their rooms. Observations and interviews revealed that these residents consistently received meals that were cold or not warm enough, with one resident stating that food was always served cold and another noting that breakfast was usually cold. Although staff offered to reheat or replace meals when complaints were made, residents often declined these offers. A test tray taken from an uninsulated food cart at the end of meal service showed food temperatures below the facility's policy requirements, with all items measuring between 124.3°F and 126°F, which is below the required minimum of 135°F for hot foods. Staff interviews confirmed that complaints about cold food were received, particularly on one hall, and that dietary staff were notified of these issues. The dietary manager and staff demonstrated inconsistent knowledge of the facility's food temperature policy, with some believing that food should be above 120°F or 125°F, rather than the policy-stated 135°F. The administrator stated that staff should not reheat served meals in the microwave but should replace them with fresh meals, though this practice was not consistently followed. The affected residents had diagnoses including diabetes, hyperlipidemia, and GERD, and were cognitively intact, able to report their dissatisfaction with food temperatures.
Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
Facility staff failed to complete an admission Minimum Data Set (MDS) assessment in a timely manner for one resident. The resident was admitted with multiple diagnoses, including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke. Documentation showed the resident arrived at the facility, but there was no record of an admission MDS being completed. Interviews with the Social Services Director, MDS Coordinator, and Administrator confirmed that the admission MDS should be completed within 14 days of admission, and acknowledged that it was not done for this resident. Additionally, the facility did not provide a policy related to MDS assessments.
Failure to Complete Significant Change MDS After Resident Transfer to Locked Unit
Penalty
Summary
Facility staff failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who was moved to the memory care (locked) unit following multiple documented behavioral incidents. The resident, who had diagnoses including paranoid schizophrenia, congestive heart failure, major depressive disorder, morbid obesity, type II diabetes, mild intellectual disabilities, impulse disorder, COPD, and hypertension, was involved in several incidents of theft or loss, such as taking and consuming other residents' food and beverages. After these incidents, the resident was moved to the locked unit, and the guardian was notified. Despite the change in the resident's condition and environment, the most recent MDS assessment on record was a quarterly assessment completed prior to the move. Staff did not complete a significant change MDS within the required timeframe following the behavioral incidents and transfer to the locked unit. Additionally, the resident's care plan was not updated to address the behaviors that led to the move, and the facility did not provide a policy related to MDS assessments. Interviews with facility staff confirmed that a significant change MDS should have been completed and that the care plan had not yet been updated for the resident's behaviors.
Failure to Complete Timely Discharge and Readmission MDS Assessments
Penalty
Summary
The facility failed to complete a discharge with return anticipated Minimum Data Set (MDS) and a readmission MDS within seven days for a resident who was transferred to the hospital and subsequently returned. Review of the resident's records showed that after experiencing chest tightness, tachycardia, and elevated temperature, the resident was sent to the hospital. Documentation confirmed the resident's hospital transfer, but staff did not complete the required discharge MDS for this event. When the resident returned from the hospital several days later, there was also no readmission MDS completed as required. Interviews with facility staff revealed that the Social Services Director was responsible for certain MDS sections, while the MDS Coordinator, who was new to the role, was responsible for completing the discharge MDS. The Administrator acknowledged that a discharge with return anticipated MDS should have been started once the resident was out of the building for 24 hours, and both the Administrator and DON confirmed that the required MDS assessments were not completed in a timely manner. The facility was unable to provide a policy related to MDS assessments during the review.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by facility policy. The policy specifies that a baseline care plan must be created within 48 hours to address the resident's immediate needs, including initial goals, physician and dietary orders, therapy, and social services. Review of the resident's electronic record showed no documentation of a baseline care plan following the resident's admission. Interviews with facility staff, including the Social Services Director, MDS Coordinator, Administrator, and Director of Nursing, revealed inconsistent understanding of the required timeframe, with some staff stating 72 hours instead of the policy-mandated 48 hours. The resident involved had multiple complex diagnoses, including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke. The resident was admitted to the facility, and nursing staff documented the arrival, but no baseline care plan was completed or documented within the required timeframe. This omission resulted in the resident's immediate care needs not being formally addressed as outlined in the facility's policy.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and implement accurate, comprehensive care plans for all residents, as evidenced by two specific cases. In the first case, a resident admitted with multiple diagnoses including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke did not have a comprehensive care plan completed within the required timeframe. The resident's electronic medical record showed no documentation of a completed care plan following admission, despite facility policy and staff interviews confirming that such a plan should have been developed within 21 days. In the second case, another resident with diagnoses including paranoid schizophrenia, congestive heart failure, major depressive disorder, morbid obesity, type II diabetes mellitus, mild intellectual disabilities, impulse disorder, COPD, and high blood pressure exhibited repeated behavioral incidents involving theft of food and beverages from other residents. These behaviors were documented in multiple incident reports and ultimately led to the resident being moved to a locked memory care unit. However, the resident's care plan was not updated to address these behaviors or the move, contrary to facility policy and staff expectations that care plans should be updated promptly when such behaviors occur or when a resident is transferred to a different unit. Interviews with facility staff, including the Social Services Director, MDS Coordinator, Administrator, and DON, confirmed that comprehensive care plans should be completed and updated in a timely manner to reflect residents' needs and changes in condition or behavior. The failure to complete and update care plans as required resulted in deficiencies in meeting the comprehensive care planning requirements for these residents.
Failure to Pay Generator Invoices Resulting in Removal of Emergency Power Source
Penalty
Summary
The facility failed to administer its operations in an effective and efficient manner by not paying invoices for a portable generator in a timely fashion. Observation revealed a disconnected natural gas generator on the facility grounds, with no other operational generator present. Review of invoices showed a significant outstanding balance, with amounts overdue for more than 90 days. The generator company had communicated multiple times regarding the overdue payments and warned that the generator would be removed if the balance was not paid. Ultimately, the generator was removed after the facility failed to resolve the outstanding debt. Interviews with facility staff indicated a lack of awareness and communication regarding the unpaid invoices. The Administrator stated that invoices were sent directly to the owners and not to him, and he was unaware of any outstanding balances or issues with the generator. The Director of Fiscal Services reported ongoing negotiations with the generator company over disputed charges, but the generator was removed during these negotiations. The facility did not provide a policy regarding the timeliness of payments to service providers.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months completed a state-approved CNA training program, competency evaluation, and certification test within the required timeframe. Specifically, two nurse aides continued to provide direct care to residents without documentation of CNA certification beyond the 120-day limit. Review of personnel files confirmed the absence of certification for both aides, and interviews with the DON and Administrator revealed that oversight and follow-through on certification requirements were lacking. Additionally, the facility did not provide a policy regarding nurse aide training classes.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
Staff failed to provide appropriate incontinent care for a resident with Alzheimer's disease, chronic kidney disease, and benign prostatic hyperplasia, who was dependent on staff for activities of daily living. The resident's care plan required frequent checks, assistance with toileting, and peri-care after each incontinent episode. Despite these directives, the resident was observed seated in a Broda chair near the nurses' station for an extended period, during which time a visible puddle of urine formed under the chair and the resident's clothing and chair became saturated with urine. Multiple staff members, including a registered nurse, certified medication tech, and nurse aides, passed by or interacted with the resident but did not check or change the resident or address the incontinence, even after the presence of urine was apparent. The resident remained in the same location for over two hours without being checked or changed, despite the facility's policy and staff statements that residents should be checked every two hours and as needed. It was only after the surveyor intervened and requested the resident be checked that staff provided incontinent care, changed the resident's clothing, and cleaned the chair. Interviews with staff revealed uncertainty about when the resident was last checked or changed, with some staff citing a busy workload and others indicating that the resident had been in the Broda chair since before their shift began. Staff acknowledged that the resident should have been checked and changed sooner, and that the presence of a puddle should have prompted immediate action. The deficiency was due to staff inaction and failure to follow the care plan and facility policy regarding incontinent care.
Ineffective Resource Management
Penalty
Summary
The facility was cited for not administering its resources effectively and efficiently, as noted in event ID NQRP12. The deficiency was identified during a survey with an exit date of January 14, 2025. The report does not provide specific details about the actions or inactions that led to this citation, nor does it mention any particular residents or staff involved. The citation is linked to the facility's overall management and resource utilization practices.
Inadequate RN and DON Staffing Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure consistent and sufficient Registered Nurse (RN) and Director of Nursing (DON) hours, which impacted the DON's ability to fulfill her duties. The DON frequently had to work as a charge nurse or certified nurse aide, which left her behind on essential DON responsibilities such as reviewing physician orders, tracking labs, hiring and terminating staff, and monitoring the infection prevention and antibiotic stewardship programs. The DON reported working multiple shifts on the floor, including every weekend in September, which contributed to the backlog in her administrative duties. Additionally, the facility did not implement an effective antibiotic stewardship program, as there were no measures in place to track residents on antibiotics for various infections. This lack of tracking was confirmed by the DON during interviews. Furthermore, the facility failed to ensure residents were free of significant medication errors, as staff did not administer warfarin sodium per physician's orders. There were also instances where ordered medications were unavailable on-site, preventing administration to residents. The DON acknowledged reviewing a computer dashboard daily for missed or unavailable medications, but these issues persisted.
Deficiency in Employing Qualified Dietary Manager
Penalty
Summary
The facility staff failed to employ a qualified dietary manager for the food and nutrition services department, as required by regulatory guidelines. The dietary manager, who started the position in March 2024, did not possess the necessary qualifications such as being a certified dietary manager (CDM), a certified food services manager, or having an associate's degree or higher in food service management or hospitality. The dietary manager had previous experience as a nutritional assistant and completed a certificate of proper temperature safety through the health department, but these credentials did not meet the requirements for the Director of Food and Nutrition Services (DFNS) in a long-term care setting. During an interview, the dietary manager confirmed the lack of required certifications and training. Additionally, the facility administrator admitted to being unaware of the necessary qualifications for the dietary manager position and indicated plans to send the manager to the required classes. The facility did not provide documentation of certification, training, or experience that met the regulatory requirements for the DFNS, resulting in a deficiency in employing appropriately qualified staff for the food and nutrition services department.
Infection Control Deficiencies in Legionella Prevention and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, particularly in preventing the growth of Legionella bacteria in the water supply. The facility did not conduct a Legionella risk assessment, lacked a diagram of the water system, and did not monitor water temperature or pH levels to prevent Legionella growth. The Maintenance Director was unaware of the necessary water temperature and pH levels and did not know the location of the facility's water system map. The Administrator confirmed that only resident room sinks and toilets were flushed, with no other preventive measures taken. Additionally, the facility did not have a policy or procedure for hand hygiene, leading to multiple instances of non-compliance with hand hygiene standards during medication passes. The Director of Nursing (DON) and Certified Medication Technicians (CMTs) were observed not performing hand hygiene before and after resident contact, after glove removal, and between medication passes. The DON was seen handling medical equipment and administering medications without washing hands, and CMTs were observed preparing and administering medications without performing hand hygiene. Interviews with staff, including CNAs, LPNs, and RNs, revealed that they were aware of the importance of hand hygiene but did not consistently practice it. The DON and Administrator acknowledged the expectation for staff to perform hand hygiene, yet observations showed a lack of adherence to these standards, contributing to the facility's failure to maintain an effective infection control program.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of a current and ongoing antibiotic log for residents with active infections. The facility's policy, dated December 2016, outlined that antibiotics should be prescribed and administered under the guidance of the Antibiotic Stewardship Program, with specific requirements for prescribers to provide detailed information about the antibiotic orders. However, the facility only provided a computer printout of residents prescribed antibiotics for September, with no additional documentation of antibiotic tracking measures. Interviews with the Director of Nursing (DON) revealed that while a monthly report of antibiotic usage is obtained and reviewed with the physician, there were no residents currently on antibiotics, and no other tracking measures or notes from the monthly physician meeting were documented. The DON also mentioned that outcome surveillance related to antibiotic use was not tracked, and although a new urinalysis is obtained upon completion of antibiotics, the results are not logged. The Administrator expected staff to follow guidelines for prescribed antibiotics, but the lack of documentation and tracking measures indicates a deficiency in the facility's antibiotic stewardship program.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and documentation for two residents, leading to deficiencies in wound management. For Resident #152, the staff did not consistently assess and document the resident's pressure ulcers on the right and left buttocks. Despite the presence of stage 2 pressure ulcers, the facility's records frequently omitted documentation of the right buttock ulcer, and there were no documented treatment orders in the system for the wounds. The resident was admitted with pressure ulcers, and the facility's policy required weekly wound assessments and documentation, which were not consistently followed. Resident #6 also experienced inadequate wound care documentation. The resident had a history of type two diabetes, peripheral vascular disease, and heart failure, and was at risk for pressure ulcers. The resident's care plan included orders for wound care, but the documentation was incomplete, with missing records for the left buttock wound and inconsistent weekly wound observations. The resident's wounds were not properly documented in the facility's system, and there was a lack of follow-through on treatment orders. Interviews with staff, including the DON and RN, revealed that the former wound nurse did not enter treatment orders into the computer system, leading to a lack of documented care. The facility's failure to adhere to its wound care policy and ensure proper documentation and treatment of pressure ulcers resulted in deficiencies in the care provided to these residents.
Deficiencies in Oxygen Equipment Management for Residents
Penalty
Summary
The facility failed to provide respiratory care per standards of practice for two residents, resulting in deficiencies related to the management of oxygen equipment. Resident #46, who has diagnoses including chronic obstructive pulmonary disease (COPD), heart disease, and chronic kidney disease, was observed with an oxygen concentrator and portable oxygen tank with undated or illegibly dated nasal cannulas and tubing. Despite physician orders to change the oxygen humidifier and tubing weekly, observations revealed that the equipment was not changed as scheduled, with dates on the equipment indicating it had not been updated since 09/16/24. Similarly, Resident #36, diagnosed with COPD and interstitial pulmonary disease, was also found with undated nasal cannulas and tubing that had not been changed since 09/16/24, contrary to the weekly change orders. Additionally, the resident's care plan did not include documentation of oxygen use, which is a critical component of their care. The September 2024 Medication Administration Record (MAR) lacked documentation for changing the humidifier and oxygen orders, further indicating a lapse in following prescribed care protocols. Interviews with facility staff, including Certified Medication Technicians, Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides, revealed inconsistencies and confusion regarding responsibilities for changing oxygen equipment. Staff members provided conflicting information about who was responsible for changing the tubing and when it should be done. The Director of Nursing confirmed that oxygen tubing should be changed weekly and that both nurses and aides are responsible for this task, yet the deficiency persisted, indicating a lack of adherence to established procedures and communication breakdowns among staff.
Inadequate Pain Management Due to Medication Unavailability and Documentation Failures
Penalty
Summary
The facility failed to provide effective pain management for residents, as evidenced by the failure to administer pain medications as ordered and the lack of documentation for pain medication orders. Resident #252, who was admitted with multiple fractures and high blood pressure, did not receive the prescribed morphine sulfate and Percocet due to delays in pharmacy delivery. Despite the resident's complaints of pain and requests for medication, staff only offered Tylenol, which was ineffective. The resident's pain levels were consistently documented as moderate, yet the ordered medications were not administered, and staff failed to provide alternative pain management solutions. Resident #36, diagnosed with COPD, prostate cancer, and interstitial pulmonary disease, also experienced inadequate pain management. The resident's prescribed Tylenol and oxycodone were not administered on multiple occasions due to unavailability. Upon returning from a leave of absence, the resident requested pain medication, but the facility did not have the prescribed oxycodone in stock. Although a substitute order for hydrocodone was obtained, it was not documented in the physician orders or the MAR, leading to further delays in pain relief. The resident reported severe pain levels, and staff interviews revealed ongoing issues with medication availability and documentation. Interviews with staff, including RNs, LPNs, and the DON, highlighted systemic issues with medication procurement and documentation. The facility struggled with timely medication delivery from the pharmacy, and there were instances where substitute medications were not properly documented. Staff were aware of the residents' pain but were unable to provide the necessary medications due to these logistical challenges. The facility's failure to adhere to its pain management policy resulted in prolonged periods of unrelieved pain for the residents involved.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 12.82% error rate with five medication errors out of 39 opportunities. These errors affected three residents. The errors included administering the wrong form of medication, incorrect dosages, and improper administration techniques. For instance, a Certified Medication Technician (CMT) administered a guaifenesin tablet instead of the prescribed liquid form to a resident with diabetes mellitus and congestive heart failure. Another resident, who was cognitively intact and diagnosed with throat cancer, lupus, and diabetes mellitus, received an incorrect dosage of olanzapine and the wrong form of ondansetron. The CMT administered a 10 mg tablet of olanzapine instead of the prescribed 5 mg and an orally dissolving tablet of ondansetron instead of the regular tablet form. These actions were contrary to the physician's orders and the facility's medication administration policy. Additionally, a resident with a feeding tube, diagnosed with nontraumatic intracerebral hemorrhage and respiratory failure, received medications improperly combined and administered through the g-tube. The Director of Nursing (DON) crushed and mixed hydralazine and tramadol tablets without a physician's order to combine them, contrary to the facility's policy and best practices for administering medications via enteral feeding tubes. This improper technique was observed during a medication administration process, highlighting a significant deviation from the prescribed method of administering and flushing medications separately.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to standards of practice, specifically regarding the storage of controlled substances and the security of medication carts. Observations revealed that controlled substances for two residents were not stored under two locks as required. Resident #1, who had diagnoses including human immunodeficiency virus and acute kidney failure, had a prescription for dronabinol capsules stored in an unlocked refrigerator. Similarly, Resident #39, with conditions such as benign intracranial hypertension and cancer, also had dronabinol capsules stored in the same unsecured manner. Additionally, medication carts were observed to be left unlocked and unattended on multiple occasions. One instance involved a nurse medication cart outside the Director of Nursing's office, which contained insulin pens and narcotics, being left unlocked while residents were nearby. Another observation noted the Director of Nursing leaving a cart unlocked near the nurses' station, with several residents in the vicinity. Interviews with staff, including Certified Medication Technicians and Registered Nurses, confirmed that medication carts and storage areas should be locked when not in use. However, the observations indicated a failure to adhere to these protocols, as controlled medications were found unsecured in the refrigerator, and medication carts were left unattended and unlocked. The Director of Nursing and Administrator acknowledged these lapses, emphasizing the expectation for medications to be stored securely and under double lock for narcotics.
Failure to Provide Accessible Hydration for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's hydration needs, as observed during a survey. The resident, who had diagnoses including chronic kidney disease, COPD, and heart failure, was found without accessible water on multiple occasions. The resident's care plan required nectar/mildly thick consistency liquids to be provided in a two-handled cup with a lid and spout. Despite this, observations showed that water was either out of reach or not present in the resident's room, and the resident was observed to be visibly thirsty with a dry mouth. Interviews with facility staff, including a CNA, RN, and the Director of Nursing, revealed that there was a misunderstanding about the resident's ability to have water in the room due to the need for thickened liquids. Staff were responsible for ensuring water was accessible during rounds every two hours, but this was not consistently done. The CNA mentioned that they were initially told the resident couldn't have water due to choking risks, but this was later clarified. Despite these instructions, the resident did not have water accessible, leading to the deficiency noted by the surveyors.
Failure to Complete PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to administer the required Preadmission Screening and Resident Review (PASARR) Level 1 screening for a resident with mental disorders prior to their admission. The resident, who was admitted with diagnoses including major depressive disorder, bipolar disorder, and psychosis, did not have a PASARR completed as required. The facility's policy mandates coordination with the Medicaid PASARR program to determine the nursing and medical needs of individuals with mental disorders, and potential residents with such conditions should only be admitted if the state mental health agency has determined the necessity of the level of service provided by the facility. The resident's records indicated cognitive intactness but an inability to complete a mental status interview, along with symptoms such as delusions and the use of antidepressant, antianxiety, and antipsychotic medications. The care plan noted confusion, disorganized thinking, and socially inappropriate behavior. Despite these indicators, a PASARR was not completed, as confirmed by an email from the Central Office Medical Review Unit. Interviews with the Social Services Designee and the Administrator revealed that the responsibility for completing the PASARR fell on the SSD, who admitted to completing it only if the hospital had not done so prior to admission.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident #15, by not ensuring the availability of prescribed medication, escitalopram oxalate, on multiple occasions. The resident, who had diagnoses including schizophrenia and major depressive disorder, required this medication as part of their treatment plan. Despite having a documented order for the medication, it was not administered on several dates in August and September 2024 due to unavailability. The facility's policies required timely reordering of medications and follow-up with the pharmacy to prevent lapses in administration. However, the documentation showed that the medication was not available on multiple dates, and staff did not consistently follow up with the pharmacy or utilize the emergency kit as per the facility's procedures. Interviews with staff, including Certified Medication Technicians (CMTs) and the Director of Nursing (DON), revealed a lack of communication and follow-up regarding the medication's unavailability. The DON acknowledged that the missed doses coincided with a period when physician orders were being redone for the pharmacy. Despite the facility's system for entering and faxing orders to the pharmacy, the medication was not received in a timely manner. The DON and other staff members were not consistently aware of the medication's unavailability, and the facility's dashboard, which tracks missed or unavailable medications, was not reviewed daily as required. This resulted in multiple missed doses of the resident's essential medication, highlighting a deficiency in the facility's pharmaceutical services.
Failure to Administer Warfarin as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when staff did not administer warfarin sodium as per the physician's order. The resident, who had a diagnosis of thrombophilia and an abnormal coagulation profile, was supposed to receive warfarin sodium, a blood thinner, to prevent blood clots. The medication was on hold from September 6th to September 11th, but after the hold ended, the resident missed three doses on September 11th, 12th, and 13th because the medication was reportedly unavailable. Certified Medication Technician (CMT) B documented that the warfarin sodium was not available on these dates and did not notify the Director of Nursing (DON) or the physician about the missed doses. Interviews revealed that CMT B was unaware that the medication was in a pill bottle until informed by the resident's responsible party. The facility's policy required staff to report any discrepancies in medication administration immediately to the DON and notify the physician and family, which was not done in this case. The DON and other staff members confirmed that the medication should have been available, possibly in the emergency kit, and that the resident should not have gone without warfarin for more than a couple of days due to the risk of blood clots. The facility's computer system was supposed to alert staff to medications not administered, and the DON was expected to review this daily. However, the missed doses were not reported or addressed in a timely manner, leading to a significant medication error.
Incomplete Documentation for Resident Transfers
Penalty
Summary
The facility failed to maintain complete medical records for two residents who were transferred to the hospital and later returned. For Resident #41, the nursing progress notes did not document the reason for the transfer, the time of transfer, or notification to the physician. Additionally, there was no record of the time or date of the resident's return from the hospital or physician notification of the return. The resident had a history of cerebral infarction, atrial fibrillation, and a fracture of the right femur, and was admitted to the ICU with atrial fibrillation, a urinary tract infection, and sepsis. For Resident #46, the nursing progress notes failed to document the notification of the physician regarding the transfer to the hospital. The resident was admitted to the hospital with an intestinal infection due to Clostridiodes difficile and returned to the facility without documentation of the return or physician notification. The resident had chronic obstructive pulmonary disease, heart disease, and chronic kidney disease, and was sent to the emergency room due to diarrhea and vomiting, which posed a risk of dehydration and acute kidney injury. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing, revealed that there were expectations for obtaining physician orders for transfers and documenting all relevant details in the resident's medical records. However, these procedures were not followed, leading to incomplete documentation for the residents involved.
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 70 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Buffalo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Springs Healthcare Center | 0.5 mi | ★★★★★ | 7 | 0 |
| Parkview Health Care Facility | 17.5 mi | ★★★★★ | 0 | 0 |
| Citizens Memorial Healthcare Facility | 18 mi | ★★★★★ | 11 | 0 |
| Webco Manor | 23.4 mi | ★★★★★ | 5 | 0 |
| Hermitage Nursing & Rehab | 23.7 mi | ★★★★★ | 13 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Buffalo Prairie Center For Rehab And Healthcare.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.