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 Mccrite Plaza At Briarcliff Skilled Facility during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and no history of diabetes was mistakenly identified as another resident and received a finger-stick blood glucose check and 20 units of long-acting insulin from an LPN after two CNAs incorrectly confirmed the resident’s identity. The resident, who had care plans for immobility and fall risk but no diabetes-related interventions, was in the wrong bed, there were no ID armbands or consistent door name identifiers, and EMR photos were not governed by a policy for updating. The resident’s blood sugar dropped, leading to hospital admission with hypoglycemia and acute metabolic encephalopathy attributed to accidental insulin administration.
A resident with severe cognitive impairment, non‑ambulatory status, and multiple comorbidities who required maximum assistance for sit‑to‑stand was transferred manually with a gait belt instead of with a mechanical lift as required by facility policy. Two CNAs looped their arms through the resident’s arms and lifted and pivoted the resident without ensuring the resident’s feet were on the floor, during which one CNA stumbled, kicked the wheelchair backward, and set the resident on the bed with excessive force, causing the resident to moan. The resident’s care plan lacked specific transfer instructions, one CNA was unaware a mechanical lift was present in the room or who updated transfer status, and leadership interviews confirmed that residents unable to bear weight should be transferred with a mechanical lift and that staff should not lift residents by the arms.
Staff failed to follow policy for signing in and securing a controlled substance after pharmacy delivery, resulting in the loss of oxycodone intended for a resident with multiple medical conditions and moderate cognitive impairment. The medication was not found despite searches and review of delivery records, and the required documentation and security procedures were not followed.
A resident with a documented DNR order experienced a medical emergency during therapy and became unresponsive. Despite the DNR status being available in the electronic medical record and a DNR book, staff initiated CPR after failing to find the appropriate visual indicator on the resident's door. CPR continued until EMS arrived and pronounced the resident deceased. Interviews confirmed that staff should have checked the DNR documentation and honored the resident's wishes.
The facility failed to follow professional standards for food service safety, with staff neglecting to date and label food products and leftovers, and not discarding expired items. Additionally, daily temperature logs for refrigerators, freezers, and dishwashers were not maintained. These deficiencies were observed in various storage and kitchen areas, posing a risk of foodborne illnesses to residents.
The facility failed to ensure proper authorization for DPOA to sign OHDNR forms for two residents with cognitive impairments, as incapacitation letters were missing. Additionally, a resident's code status was inconsistently documented as both Full Code and DNR. Staff interviews confirmed the expectation for consistent documentation, which was not met.
The facility failed to maintain a clean and homelike environment, with observations of unclean areas, holes in carpets, and stained furniture. Staffing challenges, including a vacant floor technician position, contributed to these deficiencies. The Administrator expected a clean environment, but understaffing and communication issues led to the observed problems.
The facility failed to complete criminal background checks for five employees before their start date, contrary to its policy to prevent abuse and neglect. The DON and Administrator confirmed that HR is responsible for these checks, but the deficiency was noted as the checks were not completed in time.
The facility failed to recognize and report significant weight changes in four residents, as required by their policy. Despite visible calculations of weight changes in the electronic medical record, there was no documentation of notification to the primary care providers or the Registered Dietician Nutritionist (RDN). Interviews with staff revealed a lack of awareness of residents with weight concerns and uncertainty about scale calibration procedures.
The facility failed to provide complete perineal care to residents with severe cognitive impairments and dependencies on staff for personal hygiene. Observations showed that staff did not adequately clean all areas that urine or feces had touched, particularly failing to spread the skin and clean all skin folds. This deficiency affected four residents, each with conditions such as Alzheimer's disease and Parkinson's disease. Interviews confirmed that staff were aware of proper procedures but did not follow them during care.
The facility failed to ensure proper transfer techniques for residents, leading to deficiencies in care. A resident was left swinging in a mechanical lift without stabilization, while another had incorrect brake usage during a sit-to-stand lift. Additionally, staff used improper gait belt techniques, and a resident was improperly positioned in a sling during a transfer.
The facility failed to maintain and document the maintenance of oxygen equipment for three residents, leading to deficiencies in respiratory care. A resident with chronic lung disease used an oxygen concentrator with outdated tubing and a water canister. Another resident had an oxygen concentrator with filters covered in lint, and staff were unaware of maintenance protocols. A third resident's oxygen concentrator and filters were caked in dust, with no documentation of maintenance. Staff interviews revealed a lack of knowledge and training regarding equipment maintenance.
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. Two residents received eye drop medications incorrectly, with the dropper touching their eyes and insufficient lacrimal pressure applied. Staff acknowledged the errors, confirming that the dropper should not touch the eye and pressure should be applied for the correct duration.
The facility failed to properly store and supervise medications for three residents. A resident with cognitive impairment was observed taking medication unsupervised, while two other residents had unsecured medications in their rooms, including a decongestant spray and wound cleansers. Staff interviews confirmed these practices were against facility policy, and the issues were acknowledged by the DON and Administrator.
The facility failed to ensure that call lights were accessible to residents, as observed in two resident rooms and three common area bathrooms where pull cords were wrapped around handrails, making them inoperable. Interviews with the DON and Administrator confirmed that call lights should be within reach, but the facility's system for checking call light functionality was ineffective in preventing this issue.
A resident with severe cognitive impairment and mobility issues was not repositioned as per physician's orders, remaining in a wheelchair for extended periods. Despite staff expectations to reposition every two hours, the resident was left in the wheelchair, increasing the risk of pressure ulcers. Observations and interviews confirmed the facility's failure to adhere to care protocols.
Insulin Administered to Non-Diabetic Resident Due to Misidentification
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when insulin was administered to a resident who was not diabetic. The resident had severe cognitive impairment, was non-ambulatory, and required maximum assistance with mobility, with documented diagnoses including non-Alzheimer’s dementia, traumatic brain injury, and heart disease. The resident’s care plan addressed risks such as pressure ulcer development and falls but contained no interventions related to diabetes management or care. On the evening of the incident, an LPN assisted a CNA in putting the resident to bed. The CNA was told by another CNA that the resident being assisted was a different resident, and that CNA went into the room and confirmed the incorrect identity. Relying on this information, the LPN performed a finger-stick blood glucose test, obtained a reading of 142, and administered 20 units of Insulin Glargine, a long-acting insulin, under the assumption that the resident was the diabetic resident. After the insulin was given, the LPN sought further verification with a certified medication technician and discovered that the residents had been placed in the wrong beds, and insulin had been administered to the wrong resident. The resident who received the insulin was not diabetic and subsequently experienced a drop in blood sugar, was transferred to the hospital, and was diagnosed with hypoglycemia and acute metabolic encephalopathy due to accidental insulin administration. Interviews revealed that the LPN had attempted to confirm the resident’s identity with two CNAs and the resident, but the resident was unable to self-identify, and the CNAs had incorrectly identified the resident. The LPN also used a CNA’s tablet to compare the resident’s picture in the EMR, in a setting where residents did not wear identifying armbands, there were no names on doors unless chosen by residents, and there was no policy on how often or by whom resident photos in the EMR should be updated.
Improper Manual Transfer Performed Instead of Required Mechanical Lift
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a resident who required a mechanical lift, resulting in staff using an improper manual transfer with a gait belt. The facility’s Safe Lift, Transfer and Repositioning Policy and Mechanical Lift Transfer Policy required that residents who are unable to bear weight, or who are totally dependent or require extensive assistance, be transferred with a mechanical lift and full body sling. The resident’s care plan identified risks related to immobility, including potential for pressure ulcer development and high fall risk due to deconditioning and gait/balance problems, but did not include documented interventions specifying how the resident was to be transferred. The MDS showed the resident had severe cognitive impairment, was non‑ambulatory, and required maximum assistance with sit‑to‑stand, and received scheduled pain medication, with diagnoses including non‑Alzheimer’s dementia, traumatic brain injury, and heart disease. During an observed transfer, two CNAs transferred the resident using a gait belt rather than a mechanical lift. CNA D applied the gait belt by sliding it down the back of the resident’s head and along the spine. CNA C looped an arm through the resident’s right arm and grasped the gait belt behind the resident’s back, while CNA D looped an arm through the resident’s left arm and also grasped the gait belt at the back. Without first asking the resident to scoot forward or ensuring the resident’s feet were on the floor, CNA D counted to three and both CNAs lifted and pivoted the resident onto the edge of the bed. During this maneuver, CNA D stumbled and kicked the wheelchair, propelling it backward, and then set the resident on the bed with excessive force, during which the resident moaned. Interviews revealed that CNA D believed the resident was a one‑person transfer but chose to use two staff for safety, was unaware that a mechanical lift was already in the resident’s room, and did not know who updated residents’ transfer statuses. CNA D stated that if a resident can bear weight, their feet should touch the ground during transfer. The DON stated that transfer statuses are documented in the EMR and updated by the interdisciplinary team, that residents unable to bear weight should be transferred with a mechanical lift, that during a stand‑pivot transfer the resident’s feet should remain on the ground, and that staff should not loop their arms into residents’ arms or lift at armpit level. The Administrator stated that residents listed as two‑person transfers should be able to bear weight with feet on the ground, that residents totally dependent on staff for lifting should be transferred with a mechanical lift, and that transfer and mobility status changes should be updated in the care plan so staff know what type of transfer is needed.
Failure to Secure and Account for Controlled Substance Results in Missing Medication
Penalty
Summary
Facility staff failed to secure a controlled substance, specifically oxycodone, for a resident with multiple medical conditions including a right femur fracture, osteoporosis, major depressive disorder, pain, reduced mobility, falls, obesity, and anemia. The resident had moderately impaired cognition and was receiving both scheduled and as-needed pain medication. On the afternoon following a pharmacy delivery, a nurse attempted to administer an as-needed dose of oxycodone but discovered the medication was missing from the medication cart and safe. Investigation revealed that the pharmacy had delivered a card of 18 oxycodone 5mg tablets, which was signed for by an LPN. The facility's policies required that controlled substances be properly signed in, counted, and secured in a locked compartment immediately upon receipt. However, the medication and its count sheet were not found during searches of all medication carts and lock boxes. The nurse who signed for the medication was unable to account for its whereabouts, and the missing medication was not recovered despite a review of camera footage and interviews with staff present at the time of delivery. The incident was reported to the pharmacy, facility administration, and the resident's physician. The facility's investigation confirmed that the required procedures for signing in and securing the controlled substance were not followed, resulting in the loss of the medication. The resident's pain management was temporarily affected until replacement medication was provided.
Failure to Honor Resident's DNR Order Resulting in Unwanted CPR
Penalty
Summary
Facility staff failed to honor a resident's Do Not Resuscitate (DNR) order when the resident became unresponsive during a therapy session. Despite the resident having a clearly documented DNR status in both the electronic medical record and a DNR book at the nurses station, staff initiated Cardiopulmonary Resuscitation (CPR) after the resident slumped over and became nonresponsive. The charge nurse checked the back of the resident's door for a butterfly or heart symbol, which were used to indicate DNR or full code status, but found no indicator and proceeded with CPR. The Director of Nursing arrived with the DNR paperwork, but CPR continued until Emergency Medical Services arrived and pronounced the resident deceased. Interviews with staff revealed that DNR status was accessible in multiple locations, including the electronic medical record and a designated book, and that visual indicators were intended to be placed on resident doors. However, the absence of the visual indicator led to the initiation of CPR, contrary to the resident's documented wishes. The nurse practitioner and Director of Nursing both confirmed that staff should have followed the resident's DNR order and not performed CPR.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by multiple observations of improper food storage and labeling practices. Staff did not date the receipt of incoming products in the dry storeroom, nor did they label and date used products in the freezer and refrigerator. Additionally, leftovers in the refrigerator were not labeled or dated, and expired leftovers were not discarded. The facility also failed to monitor refrigerator, freezer, and dishwasher temperatures on a daily basis, which is a critical component of food safety management. These lapses were observed in various areas, including the dry kitchen storage room, the main kitchen dry storeroom, and the main prep area kitchen. Interviews with staff revealed a lack of adherence to the facility's policies regarding food storage and labeling. Staff members acknowledged the requirement to date opened products and discard items not used within a specified timeframe, yet these practices were not consistently followed. The Registered Dietician and the Administrator both expressed expectations for proper labeling and daily maintenance of temperature logs, which were not met. The failure to follow these procedures placed all residents at risk for foodborne illnesses, given the potential for contamination and spoilage of improperly stored food items.
Inconsistent Advance Directive Documentation and DPOA Authorization
Penalty
Summary
The facility failed to ensure that an invoked Durable Power of Attorney (DPOA) was in place before allowing designated agents to sign Outside of Hospital Do Not Resuscitate (OHDNR) forms for two residents. Resident #22, who had significant cognitive impairments and was dependent on staff for daily activities, had an OHDNR form signed by their spouse without an incapacitation letter in the medical record. The Social Services Director (SSD) was unable to locate the incapacitation letter, which is necessary to validate the DPOA's authority to make such decisions. Similarly, Resident #18, who also had severe cognitive impairments and was dependent on staff, had an OHDNR form signed by their husband without any DPOA paperwork or incapacitation letter found in the medical record. The SSD acknowledged the absence of these critical documents, which should have been obtained at admission and placed in the resident's chart to ensure proper authorization for the DPOA to act on the resident's behalf. Additionally, the facility failed to ensure that Resident #295's code status was consistent across their medical records. Although the resident was cognitively intact and had signed a DNR form, discrepancies were found in the documentation, with the resident's code status listed as both Full Code and DNR in different parts of their medical record. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that the code status should be consistent throughout the resident's chart, but this was not the case for Resident #295.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by multiple observations of unclean and poorly maintained areas. Surveyors noted several deficiencies, including holes in the carpet, stained furniture, and unclean food and medication carts. Additionally, there were areas with scraped and missing paint, stained ceiling tiles, and dirty windows. These observations were made in various parts of the facility, including the dining room, east hall, and rehab hallway. Interviews with facility staff revealed that the housekeeping department was understaffed, with only four staff members responsible for the entire building. The floor technician position had been vacant for approximately a week, leading to overlooked vacuuming and floor maintenance. The Housekeeping Supervisor indicated that maintenance was responsible for fixing and repairing walls, while the floor technician was responsible for vacuuming and maintaining floors, windows, and furniture. Due to the vacancy, housekeeping staff had to assist with floor technician duties after completing their primary responsibilities. The Maintenance Technician confirmed awareness of the carpet holes and repair needs in the dining room, with plans to replace the carpet in main areas. The Administrator expressed expectations for a safe, clean, and homelike environment, including clean and sanitized food carts, debris-free floors, and maintained walls and furniture. Despite these expectations, the facility's current staffing challenges and communication issues contributed to the observed deficiencies.
Failure to Complete Timely Background Checks for New Employees
Penalty
Summary
The facility failed to complete criminal background checks for five out of ten sampled employees before their employment start date, which is a requirement to prevent abuse, neglect, and exploitation. The facility's policy mandates that all potential employees undergo a criminal background check and other screenings before they begin working with residents. However, the review of new hire employee packets revealed that five employees had started their employment before the facility received their criminal background check results. This includes a maintenance employee, a cook, a CNA, a housekeeper, and an activity assistant. Interviews with the Director of Nursing (DON) and the Administrator confirmed that an employee's hire date is considered their first day of orientation, and that the Human Resources department is responsible for ensuring all new employees have completed the necessary background checks. Despite these procedures, the facility did not adhere to its policy, resulting in the deficiency noted by the surveyors.
Failure to Monitor and Report Significant Weight Changes
Penalty
Summary
The facility failed to provide services that met professional standards of quality by not recognizing and reporting significant weight changes in four residents. The facility's policy required immediate notification of significant weight loss to the physician, resident, and/or legal representative, and a referral to the Registered Dietician Nutritionist (RDN) for recommendations. However, there was no documentation of such notifications or referrals for the affected residents, despite visible calculations of weight changes in the electronic medical record. Resident #28 experienced a significant weight loss of 35.5 lbs., or 20.5% over 35 days, without any documented notification to the primary care provider or the RDN. Similarly, Resident #295 lost 11.8 lbs., or 6.2% in five days, yet there was no documentation of notification to the primary care provider or the RDN. Resident #244 had weight fluctuations, losing 6.9 lbs. in seven days and then gaining 6.2 lbs. in five days, but again, there was no documentation of notification to the primary care provider or the RDN. Resident #294 lost 11.2 lbs., or 5.29% in four days, with no documentation of notification to the primary care provider or the RDN. Interviews with staff revealed a lack of awareness of residents with weight concerns and uncertainty about scale calibration procedures. The facility's policies and procedures for monitoring and reporting weight changes were not followed, leading to the deficiency.
Inadequate Perineal Care for Dependent Residents
Penalty
Summary
The facility failed to provide complete perineal care to residents who were unable to perform activities of daily living (ADLs) independently. Observations revealed that staff did not adequately clean all areas that urine or feces had touched, particularly failing to spread the skin and clean all skin folds. This deficiency affected four residents, each with severe cognitive impairments and dependencies on staff for personal hygiene due to conditions such as Alzheimer's disease, aphasia, and Parkinson's disease. For Resident #18, staff did not spread the skin and clean all areas during perineal care, despite the resident being frequently incontinent of bowel and bladder. Similarly, Resident #27, who required substantial assistance and was always incontinent, did not receive complete perineal care as staff failed to spread the skin and clean all necessary areas. Interviews with the staff involved confirmed that they were aware of the proper procedures but did not follow them during the observed care. Resident #22, who had a urinary catheter and was always incontinent of bowel, also did not receive proper catheter and perineal care. Staff failed to anchor the catheter tubing correctly, did not clean the port of the drainage bag, and did not separate and clean all skin folds. Additionally, Resident #14, who required extensive assistance with ADLs, did not receive thorough perineal care as staff failed to clean the skin folds and did not maintain proper hand hygiene during the process. Interviews with the Director of Nursing and the Administrator confirmed the expectations for staff to follow proper procedures, which were not met in these instances.
Improper Transfer Techniques in LTC Facility
Penalty
Summary
The facility failed to ensure proper techniques were used during resident transfers, leading to deficiencies in the care provided to four residents. For Resident #18, staff did not follow the manufacturer's guidelines for using a mechanical lift. The resident was left suspended in the lift without stabilization, as one CNA left the room, leaving the resident swinging back and forth. Both CNAs involved acknowledged the need for two staff members to operate the lift, with one stabilizing the resident, which was not adhered to during the incident. Resident #27 experienced a similar issue with the sit-to-stand mechanical lift. The CNA locked only one of the rear brakes instead of leaving them unlocked as per the guidelines, and the RN involved also failed to ensure both brakes were unlocked during the transfer. This improper handling of the lift was acknowledged by both staff members, who admitted to not following the correct procedure. For Resident #28, the staff failed to perform a safe gait belt transfer. Instead of using the gait belt correctly, the staff hooked their arms under the resident's arms, which is against the facility's policy. Both the CNA and CMT involved admitted to the incorrect technique. Additionally, Resident #14 was improperly positioned in the sling during a mechanical lift transfer, with the resident's bottom hanging over the edge and arms dangling, which was recognized by the CNA but not corrected during the transfer.
Failure to Maintain and Document Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to provide proper respiratory care for three residents by not maintaining and documenting the maintenance of oxygen equipment. Resident #244, who has multiple health conditions including chronic lung disease and emphysema, was observed using an oxygen concentrator with tubing and a water canister that had not been changed or dated for over 30 days. The resident reported not seeing any staff clean or change the oxygen equipment, despite using it continuously and experiencing lightheadedness without it. Resident #11, who has severe cognitive impairment and requires substantial assistance, was observed without a nasal cannula and with oxygen concentrator filters covered in gray lint. Staff interviews revealed a lack of knowledge about the presence and maintenance of these filters, indicating a gap in training and protocol adherence. The resident's care plan required oxygen therapy, but there was no corresponding physician order documented. Resident #28, with moderate cognitive impairment and conditions such as Parkinson's disease and pulmonary fibrosis, was observed with an oxygen concentrator and filters caked in dust. Staff interviews showed uncertainty about who was responsible for cleaning the filters, and the Director of Nursing confirmed that there were no logs to document filter changes, which should occur weekly. This lack of documentation and maintenance highlights a systemic issue in the facility's respiratory care practices.
Medication Administration Errors in Eye Drop Application
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. This deficiency was observed during the administration of eye drops to two residents. In the first instance, a Certified Medication Technician (CMT) administered Refresh Ophthalmic solution to a resident, during which the tip of the eye dropper touched the resident's eyelid and eyelashes. Additionally, the CMT applied lacrimal pressure for only 20 to 25 seconds instead of the required one to two minutes. The CMT acknowledged the error, stating that the dropper should not have touched the resident's eye and that lacrimal pressure should have been applied for a longer duration. In the second instance, another CMT administered Systane Ultra Ophthalmic Solution to a different resident. During this process, the tip of the applicator touched the resident's upper eyelashes, and the CMT failed to apply pressure to the inner corner of the resident's eyes after administering the medication. The CMT admitted that pressure should have been applied for two minutes and that the dropper should not have come into contact with any part of the resident's eye. Interviews with the Director of Nursing and an LPN confirmed the correct procedures for administering eye drops, which were not followed in these cases.
Medication Storage and Supervision Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with accepted professional principles for three residents. For Resident #12, there was no assessment for self-administration of medications, and the resident was observed taking medication unsupervised, with pills left in the room. The resident, who had moderately impaired cognitive skills and required substantial assistance with daily activities, was seen picking pills from a medication cup and taking them without supervision, contrary to facility policy. For Resident #28, medications were not stored securely. A bottle of decongestant nose spray was repeatedly observed on the resident's windowsill, with the room door open, indicating a lack of secure storage. The resident had no cognitive impairment but required extensive assistance with daily activities. Staff interviews revealed that the medication was brought in by the family and was not used by the resident, and it should have been stored in the medication cart. Resident #193 also had unsecured medications, with wound cleansers and protective spray found on the windowsill. The resident had recently returned from a hospital stay with multiple diagnoses, including a fracture and delirium. Staff interviews confirmed that wound cleansers should not be stored at the bedside but rather in a medication cart or a designated storage area. The facility's failure to adhere to its medication storage policies was acknowledged by the Director of Nursing and the Administrator.
Inaccessible Call Lights in Resident and Common Area Bathrooms
Penalty
Summary
The facility failed to ensure that residents had a means of directly contacting caregivers due to bathroom call light pull cords being wrapped around handrails, rendering them inoperable and inaccessible. This issue was observed in the rooms of two residents and in three common area bathrooms. The facility's policies on call lights and accident prevention did not adequately address the operability and accessibility of call lights for residents who might be lying on the floor in need of help. Interviews with the Director of Nursing (DON) and the Administrator revealed that call lights should always be within reach and easily usable by residents. The DON mentioned that the online call light system checks every room approximately every 30 days to ensure functionality. However, the observations indicated that this system was not effective in identifying and correcting the inaccessibility of call lights in certain areas, leading to the deficiency.
Failure to Reposition Resident as Per Physician's Orders
Penalty
Summary
The facility failed to provide quality care and treatment in accordance with professional standards of practice for a resident who was severely cognitively impaired and dependent on a wheelchair. The resident required substantial assistance with mobility and was at risk of developing pressure ulcers. Despite physician's orders to lay the resident down after lunch to offload pressure from the buttocks, staff did not comply with these orders, leaving the resident in a wheelchair for extended periods without repositioning. Observations over several days showed the resident remained in a wheelchair for hours without being laid down or repositioned, contrary to the care plan and physician's orders. Interviews with staff, including CNAs, CMTs, and LPNs, revealed an expectation for residents to be repositioned every two hours, yet this was not adhered to for the resident in question. The resident's representative also noted the presence of a sore on the resident's bottom, indicating a lack of proper care. The Director of Nursing and the facility Administrator both acknowledged the expectation for repositioning every two hours, especially for residents unable to reposition themselves. However, the facility's failure to follow these protocols resulted in the resident remaining in a wheelchair for prolonged periods, increasing the risk of pressure ulcers and compromising the resident's skin integrity.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinnacle Point Wellness & Rehabilitation | 1.4 mi | ★★★★★ | 13 | 0 |
| Northland Rehabilitation & Health Care Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Resort Kansas City, Llc | 4.2 mi | ★★★★★ | 11 | 0 |
| Linden Woods Village | 5 mi | ★★★★★ | 0 | 0 |
| Parkview Healthcare | 5.4 mi | ★★★★★ | 6 | 1 |
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