Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakridge Of Plattsburg during CMS and state inspections, most recent first.
A facility failed to maintain a clean, comfortable, and homelike environment for three residents. Observations found torn and frayed curtains, air conditioner vents covered in dust and dirt with units blowing dust into rooms, and bathroom doors and doorways in poor repair, including sticking doors, missing paint, and damaged wood. Residents said they expected their rooms to be clean and in good repair, and staff identified housekeeping and maintenance responsibilities for curtains, vents, and room repairs.
Failure to provide adequate ADL care and proper perineal care: A dependent resident with dysphagia, incontinence, and risk for dehydration remained in a wheelchair for over four hours without repositioning, toileting, oral care after meals, or being offered a drink. In a separate event, a CNA reused the same disposable cleansing wipe multiple times during perineal care for a resident with an indwelling catheter and bowel incontinence, despite other staff stating the wipe should only be used once.
Catheter Care and Infection Prevention Deficiencies: The facility failed to provide proper catheter care for two residents with indwelling urinary catheters. One resident’s CNA emptied the drainage bag without wearing EBP, placed the measuring container directly on the floor without a barrier, and did not clean the drainage tubing afterward. Another resident’s catheter tubing was observed with a large dependent loop and positioned so it could touch the floor, contrary to the care plan and staff statements that tubing should remain free of obstructions and not contact the ground.
Medication error rates were not kept below 5%, resulting in a 12% error rate. A CMT administered a rectal suppository without lubricant to one resident, and for another resident a prescribed antihypertensive was held despite BP being within ordered parameters while a nutritional supplement was documented as given but was not actually administered. The DON confirmed lubrication was necessary for suppository administration and that the medication should have been given as ordered.
Improper Labeling and Dating of Open Medications: Surveyors found multiple opened multi-use meds on a med cart that were missing open dates or were kept beyond the allowed use period, along with an unlabeled opened syringe of topical medication. The items included insulin, artificial tears, nasal spray, viscous lidocaine, and fiber lax, and staff confirmed that multi-use meds should be dated when opened and that expired or outdated meds should not remain on the cart or be administered.
Infection control failures occurred when staff did not consistently use EBP for residents with wounds and an indwelling catheter, including during perineal care and catheter drainage, and when insulin was administered without proper aseptic technique such as cleaning the pen seal and avoiding fanning the injection site. The facility also had staff whose initial TB screening was completed after hire rather than before employment, contrary to policy.
The facility failed to accurately account for resident trust funds and did not reconcile the resident trust account each month. Review of attempted reconciliations showed a carried-forward balance of $8,559.84 that did not match current resident balances, and the BOM stated the amount had been carried for years while continuing to balance the account.
A resident with cognitive impairment and physical limitations, who required assistance with feeding, was left alone in the dining room with a tray of hot food. Without staff supervision or their usual family support, the resident attempted to eat using their hands and sustained burns to multiple fingers. Staff and another resident confirmed that no one was present to assist at the time, and the injury was discovered and treated by nursing staff.
The facility failed to provide a homelike environment and ensure resident safety due to inadequate maintenance and cleaning practices. Observations included peeling vinyl and torn fabric on dining room chairs, cobwebs in various areas, a loose handrail, and water stains on the ceiling. Interviews revealed inconsistencies in cleaning schedules and maintenance practices, with no schedule for painting walls and plans to reupholster dining chairs.
Facility staff failed to provide adequate ADL and hygiene care for residents, affecting three individuals. A resident did not receive complete perineal care, and morning hygiene was neglected. Another resident was left in the same clothes for hours without repositioning or toileting. A third resident was not repositioned or toileted for an extended period and received fewer showers than scheduled. Staff interviews revealed non-compliance with care protocols.
The facility failed to ensure wheelchair safety by pushing residents without footrests, even though they could propel themselves. Staff, including CNAs and a kitchen manager, instructed residents to hold their feet up, posing a safety risk. Interviews revealed inconsistent understanding of safety requirements, with some staff believing it was acceptable to push residents without footrests if they could lift their feet.
The facility failed to assess and manage bed rail use for several residents, leading to potential safety risks. They did not conduct necessary assessments, review risks and benefits, or obtain informed consent before installation. Additionally, they did not ensure bed dimensions were appropriate or obtain physician orders. Staff interviews revealed inconsistencies in policy implementation, contributing to the deficiencies.
A long-term care facility reported a 19.35% medication error rate, affecting four residents. Errors included mislabeled eye drops, unmeasured liquid supplements, and improper administration of eye and nasal medications. Staff failed to follow facility policies and manufacturer's guidelines, leading to incorrect medication administration.
The facility exhibited multiple deficiencies in food safety and hygiene practices, including improper thawing techniques, uncovered garbage cans, inadequate hand hygiene, and poor food storage and labeling. Observations revealed staff did not consistently follow policies, leading to potential contamination risks. Interviews with staff and the Administrator confirmed expectations for proper practices, yet these were not consistently implemented.
The facility failed to follow infection control practices, particularly in using Enhanced Barrier Precautions (EBP) and handling urinary catheter drainage bags. A resident's catheter bag touched contaminated surfaces, and staff did not use available gowns for EBP. Two residents requiring EBP for wound care were not provided with proper gown usage by LPNs, and blood-stained sheets were not changed. The DON confirmed the expectation for staff to use gowns and gloves during care for residents needing EBP.
Dirty vents, damaged bathrooms, and torn curtains in resident rooms
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for three sampled residents by leaving resident rooms with torn and frayed window curtains, dirty air conditioning vents, and bathrooms in poor repair. Observations of Resident #4’s room showed the air conditioner vents covered in dust and dirt, the unit blowing cold air and dust into the room, a bathroom door that was stuck shut and hard to open, a strip of missing paint on the bathroom door, and torn, frayed curtains. Similar observations were made in Resident #27’s room, including dust-covered air conditioner vents, the unit blowing cold air and dust into the room, a bathroom door that was stuck shut and hard to open, missing paint on the bathroom door, and torn, frayed curtains. Resident #14’s room was also observed with multiple areas of missing paint and damaged wood on the bathroom doorway and doors, torn curtains with shredded lining, and air conditioner vents covered in dirt and dust while the unit was blowing cool air and dust into the room. During interviews, the residents stated they expected their rooms to be comfortable, homelike, clean, and in good repair, and that the air conditioners should be clean and not blowing dust. Staff interviews identified the Housekeeping Supervisor as responsible for curtain condition and cleaning air conditioner vents, and the Maintenance Supervisor as responsible for keeping resident rooms and bathrooms in good repair and cleaning the vents, while both staff stated resident rooms should be clean, in good repair, and homelike.
Failure to Provide Adequate ADL Care and Proper Perineal Care
Penalty
Summary
The facility failed to provide adequate ADL care for a dependent resident who was assessed as dependent on staff for eating, toileting, and all ADLs, always incontinent of bowel and bladder, and diagnosed with kidney disease, seizures, and dysphagia. The resident’s care plan identified risk for dehydration, instructed staff to offer fluids during cares, and identified risk for skin breakdown related to incontinence and impaired mobility. During continuous observation, the resident remained in a wheelchair for the entire observation period, was moved between the TV room, activity room, dining room, and room without repositioning, toileting, or oral care after meals, and was not offered a drink. The resident was later transferred to bed, incontinence care was provided, and the resident was repositioned. The report also documents improper perineal care for another resident who was cognitively intact, had an indwelling urinary catheter, and had diagnoses of urinary retention, UTI, and constipation. The resident’s care plan stated the resident was dependent on staff for catheter care and bowel incontinent care. During observation, a CNA performed perineal care and used the same disposable cleansing wipe multiple times while cleaning the resident’s perineum and bowel movement from different areas of the body, folding the wipe and reusing it repeatedly. Facility staff interviewed after the observation gave conflicting statements about wipe use during perineal care. One CNA stated disposable cleansing wipes could be folded up to three times, while a CMT, another CNA, the Infection Control Nurse, an LPN, and the DON stated the wipes should only be used once during perineal care.
Catheter Care and Infection Prevention Deficiencies
Penalty
Summary
The facility failed to ensure appropriate catheter care and services to prevent urinary tract infections for two residents with indwelling urinary catheters. The facility’s policy for emptying urinary drainage bags required staff to place a paper towel beneath the drainage bag, use a measuring container under the bag, empty the drainage tube, wipe the drain with an alcohol sponge or swab, and return the drain to its holder. The facility’s Enhanced Barrier Precautions policy required staff to wear a gown and gloves during high-contact care activities for residents with indwelling medical devices. One resident was cognitively intact, had an indwelling urinary catheter, and had diagnoses including urinary retention, UTI, and constipation. The resident’s care plan required enhanced barrier precautions because of the catheter and stated the resident was dependent on staff for catheter care and bowel incontinent care. During observation, a CNA emptied the catheter drainage bag without wearing a gown, placed the graduate directly on the floor without a barrier, and secured the drainage tube without cleaning it with an alcohol sponge or swab. Staff interviews afterward confirmed that EBP should have been worn, a barrier should have been placed between the graduate and the floor, and the tubing should have been cleaned after emptying the bag. The second resident had mild cognitive impairment, required moderate assistance with transfers and toileting, and had diagnoses including seizure disorder, hypertension, and UTI. The care plan directed staff to manage all care associated with the urinary catheter, keep tubing and any part of the drainage system from touching the floor, use EBP, and noted the resident was at risk for UTI related to a chronic suprapubic catheter and history of UTI. Nursing notes showed the resident had not been seen by urology since October 2025 despite a monthly exchange plan, and the resident had multiple hospitalizations for UTI and urosepsis. During observation, the resident’s catheter tubing was clipped near the knee, creating a large dependent loop before connecting to the drainage bag, which blocked gravity drainage and allowed urine to pool in the tubing.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication error rates were not kept below 5 percent, resulting in a 12% medication error rate based on observation, interview, and record review for two residents out of 26 opportunities. The facility failed to ensure medications were administered in accordance with prescriber orders when a rectal suppository was given without lubricant and when a prescribed medication was withheld and another medication was documented as administered when it was not. The facility census was 54, and the Medication Administration Policy stated medications are to be administered safely, timely, and in accordance with prescriber orders. For one resident, the POS ordered Bisacodyl suppository 10 mg rectally on Mondays and Thursdays for constipation. During observation, a CMT administered the suppository and the resident moaned and moved away during the procedure; the CMT stated lubricant should have been used, and the DON confirmed lubrication is necessary for suppository administration. For another resident, the POS ordered Amlodipine 2.5 mg daily, to be held only if blood pressure was less than 90/60, and Med Pass nutritional supplement 120 cc twice daily. The MAR showed Med Pass documented as administered, but during observation it was not given. The CMT also held Amlodipine despite the resident's blood pressure being 135/73 and documented the reason as pulse under 60, although the order to hold was based on blood pressure and not pulse; the DON stated the medication should have been administered and that CMTs are not allowed to hold a medication without a physician order.
Improper Labeling and Dating of Open Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, including expiration dates, for 10 sampled residents. During observation of the medication cart for the 300/400 hall, surveyors found six opened multi-use medications that were not labeled with an open date, six opened multi-use medications with open dates beyond the allowed use period, and one large opened syringe of topical medication that had no medication or resident label. The affected items included Fiber lax, Novolog insulin pen, artificial tears, Flonase nasal spray, and viscous lidocaine for residents identified in the report. The observation showed Resident #1’s Fiber lax opened on 09/22/2025 and still present on 03/03/2026, Resident #6’s artificial tears opened on 09/05/2025, Resident #8’s artificial tears opened in 11/2025, Resident #52’s artificial tears opened on 03/01/2025, and Resident #53’s artificial tears opened on 01/28/2026, all beyond the stated disposal timeframe. Other opened medications, including Resident #3’s Novolog insulin pen, Resident #29’s artificial tears, Resident #33’s artificial tears, Flonase nasal spray, and viscous lidocaine, Resident #48’s Flonase nasal spray, and Resident #56’s artificial tears, had no open dates. Staff interviews confirmed that multi-use medications should be dated when opened, that expired and outdated medications should not remain on the cart or be administered, and that eye drops are good for use for 90 days after opening.
Infection Control Failures With EBP, Insulin Administration, and TB Screening
Penalty
Summary
The facility failed to maintain its infection prevention and control program when staff did not consistently use enhanced barrier precautions (EBP) during direct care for residents with wounds and indwelling medical devices. Resident #9 had a quarterly MDS showing non-Alzheimer's dementia, dependence for activities of daily living, and diagnoses including anxiety and depression. The resident's care plan identified the need for EBP related to wounds, risk for pressure ulcers related to impaired mobility and incontinence, and inability to verbally communicate needs. During observation, two CNAs provided perineal care without wearing a gown, and there was no sign outside the room indicating EBP was required. Staff interviews showed differing understanding of when EBP should be used, and the Infection Control Nurse stated she forgot to post the sign outside the room. Resident #25 had a quarterly MDS showing cognitive intactness, an indwelling urinary catheter, and diagnoses of urinary retention, urinary tract infection, and constipation. The care plan required EBP because of the catheter and noted dependence on staff for catheter care and bowel incontinent care. During observation, a CNA emptied the catheter drainage bag without wearing a gown, used a graduate to collect urine, placed the graduate directly on the floor without a barrier, and secured the drainage tubing without cleaning it with an alcohol sponge or swab. In interviews, the CNA stated he/she should have worn EBP and used a paper towel barrier, while multiple staff members and the DON stated EBP, a floor barrier, and cleaning the catheter tubing with an alcohol wipe were required. Resident #3 had a comprehensive MDS showing an indwelling catheter, dependence on staff for personal and toileting hygiene, and diagnoses of wound infection, urinary tract infection, and diabetes. The care plan identified stage three wounds to both buttocks, risk related to diabetes, and a need for EBP related to the catheter and wounds. During insulin administration, a CMT washed hands, applied gloves, touched the computer, mouse, and medication cart drawer handles, wiped the insulin pen seal, primed the pen causing droplets of insulin to expel onto the seal, applied a needle, wiped the injection site, fanned the resident's arm, and administered insulin. The CMT stated he/she was not sure if wiping the seal was correct and should not have fanned the arm after cleansing. The DON stated the insulin pen seal should be cleaned each time, the needle should be applied before priming, the skin should not be fanned after cleansing, and insulin administration required gown and gloves for residents needing EBP. The facility also failed to ensure all staff had TB screening before beginning employment. Review of employee health files showed one LPN and one dietary aide had their first TB tests completed months after their dates of hire. The HR director stated new hires are scheduled for initial testing after hire, and the DON stated TB tests are required for all employees prior to starting employment.
Resident Trust Fund Account Not Reconciled Accurately
Penalty
Summary
The facility failed to maintain a system to ensure resident trust fund accounts were managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling the account each month. The facility managed funds for 5 residents, and review of the facility’s attempted reconciliation forms for the period 2/1/25 through 1/31/26 showed the reconciliations did not match the residents’ current balances at the time of reconciliation. An amount of $8,559.84 was carried forward each month. During interview, the Business Office Manager stated the $8,559.84 had been carried as far back as 12 years and had always been that way since she took the position, and she continued balancing while knowing there was an extra amount in the account. The Administrator stated he expected the resident trust account to be reconciled monthly to the 5 residents who actively had funds in the account.
Resident Burned After Being Left Unattended with Hot Food in Dining Room
Penalty
Summary
A deficiency occurred when a resident with impaired cognition, Parkinson's disease, peripheral nervous system disorders, and diabetes, who required staff assistance for all activities of daily living including feeding, was left unattended in the dining room with a plate of hot food. The resident attempted to feed themselves with their hands and sustained burns, resulting in fluid-filled blisters on multiple fingers of the right hand. The resident's care plan indicated a need for supervision and assistance during meals due to tremors and difficulty expressing needs. On the morning of the incident, the resident's spouse, who usually assisted with feeding, was not present. Staff were still bringing residents into the dining room while the resident's meal tray was already placed in front of them. No staff were present to assist or supervise the resident at the time, and the dietary host observed the resident with food on their hands and no one feeding them. Another resident at the table witnessed the incident, confirming that the resident picked up hot food with their fingers without staff assistance. Multiple staff interviews confirmed that the resident required nursing assistance and encouragement during meals, and that food was typically not served hot enough to cause burns, with staff usually stirring food before assisting. However, on this occasion, the resident was left alone with hot food, leading to the injury. The incident was immediately reported, and the resident was assessed and treated for burns by nursing staff.
Facility Fails to Maintain Homelike Environment and Resident Safety
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations made during a survey. In the dining room, the vinyl on chairs was peeling, and the fabric was torn, indicating a lack of maintenance. Cobwebs were observed near the ceiling next to a large upper window and by the top of the TV, suggesting inadequate cleaning practices. Additionally, the wood trim strip around the attic access panel in the dining room was pulling away from the ceiling, with nails exposed, posing a potential safety hazard. Further observations revealed a loose handrail outside a resident's room in the 100 hallway, compromising resident safety. In the common area across from the nurse's station, cobwebs were also present near the ceiling. Dark water spots and a large stain were noted on the ceiling near the main entrance, indicating possible water damage. Interviews with the housekeeping supervisor and the administrator highlighted inconsistencies in cleaning schedules and maintenance practices, with the maintenance supervisor acknowledging the lack of a schedule for painting walls and the need for reupholstering dining chairs.
Inadequate ADL and Hygiene Care for Residents
Penalty
Summary
The facility staff failed to provide adequate care for residents who were unable to perform their own activities of daily living (ADLs), affecting three residents. For Resident #4, staff did not perform complete perineal care, as they failed to expose or clean the peri area properly. The resident's morning hygiene was also neglected, as staff did not change the resident's shirt, provide oral care, or wash the resident's face. Additionally, staff did not follow proper hygiene protocols, such as changing gloves and performing hand hygiene after providing perineal care. Resident #34 was observed to have been left in the same clothes from the previous day and was not repositioned or toileted for several hours. The resident was moved between different areas of the facility without receiving necessary care, such as repositioning or changing clothes. The staff failed to anticipate and meet the hygiene needs of the resident, who was unable to communicate their needs. Resident #44, who required assistance with all activities and daily cares, was not repositioned or toileted for an extended period. The resident was observed to have a strong odor of urine, indicating inadequate incontinence care. The facility's shower schedule showed that the resident received significantly fewer showers than scheduled, further highlighting the deficiency in personal hygiene care. Staff interviews revealed a lack of adherence to care protocols, such as using the same area of a wipe for different parts of the body and not separating skin folds during cleaning.
Failure to Ensure Wheelchair Safety for Residents
Penalty
Summary
The facility failed to ensure the safety and independence of residents by pushing them in their wheelchairs without footrests, even though they were capable of propelling themselves. This practice was observed with four residents, who were either cognitively impaired or intact, and had various diagnoses such as traumatic brain dysfunction, diabetes, and paralysis. The staff, including CNAs and the kitchen manager, pushed these residents in their wheelchairs without footrests, instructing them to hold their feet up, which poses a safety risk and could contribute to a decline in their mobility. Interviews with staff revealed a misunderstanding of the safety requirements for wheelchair use. CNA A mentioned that foot pedals are available but considered it standard practice to push residents without them if they could lift their feet. LPN A acknowledged the need for footrests if residents' feet were dragging but believed it was acceptable to push residents without footrests if they could lift their feet. The DON stated that residents should not be pushed without footrests, indicating a lack of consistent policy enforcement regarding wheelchair safety in the facility.
Failure to Assess and Manage Bed Rail Use
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for several residents, leading to potential safety risks. Specifically, the facility did not conduct necessary assessments for the risk of entrapment from bed rails before their installation for Residents #5 and #45. Additionally, the facility did not review the risks and benefits of bed rail use with the residents or their representatives, nor did they obtain informed consent prior to installation. Furthermore, the facility did not ensure that the bed's dimensions were appropriate for the residents' size and weight, and failed to obtain a physician's order for the use of side rails for Resident #5. The facility's policy on bed assist bar usage, revised on 4/24/24, outlines the need for individual assist bar evaluations, education on risks and benefits, and obtaining informed consent and physician orders. However, these procedures were not followed, as evidenced by the lack of documentation and assessments for the sampled residents. For instance, Resident #5 had a U-shaped cane rail installed without consent or a side rail assessment, and there was no physician's order for the side rails. Similarly, Resident #45 had positioning bars installed without proper quarterly assessments being documented. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed inconsistencies in the implementation of the facility's policies. Staff admitted to not completing side rail assessments, not obtaining physician's orders, and not updating consents with quarterly assessments. Maintenance staff also failed to conduct regular entrapment assessments, which are crucial for ensuring resident safety. These oversights and failures in following established protocols contributed to the deficiencies identified in the report.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 19.35% error rate. This affected four residents, with errors occurring in the administration of both oral and eye medications. For Resident #29, an LPN administered eye drops from a mislabeled box, and the applicator tip touched the resident's eyelashes, contrary to the facility's policy. The LPN was unaware of the mislabeling and the correct procedure for administering eye drops. Resident #50 experienced a medication error when an LPN administered an unmeasured dose of a liquid supplement. The LPN did not use a measuring cup, as required by the facility's policy, and was unaware of the cup's capacity. The Director of Nursing confirmed that all liquid medications should be measured before administration. For Resident #49, a CMT administered eye drops incorrectly by allowing the dropper tip to touch the resident's eyelid and eyelashes and applied lacrimal pressure for longer than recommended. Additionally, Resident #5 received nasal spray without following the manufacturer's guidelines, as the CMT did not shake the bottle, have the resident blow their nose, or occlude the nostril during administration. The DON expected staff to adhere to the manufacturer's instructions for medication administration.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food preparation and storage practices. Observations revealed that staff did not utilize proper thawing techniques, with a 5 lb roll of hamburger found thawing on top of a cardboard box in the walk-in cooler. Additionally, the facility did not ensure that garbage cans were kept covered when not in use, as observed in the kitchen and dishwashing areas. Interviews with various staff members, including the Registered Dietician and Dietary Manager, confirmed that trash cans should be covered at all times, yet this practice was not consistently followed. Hand hygiene practices were also found to be inadequate. Staff members were observed turning off faucets with bare hands or using the same paper towel to dry their hands after turning off the faucet, which is not sanitary. The facility's policy requires hand washing after every activity and before and after glove use, but staff did not consistently adhere to these guidelines. Interviews with staff and the Administrator highlighted the expectation for frequent hand washing and proper use of paper towels, yet these practices were not consistently implemented. Food storage and labeling practices were deficient, with numerous opened and undated food items found in the walk-in cooler, dry storage, and spice rack. Items such as tortillas, cheese, and spices were not properly labeled with dates, and some spices were outdated. The facility's policy requires leftovers to be labeled, dated, and stored properly, but this was not consistently done. Additionally, dishware was stored upright rather than inverted, contrary to best practices for preventing contamination. Interviews with staff confirmed the expectation for proper labeling and storage, yet these practices were not consistently followed.
Infection Control Deficiencies in EBP and Catheter Care
Penalty
Summary
The facility failed to adhere to infection control practices, specifically in the use of Enhanced Barrier Precautions (EBP) and proper handling of urinary catheter drainage bags. For Resident #53, the catheter drainage bag was observed touching the floor and a trash can, which are considered contaminated surfaces. The Certified Nurses Aide (CNA) did not use the yellow isolation gown available for EBP, and there were no signs indicating the resident was on EBP. Both the CNA and a Registered Nurse (RN) acknowledged the importance of keeping the catheter drainage bag off the floor and using EBP for residents with catheters. Resident #18, who had a suprapubic catheter and required EBP, was observed during wound care without the Licensed Practical Nurses (LPNs) wearing gowns, despite the presence of reusable gowns in the room. The resident's care plan indicated the need for EBP, including wearing gloves and gowns for high-contact activities. The LPNs did not follow these precautions during the wound care process, although they washed their hands and used gloves. For Resident #24, who had a urinary catheter and stage III pressure ulcers, the facility staff failed to apply gowns during wound care. The resident's bed had blood-stained sheets, which were not changed, and there was no EBP signage outside the room. The LPNs involved in the care acknowledged the need for EBP and the use of gowns, but did not adhere to these practices. The Director of Nursing (DON) stated that staff are expected to use gowns and gloves during wound care for residents requiring EBP.
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Illustrative
What surveyors actually found near you
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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 Plattsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nick's Health Care Center | 0.9 mi | ★★★★★ | 13 | 1 |
| Gower Convalescent Center, Inc | 8 mi | ★★★★★ | 0 | 0 |
| Lawson Manor & Rehab | 15.3 mi | ★★★★★ | 4 | 0 |
| Cameron Nursing Center | 15.9 mi | ★★★★★ | 2 | 0 |
| Quail Run Health Care Center | 16.5 mi | ★★★★★ | 1 | 0 |
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