Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Schuyler County Nursing Home District during CMS and state inspections, most recent first.
Kitchen sanitation and trash can covering deficiencies were identified when surveyors observed moderate to heavy dust and debris buildup on HVAC surfaces, light fixtures, supports, and conduits above food prep and dish areas. Surveyors also found multiple uncovered trash and garbage cans in the kitchen and dishwashing areas containing used paper towels and food/paper waste. A Dietary staff member stated trash cans should be covered when not in use, and the DON said he was not aware of the identified areas.
Incomplete Legionella monitoring and infection control lapses were observed. The facility lacked a complete water management policy, did not monitor key water system parameters or cold water temperatures, and staff were unfamiliar with ASHRAE standards. Residents with pneumonia were not screened for Legionella as the policy directed. Staff also failed to perform hand hygiene during incontinence care, kept urinary catheter tubing and drainage bags on the floor, and did not consistently follow EBP/PPE requirements during high-contact care for residents with urinary catheters and an ostomy.
The facility failed to document that five NA/CNA/CMT staff members had completed the required 12 hours of annual in-service training. Their records showed attendance at various monthly topics such as dementia/Alzheimer's, resident rights, fire safety, HIPAA, and emergency preparedness, but the hours were not documented and required topics from the facility assessment were missed, including abuse and neglect, infection control, communication, QAPI, behavioral health, and dementia care. The DON stated monthly in-services were provided, but staff often missed them and sometimes missed makeup sessions as well.
Care plans did not include measurable objectives or timely updates for three residents with identified needs. One resident with CHF had orders for Lasix, fluid restriction, and weight monitoring, but the care plan did not address those issues. Another resident with a femur fracture had frequent pain scores and PRN acetaminophen and oxycodone use, but the care plan did not address pain or opioid therapy. A third resident returned from the hospital on hospice, yet the MDS and care plan did not reflect hospice status.
A resident with severe cognitive impairment, CHF-related conditions, edema, and fluid overload had repeated missed daily weights and documented weight gains that met PRN Lasix parameters, but the MAR and nurses’ notes did not show the medication was given or that the physician was notified. Other residents also had significant weight changes, missing fluid intake documentation, and no evidence that inaccurate weights were re-checked or reported. An LPN and the DON stated staff were expected to compare weights and notify the physician when ordered parameters were met.
Failure to assess bed rail entrapment risk and complete bed rail inspections: The facility did not document entrapment risk assessments or regular inspections of bed frames, mattresses, and bed rails for several residents using halo or quarter bed rails. Records showed residents with dementia, cognitive impairment, fractures, weakness, pain, and transfer/bed mobility needs had bed rail orders and consents, but the facility lacked documentation of proper risk assessment, and one safety check was completed for the wrong rail type. The DON and Maintenance Director stated the facility had no bed rail policy, no system to identify residents at risk for entrapment, and monthly checks were not consistently documented with actual measurements.
Nurse aides were not kept on track to complete state-approved training and competency requirements within four months of hire. Record review and DON interviews showed seven NAs remained in NA roles past the required timeframe because of delayed class starts, failed testing, or waiting for the next available course, and the DON confirmed they were supposed to be certified within four months or moved out of direct care.
Two residents had PRN psychotropic orders continued without 14-day stop dates or documented physician rationale for extension. One resident with dementia, wandering, and severe cognitive impairment received PRN Seroquel for reasons such as behavior issues, sleep, restlessness, and exit seeking, but the MAR and nursing notes often lacked matching behavior documentation or staff interventions, and the order did not list a duration. Another resident with anxiety and depression had PRN clorazepate continued without a stop date or documentation supporting ongoing use.
The facility failed to complete SCSAs for two residents after significant changes in condition affected multiple areas of health status. One resident had new wheelchair use, changes in mobility and ADLs, and changes in pain and PRN pain medication use. The other resident had declines in eating, hygiene, dressing, wheelchair mobility, a new indwelling urinary catheter, increased pain, significant weight loss, and later sustained major fractures after a fall that led to surgery, NWB status, and mechanical lift transfers.
A resident with dementia, COPD, seizure disorder, moderate cognitive impairment, and a history of falls was identified as a fall risk and required staff assistance, a walker, and a gait belt. The resident had repeated falls in the room, at the nurses’ station, and during a fire drill, including events with head impact, confusion, bruising, and an ER transfer. The care plan was not consistently updated after the falls, and staff did not maintain a consistent system to identify and respond to the resident’s fall risk.
A facility failed to identify and reassess the need for indwelling urinary catheters for two residents and failed to secure one resident’s catheter to the leg. Records showed catheter use after hospitalization and trauma, but no documented ongoing indication, follow-up with urology, or clear plan for discontinuation. One resident’s catheter tubing was observed moving freely and not secured, and staff were unsure why the catheter remained in place.
Failure to obtain a physician order and develop a care plan for a resident's colostomy care. A resident with colon cancer, severe cognitive impairment, and an ostomy had a care plan that only noted gloves and gowns for assistance, but it did not address colostomy care or monitoring. The chart had no physician order or MAR/TAR documentation for colostomy care, and staff interviews showed inconsistent knowledge about how often the bag and wafer were changed. During observation, the colostomy bag had no date on it, and a CNA emptied and cleaned the pouch without any documented order for the care provided.
Failure to Monitor and Report Significant Weight Loss: The facility did not consistently obtain ordered weights or respond to significant weight loss for two residents with severe cognitive impairment. One resident had weekly weights and lost 9.48% in one month, but staff did not reweigh, notify the MD or RD, or document new interventions. Another resident missed an ordered monthly weight and later showed a 9.47% loss over three months, with no documentation of MD/RD notification or reassessment of interventions.
Dietary Director Lacked Required Food Safety Training: The facility failed to ensure the Dietary Director had the competencies and skill set needed to carry out food and nutrition services. He had not completed university-based food safety and management training covering foodborne illness, sanitation, and food purchasing/receiving, and both he and the Administrator stated staffing shortages and coverage of open dietary shifts delayed completion of the program.
Failure to Provide Transfer/Discharge and Bed-Hold Notices: The facility did not provide written transfer/discharge notices with required appeal and placement information, and did not provide bed-hold notices, when multiple residents were sent to the hospital. One resident was transferred twice for abnormal labs and respiratory symptoms, another after a fall with bilateral leg fractures, and another after a fall with a hip fracture. Records showed only phone notification or no documentation of the required written notices, and the DON and Administrator stated the bed-hold policy was only given on admission.
The facility failed to accurately code several MDS assessments. Surveyors found that a resident’s pressure ulcer was coded as not present on admission even though records showed the resident arrived with an open area, two residents’ Wanderguard alarms were not documented despite orders, notes, and observation confirming use, two residents’ hospice status was left blank despite hospice records and physician documentation, and one resident’s active diagnoses of sepsis, CHF, and pneumonia were not coded as required. The DON and MDS Coordinator acknowledged the residents’ conditions and the coding expectations.
Failure to provide baseline care plan copies to residents or representatives: The facility did not document giving a written summary of the baseline care plan to three residents or their representatives, despite policy requiring it within 48 hours of admission. Records for the residents showed no proof the plans were provided, and staff interviews showed confusion about who completed the plans and how they were to be signed, given, and scanned into the EHR.
Kitchen Sanitation and Trash Can Covering Deficiencies
Penalty
Summary
The facility failed to ensure food service equipment and surfaces were cleaned under sanitary conditions in accordance with professional standards for food service safety. During observations in the kitchen, surveyors found the HVAC unit surfaces and supports above the upright refrigerator, two-compartment food prep sink, and two spice/seasoning shelves with a moderate to heavy buildup of dust and debris. A two-bulb emergency light fixture above the spice/seasoning shelves also had a moderate buildup of dust and debris, and three ceiling light fixtures, connecting flex conduit, and ceiling chain supports above the food tray prep table and coffee maker/clean glassware areas had a moderate to heavy buildup of dust and debris. The facility also failed to ensure trash cans were covered when not in use. Surveyors observed an uncovered trash can under the hand washing sink beside the coffee machine containing used paper towels, an uncovered garbage can at the end of a food prep table beside a floor food mixer containing disposed food items and paper items, and an uncovered garbage can in the dishwashing area beside the dining room serving door containing disposed food items and paper items. The Dietary staff member stated trash cans in the kitchen and dishwasher areas should be covered when not in use, and the Dietary Director stated he was not aware of the identified areas but expected the HVAC unit, emergency light fixture, ceiling lights, supports, conduits, and all trash and garbage cans in the kitchen and dishwasher areas to be free of dust and debris and covered when not in use.
Incomplete Legionella Monitoring and Breakdowns in Hand Hygiene, Catheter Care, and EBP
Penalty
Summary
The facility failed to develop and implement a complete infection prevention and control program for water system monitoring and Legionella surveillance. The facility policy on Legionella Surveillance and Detection stated that pneumonia cases diagnosed more than 48 hours after admission were to be investigated for possible Legionnaire’s disease, but the policy did not include monitoring water temperatures, dead legs, flushing unused areas, or monitoring for scaling, sediment, or biofilm, and it did not provide guidance on what to monitor or what actions to take when findings were outside established parameters. During interview, the Administrator stated the facility had not developed a policy that included those monitoring elements. The Maintenance Director stated the water management team had met only once after the last survey and had not met since, and he did not monitor cold-water temperatures, did not know whether cold water stayed below 77 degrees F, and did not check for sediment, scaling, or biofilm. The facility’s weekly water temperature log showed repeated hot water temperatures below 108 degrees F at the shower, including readings of 102 to 106 degrees F, and the documentation did not identify which shower was tested. The facility also provided no documentation showing monitoring of cold water temperatures. The CDC Legionella Environmental Assessment Form stated Legionella generally grows well between 77 degrees F and 113 degrees F, with optimal growth between 85 degrees F and 108 degrees F. The facility’s water flow map was incomplete, and staff interviewed, including the IP, DON, Maintenance Director, and Administrator, stated they were not familiar with ASHRAE standards and did not know what all needed to be monitored to prevent Legionellosis. The facility also failed to follow its own Legionella-related resident monitoring expectations for residents diagnosed with pneumonia. Resident #20 was hospitalized with pneumonia, but the resident’s record did not show screening for Legionella with urine or sputum testing as the facility policy directed. Resident #6 had a diagnosis of active pneumonia added to the record, but the record did not show Legionella screening. The IP stated she did not monitor residents with pneumonia for Legionellosis, had not done any monitoring of residents for Legionellosis, and had not educated staff on what to monitor for. The DON stated she did not know how or who to screen for Legionellosis and had not educated staff on symptoms to monitor for. The facility also failed to ensure hand hygiene, catheter drainage positioning, and enhanced barrier precautions were followed during resident care. For Resident #3, who had severe cognitive impairment and an indwelling urinary catheter, staff were observed providing toileting and peri-care without hand hygiene, wearing inconsistent PPE, and handling the resident’s catheter tubing while it lay on the floor. The resident’s catheter bag and tubing were repeatedly observed hanging below or dragging on the floor under the wheelchair, including in the hallway, and staff walked by without assisting. For Resident #40, who had severe cognitive impairment, an indwelling urinary catheter, and an ostomy, the catheter tubing was also observed lying on the floor under the wheelchair. During ostomy and catheter care, a CNA emptied the colostomy bag, handled fecal contamination, changed gloves without hand hygiene, and then emptied the urinary catheter without hand hygiene. For Resident #28, staff entered the room without hand hygiene, donned gloves, provided peri-care, and then placed clean linens and a clean brief without changing gloves or washing hands between dirty and clean tasks.
Missing Annual Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that five nurse aides/certified nurse aides/certified medication technician staff members had the required annual in-service training documented. The facility assessment dated 04/17/25 listed required education topics for direct care staff, including communication, resident rights, abuse/neglect/exploitation, infection control, culture change, identification of resident changes in condition, cultural competency, and dementia care and abuse prevention. The annual education calendar also listed monthly topics such as abuse and neglect, resident rights, infection control, Alzheimer's disease, behavioral health, dementia, communication, and QAPI. Review of the employee education records for NA O, NA J, CNA T, CNA K, and CNA/CMT S showed each had been employed for over a year, but none had documentation showing completion of the required 12 hours of annual training. Their records listed various in-services attended, such as safety, dementia/Alzheimer's, UTI prevention, fire safety, resident rights, workplace violence, hospice, HIPAA, emergency preparedness, and MDS/care plan, but the records did not include the number of hours attended. Each record also showed missed required topics identified in the facility assessment, including combinations of abuse and neglect, resident rights, infection control, communication, QAPI, behavioral health, Alzheimer's disease, and dementia. During interview, the DON stated she followed an educational calendar and provided monthly in-services, that staff sign in for meetings and individual records, and that monthly in-services were about an hour long to meet the 12-hour annual requirement. She also stated staff often missed monthly meetings and sometimes missed makeup in-services as well. The report documented that the five nurse aides/CNAs/CMT did not have documentation showing the required annual training hours or completion of all required topics.
Care plans did not reflect residents’ assessed needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents whose assessments identified ongoing medical and care needs. Review of the facility policy showed that care plans were to be developed within seven days of the required MDS assessment, include measurable objectives and timetables, and address the resident’s physical, psychosocial, and functional needs. In the sampled residents, the care plans did not reflect the identified problems or the related services being provided. For one resident with edema, shortness of breath, and diastolic CHF, the admission MDS showed heart failure and diuretic use, and later physician orders included daily Lasix, PRN Lasix for weight gain, monthly weights, and a fluid restriction of 1.5 liters per day. The care plan revised on 7/22/25 contained no documentation addressing CHF, fluid restriction, or weight monitoring. During interviews, an LPN stated the resident’s weight fluctuated and that daily weights should be checked because of the PRN Lasix order, and the DON stated staff should monitor fluid intake and that daily weights were needed to truly monitor the resident’s weights. For another resident with a femur fracture and pain, physician orders required pain assessment every shift, and the record showed repeated pain scores ranging from 3/10 to 8/10 over multiple dates. The resident received PRN acetaminophen once and PRN oxycodone 43 times in August, yet the care plan dated 8/27/25 did not address pain or opioid use. The care plan conference dated 8/27/25 noted the resident was receiving PRN acetaminophen and oxycodone, but progress notes showed no documentation of a care plan conference occurring before that date. For a third resident with dementia and carcinoma in situ of the left breast, the resident was hospitalized and then returned to the facility under hospice payer status on 7/1/25. Hospice documentation showed the resident was terminally ill and admitted to hospice, and the DON later stated the resident was on hospice. However, the significant change MDS showed severe cognitive impairment and a chronic disease with life expectancy of less than six months, but indicated no special treatments and not on hospice. The revised care plan dated 7/10/25 did not address hospice care, and the physician orders dated 9/8/25 showed no hospice orders.
Failure to Follow Weight and PRN Medication Orders
Penalty
Summary
The facility failed to follow physician’s orders for daily weights and PRN Lasix for a resident with severe cognitive impairment and diagnoses including atrial fibrillation, hypertension, dementia, malnutrition, adult failure to thrive, acute kidney failure, edema, dehydration, and fluid overload. The resident had an order for Lasix 20 mg PRN for a weight gain of 3 pounds in one day or 5 pounds in one week, along with daily weights. The record showed multiple days when weights were not obtained or were documented without explanation, and when weight gains met the ordered parameters, there was no documentation that Lasix was administered. The nurses’ notes also did not show that the physician was notified of missed weights or the documented weight gains. The resident’s weight record showed repeated increases over July and August, including gains of 6.5 pounds in one week, 3 pounds in one day, 7.5 pounds in one week, 8 pounds in one week, 5 pounds in one week, 4.5 pounds in one day, 3 pounds in one day, and 5.5 pounds in one day. Despite these findings, the MAR did not show PRN Lasix being given when the order parameters were met. On observation, the resident had edema in the ankles and sock indentions in the skin from fluid accumulation. An LPN stated the resident frequently refused weights, but this was not reported to the physician, and staff were expected to compare weights to determine whether PRN medication or physician notification was needed. The facility also failed to follow weight-monitoring and notification expectations for other residents with significant weight changes. One resident with CHF and a fluid restriction had orders for monthly weights, fluid restriction, and PRN Lasix based on a 2-pound gain in 48 hours, but the record showed missing fluid intake documentation, no evidence of the ordered weight monitoring needed to evaluate the PRN Lasix parameters, and no documentation that Lasix was administered. Three other residents had weight records showing large gains or losses, including one resident with a documented 23.23% weight loss in one week, another with a 35% weight gain in one month and then a 23.15% loss in one month, and another with an 8.57% gain in one month followed by an 8.33% loss in one month. For these residents, the record showed no evidence that the weights were re-checked when they appeared inaccurate, and staff interviews confirmed that the missed weights should have been re-weighed and compared to prior weights.
Failure to assess bed rail entrapment risk and complete required bed rail inspections
Penalty
Summary
The facility failed to assess residents for risk of entrapment from bed rails and failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four sampled residents. The Director of Nursing stated the facility did not have a policy for bed rails, and later stated that staff were to complete a bed rail risk assessment before use, that the MDS Coordinator monitored bed rails on admission and quarterly, and that the facility did not have an assessment to evaluate entrapment risk or a system to know which residents with bed rails were at risk for entrapment. Resident #40 had diagnoses of dementia and needed assistance with personal care, had severe cognitive impairment, and required substantial to maximal assistance for mobility and transfers. The care plan identified fall risk and need for assistance with transfers and bed mobility, but contained no documentation related to bed rail use. Observation showed the resident asleep in bed with a halo rail raised on the left side. The medical record contained no documentation of informed consent, no assessment of entrapment risk before use of the halo rail, and no documentation of a regular inspection of the bed frame, mattress, and halo rail to identify possible entrapment areas. Resident #5 had physician orders for two quarter bed rails to assist with moving side to side in bed and to the edge of the bed for transfers due to weakness and pain from recent abdominal surgery. The record included consent for side rails and a bed rail safety check, but the safety check was completed for a halo rail rather than the ordered quarter bed rails. The side rails assessment and consent documented medical symptoms and use of two quarter bed rails, but there was no documentation that staff assessed entrapment risk between the bed and the bed rails or completed a safety check for the ordered rails. Observation showed one quarter bed rail raised on the left side of the bed. Resident #7 had physician orders for two quarter bed rails due to fractures of both femurs, and the admission MDS showed moderate cognitive impairment, impaired range of motion in both lower extremities, and dependence on staff for bed mobility and transfers. The care plan and side rails assessment documented use of two quarter bed rails, but there was no documentation of an entrapment risk assessment. Observation showed quarter bed rails raised on both sides of the bed, and the resident used the side rails to roll side to side in bed. The record also lacked documentation of a regular inspection of the bed frame, mattress, and quarter bed rails to identify possible entrapment. Resident #14 had multiple side rail consents and physician orders over time for a halo bed rail, with assessments documenting use of the rail to assist with turning, repositioning, and sitting on the edge of the bed. The resident’s annual MDS showed severe cognitive impairment, maximum assistance for rolling in bed, and dependence for transfers. Despite repeated documentation of halo rail use and later a care plan noting one halo rail, there was no documentation that staff assessed entrapment risk between the bed and the bed rails. A bed rail safety check documented quarter bed rails and zone measurements, but the record did not show a thorough inspection to identify areas of possible entrapment between the bed rails, mattress, and bed frame. The Maintenance Director stated he performed monthly visual checks and quick measurements, kept documentation of monthly inspections, but did not document actual measurements and had an outdated list of residents and rail types.
Nurse Aides Not Certified Within Required Timeframe
Penalty
Summary
The facility failed to ensure seven nurse aides completed a state-approved training program within four months of hire. Review of the facility policy showed nurse aides were not to be employed for more than four months unless they were competent to provide nursing care and had completed a training and competency evaluation program approved by the state, or had been deemed competent under the applicable requirements. The facility census was 41. Record review and interviews showed multiple nurse aides remained in NA roles beyond the four-month timeframe without completing training and testing. NA J, NA O, NA U, NA V, NA H, NA W, and NA X each had hire dates ranging from 4/25/23 through 5/12/25, and the DON confirmed several had delayed starts, had failed portions of testing, had not retested, or were still waiting to begin classes because the program only offered one class every 12 weeks. The DON also stated NAs were supposed to be certified within four months of hire and, if not certified, were supposed to be terminated or moved to a non-direct care position.
PRN Psychotropic Orders Lacked Stop Dates and Documentation
Penalty
Summary
The facility failed to obtain a 14-day stop date for PRN psychotropic medications for two residents and did not document a clinical rationale to extend the PRN orders beyond 14 days. For one resident, the record showed PRN Seroquel (quetiapine) 12.5 mg ordered for agitation without a stop date, and for the other resident, PRN clorazepate dipotassium 7.5 mg twice daily for anxiety was continued without a stop date or documentation supporting continued use beyond 14 days. For the resident receiving Seroquel, the record showed severe cognitive impairment, diagnoses including Alzheimer’s dementia, metabolic encephalopathy, atrial fibrillation, hypertension, pain, adult failure to thrive, and a history of falls. The resident was noted to be restless, forgetful, wandering, and wanting to go home, and had a Wanderguard. The baseline care plan identified confusion, moodiness, wandering, and elopement risk, but did not include other specific behaviors or interventions. The physician’s order for Seroquel did not include a stop date, and the medication was administered multiple times for reasons such as behavior issues, other, sleep, restlessness, behavioral issue, exit seeking, and resistance. The resident’s MAR and nursing notes did not consistently match the ordered indication of agitation, and several administrations lacked documentation of the specific behavior prompting the dose or staff interventions before administration. In multiple instances, the notes documented the resident as calm, cooperative, resting, or without aggressive behaviors around the time the PRN Seroquel was given. The care plan later listed psychotropic drug use and noted Seroquel PRN for aggressive behaviors, but it did not include specific behaviors other than wandering or interventions for specific behaviors other than wandering. The medical record also did not show documentation from the physician explaining why no duration was listed for the Seroquel PRN order. For the resident receiving clorazepate, the care plan addressed anxiety and depression and directed staff to monitor for signs and symptoms of depression and anxiety. The quarterly MDS showed moderate cognitive impairment, no physical or verbal behaviors or rejection of care, diagnoses of anxiety and depression, and use of an antidepressant medication. The PRN clorazepate order, originally dated 4/17/25, remained active in later physician orders without a stop date, and the resident received four doses in September 2025. The record did not contain documentation of a physician rationale to extend the PRN order beyond 14 days or to indicate the duration of the PRN order.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to complete significant change in status assessments (SCSAs) for two residents after changes in condition that affected more than one area of health status and required interdisciplinary review and/or care plan revision. The report states that SCSAs were not completed within 14 days after the facility determined, or should have determined, that significant changes had occurred, despite the requirements described in the RAI User’s Manual. For one resident, the admission MDS showed chronic pain, sepsis, and a sacral fracture, with extensive assistance needs for dressing, toileting hygiene, bed mobility, and transfers, along with frequent pain and PRN pain medication use. The quarterly MDS later showed new wheelchair use, changes in mobility and transfer status, declines in oral hygiene, personal hygiene, toileting hygiene, and dressing, and improvement in pain with no PRN pain medication use. Observation showed the resident sitting in a wheelchair, feeding self, and propelling the wheelchair down the hall. The facility did not complete an SCSA when these changes in mobility, ADLs, and pain status occurred. For the second resident, the annual MDS showed multiple chronic conditions including sepsis, dysrhythmia, heart failure, chronic pulmonary disease, tremor, convulsions, pain, edema, bowel and bladder incontinence, and extensive assistance needs for ADLs and transfers. A quarterly MDS later showed decline in eating, oral hygiene, personal hygiene, dressing, footwear, and wheelchair mobility, along with a new indwelling urinary catheter and the addition of PRN pain medication with moderate pain. Another quarterly MDS showed bowel incontinence, significant weight loss, and a therapeutic diet, along with improvement in toilet transfer and pain status. The facility did not complete an SCSA for these changes. The report also describes a fall event for the second resident on 07/18/25, when the resident fell from a power recliner onto the floor and was sent to the emergency room. Hospital updates documented two fractures, including a right distal femur fracture and a left proximal tibial fracture, with surgery planned for the left tibial fracture and soft casting for the right femur fracture. After return to the facility, the resident was observed in bed with both legs wrapped, unable to move the legs, and having pain with movement. A CNA reported that since the fractures the resident required a mechanical lift for transfers, stayed in bed more, and had more pain. The facility did not complete an SCSA after this fall with major fractures and the resulting decline in mobility, transfers, pain, and wound/incision care needs.
Failure to Supervise and Update Fall Interventions for a High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and oversight to prevent falls for one resident who was identified as a fall risk and had a history of multiple falls. The resident’s baseline care plan documented some confusion, fall risk status, and the need for assist of one with a gait belt for ADLs. The resident’s admission MDS showed diagnoses including pneumonia, dementia, seizure disorder, and COPD, moderate cognitive impairment, use of a walker, prior falls, and need for staff assistance with walking and transfers. The care plan included reminders to use the call light, use the walker, and wear shoes or gripper socks while up. After admission, the resident experienced repeated falls, including non-injury and witnessed falls, as well as unwitnessed falls in the resident’s room, at the nurses’ station, and during a fire drill. The record showed falls on 01/03/25, 01/12/25, 01/19/25, 01/26/25, 04/15/25, 04/19/25, 04/22/25, 04/28/25, and 06/09/25. Some events involved the resident using the bathroom, carrying cards, being in bed, or reacting to the fire alarm. One fall resulted in the resident being sent to the ER after increased confusion and repeated falls, and another fall occurred when the resident was wearing slippers that were too big. During a fire drill observation, the resident became distressed and paced, and no staff came to ensure the resident was safe and not at risk for falling. The resident’s care plan was not consistently updated after these falls, and the record showed no additional interventions or updates after several of the events. The quarterly MDS later reflected two or more non-injury falls and two or more falls with injury since the last assessment, while earlier MDS documentation did not accurately reflect the number of falls. Interviews with the MDS Coordinator, DON, and administrator showed expectations that care plans be updated after each fall and that staff follow care-planned interventions, but the record demonstrated that this did not occur consistently for the resident.
Failure to Reevaluate Indwelling Urinary Catheter Need and Secure Catheter
Penalty
Summary
The facility failed to identify and reevaluate the indications for use of indwelling urinary catheters for two residents and failed to ensure catheter securement for one resident. The facility policy, Urinary Catheter Care, required catheter securement with a device to reduce friction and movement, review and documentation of clinical indications before insertion, ongoing assessment of need, and removal as soon as the catheter was no longer needed. For one resident, the record showed a history of sepsis and UTI, later hospitalization for hematuria and UTI, and placement of a urinary catheter during the hospital stay with bladder irrigation. After return to the facility, progress notes from multiple months did not document follow-up with urology or any indication for continuing or discontinuing the catheter. The resident’s MDS listed a new indwelling urinary catheter, but the diagnosis list did not show an indication for catheter use. During observation, the catheter bag was under the bed in a bath basin, and later the catheter was observed not secured to the resident’s leg, with tubing moving freely and pulling during care. Staff interviewed were unsure whether the facility had securement devices and were unsure why the resident still had the catheter. For the second resident, the admission record showed a urinary catheter ordered after hospitalization for a pelvic fracture, but the order did not include an indication for use. The resident’s MDS showed catheter use, but the diagnosis did not include an appropriate indication. The care plan identified that the resident had a urinary catheter and was at risk for MDROs, but did not include why the catheter was needed or a plan for discontinuation. Later, a physician order was written to bladder train the resident and discontinue the catheter. During observation, the catheter bag was placed under the resident’s wheelchair in a privacy bag, and the resident stated he/she did not know why the catheter was still in place. Staff and the RN stated the catheter had been placed for trauma and should not have remained in place as long as it did, and that the indication for continued use had been overlooked.
Failure to Obtain Orders and Care Plan for Colostomy Care
Penalty
Summary
The facility failed to obtain a physician's order for colostomy care and failed to develop a care plan to address the care and monitoring of a resident's colostomy. Resident #40 had diagnoses of malignant neoplasm of the colon and other functional intestinal disorders, severe cognitive impairment, dependence for toileting hygiene and personal hygiene, and an ostomy. The resident's care plan noted that the resident had a colostomy and that staff were to wear gloves and gowns when assisting with dressing, toileting, or emptying the colostomy, but it did not address the care, treatment, or monitoring of the colostomy. Review of the resident's physician's orders for September 2025 showed no order for colostomy care, and the TAR and MAR contained no documentation related to colostomy care or treatment. During observation, the resident had a colostomy bag attached to the abdomen with no date on the bag or wafer to show when they were last changed, and a CNA emptied the bag into a plastic bag in the trash can, cleaned the end of the bag with a wet wipe, and placed a clip on it. Staff interviews indicated that nurses changed the bag and wafer every three to four days or every four days and as needed, but staff were unsure how often the wafer was changed and did not know of any order documenting the frequency. The DON stated the wound nurse saw the resident weekly to check the stoma and surrounding area, but no related notes were found in the medical record, and she expected physician's orders and documentation of colostomy care on the MAR and TAR.
Failure to Monitor and Report Significant Weight Loss
Penalty
Summary
The facility failed to consistently monitor resident weights as ordered and failed to identify and respond to significant weight loss for two residents. Facility policy required weights to be monitored, significant changes to be confirmed, and the physician and dietician to be notified when weight loss was verified. The record showed that staff did not consistently obtain ordered weights, did not reweigh residents when significant loss was identified, and did not document evaluation of weight loss or implementation of new interventions. For one resident with severe cognitive impairment, weekly weights were ordered. The resident weighed 105.5 pounds on 8/02/25, 105 pounds on 8/06/25, 103.5 pounds on 8/13/25, and 106 pounds on 8/27/25. On 9/03/25, the resident weighed 95.5 pounds, which reflected a 9.48% loss in one month. The record contained no documentation that staff reweighed the resident to confirm the result, evaluated the resident for weight loss, notified the physician or dietician, or implemented new interventions to prevent further loss. Interviews showed the DON, MDS Coordinator, Infection Preventionist, Registered Dietician, and physician each described expectations for reporting and monitoring weight loss, and the physician stated he/she was not aware of the loss until the survey and then prescribed an appetite stimulant. For another resident with severe cognitive impairment, monthly weights were ordered, but no weight was documented in July 2025. The resident weighed 190 pounds on 6/02/25, 173.5 pounds on 8/02/25, and 172 pounds on 9/01/25, reflecting a 9.47% loss in three months. The record showed no documentation that staff notified the physician or the registered dietician of the weight loss, and no documentation that current interventions were re-evaluated or new interventions were identified. Interviews with nursing, the DON, the MDS Coordinator, the responsible party, and the dietician confirmed that staff were not aware of the resident’s weight loss and that the dietician expected notification of the significant change.
Dietary Director Lacked Required Food Safety Training
Penalty
Summary
The facility failed to ensure the Dietary Director had the appropriate competencies and skill set to carry out the functions of the food and nutrition service. The facility census was 41. Review of the current employee list showed the Dietary Director began working at the facility on 5/9/22. Review of the signed Dietary Supervisor Responsibilities showed duties that included overseeing daily food service operations, developing and updating menus, creating monthly work schedules, supervising and training dietary staff, ensuring food handling and sanitation procedures were followed, coordinating special diets, and completing all required certifications and maintaining current credentials. During interview, the Dietary Director stated he was enrolled in a university course but had not completed the food safety and management training covering topics such as foodborne illness, sanitation, and food purchasing/receiving. He said he started the course in February 2024 and received a nine-month extension in February 2025 because staff turnover and the need for him to work open positions delayed his progress. The Administrator stated she was aware he had not completed the training and that he had been granted a nine-month extension because the Dietary Department had open positions and he was working those shifts until new staff were hired. She stated she expected him to complete the program by the end of November 2025.
Failure to Provide Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices with the required information and failed to provide a copy of the bed-hold notice when residents were sent to the hospital. The facility policy stated that residents and representatives must be notified in writing of the reason for transfer or discharge, the effective date, the receiving location, appeal rights information, bed-hold and return policies, and contact information for the state ombudsman and other agencies, and that notice for emergency transfers should be given as soon as practicable before transfer and bed-hold notice within 24 hours of emergency transfer. For Resident #5, the record showed two hospital transfers. On 6/18/25, the resident was sent to the hospital for abnormal lab results, and staff notified the durable power of attorney by phone. On 7/7/25, the resident was sent to the emergency room for shortness of breath and chest tightness, and the durable power of attorney was again notified by phone and a message was left. In both instances, the medical record contained no documentation that the resident's representative received a written transfer notice or a written bed-hold notice. For Resident #6, the resident fell from a power recliner on 7/18/25 after the elbow pressed against the remote, could not move in time due to general weakness, and complained of pain and swelling in the right lower extremity. Staff notified the physician, family, and emergency medical services, and the resident was taken to the emergency room, where two fractures were identified. The record showed no documentation that a transfer/discharge notice or bed-hold notice was completed or provided. For Resident #39, the resident fell and was sent to the hospital for evaluation, where a hip fracture was identified, and the record also showed no documentation of a completed transfer/discharge notice or bed-hold notice. The DON and Administrator stated they expected written transfer/discharge notices to be provided with every hospital transfer, but the bed-hold policy was only given on admission and not with each transfer.
MDS Assessments Were Not Accurately Coded for Wounds, Alarms, Hospice, and Diagnoses
Penalty
Summary
The facility failed to accurately assess and correctly code multiple residents’ MDS assessments. In a review of 17 sampled residents and one additional resident, surveyors found errors involving a wound present on admission, Wanderguard alarms, hospice status, and active diagnoses. The DON stated the facility followed the RAI manual for completion of the MDS, and the Administrator said she expected the residents’ MDSs to be accurate. For one resident, the admission MDS coded a stage II pressure ulcer as not present on admission even though the resident was admitted from the hospital with a superficial open area to the right buttock covered with a small foam dressing, and the DON said the resident was admitted with a pressure ulcer. For two residents with Wanderguard devices, physician orders and nursing documentation showed the residents wore the alarms and staff checked placement and functioning, and one resident was observed with the device in place, yet the MDSs did not document the wander/elopement alarms. The MDS Coordinator said alarms should be coded in section P and was not aware alarms needed to be coded. The facility also failed to code hospice status for two residents. One resident had hospice admission documentation, a hospice certification of terminal illness, progress notes showing continued hospice care, and a physician note stating the resident was currently on hospice, but the significant change MDS did not mark hospice. Another resident’s orders and hospice binder showed hospice services had started and the resident remained on hospice, but both the significant change and quarterly MDSs left hospice blank. In addition, one resident’s MDSs failed to code active diagnoses of sepsis, chronic heart failure, and pneumonia even though the face sheet listed those diagnoses and the RAI manual required coding them in section I. The MDS Coordinator stated hospice should have been marked for one resident and said any MDS errors were probably an oversight.
Failure to Provide Baseline Care Plan Copies to Residents or Representatives
Penalty
Summary
The facility failed to provide the resident or resident representative with a copy or written summary of the baseline care plan for three residents, including Resident #5, Resident #7, and Resident #14. The facility policy, Care Plans - Baseline, revised 2022, required a baseline plan of care to meet each resident’s immediate health and safety needs within 48 hours of admission and required that the resident and/or representative receive a written summary that included goals and objectives, medication and dietary instructions, services or treatments to be provided, and any updated information from the comprehensive care plan, with documentation of provision in the medical record. For Resident #5, the baseline care plan dated 5/7/25 had no documentation that a copy or written summary was provided to the resident or representative, and the medical record also lacked such documentation. For Resident #7, the baseline care plan dated 7/14/25 likewise had no documentation of provision to the resident or representative, and the medical record did not show it was provided. For Resident #14, the undated baseline care plan also lacked documentation that a copy or written summary was given to the resident or representative, and the medical record contained no documentation of provision. During interviews, the LPN who admitted residents said the DON completed the baseline care plans and she did not know what to do with them; the MDS Coordinator said the admitting nurse should complete the baseline care plan, have the resident or representative sign it, and give them a copy; and the DON said the admitting nurse should complete the baseline care plan, obtain a signature, give a copy to the resident or representative, and scan a completed signed copy into the EHR. The DON also stated she had not monitored whether baseline care plans were completed, provided, signed, or scanned.
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What surveyors actually found near you
We read the 57 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Queen City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Davis Center | 19.9 mi | — | 0 | 0 |
| Twin Pines Adult Care Center | 20.4 mi | ★★★★★ | 3 | 0 |
| Kirksville Manor Care Center | 20.4 mi | ★★★★★ | 23 | 0 |
| Bloomfield Care Center | 21.1 mi | ★★★★★ | 5 | 0 |
| Golden Age Care Center | 23.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.