Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Vue Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Unsanitary food storage and kitchen sanitation: Surveyors observed heavy grime, debris, sticky film, and food residue on kitchen equipment and surfaces, along with inadequate dishwashing water temperatures. They also found undated and dented cans, expired and out-of-date foods, desserts left out on counters, food debris in refrigerators and freezers, and food stored on the floor. The Dietary Manager and Administrator acknowledged the sanitation and storage problems, and the facility did not provide a policy for kitchen water temperature.
Inaccurate CPR Code Status Documentation: A resident's advance directive showed DNR status on an OHDNR form, but the POS and face sheet had no code status order or entry, and the care plan did not address code status. An LPN said staff would treat a resident as full code if unsure, while the DON and Administrator stated code status should be checked in the EMR/EHR and shown on the face sheet.
The facility failed to limit PRN psychotropic medication orders to 14 days for two residents and failed to document appropriate diagnoses for psychotropic use for two other residents. One resident had buspirone ordered for Alzheimer's disease without an appropriate diagnosis, and another had Zyprexa ordered for agitation and sundowning, which the DON, Medical Director, and Administrator said were not acceptable diagnoses. Two residents also had lorazepam PRN orders without stop dates.
Incomplete bed-hold and transfer/discharge notices were found for four residents after hospital transfers. The forms did not document the resident or rep election to hold the bed, the daily bed-hold rate, or signatures, and the transfer/discharge notices did not state the reason for transfer or include required protection-and-advocacy agency contact information. The SSD and Administrator said they were unaware of these documentation requirements.
Failure to include person-centered interventions in care plans for two residents. One resident had stroke-related deficits, depression, and a smoking assessment showing cognitive intactness and safe smoking behavior, but the care plan did not address smoking. Another resident had chronic respiratory failure, DM, AFib, CHF, COPD, and an Eliquis order, but the care plan did not address the blood thinner with individualized interventions. The DON and Administrator stated smoking, blood thinners, and individualized interventions should be included in care plans.
A resident with a suprapubic catheter and diagnoses including CKD and urinary retention had the catheter drainage bag observed resting on the floor while the resident was in bed. The MDS, care plan, and physician orders called for ongoing catheter care, and multiple CNAs, an RN, an LPN, nursing assistants, the DON, and the Administrator stated the drainage bag should not touch the floor.
Failure to Address Trauma and PTSD in Care Plans: The facility failed to identify, assess, and document supportive interventions for two residents listed with PTSD/trauma on the matrix. One resident had bipolar disorder, anxiety, and paranoid personality disorder, with a positive traumatic event screen but no triggers or care plan interventions documented. Another resident with PTSD had nightmares and unwanted thoughts after a traumatic event, but the care plan still did not address triggers, trauma history, or support measures. Interviews with the Administrator, DON, SSD, and the residents confirmed the missing trauma-informed care planning.
Bed rails were used as restraints and were not properly monitored or maintained for two residents. One resident had multiple serious diagnoses, severe cognitive impairment, and no order or documentation supporting bilateral quarter side rail use, while the other resident had an order for a quarter side rail but no documented assessment, alternatives, or maintenance. Observations showed the rails in use with the bed positioned against the wall, and staff stated the rails were being used to keep the residents from rolling out of bed or staying in bed.
Failure to Reconcile Narcotics at Shift Change: Staff did not consistently reconcile narcotics at each shift change for two medication carts. Record review showed repeated missed signatures/initials on controlled substance count sheets for the 200 Hall and 400 Hall carts, despite facility policy requiring the on-coming and off-going nurses to count together and document the narcotic inventory at every shift change. Interviews with an LPN, the DON, and the Administrator confirmed this expectation.
Failure to Follow EBP and Hand Hygiene During Resident Care: Staff did not consistently use EBP PPE or proper hand hygiene and glove changes during wound care, catheter care, g-tube care, and incontinent care. An RN, LPNs, CNAs, and NAs were observed moving between dirty and clean tasks without hand hygiene, reusing contaminated gloves or supplies, and in some cases not wearing gowns for residents with wounds or indwelling devices despite EBP signage and PPE being posted.
A resident with severe cognitive impairment, a history of falls, and total dependence for transfers was lowered to the floor during a transfer with a mechanical ceiling lift when the device reportedly malfunctioned and CNAs manually assisted the resident to the floor and then to a Geri chair. The CNAs did not immediately notify the nurse, and the initial nursing assessment performed during a throat swab was not documented in the record. Bruising and discomfort of the right lower extremity were noted later in the morning, and the physician and family were not documented as being notified until late in the day, with no same-day progress notes describing a head-to-toe post-fall assessment, the incident details, or timely family notification, despite facility leadership stating that immediate assessment and notification are expected after a fall.
A resident with severe cognitive impairment, total dependence for ADLs, and a history of falls was being transferred with a mechanical ceiling lift when the device malfunctioned and the resident was lowered to the floor by a CNA. The CNAs did not immediately notify the nurse and moved the resident from the floor to a Geri chair using a gait belt and a fireman lift before any nursing assessment occurred, despite facility expectations that a nurse must assess a resident in place after any fall. Although an RN later entered the room and reportedly performed a head-to-toe assessment, there was no corresponding post-fall assessment or skin assessment documented in the record for that day, and no detailed incident note, even as bruising and discomfort of the right lower extremity were later observed and reported. This sequence of actions and omissions failed to meet the facility’s own falls protocol and professional standards requiring immediate nursing assessment and thorough documentation after a fall.
The facility failed to provide and document training and competency assessment on mechanical ceiling lift use for a CNA who had been employed for several months. The existing orientation policy did not address training on facility equipment, including mechanical lifts, and review of the CNA’s training record showed no education or competency checks related to safe lift use. The Administrator, DON, Director of Staff Development, and Nursing Manager each stated they expected CNAs to be trained and competent in mechanical lift use, yet confirmed that this CNA had not received such training, while the CNA reported having no training or demonstrated competency on the mechanical ceiling lift used to transfer a resident.
The facility failed to maintain sanitary conditions in its food service areas, with issues such as undated food items, improper storage, and significant cleanliness problems. Observations revealed grime, debris, and ice build-up in various kitchen areas, while interviews confirmed that these areas should have been cleaned according to policy. Maintenance and supply delays contributed to unresolved issues, posing a risk of cross-contamination and food-borne illness for residents.
A resident with hypertension did not receive timely segmental pressures and arterial duplex tests as ordered by the physician. The facility failed to document the completion of these tests, and the resident experienced ongoing leg and foot pain. The DON was unaware of the new imaging order, and the resident reported that Tylenol was not always effective in managing the pain.
The facility failed to ensure an appropriate diagnosis for an antipsychotic medication for a resident and did not limit PRN orders for psychotropic medications to 14 days for two other residents. A resident was prescribed Abilify without a specific diagnosis, and two residents had PRN orders for hydroxyzine and lorazepam without stop dates. Staff interviews revealed a lack of awareness regarding the necessity of proper diagnoses and adherence to PRN limits.
The facility failed to maintain a homelike environment, as personal items were found on light fixtures in several resident rooms. Despite the facility not recommending this practice, it occurred, and there was no policy in place to address it. Interviews with the Maintenance Supervisor, DON, and Administrator confirmed the lack of adherence to recommended practices.
Unsanitary food storage and kitchen sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions. Surveyors observed extensive buildup of grime, debris, sticky film, carbon, and food residue on kitchen equipment and surfaces, including the commercial dishwasher, gas range, steam table, bread shelving, refrigerator handles, ice machine, utensil drawer divider, and wall diffuser. The three-compartment sink water temperature was observed at 90°F and the dishwashing area sprayer sink at 65°F. Staff acknowledged that the stove, oven, steam table, and dishwasher required deeper cleaning and that the dishwasher grime built up between cleanings, with water temperature at the sink not staying hot. Food storage areas also contained multiple sanitation and storage problems. In the dry storage area, surveyors found undated bins of flour, sugar, and brown sugar with food debris on the tops, several undated dented cans, and an opened bag of breadcrumbs dated 07/09/25. In the walk-in refrigerator and freezer, surveyors observed scattered food debris, shredded cheese on the floor, 1-inch thick ice formation, food boxes and bags stored on the floor, and paper trash beneath shelving. Additional observations in other kitchen areas showed desserts left out on counters, expired or out-of-date food items in pantry bins and refrigerators, sticky and dirty refrigerator handles, and food debris on shelves and floors. The Dietary Manager stated that canned foods should have a use-by date, that rusty and dented cans should be placed in the return cart, and that food boxes should not be on the floor or trash under freezer shelves. The Administrator stated that freezers and refrigerators should be clean, wall vents should be clean, appliances and countertops should be clean and working properly, dented cans should not be on racks, desserts should not be left out, and expired foods should be discarded. The report also noted that the facility did not provide a policy regarding water temperature in the kitchen.
Inaccurate CPR Code Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's advance directive regarding CPR code status for Resident #81. Review of the resident's physician order sheet showed no code status order, and the face sheet also showed no code status. The resident's Outside the Hospital Do Not Resuscitate form, however, showed a DNR status with the resident's signature and the physician's signature. The resident's care plan did not address code status. During interviews, an LPN stated that if a resident's code status was not in the medical record and he or she was unsure, the resident would be treated as full code and staff would look in the EHR for the code status. The DON stated staff should check the code status in the EMR and, if it was not on the face sheet, should check further in the EHR. The Administrator stated the resident code status should be indicated on the face sheet in the EHR.
Psychotropic Medication Orders Lacked Required Stop Dates and Appropriate Diagnoses
Penalty
Summary
The facility failed to limit PRN psychotropic medication orders to 14 days for two residents. One resident with diagnoses including senile degeneration of the brain and dementia with agitation had an order for lorazepam 0.5 mg by mouth every eight hours PRN for anxiety dated 02/03/26, and the order did not include a 14-day stop date. Another resident with diagnoses including dementia, depression, parkinsonism, and Parkinson's disease with dyskinesia had an order for lorazepam concentrate 2 mg/ml, 0.25 ml sublingually every four hours as needed for anxiety and for seizures, dated 03/06/26, and this order also had no stop date. The facility also failed to ensure appropriate diagnoses were documented for psychotropic medications for two residents. One resident with diagnoses of Alzheimer's disease, anxiety disorder, bipolar disorder with current manic episode without psychotic features, and insomnia had an order for buspirone 5 mg by mouth twice a day related to Alzheimer's disease, and the record did not provide an appropriate diagnosis for the medication. Another resident with a diagnosis of dementia with anxiety had an order for Zyprexa 2.5 mg by mouth once daily for agitation and sundowning, and the record did not provide an appropriate diagnosis for the antipsychotic. The Medical Director, DON, and Administrator stated that PRN psychotropic medications should have a stop date and that sundowning and agitation were not acceptable diagnoses for an antipsychotic medication.
Incomplete bed-hold and transfer/discharge notices
Penalty
Summary
The facility failed to include required bed-hold information and complete transfer/discharge notices for four sampled residents. Review of the facility policy showed residents or their representatives were to receive written bed-hold information, including the daily bed-hold rate and the resident or representative’s election to hold the bed, and transfer/discharge notices were to include the reason for the transfer or discharge and contact information for agencies that protect and advocate for residents with developmental disabilities and mental illness. For Resident #1, Resident #9, Resident #11, and Resident #124, the medical records showed multiple hospital transfers, and in one case the resident did not return. The Bed-Hold information for each resident was undated and did not document that the resident or representative elected to hold the bed, did not list the daily bed-hold rate, and did not contain the resident’s or representative’s signature. The transfer/discharge notices for each resident also did not document the reason for the transfer/discharge and did not include the required agency contact information for protection and advocacy services. During interview, the Social Services Designee stated she was unaware that the transfer/discharge notice needed to be signed by the resident or representative and returned to the facility, needed to identify the reason for transfer/discharge, and needed to include the required agency contact information. She also stated she was unaware that the resident or representative had the right to elect to hold the bed and that the daily bed-hold rate needed to be documented on the form. The Administrator stated she was not aware the Bed-Hold form had to include the daily rate and the resident’s or representative’s signature, and was also unaware the transfer/discharge notice had to include the agency contact information for protection and advocacy of individuals with developmental disabilities and mental illness.
Failure to Include Person-Centered Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement care plans with specific, person-centered interventions to meet individual resident needs for two residents out of 24 sampled. Resident #4 was admitted with diagnoses including stroke affecting the left side, persistent atrial fibrillation, major depressive disorder, muscle weakness, lack of coordination, and weakness. A smoking assessment dated 09/15/25 documented that the resident was cognitively intact, educated on the smoking policy and designated areas, able to safely use a lighter, and demonstrated safe smoking behavior while interacting with other residents. However, the revised care plan dated 02/16/26 did not address smoking with person-centered interventions. Resident #7 was admitted with diagnoses including chronic respiratory failure, diabetes mellitus, atrial fibrillation, congestive heart failure, COPD, and paroxysmal atrial fibrillation. The resident also had an order for Eliquis 2.5 mg by mouth two times a day dated 11/26/25. The revised care plan dated 03/04/26 did not address the Eliquis with person-centered interventions. During interviews, the DON stated blood thinner medications and smoking should be addressed on a resident's care plan and that person-centered interventions should be included, and the Administrator stated smoking, blood thinner medications, and individualized interventions should be on a resident's care plan.
Catheter drainage bag left on the floor
Penalty
Summary
The facility failed to ensure the drainage bag for one resident's indwelling suprapubic catheter was kept off the floor. Resident #3 had diagnoses of chronic kidney disease and urinary retention, and the medical record showed orders for monthly catheter and drainage bag changes, daily suprapubic catheter site care, and catheter care every shift. The resident's MDS indicated use of a suprapubic catheter, and the care plan identified the resident as having a suprapubic catheter with catheter care every shift. During observations on 04/14/26 at 5:15 A.M. and 9:22 A.M., the resident was lying in bed and the catheter drainage bag was on the floor; the bottom of the bag rested on the floor because the privacy flap was intact and did not cover the bottom of the drainage bag. Multiple staff members, including CNAs, an RN, an LPN, and nursing assistants, stated that a catheter drainage bag should not touch the floor, and the DON and Administrator stated they would expect staff to keep the drainage bag off the floor.
Failure to Address Trauma and PTSD in Care Plans
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for two residents with PTSD or trauma listed on the facility matrix. For Resident #8, the medical record showed diagnoses of bipolar disorder, unspecified anxiety disorder, and paranoid personality disorder, but no documented trauma informed consent assessment. The resident’s Traumatic Event Assessment was positive for a traumatic event, yet no triggers were identified and no plan of care was developed to minimize or avoid triggers. The care plan noted a potential for past trauma and stated care would be based on past experiences and preferences, but it did not address the resident’s trauma, any triggers, or how staff would respond if behaviors occurred or provide support. For Resident #88, the medical record showed diagnoses of pneumonia, acute kidney failure, and left femur fracture, while the facility matrix identified the resident as diagnosed with PTSD. The resident’s Trauma Informed Consent Assessment documented that the resident experienced a traumatic event and had nightmares and unwanted thoughts about the event, but no triggers were addressed. The care plan, revised earlier in the year, did not address the resident’s past trauma, any triggers, or how the facility would respond to behaviors or provide support. Behavioral notes for April showed no behaviors. During interviews, the Administrator stated trauma and/or PTSD should have been addressed on Resident #8’s care plan and noted the resident wanted the details of the trauma kept confidential and had previously requested a female counselor. Resident #8 stated that visiting and talking to others helped keep the mind off things, but staff were busy, and one-to-one visits in the room or playing cards might help when thoughts of trauma occurred. The SSD stated the trauma informed care screenings were completed, but Resident #88 shut down and did not want to continue talking. The DON and Administrator stated that if a resident had PTSD, triggers and interventions should be addressed on the care plan, and if no triggers were identified, that should also be documented and followed up on at the next scheduled assessment.
Bed Rails Used as Restraints and Not Properly Monitored
Penalty
Summary
The facility failed to provide ongoing monitoring, supervision, and routine maintenance of beds with side rails in use and failed to ensure that bed rails were not used as restraints for two residents. The report states that the facility’s policy required a resident assessment, review of risks and benefits, informed consent, and correct installation and maintenance before a bed rail was used, and that restraints were never to be used for fall prevention. The facility also required side rail evaluations by nursing and maintenance review when rails were installed. Resident #6 had diagnoses including heart failure, COPD, stroke, seizures, atrial fibrillation, and repeated falls. The record showed no order for bilateral quarter side rails, no documentation of attempts at alternative methods before side rail use, and no documentation of routine maintenance. The side rail evaluation dated 03/27/26 showed no interventions trialed before considering the rails, that the resident used assist rails on both sides, requested the rails while in bed, and that no cause or medical symptom justified the use. The resident’s significant change MDS dated 04/01/26 showed severely impaired cognition, maximum assistance for bed mobility, and no side rail use, and the care plan did not address bilateral quarter side rail use. Observations on 04/13/26, 04/14/26, and 04/16/26 showed the resident in bed with the bilateral quarter side rails in the upward position and the left side of the bed against the wall. Resident #12 had diagnoses including stroke, dysphagia, high blood pressure, peripheral vascular disease, macular degeneration, anxiety, and depression. The record showed an order for a quarter side rail for positioning aid and safety and security, but no documentation of alternative methods tried, no side rail assessment, and no routine maintenance documentation. The quarterly MDS showed severely impaired cognition, maximum assistance for bed mobility, and no side rail use, while the care plan described the quarter side rail as an enabler for repositioning and noted the resident required a Hoyer lift and Geri chair. Observations on 04/14/24 and 04/16/26 showed the bilateral quarter side rails in the upward position with the left side of the bed against the wall, and during incontinent care the right side rail was lowered but remained approximately four inches above the mattress. Staff interviews stated the rails were being used to prevent the residents from rolling out of bed or to keep them in bed.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility failed to ensure staff reconciled narcotics at each shift change for two sampled medication carts, the 200 Hall cart and the 400 Hall cart. Facility policy titled Controlled Substances, revised November 2022, required controlled substance inventory to be monitored and reconciled to identify loss or potential diversion, with nursing staff counting controlled medication inventory at the end of each shift and the on-coming and off-going nurses making the count together and documenting any discrepancies. Record review showed repeated missed signatures and/or initials on the shift verification of controlled substance count sheets for both carts across multiple date ranges. For the 200 Hall cart, there were 12 missed opportunities out of 144, 15 missed opportunities out of 158, and 10 missed opportunities out of 80. For the 400 Hall cart, there were nine missed opportunities out of 120, eight missed opportunities out of 144, and two missed opportunities out of 80. During interviews, an LPN, the DON, and the Administrator each stated that two staff members were expected to count and reconcile narcotics together at every shift change and sign the narcotic count verification form.
Failure to Follow EBP and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to provide an infection prevention and control program by not following enhanced barrier precautions and by not using proper hand hygiene and glove-changing practices during resident care. The report identified failures for residents with wounds, urinary catheters, and a g-tube, including residents who had EBP signage and PPE posted outside their rooms and residents who were receiving wound care, catheter care, g-tube care, and incontinent care. Facility policy stated that EBP required gown and glove use during high-contact care activities for residents with wounds or indwelling devices, and that hand hygiene was required before and after resident contact, after glove removal, and when moving from dirty to clean tasks. During wound care for one resident, an RN performed hand hygiene, donned gloves and a gown, turned off and disconnected the wound vac, removed the canister and tubing, and then did not perform hand hygiene or change gloves before attaching new tubing and a new canister. During wound care for another resident, an RN performed hand hygiene, donned gloves and a gown, cleaned the wound, measured it, and handled a pen from the bedside table without performing hand hygiene or changing gloves, then removed PPE and did not perform hand hygiene before leaving. For a resident with a wound and EBP signage, an LPN performed hand hygiene and donned gloves but did not put on a gown during wound care and dressing change. The report also described multiple failures during incontinent care and catheter care. For one resident, two CNAs entered without hand hygiene, used gloves inconsistently, moved between dirty and clean tasks without hand hygiene or glove changes, touched clean items and the environment, and one CNA exited the room with trash bags in a bare hand before disposing of them. For another resident, CNAs provided urinary catheter care while wearing gloves but no gowns despite EBP signage and PPE posted outside the room. For a resident with a urinary catheter dressing change, an RN touched gauze with bare hands before care, then cleaned the catheter insertion site by using the same area of saline-soaked gauze multiple times, and later picked up glasses that had fallen onto the resident’s bed without cleaning them. For another resident with a wound and EBP signage, no EBP signage or PPE was available outside the room during wound care, and the LPN did not wear a gown and did not perform hand hygiene or glove changes during the procedure.
Failure to Timely Notify Family and Physician and Complete Post-Fall Assessment After Lift Incident
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a resident’s family/representative and physician of a significant change in condition following a fall from a mechanical ceiling lift, as well as incomplete post-fall assessment and documentation. The facility’s Falls – Clinical Protocol required that families be notified of all falls but did not specify a timeframe for notification or address post-fall assessments, monitoring, or documentation. For the involved resident, who had severe cognitive impairment, a history of falls, arthritis, non-Alzheimer’s dementia, anxiety disorder, muscle weakness, and dependence on staff for all transfers and ADLs, there was no documentation of a post-fall assessment, post-fall skin assessment, or timely communication to the physician or representative on the date of the incident until late in the afternoon. On the day of the incident, the resident, who was care planned as a Hoyer lift transfer and at risk for falls, was being transferred from bed to a Geri chair with a portable ceiling lift by a CNA. The CNA reported that the lift broke and the resident began to come down, so the CNA grabbed the resident, slid the resident against the CNA’s body, and lowered the resident to a seated position on the floor. Another CNA responded to yelling, found the resident seated on the floor in front of the first CNA, and together they used a gait belt and a fireman lift to move the resident to a Geri chair. Both CNAs reported no immediate distress and did not immediately notify the nurse, with one CNA stating the nurse was busy and they did not feel the resident was injured, and the other CNA acknowledging awareness that immediate notification should have occurred. RN C later entered the room to perform a throat swab and assessed the resident, reportedly noting no injuries or immediate distress at that time, but did not document this assessment in the progress notes. Mid-morning, staff observed bruising and discomfort in the resident’s right lower extremity, and the physician was contacted for a STAT x-ray order. Documentation shows that family notification of the fall and physician contact were not recorded until late afternoon, and there were no progress notes on the date of the incident addressing a head-to-toe assessment, family contact, or a detailed description of the incident. The resident’s responsible party reported not being informed of the fall until early afternoon, despite a spouse being present in the facility earlier that morning and not being told of the incident. Facility leadership, including the DON, Nursing Manager, and Administrator, stated their expectation that nurses immediately assess residents and contact the physician and family after a fall, which did not occur in this case.
Failure to Immediately Assess and Document Resident After Witnessed Fall During Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed professional standards of practice by not immediately assessing a resident after a witnessed fall and not documenting a timely post-fall assessment. The facility’s Falls – Clinical Protocol required that residents who fall be assessed for injury at the time of the fall, with nursing assessment and documentation of vital signs, injury, musculoskeletal function, cognition, neurological status, pain, and details of the fall. The protocol also required assessment and charting for 72 hours and notification of family for all falls. Despite these requirements, there was no documentation of a post-fall assessment or post-fall skin assessment for the resident on the date of the incident. The resident involved had an admission date of 11/16/22 and diagnoses including arthritis, non-Alzheimer’s dementia, anxiety disorder, muscle weakness, and a history of falling. The resident’s MDS showed severely impaired cognition and dependence on staff for all ADLs and transfers, and the care plan identified the resident as at risk for falls due to weakness, impaired vision, dementia, medications, inability to stand, agitation, restlessness, and poor safety awareness. The care plan also specified use of a Hoyer lift for transfers. On the day of the incident, staff used a portable ceiling lift to transfer the resident after a shower. CNA A reported that the lift broke and the resident began to drop, so CNA A grabbed the resident, pulled the resident toward his/her chest, and slid the resident to a seated position on the floor, resting on the CNA’s feet. CNA B entered the room and observed the resident seated on the floor in front of CNA A. CNA A and CNA B did not immediately notify the nurse of the fall because they did not feel the resident was injured and believed the nurse was busy. Instead, they assisted the resident from the floor to a Geri chair using a gait belt and a fireman lift without a prior nursing assessment. This action was contrary to the expectations described by multiple staff and leadership interviews, which stated that when a resident falls or is found on the floor, the nurse should be called immediately, the resident should not be moved until assessed by the nurse, and only the nurse should perform the post-fall assessment. Although the incident report and progress notes indicate that RN C later entered the room and performed a head-to-toe assessment with no injuries noted, there was no corresponding progress note documenting this assessment or a detailed description of the incident on that date, and there was no documented post-fall skin assessment. Later that day, staff reported bruising and discomfort in the resident’s right lower extremity, leading to physician notification and orders for x-rays, but the initial failure to immediately notify the nurse, perform, and document a timely post-fall assessment constituted the cited deficiency.
Failure to Train CNA on Mechanical Ceiling Lift Use
Penalty
Summary
The facility failed to implement and maintain an effective training program for mechanical ceiling lift equipment for at least one CNA, resulting in a deficiency related to staff training and competency. The facility’s written policy titled “Orientation Program for Newly Hired Employees, Transfers, Volunteers,” revised May 2019, did not address training on facility equipment, including mechanical lifts. Review of CNA A’s training record, with a hire date of 10/08/25, showed no documentation of education or competency validation on the safe use of mechanical lifts. The Administrator stated she would expect CNAs to be trained and competent to use mechanical lifts prior to transferring a resident, and the Director of Staff Development confirmed that CNA A had not received training or a competency check for a mechanical lift. The DON stated she would expect CNAs to be trained on the mechanical ceiling lift if they cared for a resident who utilized it, but acknowledged CNA A did not have such training, and the Nursing Manager confirmed no one had trained CNA A on the mechanical ceiling lifts. In a phone interview, CNA A reported working at the facility for three months without any training or demonstrated competency on the mechanical ceiling lift used to transfer a resident. This deficiency was identified through interviews and record review, which showed the absence of a facility policy on employee training and competencies specific to equipment, and the lack of documented training and competency assessment for CNA A regarding mechanical ceiling lifts, despite expectations from leadership that such training should occur.
Sanitation Deficiencies in Food Service Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and preparation areas, as observed during multiple inspections. Key issues included undated and unlabeled food items, such as a partially full storage bin of powdered milk, and improper storage practices, with food containers placed directly on the floor. The kitchen areas were found to have significant cleanliness issues, including oily film and grime on various surfaces, white build-up on ice machines and dishwashers, and pooled water in the dishwashing area. Additionally, the walk-in refrigerator and freezer had scattered food debris and ice build-up, with several food items covered in thick ice. Further observations revealed that the dry food storage area had undated cans with a brown substance, scattered food debris, and improperly stored food items on the floor. The Whispering Pines kitchen had a ceiling diffuser with dust and a brown substance, while the Flowering Dogwood kitchen had white and brown substances on the ice machine and refrigerator dispenser. The Sleepy Oaks kitchen had food debris on the floor, a red substance and black debris in the refrigerator, and grime in the oven. Interviews with dietary aides and the dietary manager confirmed that these areas should have been cleaned and maintained according to the facility's sanitation policy. Interviews with the dietary manager and maintenance director indicated that there were delays in receiving cleaning supplies and that maintenance issues, such as ice build-up in the freezer, had been reported but not resolved. The administrator acknowledged the need for adjustments to prevent water splashing in the dishwashing area and confirmed that food should not be stored on the floor. The maintenance director was aware of the ice build-up in the freezer and stated that some had been removed, but it should not have been present. Overall, the facility's failure to adhere to its sanitation policy and maintain clean and sanitary conditions in food service areas posed a risk of cross-contamination and food-borne illness for all residents.
Failure to Follow Physician Orders for Diagnostic Tests
Penalty
Summary
The facility failed to adhere to physician's orders for a resident diagnosed with hypertension, specifically by not obtaining segmental pressures and an arterial duplex in a timely manner. The physician's order sheet dated 11/14/24 included an order for segmental pressures of the bilateral lower extremities, and the provider progress notes included an order for an arterial duplex. However, there was no documentation that the segmental pressures were completed or that a findings report was generated. The arterial duplex was eventually completed on 01/23/23, revealing mild to moderate peripheral vascular disease and moderate stenosis in the left lower extremity. Interviews and observations revealed that the resident experienced pain in the legs and feet, with complaints of pain when touched and discomfort when wearing shoes. The Director of Nursing acknowledged that the order for segmental pressures was not followed up on due to it not being entered into the system, and there was a lack of awareness regarding the new imaging order. The resident reported that Tylenol provided by the nurse did not always alleviate the pain, and the resident was observed with non-slip socks and legs resting on a pillow.
Failure to Ensure Proper Diagnosis and PRN Limits for Psychotropic Medications
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication for one resident and did not limit the use of PRN orders for psychotropic medications to 14 days for two other residents. Resident #16 was prescribed Abilify for unspecified dementia with behavioral disturbances, but the facility did not provide a specific diagnosis or identify the behaviors addressed by the medication. Observations showed the resident exhibited nonsensical speech and occasional yelling, but these behaviors were not clearly linked to the medication's purpose. Interviews with staff revealed a lack of awareness regarding the necessity of a proper diagnosis for antipsychotic prescriptions. Additionally, the facility did not adhere to the 14-day limit for PRN psychotropic medications for Residents #71 and #267. Resident #71 had a PRN order for hydroxyzine without a stop date, and Resident #267 had a PRN order for lorazepam also lacking a stop date. Interviews with the RN, DON, and Administrator indicated a lack of awareness and adherence to the requirement for PRN psychotropic medications to have a 14-day stop date or a physician reevaluation for an extended period. The facility did not provide a policy for appropriate diagnosis and PRN psychotropic medication use.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple observations of personal items placed on light fixtures in resident rooms. These items included figurines, picture frames, stuffed animals, and decorative objects, which were found on light fixtures in several rooms. The presence of these items on light fixtures was not recommended by the facility, as confirmed by interviews with the Maintenance Supervisor, the Director of Nursing (DON), and the Administrator. The Maintenance Supervisor acknowledged that some residents had items on their lights, although it was not recommended. The DON also confirmed that while it was not recommended, it happened, and residents usually had to purchase shelves themselves for their belongings. The Administrator stated that items should not be on top of light fixtures and expected staff to inform maintenance to install shelves for residents' belongings. The facility did not provide a policy for maintaining a homelike environment, which contributed to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 24 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, West Plains | 0 mi | ★★★★★ | 0 | 0 |
| Brooke Haven Healthcare | 0.9 mi | ★★★★★ | 9 | 0 |
| Willow Care Nursing Home | 18.7 mi | ★★★★★ | 8 | 0 |
| Mountain View Healthcare | 21.6 mi | ★★★★★ | 0 | 0 |
| Shady Oaks Healthcare Center | 23.3 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.