Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Sidney Health Center Extended Care during CMS and state inspections, most recent first.
Multiple residents experienced falls resulting in injuries such as fractures and lacerations due to the facility's failure to implement an effective fall prevention program. Staff did not consistently complete required fall checklists, update care plans, or conduct thorough post-fall assessments. Communication about fall risk was inadequate, and staff training on fall prevention interventions was lacking, leading to repeated incidents and insufficient individualized interventions.
Food in the steam table was observed uncovered while a staff member was talking with a resident in the dining room. When temperatures were checked, stuffed peppers measured 127 F and chicken strips measured 131 F. The staff member stated the intervention would be to place lids on the trays, but the trays remained uncovered after the low temperatures were identified.
The facility failed to ensure the Medical Director participated in QAPI meetings so the committee met required membership and frequency expectations. Staff stated attendance was not tracked with sign-in sheets, the Medical Director did not attend meetings regularly, and he received updates through meeting notes instead. The Medical Director was listed as a core QAPI member, but meeting records showed he was not present at the documented QAPI meetings, and staff were unsure whether falls had been identified as a QAPI concern.
Missing Infection Surveillance Logs: The facility failed to maintain adequate infection surveillance and documentation for several months, with staff unable to locate infection surveillance logs for the period reviewed. One staff member reported only having line lists for prior norovirus and COVID outbreaks, while another said she did not know how infections were tracked before she started in the role. The facility’s IPC program required surveillance, data analysis, documentation, and communicable disease reporting, but no requested logs were provided to surveyors.
The facility did not submit required reports to the State Survey Agency within mandated timeframes for several incidents, including unwitnessed falls with injury and an incident of staff-to-resident abuse. In each case, reports were filed late despite prompt internal notifications and investigations, with staff unable to explain the delays or clarify reporting responsibilities.
The facility did not complete or document thorough investigations for multiple facility-reported events, including unwitnessed falls with injury and a resident-to-resident abuse incident. In each case, only the event submission to the State Survey Agency was available, with no formal investigation files maintained or provided to surveyors.
The facility did not update care plans for several residents after fall incidents, failing to add new interventions or address root causes as required. Multiple residents experienced falls with injuries, but care plans were not revised, event forms were incomplete, and root cause analyses were not performed. Staff interviews indicated unclear processes and communication gaps regarding care plan updates after falls.
Staff physically restrained a resident to administer an IM medication, violating the resident's right to be free from restraint. The staff did not follow the care plan's behavioral interventions, and there was no physician order to hold the resident during the procedure. The facility's investigation confirmed that staff actions contributed to the escalation of the resident's behaviors and substantiated the occurrence of abuse.
Missing Documentation for Influenza Vaccine Education: The facility failed to maintain documentation that education on the risks and benefits of the seasonal influenza vaccine was provided to the resident or responsible party for three residents who declined the vaccine. An RN stated the EMR had a section for documenting vaccine education and that she needed to go back and update records to show the education was provided. The facility policy required education before offering influenza or pneumococcal immunizations and required that documentation be placed in the medical record.
The facility failed to document that education on the risks and benefits of the COVID-19 vaccine was provided before the vaccine was offered or given. An RN stated the EMR had a section for this information but it had not been updated. Records for four residents who declined the vaccine did not show the required education documentation, despite the facility’s IPC program stating that vaccine education and documentation were to be completed before offering the vaccine.
The facility failed to provide continuous oxygen to two residents, leading to hypoxic episodes. One resident with severe COPD was found unresponsive without oxygen in the tub room, and another was taken to the dining room without oxygen, resulting in low oxygen levels and seizure-like activity. A second resident on the dementia unit was also found without oxygen, with saturation at 88%. The facility's policy requires a physician's order for oxygen use, but these incidents show a lack of adherence to this standard.
The facility failed to maintain a full-time on-site Director of Nursing (DON), leading to inadequate oversight and negative outcomes in respiratory care for two residents. The interim DON worked on-site for two weeks and remotely for two weeks, resulting in insufficient oxygen saturations due to lack of adherence to professional standards and physician orders.
A resident with dementia was found with bruises of unknown origin, and the facility failed to investigate thoroughly or report the incident to required officials. Despite staff noting the bruises were inconsistent with the facility's explanation, the investigation was limited and lacked proper documentation. The State Survey Agency was not notified, and the investigation did not adequately address the cause of the bruising.
A facility failed to implement a baseline care plan for a resident's oxygen use within 48 hours of admission, resulting in a hypoxic event. The resident had a long history of continuous oxygen use and was admitted with specific oxygen orders, which were not included in the initial care plan. The oversight was only corrected after the resident experienced a hypoxic event.
The facility failed to maintain consistent enhanced barrier precautions for two residents and lacked infection surveillance documentation for six months. Observations revealed missing precaution signs and PPE supplies, while interviews highlighted staff unawareness of precautionary measures. Additionally, the facility did not document infection surveillance or report communicable diseases as required, posing increased risk to residents.
A facility failed to update a comprehensive care plan for a resident using oxygen therapy, despite multiple MDS assessments indicating its necessity. The resident, diagnosed with acute and chronic respiratory failure, pneumonia, and pulmonary hypertension, was observed using oxygen therapy, yet the care plan lacked details on oxygen use, respiratory status, and necessary interventions. This oversight was a repeated failure from admission to the survey date.
The facility failed to update care plans for two residents, leading to deficiencies in their care. A resident who fell and complained of head pain did not have their care plan updated to address fall risks. Another resident with multiple sclerosis requested gait belts for leg support, but their care plan lacked documentation and assessment for the belts' use. Staff admitted to not reviewing or updating care plans, indicating a lack of oversight.
The facility failed to complete POLST forms for three residents, with missing dates, signatures, and contact information. Staff oversight was lacking, as there was no process to ensure forms were completed, and they were only discussed during care plan meetings.
A resident reported a grievance about a nurse's strong perfume odor, which was not documented or resolved by the facility. Despite a policy against strong scents, the issue was only addressed verbally, and staff were unsure of any follow-up actions, indicating a failure to adhere to the grievance policy.
A facility failed to identify and report irregularities in a resident's use of Xanax, a psychotropic medication, beyond the recommended 14-day period without proper documentation. The pharmacist incorrectly deemed the continued use acceptable, and a staff member indicated the physician intended to make it scheduled, but no documentation supported this change. The oversight highlights a failure in the facility's medication management process.
A facility failed to review or discontinue a resident's PRN Xanax after 14 days, as required by policy. The physician's progress note showed uncertainty about the resident's Xanax use, and despite requests, no documentation was provided to justify continued use. The facility's policy mandates PRN orders be limited to 14 days unless extended with documented rationale, which was not received. Staff noted that physician documentation was in a different system, contributing to the issue.
A facility failed to administer the recommended pneumococcal vaccine to a resident, as revealed during interviews and record reviews. The facility's policy was outdated, and staff were unclear about the immunization process. The resident had not received the necessary vaccine dose according to CDC guidelines, and there was no documentation of consent or declination for the vaccine.
Failure to Implement Effective Fall Prevention Program and Inadequate Post-Fall Response
Penalty
Summary
The facility failed to implement and maintain an effective fall prevention program, as evidenced by multiple incidents involving residents who experienced falls resulting in injuries, including fractures and lacerations. In several cases, staff did not complete required fall checklists or event forms, and there was a lack of timely and thorough nursing assessments following fall events. For example, one resident experienced a fall in the bathroom resulting in a rib fracture, but no fall checklist was completed, and there were no nursing progress notes documenting assessments of the resident's condition in the days following the incident. Another resident with a history of multiple falls, cognitive impairment, and high-risk medications experienced several falls, some resulting in head lacerations and bruising. The care plan for this resident was not updated to reflect new risks or interventions after each fall, and interventions such as fall or bed alarms were not considered or implemented. Staff interviews revealed inconsistent understanding and application of fall prevention protocols, and care plans often contained outdated or irrelevant interventions. Additionally, there was a lack of individualized interventions addressing specific risk factors such as incontinence and confusion. Further review showed that staff were not consistently trained or updated on fall prevention interventions, and communication regarding residents' fall risk was inadequate. Assignment sheets and room signage did not reliably indicate which residents were at high risk for falls. In some cases, falls were not investigated or discussed by the interdisciplinary team, and root cause analyses were not completed. Facility policies required comprehensive post-fall management and care plan updates, but these were not consistently followed, resulting in repeated falls and injuries among residents.
Food Not Held at Safe Temperatures in Steam Table
Penalty
Summary
Food was not held at safe temperatures in the steam table during an observation of the dining room. Staff member G was observed in the dining room talking with a resident while a steam table contained trays of stuffed peppers, chicken strips, and soup. The trays were uncovered, and the lids were set off to the side of the steam table. When prompted to check holding temperatures, staff member G measured one stuffed pepper on the top layer at 127 degrees Fahrenheit and the chicken strips at 131 degrees Fahrenheit. Staff member G stated that the recommended intervention if food was not held at warm enough temperatures would be to place the lids on the food trays, but did not place lids on the trays after identifying and reporting the low temperatures. Staff member A later stated that staff member G did not cover the food on the steam table after identifying the low temperatures.
QAPI Committee Lacked Required Medical Director Participation
Penalty
Summary
The facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement (QAPI) meetings so the committee met the minimum requirements for attendees and frequency. During interview, staff member A stated that sign-in attendance sheets were not used to track who participated in QAPI meetings, and attendance was instead noted in the meeting minutes by listing the word "present" next to attendee names. Staff member A also stated the Medical Director was a member of the QAPI team but did not attend meetings regularly and was provided the meeting minutes and updates on significant action items. During interview, staff member D stated he did not physically attend QAPI meetings, though he planned to start, and that he received updates through meeting notes. He stated he was not aware whether the QAPI committee had identified resident falls as a concern or whether a performance improvement plan had been created to decrease falls. Staff member A stated she was not sure when staff member D last attended a QAPI meeting and thought it had been a couple of years. Facility documents identified the Medical Director as a core member and committee member of QAPI, but the QAPI meeting records for May 22, 2025, July 31, 2025, and October 23, 2025 showed staff member D was not marked present at any of those meetings.
Missing Infection Surveillance Logs
Penalty
Summary
The facility failed to maintain adequate infection surveillance and documentation over a four-month period for the early identification and monitoring of infections and safe infection control practices. During interview, staff member A stated she was unable to locate infection surveillance logs for February 2025 through June 2025 and said she only had line lists for a norovirus outbreak and a COVID outbreak tracked earlier in 2025. Staff member R stated she began in the position in July 2025 and had updated many program components in September 2025 to bring the facility back into compliance, but she did not know how infections were being tracked before she started and said staff member A would have to provide information for infection surveillance logs before July 2025. Review of the facility’s Infection Prevention and Control Program showed surveillance was to include monitoring, data analysis, documentation, and communicable disease reporting, and a request for infection control surveillance logs for any facility infections from February through June 2025 was made, but no documentation was provided before the end of the survey.
Failure to Timely Report Abuse, Neglect, or Injury Events
Penalty
Summary
The facility failed to submit timely reports to the State Survey Agency for multiple reportable events involving suspected abuse, neglect, or injury. In five separate cases, the facility did not meet the required two-hour reporting window for incidents involving serious bodily injury or suspicion of abuse. These included unwitnessed falls resulting in injuries such as a vertebral fracture, and an incident where a resident was held down by staff during medication administration, which led to the termination of two staff members for abuse. In each case, the initial or final reports were submitted late, sometimes by more than a day, despite internal notifications and initiation of investigations occurring promptly after the incidents. Interviews with staff revealed a lack of clarity regarding responsibility and procedures for timely reporting. Staff members acknowledged that reports should be filed as soon as possible, especially in cases of serious injury or abuse, but were unable to explain the delays. In some instances, the responsible staff member was not present in the facility at the time of the incident, and reporting was delayed until their return. The facility's investigation processes were noted to be in need of improvement, as evidenced by the repeated late submissions of required reports to the State Survey Agency.
Failure to Investigate and Document Facility-Reported Events
Penalty
Summary
The facility failed to conduct thorough investigations and maintain comprehensive documentation following facility-reported events for three residents. In one case, a resident experienced an unwitnessed fall resulting in a significant injury, including a fracture of the S5 vertebrae, and was treated in the ER. Despite the seriousness of the injury and the resident being an unreliable reporter, the facility did not provide an investigation file when requested by surveyors. In another instance, a resident was involved in a resident-to-resident abuse incident where they were pinched by another resident, but again, no investigation file was available for review. Additionally, a third resident sustained an unwitnessed fall with injury and was treated in the ER. Documentation revealed that no investigation was conducted for this incident, as the DON was not present in the facility at the time and did not initiate an investigation upon return. The only documentation available for these events was the submission of the event to the State Survey Agency, with no formal investigation files maintained. Interviews with staff confirmed the lack of investigation and documentation for these incidents.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to update and revise care plans for multiple residents following fall events, as required by policy and regulatory standards. For four residents, care plans were not updated to reflect new interventions or to address the root causes of falls, even after incidents that resulted in injuries. In several cases, fall safety event forms were not completed, and there was no documentation of root cause analyses or evaluation of existing interventions. For example, one resident experienced a fall resulting in a rib fracture while on anticoagulant medication, but the care plan was not updated to reflect this risk or to include new interventions. Another resident had an unwitnessed fall, but the care plan was not reviewed or revised, and the event remained open without a root cause analysis for over a month. Additionally, two other residents experienced multiple falls with injuries within a short time frame, yet their care plans showed no updates or new interventions in response to these incidents. Staff interviews revealed confusion regarding responsibility for updating care plans after falls, and there was a lack of clear communication about care plan changes to direct care staff. The facility's own fall prevention policy required care plan review and updates after any fall, but this process was not consistently followed, as evidenced by the lack of documentation and intervention updates in the residents' records.
Failure to Prevent Abuse and Use of Physical Restraint During Medication Administration
Penalty
Summary
Facility staff held a resident down to administer an intramuscular (IM) medication due to the resident's behaviors, which constituted a violation of the resident's right to be free from physical restraint. The staff's actions were not in accordance with the resident's care plan, as the behavioral interventions outlined in the care plan were not followed. Documentation indicated that staff attempted three interventions—offering food, assessing pain, and playing music—before administering the medication, but only the pain assessment was a care plan intervention, and there was no evidence that it resulted in an actual intervention such as administering pain medication. Additionally, offering food and music were not listed in the care plan as interventions. The facility's investigation substantiated that abuse occurred and found that staff interactions contributed to the escalation of the resident's behaviors. The resident's behaviors did not pose an immediate risk of harm to herself or others at the time of the incident. There was also no physician order authorizing staff to physically restrain the resident during medication administration. The incident was reported to the State Survey Agency, and the facility's investigation confirmed that the staff failed to follow established protocols and care plan interventions, resulting in the substantiated finding of abuse.
Missing Documentation for Influenza Vaccine Education
Penalty
Summary
The facility failed to ensure adequate documentation was completed and maintained for education provided to residents or their responsible parties regarding the risks and benefits of the seasonal influenza vaccination. During interview, staff member R stated she administered seasonal influenza and COVID vaccinations to residents and that the electronic medical record contained a section for documenting vaccination administration information, including education provided to the resident or responsible party. She also stated she needed to return to the resident records to update that section to show the education had been provided, and noted that other nurses also administered vaccinations, although she administered most of the seasonal vaccinations. Review of a facility document listing residents who consented or declined influenza and COVID vaccinations in October 2025 showed that resident 6, resident 7, and resident 13 declined the influenza vaccination. Review of those residents’ vaccination records did not show documentation that education explaining the risks and benefits of the influenza vaccination had been provided to the resident or their responsible party. The facility’s Influenza and Pneumococcal Immunizations policy stated that before offering influenza or pneumococcal immunization, each resident or legal representative would receive education regarding the benefits and potential side effects, and that documentation of this education would be placed in the resident’s medical record.
Missing COVID-19 Vaccine Education Documentation
Penalty
Summary
The facility failed to ensure documentation was completed and maintained showing that education on the risks and benefits of the COVID-19 vaccine was provided to the resident or their representative before the vaccine was given or offered. During interview, staff member R stated she had administered COVID-19 vaccinations to facility residents and that the electronic medical record contained a section for documenting vaccine administration information, including education provided to the resident or representative, but she needed to go back into the records to update that section. Review of a facility document listing residents who consented or declined COVID-19 vaccination in October 2025 showed that residents #6, #7, #13, and #14 declined vaccination. Review of the vaccination records for these residents did not show documentation that education on the risks and benefits had been provided prior to the vaccine being given or offered to the resident or responsible party. The facility’s Infection Prevention and Control Program stated that education about the vaccine, risks, benefits, and potential side effects would be given to residents or resident representatives and staff prior to offering the vaccine, and that documentation would reflect the education provided and whether the vaccine was received.
Failure to Provide Continuous Oxygen to Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services to two residents, leading to insufficient oxygen saturations. One resident, who had severe COPD and was oxygen-dependent, experienced a hypoxic episode in the tub room without her oxygen on. Staff member M applied oxygen and called the physician after the resident turned blue and was unresponsive. The resident's care plan did not initially include oxygen use, and it was only revised after the incident. Another incident involved the same resident being taken to the dining room without oxygen, resulting in low oxygen levels and seizure-like activity. The CNA responsible was new and reportedly not educated on which residents required oxygen. Another resident was found without oxygen on the dementia unit, with an oxygen saturation of 88%. Staff member N applied oxygen immediately, and the resident's levels returned to baseline. The facility's policy on oxygen administration requires a physician's order for its use, but the incidents indicate a failure to adhere to these standards, as both residents were found without their prescribed continuous oxygen.
Deficiency in Full-Time On-Site Director of Nursing
Penalty
Summary
The facility failed to ensure that a Director of Nursing (DON) was working full-time for 35 or more hours per week on-site, which increased the risk of negative outcomes for all residents due to the lack of onsite oversight. This deficiency was identified during a survey where harm was noted in the area of respiratory care and services, affecting two residents who experienced insufficient oxygen saturations. The facility had been unable to hire a permanent DON and had contracted an interim DON who worked on-site for two weeks and then remotely for two weeks. Observations during the survey confirmed the absence of the DON on several occasions, which contributed to the failure in providing necessary respiratory care and services in accordance with professional standards and physician orders.
Failure to Investigate and Report Bruising of Unknown Origin
Penalty
Summary
The facility failed to adequately respond to allegations of abuse concerning a resident who was found with bruises of unknown origin. The resident, who had dementia and required assistance for toileting, was noted to have dark purple and red bruising on her buttocks and thighs. Despite the bruising being reported to facility management, there was no evidence that the incident was thoroughly investigated or that it was reported to the required officials. The initial assessment by a staff member indicated that the bruising was higher than where a toilet seat would typically cause such marks, contradicting the facility's event report that suggested the bruises were from sitting down hard on the toilet. Interviews with staff revealed inconsistencies and a lack of thorough investigation into the cause of the bruising. One staff member mentioned that another staff member had found the resident on the floor, but this was not further investigated. Additionally, the State Survey Agency was not notified about the bruises, and the investigation only included interviews with four staff members, which were not dated to indicate when the investigation began. The lack of a comprehensive investigation and failure to report the incident to the appropriate authorities contributed to the deficiency.
Failure to Implement Baseline Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident's oxygen use within 48 hours of admission, leading to a hypoxic event. The resident, who had been using oxygen continuously for many years prior to admission, was admitted with a physician's order for oxygen at 2-4 liters per minute via nasal cannula to maintain SaO2 at 90% or above. This order was later adjusted to titrate oxygen as needed to keep SaO2 at 88% or above, with the resident currently on 4 liters continuously. However, the baseline care plan did not include any problems, goals, or interventions for oxygen use. The omission was identified after the resident experienced a hypoxic event, and the oxygen usage was only added to the care plan post-incident. Staff acknowledged the oversight but indicated there was nothing that could be done about it after the fact.
Inconsistent Infection Control Practices and Documentation Lapses
Penalty
Summary
The facility failed to ensure consistent enhanced barrier precautions for two residents, which was identified through observations and interviews. Resident #37's door had a yellow isolation bag with gowns, gloves, and wipes, but lacked a precaution sign. Similarly, staff member M was unaware of the reason for an enhanced barrier precaution sign on resident #16's door, and no PPE supplies were found in the room or bathroom. These observations indicated a lack of proper communication and availability of necessary infection control supplies for residents under enhanced barrier precautions. Additionally, the facility did not provide documentation of infection surveillance and mandatory communicable disease reporting for six consecutive months. Staff member L, who had recently returned from medical leave, acknowledged the absence of surveillance tracking from March to August 2024. The facility's infection control program, which should include a system for prevention, identification, reporting, investigation, and control of infections, was not adequately maintained during this period. The facility's policies required healthcare providers to report confirmed or suspected cases of communicable diseases to the local health department. However, the lack of updated documentation and surveillance tracking suggests that these procedures were not followed. This deficiency in infection control practices posed an increased risk to the entire facility population.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was created for a resident who utilized oxygen therapy. Despite the resident having three MDS assessments completed, all indicating the use of oxygen therapy, the care plan was never updated to reflect this need. This oversight was observed from the resident's admission and continued through multiple assessments, demonstrating a repeated pattern of failure. The resident's electronic medical record showed pertinent diagnoses, including acute and chronic respiratory failure with hypoxia, pneumonia, and pulmonary hypertension, yet these were not adequately addressed in the care plan. Observations and interviews confirmed the resident's ongoing use of oxygen therapy, with a nasal cannula connected to an oxygen concentrator set at 3 liters. However, the comprehensive care plan, revised shortly before the survey, lacked any mention of the resident's oxygen use, respiratory status, or necessary interventions. The care plan did not include problems, goals, or interventions related to oxygen use, nor did it provide guidance on oxygen saturation levels, flow rates, precautions, or equipment management. This deficiency was noted as a repeated failure from the time of the resident's admission to the date of the survey.
Failure to Update Care Plans for Fall Prevention and Gait Belt Usage
Penalty
Summary
The facility failed to review and revise the individualized care plans for two residents, leading to deficiencies in their care. Resident #10 experienced a fall on 11/30/23, resulting in head pain. The facility did not identify the root cause of the fall, and the care plan was not updated to address the risk of nighttime falls or toileting needs until 7/8/24. Staff member F admitted to not reviewing or updating the care plan after the fall, indicating a lack of oversight and stability in the care planning process. Resident #4, who has multiple sclerosis, requested the use of gait belts to hold her legs together while in a wheelchair due to muscle weakness. However, the care plan did not address the use of these gait belts, nor did it include a restraint assessment or guidelines for their use. Staff member I confirmed that the application of the gait belts was not documented in the care plan. The facility's policy requires comprehensive care plans to be periodically reviewed and revised, but this was not done for resident #4, resulting in a lack of documented interventions and assessments related to the gait belt usage.
Incomplete POLST Forms for Residents
Penalty
Summary
The facility failed to ensure that Provider Orders for Life-Sustaining Treatment (POLST) forms were properly completed for three residents. For one resident, the POLST form was not dated when signed by the resident's legal decision maker. Another resident's POLST form lacked the printed name, telephone number, and dates indicating when the form was prepared and signed. Similarly, a third resident's POLST form was missing the printed name, telephone number, and dates showing when the form was prepared and completed by the medical provider. Interviews with staff revealed a lack of oversight and process in ensuring POLST forms were completed. Staff member K, who was responsible for overseeing POLST forms and advance directives, admitted to not checking the forms when another staff member started filling them out. There was no established process to ensure the completion of POLST forms, and they were only discussed during individual resident care plan meetings. The facility's policy on advance directives indicated that residents should be informed of their rights to make medical decisions, but no specific POLST policy was provided during the survey.
Failure to Investigate and Resolve Resident Grievance on Strong Perfume Odor
Penalty
Summary
The facility failed to fully investigate and resolve a grievance reported by a resident regarding a strong perfume odor from a nurse, which was causing discomfort. The resident expressed concern about the potential impact on other residents with respiratory issues. This grievance was raised during a care planning meeting attended by staff members, but the resident did not receive any follow-up regarding the issue. Interviews with staff revealed that the facility had a policy against strong scents, allowing only lightly scented deodorant and laundry soap. Despite this policy, there was no written documentation of the grievance, and the issue was only addressed verbally. Staff members were unsure if any follow-up actions had been taken, indicating a failure to adhere to the facility's grievance policy, which requires prompt investigation and documentation of grievances.
Failure to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the monthly drug regimen review process was effectively used to identify and report irregularities in medication use for a resident. Specifically, the pharmacist did not recognize a problem with the continued use of Xanax, a psychotropic medication, beyond the recommended 14-day period without proper documentation from the attending physician. The facility's policy on psychotropic medication management requires that PRN orders for such drugs be used only for a diagnosed specific condition and for a limited duration unless the physician provides a documented clinical rationale for extending the order. However, in this case, the pharmacist incorrectly deemed the continued use of Xanax acceptable, stating that it was not an antipsychotic and thus could be used beyond 14 days. The deficiency was further highlighted during an interview with a staff member responsible for tracking psychotropic drug use and notifying physicians of medication irregularities. The staff member indicated that the resident was allowed to continue using Xanax as needed because the physician intended to make it a scheduled medication. However, there was no documentation from the physician to support this change, and the as-needed Xanax had been refilled five times without the necessary documentation. This oversight indicates a failure in the facility's process to ensure compliance with its own policies and procedures regarding psychotropic medication management.
Failure to Review or Discontinue PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as-needed psychotropic medication, Xanax, was reviewed or discontinued after 14 days for a resident. The resident's physician progress note indicated uncertainty about whether the resident had been using Xanax regularly or only as needed. Despite requests for medical provider documentation on the continued use of Xanax, no additional information was received by the end of the survey. The facility's policy on psychotropic medication management requires that PRN orders for psychotropic drugs be used only when necessary for a diagnosed condition and for a limited duration of 14 days unless extended with documented clinical rationale. However, the facility did not receive the necessary physician justification for the continued use of Xanax. Staff member D, responsible for tracking psychotropic drug use, noted that the physician documented notes in a different computer system than the one used by the extended care center, contributing to the lack of information.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide standard infection control practices by not ensuring that a resident received the recommended pneumococcal immunization. During interviews, it was revealed that the facility's pneumococcal policy was in the process of being updated, but the person responsible for this task had left the facility. Staff members were unclear about the exact process for maintaining immunization records, and it was noted that immunization status was only checked upon request. The facility had access to imMTrax for reviewing immunization statuses, but this was not routinely utilized. Resident #34's Preventive Health Care Report indicated that the resident was not current on her pneumococcal vaccination, having last received the PCV13 vaccine in 2018. According to CDC guidelines, the resident should have received a dose of PCV20 or PPSV23 at least one year after the PCV13 vaccine. The facility's policy required that residents or their legal representatives receive education about immunizations and have the opportunity to receive them unless contraindicated or refused. However, no documentation was provided for the resident's pneumococcal immunization consent or declination, indicating a lapse in following the facility's policy.
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 citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sidney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Lutheran Nursing & Rehabilitation Center | 39.4 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sidney Health Center Extended Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.