Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of O'neill during CMS and state inspections, most recent first.
The facility failed to carry out multiple provider orders for a resident with CKD, pulmonary issues, and an indwelling catheter, including ordered BMP testing and IV LR, and the resident later had a critically high creatinine and was sent to the ER. The facility also missed or delayed routine labs for other residents, including CBC, CMP, TSH, Vitamin D, and UA testing, with some orders not completed until days or months later.
A facility failed to manage ongoing weight loss for two residents. One resident with severe cognitive impairment, wandering behavior, and a mechanically altered diet lost significant weight, had a malnutrition score, and had no documented follow-up on RD recommendations or evidence that ordered supplements were consistently provided. Another resident with ESRD, DM, dementia, and dialysis had repeated weight loss, frequent refusal or unavailability for ordered supplements, no documented intake amounts, and no evidence that RD recommendations or fortified foods/drinks were implemented.
QAPI Program Failed to Sustain Monitoring of Prior Deficiencies: The facility failed to ensure its QAPI/QAA process effectively tracked previously cited deficient practices after the prior standard survey. The QAPI team discussed survey citations through the POC dates, but an RN was unsure whether concerns continued to be monitored, and the Administrator confirmed there was no long-range QAPI process to keep monitoring issues involving informed consent for psychotropic meds, quality of care, gradual dose reductions or contraindications for psychotropic meds/chemical restraints, drug storage, infection control, and antibiotic stewardship.
Incomplete informed consent for psychotropic meds was found for multiple residents. Records showed residents with diagnoses such as dementia, schizophrenia, anxiety, depression, bipolar disorder, PTSD, and brain dysfunction were receiving antipsychotic, antidepressant, and antianxiety meds, but the consent forms did not identify the specific diagnoses or symptoms being treated and often lacked potential effects, adverse effects, and alternative treatment options. One resident’s consent was undated and did not match current doses, and another resident had no evidence that consent was obtained before psychotropic meds were given.
Unsecured Medication Cart and Stock Medications: A medication cart was observed parked in a hallway unlocked and unattended while residents passed by, with multiple stock meds left on top of the cart, including Tylenol, Miralax, Colace, senna, iron, folic acid, loratadine, fish oil, and other meds. RN-K later confirmed that stock meds were kept on top of the cart during med pass and that the cart and meds were to be locked when not in the nurse's view.
Food was not stored, prepared, and served in a sanitary manner. Multiple prepared foods were kept past the facility’s 7-day limit in the walk-in cooler, the DM was observed preparing and serving food without a beard restraint, and kitchen surfaces including a window blind and wire shelf had heavy brown buildup near exposed food. The daily and weekly cleaning checklists were not completed for several months, and a trash can lid was observed leaning against clean pans.
Failure to Follow Hand Hygiene and EBP During Resident Care: Staff did not consistently perform hand hygiene or use required gowns and gloves during high-contact care for residents with indwelling catheters and a feeding tube. Surveyors observed an RN, LPN, nurse aides, and a bath aide providing care without full EBP PPE, including repositioning, catheter care, emptying a drainage bag, shower assistance, and feeding tube administration, despite EBP signs, supplies, and care plans requiring PPE.
Failure to Define Duration for Antibiotic Orders: The facility did not follow its Antibiotic Stewardship Plan for three residents whose antibiotic orders lacked a defined duration or stop/review date. One resident received Cephalexin for UTI prophylaxis, another received Trimethoprim for prophylaxis, and a third received Minocycline for osteomyelitis; MARs showed the medications were administered as ordered, and the DON confirmed the orders had no stop date.
A facility failed to report suspected neglect involving a resident with CKD stage 4, chronic lung disease, cognitive impairment, and DNR status after ordered BMP testing was not completed and 1 liter of LR was not given as scheduled. The missed lab and IV fluid were later identified, the BMP showed a critical high creatinine, and the resident was transferred to the ER, but the facility did not report the potential abuse/neglect, investigation, and findings to the State Agency as required.
A resident with an indwelling urinary catheter, MDRO, and other chronic conditions had catheter care that did not follow the care plan or facility policy. Staff repeatedly allowed the drainage bag and tubing to contact the floor in the resident’s room, hallways, dining room, and shower room, and during a shower the bag was placed on the floor and stepped on by a BA.
A resident with a history of TBI, Alzheimer’s dementia with agitation, depression, Bipolar Disorder, and Schizophrenia did not have an updated PASRR review after new SMI diagnoses were documented. Records showed the resident was receiving Risperidone for agitation/aggression related to Bipolar Disorder, Sertraline for depression, and Lorazepam for restlessness, while the SSD and RN consultant confirmed the PASRR was not reviewed to determine whether a Level 2 assessment was needed.
A resident with an indwelling Foley catheter and diagnoses including renal disease, anxiety, depression, psychotic disorder, and respiratory failure was ordered EBP, catheter care every shift, and Foley output monitoring every shift. The care plan documented the catheter and other resident needs, but EBP was not included, and the RN confirmed the resident was on EBP and that it was missing from the care plan.
Failure to Document Clinical Rationale for Denied GDRs: A resident with dementia, anxiety, psychotic disorder, schizophrenia, and PTSD was receiving Celexa and Lorazepam. The facility sent GDR requests for both psychotropic meds, but the provider denied them with “Keep Same,” and there was no resident-specific clinical rationale documented for the denied GDRs.
Failure to administer ordered vaccinations. A resident's guardian consented to influenza, pneumococcal, and Covid vaccines, and the MD ordered them, but the resident's immunization record showed the vaccines were not given. The DON confirmed the resident had not received the ordered immunizations.
Failure to document GDRs for antipsychotic medications. Two cognitively intact residents with no behaviors were receiving antipsychotics, including Loxapine and Abilify, for psychiatric diagnoses. One GDR request was denied without a resident-specific clinical rationale documented, and the other resident had repeated pharmacist recommendations for dose reduction that were not addressed in the record.
The facility failed to complete State Nurse Aide registry background checks for 2 of 5 sampled employees. Policy required screening for findings of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, but two newly hired workers had no evidence of registry checks in their files. The BOM confirmed the facility was not checking the Nurse Aide/Medication Aide Registry for negative findings for all new staff.
Facility staff failed to timely report an elopement to the State Agency as required by policy and state regulations. A resident with severe cognitive impairment, who required total assistance with toileting and extensive assistance with dressing and hygiene but could ambulate independently, opened a back door, exited into the parking lot, and triggered a door alarm. A NA first checked the front door, then the back door, and upon opening it observed the resident walking in the back parking lot and redirected the resident inside. Review of facility reporting records showed the incident was not reported within required timeframes, and the DON confirmed the elopement had not been reported as it should have been.
The facility did not follow its own Antibiotic Stewardship Program protocols, failing to track, document, or review antibiotic use and related laboratory data. The Infection Preventionist confirmed that there was no identification or analysis of organisms to determine if antibiotic prescribing met established criteria, potentially affecting all residents.
Several residents did not receive timely lab work, prescribed medications, or required treatments due to delays, lack of documentation, and failure to follow physician orders. There were also failures to monitor fluid restrictions, administer eye drops and compression garments, and complete weekly wound assessments, with staff and the DON confirming these deficiencies.
Staff did not consistently follow individualized care plans and facility policies for safe transfers and fall prevention. For example, a resident with hemiplegia was not always assisted by two staff during mechanical lift transfers, and several residents at high risk for falls did not have required interventions such as alarms, stop signs, or body pillows in place. Additionally, new interventions were not developed after repeated falls, and some residents were not laid down after meals as care planned. These actions and inactions resulted in an unsafe environment and failure to prevent accidents.
The facility did not ensure that GDRs for psychotropic medications were addressed in a timely manner or that clinical rationales for not attempting GDRs were documented. For three residents with histories of mental illness or depression, the consultant pharmacist made repeated recommendations for GDRs, but prescribers either declined without providing clinical justification or did not address the recommendations, and the required documentation was missing.
Multi-dose insulin pens for several residents with diabetes were not dated when first opened, as required by facility policy and professional standards. During a medication cart observation, it was found that insulin pens lacked opening dates, and both an LPN and the DON confirmed that insulin should be dated to prevent use beyond 28 days. This deficiency affected multiple residents receiving scheduled and sliding scale insulin.
Surveyors observed staff failing to perform proper hand hygiene, use required PPE during high-contact care for residents on Enhanced Barrier Precautions, and clean shared equipment such as mechanical lifts between uses. These deficiencies were noted during care for residents with incontinence, MDRO history, wounds, and indwelling devices, with staff often not following facility policies for infection prevention.
A resident with an indwelling catheter and multiple medical conditions was repeatedly observed with their catheter drainage bag uncovered and visible from the hallway, contrary to facility policy requiring privacy bags. The DON confirmed that dignity bags should have been used for all residents with catheters, but this was not done in this case.
The facility did not notify practitioners when two residents experienced missed medications, non-compliance with fluid restrictions, and absence of prescribed compression garments. One resident did not receive an anticoagulant for several days without physician notification, while another exceeded fluid limits, missed steroid eye drops, and went without compression garments for an extended period, with delayed and incomplete communication to the physician.
The facility did not document clinical rationales for not attempting gradual dose reductions of psychotropic medications for a resident with serious mental illness, and also failed to limit and properly renew PRN antipsychotic medication orders for another resident with severe cognitive impairment, as required by policy and regulation.
A resident admitted with a stage II sacral pressure ulcer did not receive any wound care or treatment orders during their stay, despite clear documentation of the ulcer and its required care. The resident, who had multiple health issues, left the facility after reporting the lack of wound care. The DON confirmed that no treatment orders were obtained and no policy for pressure ulcer management was in place.
The facility failed to develop and implement a water management program, including a risk assessment and control measures/testing protocols, to address potential hazards. The administrator confirmed the absence of these measures, affecting all 34 residents.
The facility failed to maintain a system to identify repeat resident grievances and ensure sustainable resolutions. Recurring concerns such as cold food, untimely call light responses, and missing laundry were documented, but no evidence of corrective actions or sustained resolutions was found. Interviews confirmed that the facility had not come up with solutions or followed up with residents to ensure acceptable resolutions.
The facility failed to ensure proper accounting and documentation for medications awaiting destruction for eight residents. An observation revealed a locked cabinet with a large quantity of medications without any record keeping. The DON confirmed the absence of required documentation, putting the medications at risk of potential loss or theft.
The facility failed to maintain food service equipment cleanliness, allowed outdated food to be available for consumption, and did not ensure staff adhered to safe handling of ready-to-eat food. Observations included a nurse aide handling food with bare hands and significant cleanliness issues in the kitchen, including a grease-coated stove and overdue fire suppression system inspection.
A resident was transferred to the hospital after a fall, but the facility failed to provide the required written bed hold notification to the resident or their representative. The DON confirmed the notification was not given as per policy.
The facility failed to complete a PASARR for two residents after they were diagnosed with serious mental disorders and received antipsychotic medications. This was confirmed through medical records and staff interviews.
Failure to Carry Out Ordered Treatments and Diagnostic Testing
Penalty
Summary
The facility failed to implement physician orders for multiple residents, including orders for laboratory testing, medications, oxygen, IV fluids, and urology follow-up. The report states that the facility’s policy required residents to receive treatment and care in accordance with professional standards, care plans, and resident choices, but several ordered interventions were not completed or were delayed. For one resident with chronic kidney disease, pulmonary hypertension, weakness, and chronic lung disease, the record showed multiple missed or delayed orders after hospital discharge and subsequent provider visits. The resident had worsening respiratory status, was transferred to the hospital for low oxygen saturation, later returned with an indwelling catheter and oxygen needs, and then had orders for oxygen, discontinuation of Lasix and potassium, a BMP, and IV LR. The BMP and IV fluid order were not entered into the computer by an agency nurse, and the ordered BMP and IV fluids were not completed as directed. The resident later had a critically high creatinine and was transferred to the ER. The report also noted that the resident’s catheter was removed and reinserted during the course of care, and that the facility identified the missed IV fluid order only after the follow-up appointment. For another resident, the facility did not complete ordered routine labs for CBC, CMP, TSH, and Vitamin D that were to be drawn every 6 months. The record showed the CBC was drawn on one occasion, but there was no evidence the other ordered labs were completed when due in September or March. For a different resident with heart failure, MDRO, anxiety, and depression, a CMP and CBC ordered months earlier were not drawn until several months later, despite the consultant pharmacist identifying the missed labs and the PCP being notified. For a fourth resident, a UA ordered for altered mental status was not collected within the expected timeframe, and the UA results were delayed; the resident later received Levaquin for UTI, and the record showed the UA should have been completed within 48 hours but was not collected until 8 days after the order was received.
Failure to Provide and Monitor Nutritional Supplements for Residents With Weight Loss
Penalty
Summary
The facility failed to implement nutrition measures to maintain the health of residents with ongoing weight loss. For Resident 14, the record showed severe cognitive impairment, wandering behavior, dependence for most activities of daily living, and a mechanically altered diet with thickened liquids. The resident’s weights showed progressive loss from 142.3 pounds on admission to 120.4 pounds 176 days later, and a Mini Nutritional Assessment score of 7 indicated malnutrition. The record also showed no documented nutritional interventions in the assessment, no evidence that the significant weight loss was evaluated, and no follow-up documentation from the RD, Dietary Manager, or Nursing Department regarding the ongoing weight loss or the effectiveness of supplements. Resident 14’s RD note recommended Ensure 4 ounces daily after identifying significant weight loss, but the MARs reflected only Magic Cup twice daily, with no documentation that Ensure was actually ordered or provided. Observations on multiple days showed the resident wandering in and out of the dining room, being redirected by staff, eating meals, and no observed Magic Cup or Ensure being served or present in the resident’s room. Interviews with nursing and dietary staff confirmed the Magic Cup was the only supplement being used, that dietary staff were responsible for administering it, and that the facility was unaware of the RD recommendation for Ensure and had not implemented interventions when the resident’s weight loss was identified. For Resident 1, the record showed end stage renal disease, diabetes, non-Alzheimer’s dementia, dialysis three times weekly, assistance needed with eating and drinking, and documented weight loss of 5% or more in one month and 10% or more in six months. The care plan identified risk for altered nutrition and included fortified food/drink at meals, monitoring intake, and weight monitoring. The RD recommended Glucerna twice daily until weight stabilized, but the MARs showed the supplement was frequently refused or the resident was unavailable, with no documentation of how much was consumed when it was given. The record also showed no evidence the RD assessed the resident for extended periods, a later RD note documented significant weight loss and recommended discontinuing Glucerna and starting a different supplement, and the facility continued to document Glucerna on the MAR without evidence that the new recommendation was implemented or that fortified food/drinks were actually being provided.
QAPI Program Failed to Sustain Monitoring of Prior Deficiencies
Penalty
Summary
The facility failed to ensure its QAPI plan was effective in addressing recently identified deficient practice and preventing repeat deficient practice with similar concerns. The facility policy for QAPI/QAA, dated 5/23/23, described a process for identifying and correcting deficiencies through continuous attention to quality of care, quality of life, and resident safety, with the Administrator and DON designated to oversee the program. The policy also stated that opportunities for improvement were to be identified through survey results, complaint investigations, self-reports, clinical care concerns, medication errors, hospitalizations, resident satisfaction, quality measures, and adverse events. Review of the most recent standard survey dated 5/6/25 showed citations for resident rights, changes in resident conditions, restraints involving chemical/psychotropic medications, quality of care, medication storage, infection control, and antibiotic stewardship. During interview, RN-K stated the QAPI team discussed prior survey citations through the POC dates and any further concerns identified, but was unsure whether those concerns continued to be monitored. The Administrator later confirmed the facility had not used a long-range QAPI process to ensure the deficient practices identified on the prior standard survey continued to be monitored through the QAPI program, and confirmed that concerns related to informed consent for psychotropic medications, quality of care, gradual dose reductions or documented contraindications for psychotropic medications/chemical restraints, drug storage, infection control, and antibiotic stewardship remained.
Incomplete Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain comprehensive informed consent for psychotropic medications for Residents 2, 3, 4, 14, and 29. The report states that the facility’s resident rights policy required residents to be fully informed, and the psychotropic medication policy required residents, families, and/or representatives to be informed in advance of the risks and benefits, black box warnings, and treatment alternatives before a psychotropic medication was initiated or increased. During interview, the DON confirmed the facility consents were not comprehensive and did not include the symptoms and/or diagnoses being treated, potential effects, potential adverse effects, or alternate non-pharmacological treatment options. Resident 29’s record showed diagnoses including Alzheimer’s dementia, anxiety, depression, and a psychotic disorder, and the resident received Seroquel and Lexapro. The informed consent form listed those medications, but it did not identify the diagnoses or symptoms being treated and did not include potential effects, adverse effects, or alternate treatment options. Resident 4 was cognitively intact, had no behaviors, and received Abilify, Lexapro, and Klonopin for diagnoses including heart failure, MDRO, anxiety, and depression; however, the consent form was undated, did not match the current dosages, and did not identify the diagnoses or symptoms, potential effects, adverse effects, or alternate options. Resident 2 was cognitively intact, had delusional behaviors, and received Haldol, Seroquel, Venlafaxine, Klonopin, and Ativan for diagnoses including non-traumatic brain dysfunction, anxiety, bipolar disorder, and schizophrenia, but the consent form did not document the diagnoses, side effects, or alternative non-pharmacological treatment options. Resident 3 was cognitively intact, had no behaviors, and received Celexa, Lorazepam, and Loxapine for dementia, anxiety, psychotic disorder, schizophrenia, and PTSD, but the consent form lacked the diagnoses, side effects, and alternatives. Resident 14 had severe cognitive impairment, rejection of care, wandering, and other behaviors, and received Buspirone, Mirtazapine, and Olanzapine for schizophrenia, depression, and anxiety; the medical record contained no evidence that informed consent for psychotropic medications was obtained before administration.
Unsecured Medication Cart and Stock Medications
Penalty
Summary
The facility failed to provide safe storage of drugs and biologicals by leaving medications on top of a medication cart and leaving the cart unlocked and unattended. The facility policy stated that medication and biologicals were to be stored safely, securely, and properly, and that medication rooms, carts, and medication supplies were to be locked when not attended by authorized personnel. On 6/3/26 at 8:00 AM, the medication cart was observed parked in the hall by the activity room door, unlocked and unsupervised, while residents were ambulating or pushing wheelchairs past it. Multiple stock medications were left on top of the cart, including Preservision, iron, multivitamin, folic acid, senna, Colace, Aleve, loratadine, fish oil, Tylenol 325 mg, Tylenol 650 mg, half a bottle of Miralax, and acetaminophen 500 mg. At 8:15 AM, the cart remained unlocked and unattended with the medications still on top for 15 minutes until RN-K approached to administer medications. At 8:45 AM, RN-K confirmed that stock medications were kept on top of the medication cart during the medication pass, and later confirmed that medications and the cart were to be locked when not in the nurse's view.
Food Storage, Hair Restraint, and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, and served in a manner to prevent cross contamination and food borne illness. During the kitchen tour, multiple prepared food items were found in the walk-in refrigerator past the facility’s 7-day limit, including chicken salad dated 5/16/26, tuna salad dated 5/19/26, lemon meringue pudding dated 5/20/26, and banana pudding dated 5/24/26. Facility policy required leftover food to be used within 7 days or discarded, and refrigerated foods to be covered, labeled, dated, and monitored for safe use dates. The facility also had cleaning schedules for food service areas, but the daily and weekly cleaning checklists had not been completed for March, April, May, and June 2026. During observations, the Dietary Manager was preparing sandwiches and later a lettuce salad without a beard restraint, and again was observed without a beard restraint while serving breakfast. A window blind across from the grill area had a thick layer of brown particles while hamburgers were being cooked, and a silver-colored wire shelf above open bread, peanut butter, lettuce, and tomatoes was also covered with a thick layer of brown particles. On follow-up observation, a large trash can lid was leaning against clean pans. The Dietary Manager confirmed leftover foods were to be discarded after 7 days and that the cleaning checklists had not been completed, and the Administrator confirmed dietary staff were to wear hair restraints including beard and mustache restraints and that the trash can lid should not be touching clean items.
Failure to Follow Hand Hygiene and EBP During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program, including hand hygiene and Enhanced Barrier Precautions (EBP), during resident care. The report states that the facility’s policies required proper hand hygiene and the use of gowns and gloves for residents on EBP during high-contact care activities, including care involving indwelling devices and feeding tubes. Surveyors observed multiple instances where staff did not follow these requirements during direct care for residents with catheters, a feeding tube, and other conditions requiring EBP. For one resident with an indwelling urinary catheter and a care plan directing EBP during catheter care, a nurse aide and an RN repositioned the resident and checked skin under an incontinence brief while wearing gloves but no gowns. The resident also had a catheter and drainage bag secured to the leg, and a sign on the door indicated EBP. During interview, the nurse aide confirmed awareness that gowns were required for high-contact care but stated a gown was not worn and that staff were rarely monitored to ensure gown use. An RN later confirmed staff were to wear both gown and gloves during catheter and other high-contact care for this resident. For another resident with a feeding tube and care plan requiring EBP during tube-related care, surveyors observed an LPN perform hand hygiene and glove use but no gown while administering nutrition, water, and medications through the feeding tube. The LPN’s clothing touched the resident’s bed linens throughout the treatment. The resident’s room had EBP signage and PPE supplies available. A consultant RN confirmed the resident was supposed to be on EBP and that PPE should have been worn during feeding tube care. Additional observations showed similar failures for other residents with indwelling catheters. One resident’s catheter care and emptying of the drainage bag were performed by a nurse aide who used gloves and hand hygiene but did not wear a gown, despite EBP signage and a care plan requiring PPE for catheter care. Another resident with an indwelling catheter and MDRO history was assisted by a bath aide who did not perform hand hygiene before care and did not wear gloves or an isolation gown while positioning the resident, handling the catheter drainage bag, removing clothing and an incontinence brief, and preparing the resident for a shower. The bath aide later confirmed the resident was to be on EBP and acknowledged not using the required PPE or hand hygiene as observed.
Failure to Define Duration for Antibiotic Orders
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Plan to ensure antibiotics had a defined duration of use for Residents 28, 29, and 48. The plan stated that antibiotic use was to be optimized by ensuring residents who required antibiotics were prescribed the appropriate antibiotic, with correct indication, dose, and duration, and that surveillance, monitoring, and preventative measures were included to improve outcomes and reduce adverse effects from unnecessary or inappropriate antibiotic use. Resident 29’s MDS showed antibiotic use, and the resident was frequently incontinent of bladder, involuntary of bowel, and dependent for toileting hygiene. The resident’s order summary showed Cephalexin 500 mg daily for UTI prophylaxis started on 4/29/26, but there was no defined duration or scheduled review date, and the MAR showed the medication was administered daily. Resident 28’s order summary showed Trimethoprim 100 mg daily for prophylaxis initiated 9/3/25 with no defined duration, and the MAR showed daily administration. Resident 48’s order summary showed Minocycline Hydrochloride 100 mg by mouth twice daily for osteomyelitis initiated 6/1/26 with no defined duration, and the MAR showed the medication was administered as ordered. Care plans for Residents 28 and 29 did not show evidence of treatment for an active infection, and Resident 48’s care plan identified Alzheimer’s disease with no evidence found that the resident was being treated for an active infection. The DON confirmed that Resident 29’s Cephalexin and Resident 28’s Trimethoprim were prophylactic antibiotics and that Resident 48 received Minocycline Hydrochloride for osteomyelitis, but there was no stop date for the antibiotics.
Failure to Report Suspected Neglect Involving Missed Lab Work and IV Fluids
Penalty
Summary
The facility failed to report suspected neglect involving a resident who had severe chronic kidney disease stage 4, chronic lung disease, cognitive impairment, and a do-not-resuscitate status. The resident had physician orders on 1/14/26 to stop Lasix and Potassium Chloride and to obtain a BMP in 2 days. After the resident returned from a urology appointment on 1/16/26, there was no evidence the ordered BMP had been completed at the facility or the urology clinic, and the resident also had not received 1 liter of LR that had been ordered on 1/14/26 and scheduled for 1/15/26. On 1/21/26, the facility identified that the BMP had not been obtained and that the IV fluid had not been given. Later that day, the BMP results were reviewed by the physician and showed a critical high creatinine of 6.1, and the resident was transferred to the ER. The facility’s records showed no report to the State Agency about the missed lab work or IV fluids, and the Administrator confirmed the facility investigated the issue after it was identified but did not report the potential abuse/neglect, investigation, and findings to the State Agency as required.
Improper Catheter Drainage Bag Positioning
Penalty
Summary
The facility failed to provide appropriate care and services for the management of a resident’s indwelling urinary catheter to prevent the potential for infections. The resident had diagnoses including heart failure, MDRO, anxiety, high blood pressure, and depression, and the care plan directed catheter changes as ordered, monitoring for UTI signs, and catheter care twice daily. Facility policy stated the goal of preventing UTIs and maintaining proper functioning of the urinary drainage system. Observations showed the resident’s catheter drainage bag and tubing were repeatedly positioned inappropriately. The drainage bag was observed hanging from a brace underneath the wheelchair seat, with the tubing and bag in direct contact with the floor in the resident’s room, corridors, and dining room. During a shower, the drainage bag was placed directly on the shower room floor and was stepped on by the bath aide while the resident was being assisted. The bath aide confirmed the drainage bag and tubing should not have been in direct contact with the floor in the room, shower room, corridors, or dining room.
Failure to Update PASRR After New SMI Diagnoses
Penalty
Summary
The facility failed to complete an updated PASRR review for a resident after the resident was diagnosed with Bipolar Disorder and Schizophrenia. The resident’s Level 1 PASARR screen dated 1/29/25 showed trouble concentrating, persistence and pacing with serious difficulty maintaining sustained focus or attention, and also noted a diagnosis of Dementia/Neurocognitive Disorder, Alzheimer’s Disease, or an Organic Disorder, but it did not indicate signs of SMI, DD, or RC. The resident’s care plan, revised 2/5/25, documented a traumatic response to seeing self in the mirror, a history of TBI, Alzheimer’s Dementia with agitation, Depression, Bipolar Disorder, and Schizophrenia, yet there was no evidence of a PASARR Level 2 screen. Additional records showed that a note to the attending physician/prescriber for the resident requested a diagnosis for Risperdal and documented Schizophrenia with agitation/aggression associated with Schizophrenia and/or Bipolar Mania, and a later note documented Bipolar Disorder, agitation/aggression associated with Schizophrenia or Bipolar Mania, and a Delusional Disorder. The MAR for June 2026 showed the resident receiving Risperidone for agitation and aggression related to Bipolar Disorder, Sertraline for depression, and Lorazepam for restlessness. During interview, the SSD confirmed the PASARR was not reviewed when the resident was diagnosed with Schizophrenia and/or Bipolar Disorder to determine whether a Level 2 assessment was required, and the RN Consultant confirmed the facility did not have a written PASARR policy but should have completed a new assessment when those diagnoses were identified.
Failure to Include Enhanced Barrier Precautions in Care Plan
Penalty
Summary
The facility failed to develop, implement, review, and revise a comprehensive care plan for a resident's Enhanced Barrier Precautions (EBP). The resident's record showed the resident was admitted on an unspecified date, was cognitively intact, was independent with dressing, transfers, and hygiene, and was dependent with toileting. The resident also had an indwelling catheter and diagnoses of renal disease, anxiety, depression, psychotic disorder, and respiratory failure. The resident's active orders included monthly Foley catheter changes, EBP due to the indwelling Foley catheter, catheter care every shift, and monitoring of Foley output every shift. The care plan last revised on 4/2/26 documented the indwelling catheter and several functional and psychiatric diagnoses, but there was no evidence that EBP had been included in the care plan. During interview, the RN confirmed the resident had an indwelling catheter, was on EBP, and that EBP was not included in the resident's care plan.
Failure to Document Clinical Rationale for Denied GDRs
Penalty
Summary
The facility failed to complete gradual dose reductions, or document resident-specific clinical contraindications, for a resident receiving psychotropic medications. Review of the facility policy on psychotropic medications stated that residents who use psychotropic medications would receive gradual dose reductions unless clinically contraindicated. Resident 3’s MDS dated 4/30/26 showed diagnoses including dementia, anxiety, psychotic disorder, schizophrenia, and post-traumatic stress disorder, and indicated the resident received antipsychotic, antianxiety, and antidepressant medications. The care plan identified a mood disorder and psychotropic medication use related to anxiety, delusional disorder, and schizophrenia. Record review showed active orders for Celexa and Lorazepam. Faxed documentation dated 12/3/25 showed a gradual dose reduction request was sent to the provider for Celexa and another for Lorazepam, but both were denied with the notation “Keep Same.” There was no evidence that a resident-specific clinical rationale was documented for either denied gradual dose reduction. During interview on 6/4/26, the RN consultant confirmed the resident was receiving antidepressant and antianxiety medications and confirmed there was no evidence of a clinical rationale for the contraindicated gradual dose reduction.
Failure to Administer Ordered Vaccinations
Penalty
Summary
The facility failed to administer requested immunizations to Resident 14. The resident's guardian signed an acknowledgement of vaccination consent on 12/4/25 for the influenza vaccine, the pneumococcal vaccine, and the Covid vaccine, and the physician signed an order on 12/5/25 to administer Pneumovax, influenza, and Covid vaccines. Review of the resident's immunization record showed that the resident had not received the influenza, Pneumovax, or Covid vaccine. During an interview on 6/4/26 at 10:15 AM, the Director of Nursing confirmed that Resident 14 had not received the ordered vaccines.
Failure to Document GDRs for Antipsychotic Medications
Penalty
Summary
The facility failed to complete gradual dose reductions or document contraindications for antipsychotic medications for two residents. The cited deficiency was based on record review and interview and involved the use of psychotropic medications without documented resident-specific clinical rationale when dose reduction was not pursued. The facility policy stated that residents receiving psychotropic medications should receive gradual dose reductions unless clinically contraindicated. One resident was cognitively intact, had no behaviors, and was independent with dressing, toileting, and hygiene, yet received Loxapine for diagnoses including dementia, anxiety, psychotic disorder, schizophrenia, and PTSD. A GDR request for Loxapine was sent to the provider, but the provider denied it and there was no evidence of a resident-specific clinical rationale documenting the contraindication. Another resident was cognitively intact, had no behaviors, and received Abilify 1 mg daily for recurrent depressive disorder, mixed anxiety disorder, and mood disorder. The consultant pharmacist recommended a GDR to reach the minimum effective dose, but monthly medication reviews showed no response in the record and no evidence that the PCP addressed the recommendation.
Failure to Check State Nurse Aide Registry for New Employees
Penalty
Summary
The facility failed to ensure background checks through the State Nurse Aide registry were completed for 2 of 5 sampled employees. Review of the facility policy titled Vulnerable Adult showed the facility required background checks and verification of certification status for nursing assistants and stated it would not employ individuals with findings of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. However, review of employee files showed no evidence that Van Driver-U, hired 4/15/26, or Universal Worker-V, hired 4/29/26, had State Nurse Aide registry background checks completed at the time they were hired. During interview, the Business Office Manager confirmed the facility was not checking the Nurse Aide/Medication Aide Registry for negative findings for all newly employed staff.
Failure to Timely Report Resident Elopement to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an elopement to the State Agency as required by its reporting policy and state licensure regulations. The facility’s undated policy titled “Reporting requirements” states that whoever first identifies or is notified of a potential self-report event must immediately notify the DON and Administrator after ensuring safety, and that the Administrator or DON will then proceed with required notifications and investigations. Record review of the facility’s reports to the State Agency showed that the elopement incident involving one resident was not reported within the required timeframes. The resident involved had a BIMS score of 5 on the MDS, indicating severe cognitive impairment, required total assistance with toileting, and extensive assistance with dressing and hygiene, but could walk 150 feet independently. Progress notes documented that the resident opened the back door of the facility and went out into the parking lot; the door alarm sounded and the resident was redirected back into the facility. A nursing assistant reported hearing a door alarm, checking the front door and finding no one exiting, then checking the back door, which was closed, and upon opening it observed the resident walking in the back parking lot. In an interview, the DON confirmed that the facility had not reported this elopement to the State Agency and acknowledged that it should have been reported.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by its own policies and regulatory standards. Although the facility had established protocols and policies for antibiotic stewardship, including the use of infection screening evaluations, laboratory testing, and monitoring of antibiotic use, these were not followed in practice. A review of infection surveillance records for a one-year period revealed that there were no documented culture results, no data on pathogens, and no evidence of review to determine if antibiotic prescribing met established criteria. During an interview, the Infection Preventionist confirmed that the facility had not identified, tracked, or analyzed organisms found through laboratory testing to assess whether antibiotic use was appropriate or met treatment criteria. This lack of monitoring and documentation meant that the facility could not ensure antibiotics were being used according to best practices, as outlined in their own policies and procedures. The deficiency had the potential to affect all residents in the facility, which had a census of 45 at the time of the survey.
Failure to Provide Timely Care, Medication, and Monitoring per Physician Orders
Penalty
Summary
The facility failed to provide timely and appropriate treatment and care according to physician orders and residents' needs in several instances. For one resident, laboratory work was not obtained in a timely manner, with significant delays between the ordering and collection of blood and stool tests. Documentation was lacking regarding when orders were received, when labs were obtained, and when results were communicated to the provider. The DON confirmed that staff did not document refusals, collection, or notification of lab results as required by facility policy. In multiple cases, residents did not receive prescribed medications due to unavailability, and there was no evidence that the facility took appropriate steps to address the situation. One resident missed seven days of an anticoagulant medication, while another missed several days of blood pressure medication, aspirin, and electrolyte replacement. The facility did not document efforts to determine the cause of the unavailability, did not notify the physician, and did not monitor the residents for adverse effects during the period the medications were not administered. The DON confirmed these lapses and the absence of required documentation and follow-up. Additional deficiencies included failure to monitor and document a resident's fluid restriction, with intake exceeding the prescribed limit on multiple occasions and no evidence of physician notification or documentation of the reason for the restriction. Another resident did not receive prescribed eye drops or compression garments as ordered, with delays in obtaining the necessary supplies and lack of timely physician notification. Furthermore, a resident with a pressure injury did not have weekly wound assessments or documentation as required by facility policy. These failures were confirmed through interviews and record reviews.
Failure to Implement and Monitor Fall Prevention and Safe Transfer Interventions
Penalty
Summary
Staff failed to utilize safe transfer techniques and follow individualized care plans for multiple residents, resulting in an unsafe environment. For one resident with left-sided hemiplegia and a history of stroke, staff did not consistently use two staff members during mechanical lift transfers as required by the care plan and facility policy. Observations showed that the resident's left arm was not properly supported during transfers, and staff confirmed that two-person assistance was not always provided, despite education on this requirement. Several residents at risk for falls did not have their care plan interventions implemented or revised as needed. One resident with severe cognitive impairment and contractures had a mesh stop sign and body pillow ordered as fall interventions, but these were repeatedly not in place during observations. The DON confirmed that these interventions were not consistently implemented after falls. Another resident with dementia and a history of falls was left unattended in their wheelchair without required alarms in place, and staff confirmed that the resident was sometimes left alone despite care plan instructions. Additional deficiencies included a resident who was to be laid down after meals as a fall prevention measure, but this was not consistently done within the expected timeframe. Another resident with a history of falls and high fall risk did not have new interventions implemented after multiple falls, despite care plan reviews and incident reports. These failures to implement, monitor, and revise fall prevention interventions and safe transfer practices directly contributed to the facility's noncompliance with accident prevention requirements.
Failure to Document Clinical Rationale for Not Attempting Gradual Dose Reductions
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were addressed in a timely manner and that clinical rationales for not attempting GDRs were documented, as required by policy. For one resident with a history of serious mental illness, including anxiety, bipolar disorder, and schizophrenia, the record showed ongoing administration of anti-psychotic, anti-depressant, and anti-anxiety medications. Although a GDR for Venlafaxine was marked as contraindicated by the prescriber, there was no documented clinical rationale provided for this decision. Another resident, admitted with diagnoses including stroke, high blood pressure, seizure disorder, and depression, was receiving daily antidepressant medications. The consultant pharmacist made multiple recommendations over several months for GDRs of Prozac and Trazadone. While the physician declined the GDRs, there was no evidence that a clinical rationale was documented to explain why the reductions were not clinically appropriate. Eventually, only the Trazadone dose was reduced, with no documentation regarding the Prozac. A third resident, with diagnoses of debility, heart failure, previous stroke, depression, and anemia, was also receiving daily antianxiety and antidepressant medications. The consultant pharmacist repeatedly recommended GDRs for Buspar and Remeron, but the prescriber did not order dose reductions and failed to provide a clinical rationale for not doing so. Interviews with the DON confirmed the absence of required documentation for all three residents, despite multiple pharmacist recommendations and follow-up communications.
Failure to Date Opened Insulin Pens for Multiple Residents
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens for four residents were dated when first opened, as required by both facility policy and professional standards. During an observation of the medication carts, it was found that insulin pens for these residents did not have dates indicating when they had been accessed. The facility's policies specify that all multi-use vials must be dated upon first use and discarded within 28 days unless otherwise specified by the manufacturer. Record reviews confirmed that these residents had orders for various types of insulin, including Glargine, Novolog, and Insulin Aspart, administered on scheduled and sliding scale regimens for diabetes management. Interviews with an LPN and the Director of Nursing confirmed that insulin is required to be dated when opened to prevent use beyond the recommended period. The lack of dating on the insulin pens meant there was no way to ensure the insulin was not being used past the effective date, which is contrary to both facility policy and accepted professional practice. The facility census at the time was 45, and six residents were identified as receiving insulin injections.
Infection Control Deficiencies: Hand Hygiene, PPE, and Equipment Cleaning
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices, specifically related to hand hygiene, use of personal protective equipment (PPE), and cleaning/disinfection of shared equipment. Staff were observed failing to perform hand hygiene at critical points, such as before donning gloves, after removing soiled gloves, and between resident contacts. In several instances, staff did not provide complete perineal care to residents who were incontinent, and failed to change gloves or perform hand hygiene when required by facility policy. For example, during care for a resident with cancer, dementia, and incontinence, staff did not wash hands before or after glove use, did not provide full perineal hygiene, and did not disinfect the mechanical lift after use. The report also documents failures in the use of Enhanced Barrier Precautions (EBP) for residents with a history of multidrug-resistant organisms (MDROs), wounds, or indwelling medical devices. Staff did not consistently wear required PPE, such as gowns and gloves, during high-contact care activities for residents on EBP. In one case, a medication aide assisted a resident with a history of MRSA with toileting and perineal care without wearing a gown and failed to change gloves or perform hand hygiene at appropriate intervals. Another instance involved a nurse not removing PPE before exiting a resident's room and placing potentially contaminated items on the medication cart without a barrier or cleaning. Additionally, the facility failed to clean and disinfect mechanical lifts between resident uses, as required by policy. Multiple staff members confirmed during interviews that lifts were not cleaned after transferring residents, including those with cognitive impairments and those dependent on staff for mobility. These lapses in infection control practices were observed across several residents and staff, indicating a systemic failure to adhere to established protocols designed to prevent cross-contamination and the spread of infection within the facility.
Failure to Use Privacy Bag for Catheter Compromises Resident Dignity
Penalty
Summary
Staff failed to ensure the use of a privacy bag for a resident's catheter drainage bag, as required by facility policy. Multiple observations over several days showed the resident's catheter bag hanging on their walker without a privacy cover, making it visible from the hallway. This occurred both when the resident was in bed and when the catheter bag was attached to the walker, with no privacy bag in use during any of the observed times. The resident involved had an indwelling catheter due to neurogenic bladder and other medical conditions, including renal disease, anxiety, depression, and schizophrenia. The resident's care plan specified that the catheter bag and tubing should be kept below the bladder and away from the entrance room door, but did not address the use of a privacy bag. Interviews with the DON confirmed that dignity bags were expected to be used for all residents with catheters, but this was not done for this resident.
Failure to Notify Practitioners of Missed Medications and Non-Compliance with Care Orders
Penalty
Summary
The facility failed to notify practitioners regarding significant changes and issues affecting two residents. For one resident with severe cognitive impairment and multiple diagnoses including cancer, atrial fibrillation, and malnutrition, the facility did not administer a prescribed anticoagulant (Xarelto) for seven consecutive days. Despite the facility's policy requiring physician notification when medications are unavailable or missed, the resident's practitioner was not informed of the missed doses. Another resident, who had orders for fluid restriction, steroid eye drops post-cataract surgery, and thigh-high compression garments, experienced multiple lapses in care. The facility did not notify the physician when the resident repeatedly exceeded fluid intake limits, missed multiple doses of prescribed eye drops, and went without compression garments for over a month while waiting for a larger size. Although the physician was eventually notified of increased edema and the absence of compression garments, this notification was delayed, and there was no documented follow-up with the physician after the initial contact.
Failure to Document GDR Rationale and Limit PRN Antipsychotic Orders
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were properly documented with a clinical rationale when not attempted for a resident with serious mental illness. Specifically, a resident with diagnoses of anxiety, bipolar disorder, and schizophrenia was receiving multiple psychotropic medications, including Haloperidol, Quetiapine, Clonazepam, and Lorazepam. Although GDRs for these medications were marked as contraindicated in communications with the prescribing provider, there was no documented clinical rationale in the resident's medical record explaining why dose reductions were not attempted. Additionally, the facility did not comply with requirements for limiting as-needed (PRN) antipsychotic medication orders to 14 days for another resident with severe cognitive impairment and diagnoses including Alzheimer's disease, dementia, anxiety, and depression. The resident was receiving a PRN antipsychotic combination (ABH gel) for agitation and restlessness, with the order in place and administered intermittently over several months. Despite repeated recommendations from the consultant pharmacist to add a stop date and renew the order every 14 days, the facility continued to administer the medication without proper renewal or documentation of appropriateness by the prescribing practitioner. Interviews with the Director of Nursing confirmed the lack of required documentation for both the clinical rationale for not attempting GDRs and the failure to renew PRN antipsychotic orders as mandated. These actions were inconsistent with the facility's own policy and regulatory requirements regarding the use and management of psychotropic medications.
Failure to Provide Pressure Ulcer Treatment Upon Admission
Penalty
Summary
Facility staff failed to obtain and provide pressure ulcer treatment for a resident who was admitted from the hospital with a stage II pressure ulcer to the sacral region. Upon admission, the resident's medical record and skin assessment documented the presence of a 3.5 cm by 2.8 cm pressure ulcer with a depth of 1.5 cm, and the hospital discharge summary indicated the need for dressing changes 1-2 times daily. Despite these findings, there was no evidence in the electronic medical record from admission through discharge that any treatment was ordered or completed for the pressure ulcer. The resident, who had diagnoses including chronic pain, adult failure to thrive, malnutrition, and alcohol use, reported to staff that the wound was not being treated or assessed. The resident subsequently decided to leave the facility, citing the lack of wound care as the reason. An interview with the DON confirmed that no admission orders for wound care were obtained, staff did not contact the resident's physician for a treatment order, and the facility did not have a current policy for pressure ulcer care and management.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to develop and implement a water management program that included a risk assessment and control measures/testing protocols to address potential hazards. The facility's policy, dated 9/2022, indicated the need for a water management plan to reduce the risk of Legionella and other opportunistic pathogens in the water system. However, a review of the facility's water management program revealed no documentation of a risk assessment or implementation of control measures and testing protocols. During an interview, the administrator confirmed that no risk assessment had been completed and no control measures or testing protocols were in place to address potential hazards. This deficiency had the potential to affect all 34 residents in the facility.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain a system to identify repeat resident grievances and ensure sustainable resolutions of resident concerns. The facility's grievance policy stated that residents had the right to voice grievances without fear of reprisal and that the facility would ensure prompt resolution and keep residents informed throughout the process. However, a review of the Resident Council Meeting Minutes from March 2023 through April 2024 revealed recurring concerns such as cold food, untimely call light responses, missing laundry, and inadequate snack options. There was no evidence that the facility discussed old business or included what actions were taken to resolve previous concerns in subsequent meetings. The facility's grievance log from June 2023 through April 2024 showed multiple grievances related to call light response times, food options, snack cart availability, treatment and medication concerns, missing laundry items, and the availability of fresh water/ice. Despite these documented grievances, there was no evidence that the facility had implemented corrective actions or sustained resolutions to prevent repeat concerns. Interviews with Resident Council Representatives confirmed that the facility had not come up with solutions to grievances or followed up with residents to ensure the resolutions were acceptable. The facility Administrator confirmed that the facility had not implemented a grievance process that consistently identified repeat grievances or ensured sustainable resolutions. The facility also lacked evidence of presenting sustainable resolutions to the Resident Council to ensure the resolutions were acceptable to those involved in the grievance process. This failure to address and resolve resident grievances led to ongoing dissatisfaction and repeated concerns among the residents.
Failure to Document Medications Awaiting Destruction
Penalty
Summary
The facility failed to ensure proper accounting and documentation for medications awaiting destruction for eight residents. An observation of the medication storage room revealed a locked cabinet labeled 'destroyed medications' containing a large quantity of medications without any record keeping or accounting. The facility policy requires a Non-Controlled Medication Destruction Record to be maintained for all non-controlled drugs destroyed, verified by the consultant pharmacist, and include specific information such as the name and address of the facility, date medication destroyed, prescription number, name, strength, and quantity of the medication being destroyed, and signatures of persons witnessing the destruction. However, this documentation was missing for the medications of Residents 12, 138, 139, 140, 141, 142, 143, and 144. During an interview, the Director of Nurses (DON) confirmed the absence of documentation for the medications awaiting destruction, which included various medications such as Bisacodyl, Insulin Aspart, Insulin Lantus, Milk of Magnesia, Aloe Vesta, Maalox, Antacid-antigas, Lasix, Melatonin, Tylenol, Aspercreme, zinc oxide cream, Baza cream, Biofreeze gel, Desitin cream, Vaseline jelly, triamcinolone cream, Nystatin cream, Betamethasone cream, Nystatin powder, Gabapentin, and Omeprazole. The lack of required documentation put the residents' medications at risk of potential loss or theft, as there was no record of the residents' names, dates, medication names, dosages, and quantities of each medication.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food service equipment was cleaned and maintained, outdated food was not available for consumption, and staff adhered to safe handling of ready-to-eat food. During an observation, a nurse aide was seen handling a resident's toast and bacon with bare hands, which is against the facility's policy. Additionally, a large container of egg salad dated beyond the allowable three days was found in the walk-in refrigerator. The dietary aide confirmed that leftovers should be disposed of after three days, indicating a lapse in following the facility's food safety protocols. Further inspection revealed significant cleanliness issues in the kitchen. The stove/oven had a buildup of grease and grime, and the fire suppression system was overdue for inspection and cleaning. The piping above the stove was also coated with grease and debris. The facility lacked evidence of a cleaning schedule for food service equipment, and the cook confirmed that cleaning was done only when staff had time. The Corporate Certified Dietary Manager acknowledged these deficiencies, confirming that staff should not handle ready-to-eat food with bare hands and that the leftover egg salad should not have been available for consumption.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide Resident 35 or the resident's representative with the required bed hold notification when the resident was transferred to the hospital. The facility's policy mandates that written notice be given at the time of transfer, specifying the duration of the bed-hold policy and information about the resident's return. Resident 35 was transferred to the hospital after a fall, but there was no documented evidence that the resident or the resident's representative received the required written notification. The Director of Nurses confirmed that the notification was not provided as required by the facility's policy.
Failure to Complete PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was completed for two residents after they were diagnosed with serious mental disorders and received antipsychotic medications. Resident 22 was diagnosed with Post Traumatic Stress Disorder (PTSD) on 3/14/23 and had been taking an antipsychotic medication (Seroquel) since 2/13/24. Despite these significant changes, no new PASARR was completed for Resident 22. This was confirmed by both the Social Services Director and a Registered Nurse during interviews on 4/17/24. Similarly, Resident 24, who had diagnoses of anxiety disorder, depression, bipolar disorder, psychotic disorder, and Alzheimer's disease, was receiving antipsychotic and antidepressant medications. The resident's medical records indicated that they had been taking Quetiapine for bipolar disorder since 3/14/23. However, there was no documentation that a new PASARR had been completed following the new diagnosis of bipolar disorder. This oversight was confirmed by a Registered Nurse during interviews on 4/17/24.
What surveyors are citing around you — mapped
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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 16 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 O' Neill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Atkinson | 16.6 mi | ★★★★★ | 16 | 0 |
| Parkside Manor | 26.5 mi | ★★★★★ | 2 | 0 |
| Butte Senior Living | 32.4 mi | — | 0 | 0 |
| Alpine Village Retirement Center | 32.6 mi | ★★★★★ | 3 | 0 |
| Avera Creighton Care Centre | 37.7 mi | ★★★★★ | 7 | 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 October 2026) and official state health department websites.