Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Heritage Of Webster County during CMS and state inspections, most recent first.
Incomplete APS/CAN checks were found for 4 of 5 sampled staff, including an NA, a dietary aide, housekeeping staff, and a medication aide. HR confirmed the checks had been run for these employees but were not reviewed or printed before they began working, and one employee’s file only contained APS/CAN checks from prior employers rather than documentation for the current hire.
Nurse Aide Registry Checks were not completed before hire for 3 of 5 sampled staff. An NA was observed providing care, but the registry check was completed months after hire. A dietary aide and a housekeeping staff member were also observed in resident rooms, and their files did not contain the required registry checks. HR confirmed the checks were expected before staff began working.
Improper hand hygiene was observed during meal prep and service when a cook and a dietary aide completed soap-and-water handwashing for less than 20 seconds, failed to use a clean paper towel to shut off the sink, and did not perform hand hygiene after removing gloves while handling raw meat and ready-to-serve food items. Staff also transported soiled linens and dirty clothing through the hallway without placing them in a bag or covered container, creating cross-contamination concerns.
Surveyors identified that staff failed to properly date and discard glucometer testing supplies, did not follow manufacturer instructions for calibration and cleaning, and lacked adequate training in the use of CGM systems. Additionally, insulin was not always administered or withheld according to prescriber orders, and documentation was incomplete when deviations occurred. These deficiencies affected all diabetic residents, including those using CGMs and receiving insulin.
A deficiency was cited because required physician visits were not completed face-to-face by a physician for multiple residents. Records showed an APRN was listed as the attending or primary provider for residents, and visit forms, recertifications, admission documentation, and H&P notes were completed and signed by the APRN instead of a physician. Staff confirmed that physicians do not see the residents and that the APRN oversees care, orders, visits, and recertifications.
A licensed pharmacist did not complete required monthly MRRs, including chart review, for two residents receiving multiple medications. One resident had severe cognitive impairment and was on several routine medications, yet the pharmacist record showed multiple missed months of review. For another resident, the pharmacist record listed reviews during months when the resident was not even in the facility, and the ICC and DON confirmed the monthly reviews were not done as required.
Medication Error Rate Exceeded Allowed Threshold: The facility had an 18.5% medication error rate, with multiple insulin administration errors observed. An RN administered insulin pens without priming and did not hold the pens in place for the required number of seconds, while another insulin dose was given before a meal without a nutritive snack when the meal was delayed. Interviews showed the RN, ICC, and DON were not aware of the correct insulin pen technique, hold times, or the timing required for Fiasp in relation to meals.
A resident with severe cognitive impairment and dementia spilled hot coffee on themselves, resulting in a minor burn. Although the incident was documented and monitored, the DON confirmed that the required investigation report was not submitted to the state agency within the mandated timeframe.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The report highlights insufficient environmental safety measures and inadequate supervision protocols.
The facility did not notify the state agency within the required timeframe after hiring a new DON, as confirmed by interviews with the DON and Administrator. The Administrator acknowledged that the notification had not been completed, despite the new DON having started about a month earlier.
The facility failed to document a rationale for not completing a GDR for a resident receiving Quetiapine 25 mg daily for vascular dementia with behavioral disturbance. The resident had severe cognitive impairment on MDS, pharmacy recommended dose reduction, and the physician disagreed without documenting a rationale; the DON confirmed no rationale was provided.
The facility did not employ a qualified Infection Preventionist separate from the DON, who was serving in both roles without the necessary training. An LPN with the required training was not overseeing the infection control program, potentially affecting all 26 residents.
The facility failed to update care plans for residents, leading to deficiencies in addressing their needs. A resident with muscle weakness had an outdated care plan that did not reflect their inability to ambulate. Another resident, severely cognitively impaired, had no new interventions after a fall, and a cognitively intact resident's care plan lacked focus after sliding out of a recliner. The DON confirmed the care plans were not updated to reflect current needs.
The facility failed to involve a resident in their care plan development and did not address their high risk for elopement. Another resident's care plan was not updated to reflect hospice admission, and two other residents had care plans that did not address specific health issues. The DON confirmed these omissions, indicating a pattern of inadequate care plan updates.
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents, leading to potential cross-contamination. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for three residents with open wounds. Observations showed that gowns were not used, and staff were unaware of EBP. The Director of Nursing confirmed the lack of a policy for EBP and acknowledged the necessity of proper infection control measures.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents, informing them of charges for non-covered care items and services prior to a change in Medicare A coverage. Both residents were discharged from Medicare A services with benefit days remaining and continued to reside in the facility without receiving the required notice, as confirmed by the Director of Nursing.
A resident with hemiplegia and cognitive intactness was observed with a wheelchair strap they could not unfasten, indicating restraint use without evaluation. Interviews confirmed the resident's inability to remove the strap independently, and records lacked documentation of evaluation or consent. The facility's guidelines require such evaluations, but none were completed.
The facility failed to document weekly non-pressure wound assessments for two residents, affecting their care planning and monitoring. One resident had multiple leg wounds, while another had a buttock wound, both without recent measurements. The DON confirmed the lapse in documentation.
A resident with multiple health issues, including a Stage 3 pressure ulcer, did not receive documented weekly assessments as required by the facility's policy. The DON monitored wounds but failed to document them in the medical record, using Risk reports instead. This led to a deficiency in adhering to the facility's Skin and Wound Management Standard.
Incomplete APS/CAN Checks for Multiple Staff
Penalty
Summary
The facility failed to ensure Adult Protective Service/Child Abuse Neglect checks were completed prior to hire for 4 of 5 sampled staff, contrary to its policy that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property and that documentation of the screening will be maintained. Record review showed Nurse Aide-E had a hire date of 04/14/2025, but the employee file listed the APS/CAN check as incomplete. Human Resources confirmed that pre-employment background and registry checks were expected to be completed before staff started working in the facility, including APS/CAN checks, and stated that the checks had been run but not reviewed or printed for this employee. Similar findings were identified for a Dietary Aide, a Housekeeping staff member, and Medication Aide-G. The Dietary Aide and Housekeeping staff member each had APS/CAN checks labeled incomplete in their employee files, and HR again confirmed the checks had been run but not reviewed or printed. For Medication Aide-G, the employee file contained APS/CAN checks printed by previous employers before hire, but APS/CAN checks were not available and/or printed for the date of hire of 05/13/2025. A nursing schedule showed Medication Aide-G worked multiple dates in August 2025, and HR confirmed the APS/CAN checks were run but not printed for this employee.
Nurse Aide Registry Checks Not Completed Before Hire
Penalty
Summary
The facility failed to ensure that Nurse Aide Registry Checks were completed prior to hire for 3 of 5 sampled staff. Record review of the facility policy titled Abuse, Neglect and Exploitation showed that potential employees are to be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks are to be conducted with documentation maintained. During observation, Nurse Aide-E was seen exiting a resident's room, and record review showed a hire date of 04/14/2025. The employee file contained a Nurse Aide Registry Check dated 08/12/2025, which was completed almost 4 months after the staff member began working in the facility. Additional record review showed that a Dietary Aide entered and exited a resident's room delivering a meal, and the employee file did not contain a Nurse Aide Registry Check. A Housekeeping staff member was also observed entering and exiting a resident's room while cleaning, and that employee file likewise did not contain a Nurse Aide Registry Check. Human Resources confirmed that pre-employment background and registry checks were expected to be completed before staff started working in the facility, including Nurse Aide Registry Checks, and confirmed that the registry checks for these staff members were not completed as required.
Infection Control: Improper Hand Hygiene and Soiled Linen Handling
Penalty
Summary
The facility failed to utilize proper hand hygiene during meal preparation and service. During observations in the kitchen, a cook picked up a package of raw ground beef with a gloved hand, placed the meat into a container, removed the glove, and continued food preparation without performing hand hygiene. The cook was also observed completing hand hygiene with soap and water for 12 seconds and later for 10 seconds, and a Dietary Aide was observed completing hand hygiene for 15 seconds and 16 seconds. The Dietary Aide also turned off the sink using the paper towels used to dry hands rather than a clean paper towel. The cook was further observed using gloved hands to mix salad ingredients, removing the gloves, and then stirring meat on the stove and handling the salad bowl and foil without performing hand hygiene after glove removal. The facility also failed to transport clean and soiled linens in a manner to prevent cross contamination. One Medication Aide carried dirty bedding to the laundry area through the hallway in both arms without placing the linens in a bag or closed container, with the soiled linens against the aide's clothing. Another Medication Aide took dirty clothing from a resident's room to the spa room and placed it in a dirty linen hamper, but the items were not carried in a plastic bag or covered soiled linen container. The Infection Control Coordinator confirmed that soiled linens were expected to be placed in a bag before being carried down the hallway.
Deficient Glucose Monitoring and Insulin Administration Practices
Penalty
Summary
The facility failed to ensure proper management and use of glucometer testing supplies and continuous glucose monitoring (CGM) systems for residents with diabetes. Surveyors found that glucometer testing solutions and test strips were not dated when opened, and expired supplies were not discarded according to manufacturer instructions. Staff were observed using control solutions and test strips beyond the recommended 90-day period after opening, and the required dating of these items was not consistently performed. Additionally, staff did not follow proper procedures for mixing and applying control solutions during calibration, and cleaning protocols for testing equipment were not adhered to as specified by the manufacturer. Nursing staff lacked adequate training and competency in the use of CGM systems and glucometers. Interviews revealed that staff had only received brief, informal instruction on CGM use, without review of manufacturer guidelines or formal documentation of competency. There were no records of staff training or competency assessments related to insulin administration, insulin pens, CGM systems, or glucometer calibration. Staff demonstrated inconsistent understanding of when and how to calibrate CGMs with glucometer readings, and there was confusion regarding the frequency and documentation of calibration checks. The Infection Control Coordinator and the DON confirmed the absence of training records and acknowledged that staff were not following established protocols. The facility also failed to ensure that insulin was administered or withheld in accordance with prescriber orders for a resident with diabetes. Medical records showed that insulin was sometimes given when blood glucose levels were below the physician-ordered threshold, and documentation was lacking when insulin was administered outside of prescribed parameters. The DON confirmed that staff should have followed physician orders and documented rationale when deviations occurred. These deficiencies affected all residents with diabetes in the facility, including those using CGM systems and those receiving insulin therapy.
Physician Visits Completed by APRN Instead of Physician
Penalty
Summary
The facility failed to ensure that required physician visits were made face-to-face by a physician for 3 of 5 sampled residents. For Resident 5, the admission record listed an APRN as the attending physician, and multiple Physician Visit/Communication Forms documented visits completed by the APRN on 3/3/2025, 3/31/2025, 5/5/2025, 6/3/2025, 6/16/2025, and 8/4/2025. The hospital record prior to admission also showed the resident was seen by an APRN, who provided review of the resident, care coordination, and admission to the nursing facility. For Resident 6, the admission record also listed an APRN as the attending physician, and the Physician Visit/Communication Forms and office clinic notes for 60-day recertification visits on 7/1/2024, 10/7/2024, 12/09/2024, 2/10/2025, 4/14/2025, and 6/15/2025 were all signed as the Primary Care Physician by an APRN. For Resident 24, the clinical census and admission records listed an APRN as the admitting and primary physician. The admission History and Physical was written and signed by the APRN, and there was no admission note from a physician. The EMR did not show a 30-day visit by either a physician or an advanced practice provider, and it also did not show a 90-day visit after admission by either a physician or an advanced practice provider. The 60-day visit note dated 05/13/2025 showed the resident was seen by an APRN, and the later History and Physical dated 07/15/2025 was also completed by an APRN. The DON stated that Resident 5 and Resident 6 were not under the care of a physician and that the APRN oversaw and conducted care, orders, visits, and recertifications as the Primary Care Physician even though the APRN was not a licensed physician. The ICC also confirmed that physicians do not see the residents and that all 60-day visits are completed by the APRN.
Missing Monthly Pharmacist Medication Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly medication regimen reviews (MRRs), including review of the medical chart, for residents receiving medications. The facility policy stated that the consultant pharmacist was to review each resident’s medication regimen at least monthly and document irregularities, with written reports maintained in the medical record. Survey review found that the facility did not have monthly MRR data in the permanent EMR for Resident 13, and the consulting pharmacist’s records showed missing reviews for multiple months. Resident 13 was admitted to the facility and had severe cognitive impairment based on the MDS. The resident was receiving multiple medications, including routine antipsychotic, anti-anxiety, antidepressant, diuretic, antihypertensive, and anticonvulsant medications. The MAR showed active medication use since admission with additional medication orders added over time, including acetaminophen, gabapentin, hydrochlorothiazide, lisinopril, olanzapine, and Senna S. The consulting pharmacist’s record of medication regimen and chart review showed no review for August 2024 and September 2024, and no chart review for October 2024, January 2025, February 2025, March 2025, or April 2025. Resident 24’s record showed an admission, discharge on 11/22/2024, and then another admission. The consulting pharmacist’s record showed an MRR during months when the resident was not in the facility, specifically 12/2024 and 01/2025, and the ICC stated there was no explanation for why Resident 24 was listed as reviewed during those months. In interviews, both the ICC and DON confirmed that the pharmacist should have completed monthly medication regimen reviews and that this did not occur for Residents 13 and 24.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. Record review showed 5 medication errors out of 27 opportunities, for an actual error rate of 18.5 percent. The cited deficiency involved insulin administration practices observed with multiple residents and multiple nurses, along with interviews confirming that the observed practices did not match the manufacturers’ directions or the physician orders. For one resident, an RN administered Fiasp insulin by pen without priming the needle and did not keep the pen in place for the required 6 seconds. The RN later confirmed both omissions. For another resident, an RN administered HumaLOG KwikPen insulin without priming the pen needle and did not count to 5 seconds before removing the needle; the RN confirmed this during interview. For a third resident, an RN administered NovoLOG insulin 58 units before the noon meal, but no nutritious snack was given at the time of administration, and the resident was not served the meal until later. The RN stated a belief that insulin could be given up to one hour before a meal and did not know about the need for a nutritive snack if the meal was not served within the expected time frame. Additional observations showed an RN administering NovoLOG FlexPen insulin to another resident without priming the needle and holding the pen in place for only one second. The same RN administered Fiasp insulin to a resident, primed the pen, but held it in place for only 1.5 seconds instead of 6 seconds or more, and did not offer a nutritious snack before leaving the room. During that same meal period, the resident was observed seated at the dining table with only water and tea while the meal had not yet been served. Interviews with the Infection Control Coordinator and the DON showed they were not aware of insulin training or competencies related to insulin pen use, did not know the required hold times for the pens, and did not know that Fiasp had to be administered within 2 minutes of the start of the meal per the order and manufacturer directions.
Failure to Timely Report Investigation of Resident Injury
Penalty
Summary
The facility failed to submit a written investigation of a possible instance of abuse or neglect to the state agency within the required 5 working days. According to facility policy, all alleged violations of abuse or neglect must be reported within 24 hours, and the results of the investigation must be submitted within 5 working days. However, for one resident with severe cognitive impairment and a diagnosis of dementia, the facility did not follow this protocol after an incident occurred. The resident, who was at risk for hot liquid accidents due to impaired cognition and confusion, spilled coffee on themselves while sitting at the dining room table. The incident resulted in a light pink area on the resident's abdomen, and an order was placed to monitor the burn. Despite this, the Director of Nursing confirmed that the investigation into the incident was not submitted to the state agency as required.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific hazards, the nature of the supervision lapse, or information about the residents involved were provided in the report.
Failure to Notify State of Change in DON
Penalty
Summary
The facility failed to notify the state department of a change in the Director of Nursing (DON) within the required 5 working days. Observations and interviews revealed that the current DON began their position approximately one month prior to the survey, having previously worked as a floor nurse for about a year. The Administrator confirmed that the previous DON left about a month ago and a new DON was hired and is currently active. During interviews, the Administrator admitted that the department had not yet been notified of the change in DON and acknowledged that this notification was overdue. The facility census at the time was 28 residents.
Failure to Document Rationale for Not Completing GDR of Quetiapine
Penalty
Summary
The facility failed to provide a rationale for not conducting a Gradual Dose Reduction (GDR) for one resident sampled. Record review showed the resident had a MDS dated 7/16/2025 with a BIMS score of 1/15, which was identified as severe impairment. The resident’s medication order summary showed Quetiapine Fumarate 25 mg ordered once daily for vascular dementia, unspecified severity, with other behavioral disturbance. A pharmacy review of the medication on 07/02/2025 recommended gradually reducing the dose, but the primary physician disagreed with the recommendation and did not provide a rationale for the disagreement. During an interview on 08/14/25 at 9:16 AM, the DON confirmed there was no rationale documented by the doctor for not conducting the GDR of Quetiapine for the resident.
Failure to Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist (IP) who is not the Director of Nursing (DON), as required for the infection prevention and control program. The DON was listed as both the Director of Nursing and the Infection Control Coordinator on the Licensed Personnel and Consultants sheet, as well as the Infection Control Nurse on the Quality Assurance Performance Improvements (QAPI) Committee Members sheet. During an interview, the DON confirmed they had not completed the necessary course for the Infection Preventionist role and were serving full-time as both the DON and the Infection Preventionist. Although a Licensed Practical Nurse (LPN) from the hospital had the required training for infection control, they had not been overseeing the infection control program at the facility. This deficiency had the potential to affect all 26 residents in the facility, which had a census of 26.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to develop and update care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #7, who was admitted with multiple diagnoses including muscle weakness and difficulty in walking, had a care plan that included a goal to prevent decline through ambulation. However, observations and interviews revealed that the resident had not ambulated for over six months and required assistance from two staff members for transfers, indicating that the care plan was outdated and not reflective of the resident's current condition. Similarly, Resident #18, who was severely cognitively impaired and had a history of falls, did not have any new interventions added to their care plan following a fall incident. The resident's walker was found out of reach, contributing to the fall. Resident #25, who was cognitively intact, also experienced a fall after sliding out of a recliner, yet their care plan lacked any focus, goals, or interventions to address this incident. Interviews with the Director of Nursing confirmed that the care plans for these residents were not updated to reflect their current needs and incidents.
Care Plan Deficiencies in Resident Involvement and Updates
Penalty
Summary
The facility failed to involve Resident #26 in the development of their Comprehensive Care Plan (CCP) and did not address their high risk for elopement. Despite being cognitively intact with a BIMS score of 15, Resident #26 was not aware of the care plan or invited to the care plan meeting. The facility also did not document the meeting in the progress notes or have a signed care plan acknowledgment form. Additionally, although Resident #26 was identified as a high risk for elopement and wore a wanderguard bracelet, their CCP lacked focus, goals, or interventions related to this risk. Resident #18, who was severely cognitively impaired with a BIMS score of 4, was admitted to hospice services, but this was not reflected in their CCP. The Director of Nursing confirmed that the care plan had not been updated to include hospice admission. This oversight indicates a failure to ensure that the care plan accurately reflected the resident's current care needs and services. Resident #11 and Resident #17 also had deficiencies in their care plans. Resident #11's CCP did not address a bruise on their right hand middle digit, and Resident #17's CCP failed to include an open area on their right buttock, which was identified as moisture damage. The facility's Skin and Wound Management Standard requires that non-pressure skin conditions be assessed and documented in the care plan, but this was not done for Resident #17. The DON confirmed these omissions, highlighting a pattern of inadequate care plan updates for residents with changing health conditions.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents, leading to potential cross-contamination. Observations revealed that an LPN did not change gloves or perform hand hygiene between removing old dressings, cleaning wounds, and applying new dressings. The LPN also reached into a package of clean gauze with soiled gloves, which is against standard infection control practices. These actions were confirmed by the LPN during interviews, acknowledging the failure to adhere to the required 20-second handwashing protocol. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for three residents with open wounds, which is a critical infection control measure to prevent the transmission of multidrug-resistant organisms. Observations showed that gowns were not used during wound care, and there were no signs indicating the need for EBP in the residents' rooms. Interviews with staff, including a Medication Aide, a Nurse Aide, and the LPN, revealed a lack of awareness and understanding of EBP, further contributing to the deficiency. The Director of Nursing confirmed that the facility lacked a policy for EBP and had not been implementing it for the affected residents, despite their open wounds. This oversight was acknowledged during interviews, highlighting a significant gap in the facility's infection prevention and control program. The DON also confirmed the necessity of EBP for residents with open wounds and the importance of proper hand hygiene practices, which were not being followed by the staff.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents, Resident 9 and Resident 21, or their representatives, to inform them of charges for non-covered care items and services prior to a change in Medicare A coverage. This deficiency was identified during a review of records and interviews conducted by surveyors. Resident 9 was discharged from Medicare A services on April 22, 2024, with benefit days remaining, and continued to reside in the facility. The facility did not provide a SNF ABN to Resident 9, as confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident 21 was discharged from Medicare A services on June 20, 2024, also with benefit days remaining, and remained in the facility. The facility again failed to provide a SNF ABN to Resident 21, as confirmed by the DON. The absence of the SNF ABN meant that both residents were not informed in advance about the potential denial of Medicare coverage for the services they were receiving, which is a requirement to allow beneficiaries to make informed decisions about their care options.
Failure to Evaluate Need for Physical Restraints
Penalty
Summary
The facility failed to evaluate the need for physical restraints for a resident, identified as Resident 2, who was observed with a strap on their wheelchair that they could not unfasten without assistance. Resident 2, who was admitted with diagnoses including hemiplegia, hemiparesis, unspecified kyphosis, and generalized muscle weakness, was cognitively intact with a BIMS score of 14. Observations on two separate occasions revealed the resident sitting in a wheelchair with a strap that went under the left arm and over the left shoulder, which the resident confirmed they could not remove without help. The resident stated the strap was to help them sit up straight, but they would still be unable to get out of the wheelchair without it. Interviews with the resident and a medication aide confirmed the resident's inability to unfasten the strap independently. A review of the resident's electronic health record showed no documentation of an evaluation for the use of the wheelchair strap or any discussion of risks and benefits with the resident or their representative. The facility's guidelines require evaluation of devices that may impede movement before application, but the Director of Nursing confirmed that no such evaluation or consent form was completed for the shoulder strap, indicating it was used as a restraint without proper assessment or consent.
Failure to Document Weekly Wound Assessments
Penalty
Summary
The facility failed to complete and document weekly non-pressure wound assessments for two residents, Resident 15 and Resident 17, as required by their Skin and Wound Management Standard. Resident 15, who was cognitively intact, had multiple wounds on both lower legs, with no measurements documented since early June 2024. Despite attending a wound clinic weekly, the facility did not maintain up-to-date records of the wound assessments. Resident 17, also cognitively intact, had a wound on the right buttock, initially noted as a blister, which was documented as moisture damage. However, the last recorded assessment was in early June 2024, with no subsequent weekly documentation. Interviews with the Director of Nursing (DON) confirmed that the facility's wound documentation was not current, and non-pressure skin issues were not being assessed and documented weekly as required. The DON acknowledged the lapse in maintaining up-to-date wound records, which affected the care planning and monitoring of residents with impaired skin integrity. This deficiency was identified through observations, record reviews, and interviews, impacting the quality of care provided to the residents.
Failure to Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to complete weekly pressure ulcer assessments for a resident, identified as Resident 3, who was admitted with multiple diagnoses including respiratory failure, COPD, heart failure, and peripheral vascular disease. The resident had a Stage 3 pressure ulcer on the left heel, first noted on 03/12/2024, with the last documented assessment on 06/11/2024. Despite the facility's policy requiring weekly assessments, there was no documentation of wound assessment after this date. The Director of Nursing (DON) admitted to monitoring wounds but not documenting them in the medical record, instead using Risk reports as a tracking tool. This lack of documentation and adherence to the facility's Skin and Wound Management Standard, which mandates formal assessment and documentation every seven days, led to the deficiency. The facility census at the time was 26, and the failure to document wound assessments was identified during a review of the resident's progress notes and interviews with the DON.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Red Cloud
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adept Nursing & Rehab Of Blue Hill | 16.8 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Franklin | 23.5 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Superior | 24.1 mi | ★★★★★ | 0 | 0 |
| Sunporch Of Smith County | 25.5 mi | ★★★★★ | 0 | 0 |
| Smith Center Health And Rehab | 27.2 mi | ★★★★★ | 0 | 0 |
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