Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Emerald Care Center Southwest Llc during CMS and state inspections, most recent first.
A resident with vascular dementia was admitted and eloped from the facility within several hours, later being found by police down the road. Facility policy required completion of an elopement risk data collection at admission or within eight hours, but the Nursing Admission Data Collection, including the elopement risk assessment, was not completed until several days after admission. During interview, the admission nurse acknowledged the assessment was not done within the required timeframe, citing being off for a holiday.
A resident with cognitive impairment did not have a physician-ordered urinalysis completed after only one unsuccessful attempt to collect a specimen, with no further documented efforts. Later, after a hospital visit for a fall and UTI diagnosis, the resident's antibiotic order was inaccurately transcribed, resulting in administration at a lower frequency than prescribed. The resident subsequently developed hypoglycemia and sepsis due to UTI.
The facility did not ensure safe and appropriate administration of IV therapy for two residents. One resident's PICC line dressing was not changed as ordered, remaining in place beyond the required interval, while another resident's IV fluids were administered at a rate higher than prescribed until an LPN adjusted it to the correct rate. These actions were not consistent with physician orders or professional standards of practice.
During a meal service, staff did not follow the prescribed menu or serving sizes, resulting in meals being served with incorrect portions and missing required components, such as pureed vegetables for a resident on a pureed diet. The cook acknowledged not adhering to the menu, and 63 residents received meals from the kitchen during this time.
Staff failed to follow infection control protocols during care for two residents, including improper sterile technique during a PICC line dressing change by an LPN and failure to change gloves or bag soiled linens during incontinent care by a CNA. Both residents had significant medical needs and required staff assistance, and staff acknowledged not following proper procedures.
A resident with moderate cognitive impairment refused to provide a urine specimen for urinalysis, and neither the physician nor the emergency contact were notified of this refusal. Additionally, when the resident experienced a low blood sugar, the physician was not notified as required by physician order. Staff interviews and documentation review confirmed these notifications were not made or recorded, contrary to facility policy.
A resident with a history of bladder dysfunction had a physician order for a urinalysis with culture and sensitivity, but the urine specimen was not collected until three days after the order was placed. Staff interviews confirmed that the expectation was for same-day collection, and there was no documentation explaining the delay.
A facility failed to update a care plan for a resident with autism who was identified as a smoker. Despite being listed on the facility's smoking list and reporting smoking three to five times a day, the resident's care plan did not include smoking. The DON confirmed this omission, which is against the facility's policy requiring immediate care planning for high-risk areas.
A facility failed to conduct a smoking assessment for a resident with autism who smoked three to five times daily. Despite being listed as a smoker, the resident's electronic medical record lacked the required assessment to determine the necessary supervision and equipment for safe smoking. The DON confirmed the absence of this documentation.
The facility failed to provide correct medication administration for three residents. An LPN gave an inhaler to a resident that belonged to another, and two residents did not receive antibiotics as ordered. One resident missed doses after an ER visit, and another did not receive a full course of antibiotics due to unavailability. The DON and ADON acknowledged the issues, but the documentation did not accurately reflect the medication administration.
A medication cart was found unlocked and unattended in the main lobby of the facility, contrary to the facility's policy requiring secure storage of medications. An LPN confirmed that the cart should have been locked, highlighting a failure to adhere to established procedures for medication security.
The facility failed to maintain food safety and hygiene standards, with dietary aides not wearing hair nets properly, an unclean kitchen with mouse droppings and expired items, and improper hand hygiene and glove usage by staff. The dietary manager admitted to lapses in daily cleaning and non-compliance with handwashing protocols.
The facility did not follow its antibiotic stewardship policy by failing to complete a standardized tool for a resident treated for UTIs. Despite multiple antibiotic prescriptions, there was no documentation of the required McGeer form in the resident's records. The ADON confirmed the absence of this documentation.
The facility failed to document that pneumococcal vaccines were offered and/or administered to two residents. The facility's policy required assessments of vaccination status within five days of admission, but records for two residents lacked documentation of receiving or being offered the vaccine. Staff interviews revealed confusion about the vaccine ordering process, with an LPN unsure of how vaccines were ordered and the DON stating that vaccination status should be documented upon admission. The ADON/Infection Preventionist could not find the necessary documentation for the residents.
The facility failed to maintain effective pest control, with mouse droppings found in the kitchen and a cockroach observed on a resident. Staff reported occasional sightings of roaches and bedbugs, despite frequent pest control treatments. The administrator noted recent pest control visits and suggested treatments take time to be effective.
A resident with depressive episodes reported being slapped by the Business Office Manager (BOM) during an interaction. The BOM admitted to brushing the resident's hand aside, acknowledging it could be considered abuse. This incident violated the facility's policy ensuring residents' right to be free from abuse.
A facility failed to administer medications as ordered for a resident with a physician's order for oxycodone HCL for pain management. The September TAR showed discrepancies, with entries marked as 'nine' and blanks, indicating uncertainty about medication administration. A progress note mentioned awaiting medication from the pharmacy. The DON could not confirm if the medication was administered, indicating a failure in following the medication administration policy.
The facility failed to provide physician-ordered ulcer care for two residents. One resident with non-pressure chronic ulcers had missing documentation for treatments on several dates, indicating the treatments were not performed. Another resident with a stage four pressure ulcer also had lapses in care, with missing documentation for prescribed treatments. The Wound Care LPN confirmed that the treatments were not completed as required.
A resident with functional limitations and a broken back experienced a significant delay in receiving assistance to get off a bed pan, despite activating their call light. Multiple staff members, including an LPN and CNAs, failed to respond promptly, leaving the resident waiting for over 40 minutes. This incident highlights a deficiency in the facility's adherence to its policy on timely response to call lights.
A resident in an LTC facility experienced a delay in receiving prescribed pain and nausea medications due to communication failures among staff. Despite a request for medication being made, the resident did not receive the necessary medications until over an hour later, which was considered unacceptable by facility standards.
The facility failed to provide ordered pressure ulcer treatment for three residents, resulting in multiple missed wound care treatments as documented in the TARs. The Wound Care Nurse confirmed the treatments were not provided and could not explain the missed treatments.
The facility failed to ensure medications were administered as ordered for two residents. One resident with a stage four pressure wound and GERD had multiple instances of missed medication administrations. Another resident with chronic diastolic heart failure received carvedilol despite having a heart rate below the ordered threshold on several occasions.
A resident with constipation was found to have Ex-Lax and a stool softener at their bedside, brought in by a family member, without any assessment or physician order for self-administration. The facility's policy on medication storage was not followed, and the DON and ADON were unaware of the medications at the resident's bedside.
The facility failed to obtain a physician-ordered urinalysis for a resident with a stage four sacrum wound and intestinal obstruction. The ADON stated that they would not know if a urinalysis was ordered if it was on the physician's liaison order form during rounds. The DON confirmed the order was documented but not obtained.
The facility failed to provide adequate portion sizes during a meal service, using a four-ounce scoop instead of the required six-ounce scoop for beef stroganoff, resulting in residents receiving smaller portions than specified in the menu.
The facility failed to document wound care treatment for a resident with a stage four pressure ulcer. The Wound Care Nurse confirmed that the care was provided but not documented on specific dates due to being assigned other tasks.
Failure to Complete Timely Elopement Risk Assessment on Newly Admitted Resident
Penalty
Summary
The facility failed to ensure timely completion of a Nursing Admission Data Collection, including an elopement risk assessment, for one resident, resulting in noncompliance with its elopement policy. The facility’s written policy on Elopement, Risk Reduction Strategies and Management of Missing Resident, revised 01/2024, required nursing staff to complete an elopement risk data collection on all residents at admission or no later than eight hours after admission. An admission record showed that Resident #1 was admitted at 11:14 a.m. with a medical diagnosis of vascular dementia. A nursing note documented that on the day of admission, the resident was found by police outside the facility down the road, having eloped within 4.5 hours of admission. The Nursing Admission Data Collection, which included the elopement risk data collection, was not signed as completed until five days after admission, after the elopement had already occurred. In an interview, the admission nurse confirmed that the assessment was not completed within eight hours of admission and attributed the delay to being off for the holiday. The administrator reported that 71 residents resided in the facility at the time of the survey, and Resident #1 was the only sampled resident reviewed for elopement. The record review and staff interview confirmed that the required elopement risk assessment was not performed within the policy’s specified timeframe for this resident with vascular dementia, and that the resident left the facility unsupervised and was located by police down the road on the same day as admission.
Failure to Complete Ordered Urinalysis and Accurate Antibiotic Transcription
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis was completed and that an antibiotic was transcribed and administered as ordered for a resident with moderate cognitive impairment following a cerebral infarction. The resident was admitted with orders for a urinalysis, among other tests, but documentation showed that only one attempt was made to collect a urine specimen, which was unsuccessful due to the resident's refusal. There was no evidence of further attempts or documentation that the urinalysis was completed, despite facility policy requiring timely completion of laboratory services as ordered by a physician. Subsequently, the resident experienced a fall and was sent to the emergency room, where they were diagnosed with a urinary tract infection (UTI) and prescribed Keflex 500 mg to be taken four times daily. Upon return to the facility, the antibiotic order was inaccurately transcribed as three times daily, and the resident received the medication at this incorrect frequency. There was no documentation that the facility provider changed the order, and staff confirmed the transcription error. The resident later developed hypoglycemia and sepsis due to UTI, requiring another hospital transfer.
Failure to Follow Physician Orders for IV Therapy and PICC Line Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice and in accordance with physician orders for two residents requiring intravenous (IV) therapy. For one resident with a peripherally inserted central catheter (PICC) line, the dressing was observed to be dated nearly two weeks prior, despite a physician's order to change the dressing weekly and as needed. Staff interviews confirmed that the dressing should have been changed according to the order, but it was not, and the Director of Nursing (DON) acknowledged that nurses are expected to follow physician orders for dressing changes. In a separate incident, another resident receiving IV fluids was observed to have their infusion running at a rate higher than the physician-ordered 75 ml/hr, with the dial set between 80 and 100 ml/hr and the actual rate at approximately 90 ml/hr. The resident was unaware of the infusion rate, and an LPN later adjusted the rate to match the physician's order after being informed. Both incidents demonstrate a failure to administer IV therapy as ordered and in accordance with professional standards.
Failure to Follow Prescribed Menu and Serving Sizes During Meal Service
Penalty
Summary
The facility failed to follow the prescribed menu during an observed meal service, impacting the nutritional adequacy of meals served to residents. During the lunch service, the cook was observed plating meals that did not match the menu specifications for serving sizes and food items. For example, regular diet plates were served with three chicken tenders, one scoop of coleslaw, one scoop of mashed potatoes, and one scoop of gravy, while the mechanical soft diet plate included ground chicken tenders, mashed potatoes, gravy, and cooked cabbage. The pureed diet plate was served with pureed chicken tenders, mashed potatoes, and two scoops of gravy, but no pureed vegetables were included as required by the menu. The facility's policy and the extended menu spreadsheet specified serving sizes and required components for each diet type, including pureed vegetables for residents on pureed diets. The cook acknowledged not following the menu, serving incorrect portion sizes for coleslaw and chicken tenders, and omitting pureed vegetables for the pureed diet plate. The Director of Nursing identified that 63 residents received meals from the kitchen during this service.
Failure to Maintain Infection Control During PICC Line Dressing Change and Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the provision of care for two residents. In one instance, an LPN performed a peripherally inserted central catheter (PICC) line dressing change without adhering to sterile technique. The LPN placed the dressing kit on the resident's bed, used gloves from their pocket instead of sterile gloves for part of the procedure, and did not maintain sterility throughout the process. The LPN also left the room to retrieve a new dressing kit, removing and re-donning personal protective equipment, and continued the procedure without following sterile protocol. The resident involved had a history of orthopedic aftercare following surgical amputation and atherosclerosis with gangrene, and was ordered to have weekly PICC line dressing changes. In another instance, a CNA provided incontinent care to a resident without changing gloves between cleaning the peri area, applying cream, dressing the resident, and handling personal items such as the bed remote and hairbrush. The CNA also transported the resident's soiled clothing to the utility room without placing them in a bag, contrary to facility policy. The resident was dependent on staff for toileting and dressing and had a history of lower limb amputation. Both staff members acknowledged during interviews that their actions did not follow proper infection control procedures, and the DON confirmed the expected protocols for glove changes and handling of soiled linens.
Failure to Notify Physician and Emergency Contact of Resident Condition Changes
Penalty
Summary
The facility failed to notify a resident's emergency contact and physician regarding the resident's refusal to provide a urine specimen for urinalysis, as well as failed to notify the physician of a low blood sugar result as ordered. The resident in question had moderate cognitive impairment and a history of cerebral infarction, with physician orders in place to notify the provider if blood sugar was less than 60 or greater than 250, and to obtain a urinalysis. Documentation showed that the resident refused to provide a urine specimen, but there was no record that the physician or emergency contact were informed of this refusal, nor was there documentation that another attempt was made to collect the specimen. Additionally, when the resident's blood sugar was recorded at 57, insulin was held as per protocol, but there was no documentation that the physician was notified of this low blood sugar, despite an order requiring such notification. Interviews with staff confirmed that the notifications were not made and not documented, and the facility's policy required immediate sharing of changes in a resident's condition or treatment with the resident, their representative, and the attending physician.
Delay in Completion of Ordered Urinalysis
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis with culture and sensitivity was completed in a timely manner for a resident diagnosed with neuromuscular dysfunction of the bladder. The order for the urinalysis was placed on 02/18/25, but the urine specimen was not collected until 02/21/25. There was no documentation explaining the delay in specimen collection. Nursing notes indicated that the resident exhibited behavioral changes, which the resident's representative associated with urinary tract infections, prompting further communication with the nurse practitioner and a new order for the urinalysis. Interviews with facility staff confirmed that nurses were responsible for collecting urine specimens and notifying the laboratory for pick-up, with the expectation that such orders should be completed the same day they are received. The ADON confirmed that the order was entered into the lab system on the day it was written, but the specimen was not collected until three days later, and there was no documentation to account for the delay. The DON also stated that while there is no specific time frame for completing urinalysis orders, the expectation is for same-day completion, and any inability to collect a specimen should be documented in the resident's notes.
Failure to Update Care Plan for Resident Smoker
Penalty
Summary
The facility failed to include and update a care plan for a resident with autism, who was identified as a smoker. The facility's Care Plan Process policy requires that high-risk areas such as smoking be care planned immediately upon identifying risk via evaluation. However, the resident's care plan did not include smoking, despite the resident being listed on the facility's smoking list and reporting smoking three to five times a day. The Director of Nursing (DON) confirmed that smoking was not included in the resident's care plan.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for a resident, identified as Resident #27, who was part of a sample of 19 residents evaluated for smoking assessments. The facility's Resident Smoking Policy requires that residents who smoke be evaluated to determine the necessary adaptive equipment and level of supervision required for safe smoking. Despite being listed as a smoker on the facility's smoking list, Resident #27 did not have a smoking assessment documented in their electronic medical record. The Director of Nursing (DON) confirmed the absence of this assessment. Resident #27, who has a diagnosis of autism, reported smoking three to five times a day.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure the correct inhaler medication was provided to a resident. An LPN administered an inhaler to a resident with chronic obstructive pulmonary disease, but the inhaler belonged to another resident. The LPN admitted to not following the facility's policy of verifying the five rights of medication administration, and there was no order for the inhaler in the resident's records. Another deficiency involved two residents who did not receive medications according to physician orders. One resident with a history of UTIs and kidney issues did not receive the last two doses of an antibiotic after returning from an ER visit. The ADON acknowledged that the medication should have been completed, but there was no order to restart or continue the missed doses. A third resident with a UTI did not receive the full course of an antibiotic as ordered. The EMAR showed that the resident missed doses, and the CMA confirmed that the medication was not available. The DON was unable to explain why the medication was not administered as ordered, and the documentation did not accurately reflect the resident's medication administration.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that a medication cart was securely locked and attended to, as required by their policy and procedure. The policy mandates that medications and biologicals be stored safely, securely, and properly, accessible only to authorized personnel. On December 10, 2024, at 11:43 a.m., a medication cart located on the North end of the main lobby was observed to be unlocked and unattended. Shortly after, at 11:44 a.m., an LPN confirmed that the medication cart should have been locked, indicating a lapse in adherence to the facility's medication storage policy.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to its policies regarding food safety and hygiene, resulting in several deficiencies. Observations revealed that dietary aides did not wear hair nets properly, allowing hair to be exposed, which could potentially contaminate food. The kitchen was found to be unclean, with mouse droppings on baking soda boxes, an open and undated corn starch box, and expired Worcestershire sauce in the dry storage area. Additionally, the kitchen floor was dirty, and there were unclean containers with dishes. A cup of water with a straw was improperly placed on the dish rack with large pots and pans. The dietary manager admitted to being unaware of the mouse droppings and the condition of the corn starch box, and acknowledged the lack of daily cleaning due to their absence on vacation. Further deficiencies were noted in hand hygiene and glove usage. Dietary aide #1 was observed handling the puree machine with bare hands, contrary to the facility's policy of wearing gloves when handling food. The dietary manager was seen touching a serving cart with gloved hands and then handling food without changing gloves or washing hands. This improper practice was repeated when the dietary manager opened a new package of bread and continued to touch the bread without changing gloves or washing hands. The dietary manager acknowledged the requirement to wash hands and change gloves after touching non-food items, but failed to comply with this standard.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy by not completing a standardized tool for the initiation of antibiotics for a resident treated for urinary tract infections (UTIs). The policy required the use of McGeer and/or LOEB Criteria to track antibiotic use. The resident, who had a history of congenital occlusion of the ureteropelvic junction, hydronephrosis, obstructive and reflux uropathy, crossing vessel, and stricture of the ureter, was prescribed antibiotics on three separate occasions for UTIs. Despite these prescriptions, there was no documentation of a McGeer form being completed in the resident's infection control book or electronic medical record for the antibiotic use in May, July, or November. The Assistant Director of Nursing (ADON) confirmed the absence of the required documentation during an interview.
Failure to Document Pneumococcal Vaccination Offer and Administration
Penalty
Summary
The facility failed to provide documentation that pneumococcal vaccines were offered and/or administered to two of the five sampled residents reviewed for immunizations. The facility's Infection Control Immunizations policy, dated March 20, 2024, stated that all residents would be offered pneumococcal vaccines, with assessments of vaccination status conducted within five working days of admission. However, a review of the immunization records for two residents did not document that they had received or been offered the pneumococcal vaccination. Interviews with staff revealed a lack of clarity regarding the process for ordering and administering vaccines. An LPN stated they were unsure how vaccines were ordered but administered them if an order appeared during their shift. The DON indicated that upon admission, staff were to document vaccination status and obtain consent to provide the vaccine if the resident desired it. The ADON/Infection Preventionist was unable to locate the necessary documentation for the two residents in question.
Failure to Maintain Effective Pest Control
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by multiple observations and staff interviews. During an initial tour of the kitchen, mouse droppings were found on four boxes of baking soda in the dry storage area. The dietary manager was unaware of the droppings' nature but acknowledged they should not be present and discarded the affected boxes. Additionally, a cockroach was observed on a resident's hand and prosthetic leg in the dining room. A housekeeper/CNA mentioned that roaches are occasionally seen, and pest control services are used frequently. Another CNA reported seeing roaches and bedbugs, noting that while treatments are applied, the pests return. The administrator stated that pest control had recently visited and suggested that treatments might take 24-48 hours to be effective, attributing the presence of pests to residents bringing them in.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving a resident with a diagnosis of other specified depressive episodes. The incident was documented in an Initial State Reportable Incident form, where the resident was found standing outside the Business Office Manager's (BOM) doorway, yelling that they had been slapped. The BOM was immediately suspended pending investigation. A subsequent Final State Reportable Incident form detailed that during an interaction, the BOM wagged their finger in the resident's face, telling them to shush, and when the resident pointed their finger back, the BOM slapped the resident's hand. The resident then began yelling for the administrator, claiming they had been slapped. Interviews conducted on 10/08/24 revealed that the resident confirmed the BOM slapped their hand during the interaction, while the BOM admitted to brushing the resident's hand aside. The BOM acknowledged that the incident could be considered abuse because they touched the resident, although they denied abusing the resident. This incident highlights a failure in the facility's adherence to its Abuse, Neglect, and Exploitation policy, which mandates that each resident has the right to be free from abuse, including physical abuse such as hitting and slapping.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident reviewed for misappropriation of property. The resident had a physician's order for oxycodone HCL, a narcotic medication, to be administered via peg tube every four hours for pain. However, the September 2024 Treatment Administration Record (TAR) showed discrepancies in medication administration, with entries marked as 'nine' indicating 'other/see nurses notes' and blanks on certain dates and times, suggesting uncertainty about whether the medication was administered. Additionally, a progress note indicated that the medication was awaited from the pharmacy, further complicating the administration process. The Director of Nursing (DON) was unable to confirm if the medication was administered during these instances, highlighting a failure in adhering to the medication administration policy.
Failure to Provide Physician-Ordered Ulcer Care
Penalty
Summary
The facility failed to provide ulcer care as ordered by the physician for two residents. Resident #1, who was admitted with a diagnosis of non-pressure chronic ulcers on the back and right thigh, had several instances where the prescribed treatments were not documented as completed. Specifically, the Treatment Administration Record (TAR) for May and June 2024 showed missing documentation for the application of Hibiclens, calcium alginate with collagen powder, and Nystatin powder on multiple dates. The Wound Care LPN confirmed that the absence of documentation indicated that the treatments were not performed. Similarly, Resident #3, admitted with a stage four pressure ulcer in the sacral region, also experienced lapses in care. The TAR for June 2024 lacked documentation for the prescribed cleansing and application of Triad and hydrophilic paste to the bilateral buttocks, as well as the treatment for other skin changes. The Wound Care LPN acknowledged that these treatments were not completed as required by the end of the shift, as indicated by the blanks in the TAR.
Delayed Response to Resident's Call Light
Penalty
Summary
The facility failed to provide timely assistance for activities of daily living (ADL) to a resident with functional limitations in both lower extremities, who required substantial maximum assistance for bed mobility. On the morning of May 17, 2024, the resident activated their call light to request help getting off a bed pan. Despite the call light being on, staff members, including an LPN and several CNAs, either ignored or failed to respond promptly to the resident's request. The call light was initially activated at 5:23 a.m., but it was not until 6:09 a.m. that the resident received the necessary assistance. During this period, multiple staff members were observed walking past the resident's room without responding to the call light. The resident expressed discomfort and frustration, stating they had been on the bed pan for an extended period and had a broken back in three places. The facility's policy required staff to respond to call lights promptly, yet the resident's call light remained unanswered for over 40 minutes. This delay in providing care highlights a deficiency in the facility's adherence to its policy on timely response to call lights.
Delayed Administration of Pain and Nausea Medication
Penalty
Summary
The facility failed to administer pain and nausea medication in a timely manner for a resident, as observed during a survey. The resident had physician's orders for Norco and Ondansetron to be administered every six hours as needed for pain and nausea, respectively. However, the Medication Administration Record (MAR) did not document the administration of these medications. On the morning of the incident, the resident was observed to be in pain and vomiting, and a request for medication was made by the resident's family representative. Despite this request, the resident did not receive the medication until over an hour later. The delay in medication administration was due to a lack of communication and awareness among the staff. The Certified Nursing Assistant (CNA) was informed of the resident's need for medication but did not relay this information to the Licensed Practical Nurse (LPN) responsible for medication administration. The LPN, who was working as a Certified Medication Aide (CMA) that day, was not aware of the request until later and initially confused the resident with another. The Director of Nursing (DON) confirmed that no PRN medication had been given that morning. The LPN eventually administered the medication but acknowledged the delay, which was deemed unacceptable by another LPN who stated that pain and nausea medications should be administered within a much shorter timeframe.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered for three residents. Resident #3, who had a stage four sacrum wound, had multiple instances where wound care was not documented or provided as per the treatment administration record (TAR). Specifically, there were blanks in the November and December 2023 TARs indicating missed treatments on several dates. The Wound Care Nurse confirmed that the treatments were not provided on these dates and mentioned being off duty on some of those days. Resident #5, diagnosed with a stage four pressure wound of the sacrum, also had missed wound care treatments as documented in the December 2023 and January 2024 TARs. The Wound Care Nurse could not explain why the treatments were missed. Similarly, Resident #8, with a stage four pressure ulcer of the sacral region, had missed wound care treatments on specific dates in December 2023. The Wound Care Nurse confirmed that if the wound care was not documented, it was not done and could not explain the missed treatments for Resident #8.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents. Resident #5, who had diagnoses including a stage four pressure wound of the sacrum and GERD, had multiple instances where medications were not documented as administered according to the physician's orders. Specifically, the December 2023 and January 2024 Treatment Administration Records (TAR) showed blanks for the administration of hydrocodone-acetaminophen and Reglan at various times, indicating that the medications were likely not given. An LPN confirmed that blanks on the MAR/TAR would be assumed to mean the medication was not administered, and the policy was to follow physician orders when administering medications. Resident #8, diagnosed with chronic diastolic heart failure, had a physician order for carvedilol to be held if the heart rate was less than 65. However, the January 2024 Medication Administration Record (MAR) documented that carvedilol was administered despite the resident's heart rate being below the specified threshold on multiple occasions. The DON confirmed that staff were supposed to hold the medication if the heart rate was below 65 and acknowledged that the medication was incorrectly administered on the specified dates.
Failure to Ensure Proper Medication Storage
Penalty
Summary
The facility failed to ensure medications were not stored at a resident's bedside for one of three sampled residents reviewed for medication administration. Resident #8, who had a diagnosis of constipation, was found to have Ex-Lax and a stool softener at their bedside, which were brought in by a family member. The resident was observed taking these medications without any assessment or physician order for self-administration, as required by the facility's policy. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware that the resident had these medications at their bedside. The facility's policy on Self-Administration of Medications by Residents, dated 2021, requires an assessment of the resident's ability to safely self-administer medications and a physician order for bedside medication storage. However, this policy was not followed in the case of Resident #8. The DON and ADON confirmed that no assessment had been completed, and no physician order was in place for the resident to self-administer the medications found at their bedside.
Failure to Obtain Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis for a resident with diagnoses including a stage four sacrum wound and intestinal obstruction. The physician's order for the urinalysis was dated 12/20/23, but there was no documentation that the urinalysis was obtained. The Assistant Director of Nursing (ADON) stated that if the urinalysis order was on the order form from the physician's liaison during rounds, they would not know if a urinalysis was ordered or needed to be obtained. The ADON mentioned that they input the prescribed orders into the resident's medical records. The Director of Nursing (DON) provided the physician's order form dated 12/20/23, which documented the order to obtain a urinalysis.
Inadequate Portion Sizes During Meal Service
Penalty
Summary
The facility failed to ensure adequate portion sizes were offered to residents during a meal service. The facility's policy required that menus be followed to meet the nutritional needs of residents. However, during an observation of lunch service, it was found that the Certified Dietary Manager (CDM) used incorrect portion sizes. Specifically, the CDM used a number eight grey scoop, which was identified as a four-ounce scoop, instead of the required six-ounce scoop for beef stroganoff. The CDM acknowledged the error and mentioned that the correct six-ounce scoop was broken and had been ordered. This resulted in residents receiving smaller portions than specified in the menu, which did not meet their nutritional needs as per the facility's policy.
Failure to Document Wound Care Treatment
Penalty
Summary
The facility failed to ensure wound care treatment was accurately documented for one of three sampled residents reviewed for pressure ulcers. Resident #8, who had a diagnosis of a stage four pressure ulcer in the sacral region, had a physician's order for daily wound care. However, the Medication Administration Records (MAR) for December 2023 and January 2024 were found to be blank on specific dates, indicating that the wound care was not documented. The Wound Care Nurse confirmed that they had worked on the dates in question and completed the wound care but failed to document it due to being pulled to perform other tasks in the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 237 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Park East | 1.5 mi | ★★★★★ | 14 | 1 |
| Accel At Crystal Park | 1.5 mi | ★★★★★ | 10 | 1 |
| Capitol Hill Skilled Nursing And Therapy | 1.9 mi | ★★★★★ | 0 | 0 |
| Brookwood Skilled Nursing And Therapy | 1.9 mi | ★★★★★ | 8 | 0 |
| South Pointe Rehabilitation And Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
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