Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Manor during CMS and state inspections, most recent first.
Unsecured Medication Cart Left Unattended: A medication cart was observed unlocked and unattended on the south hall, with no staff in sight. The ADON walked to the cart and left without locking it, and a CMA later left the cart unlocked while helping another resident. Facility policy required medication carts to be securely locked when out of the nurse's view, and the ADON stated anyone could have taken the medications from the cart.
The facility failed to ensure residents or their representatives understood a binding arbitration agreement, knew signing was not required for admission or continued care, and were told they could rescind within 30 days. The social services director was observed using Docusign to click through the admission packet, including the arbitration section, and multiple residents said they did not know what the agreement was, did not remember signing it, or were unaware that refusing to sign would not affect their care. The ADON stated it did not sound like all residents understood the agreement.
A facility failed to ensure its arbitration agreement included the selection of a neutral arbitrator agreed upon by both parties and a venue convenient to both parties. The administrator identified 51 residents in the facility, and the social services director stated all 51 had signed a binding arbitration agreement. The Admissions Agreement’s Dispute Resolution Plan stated that mediation or arbitration would be governed by the FAA and administered by Dispute Solutions, Inc., and the social services director said the admission packet was reviewed section by section.
Incomplete Advance Directive Acknowledgements were found for 3 residents reviewed. Their forms were signed but left blank on whether they had or had not executed an advance directive, despite admission assessments showing they were cognitively intact. The social services director said an unmarked form was assumed to mean no advance directive, while the ADON stated the form was not completed.
Unsafe Storage of Ice Machine and Freezers in Dining Area: The facility failed to keep an ice machine and 2 of 3 freezers in the dining area locked and restricted to staff access. During observation, residents were walking in the dining area while the ice machine and freezers were unsecured, and there was no staff-only signage. Facility policy required access to ice machines and food storage areas to be limited to employees and authorized personnel only.
Failure to Thoroughly Investigate Abuse Allegation: A resident with hemiplegia, aphasia, and diabetes, who was cognitively intact and needed substantial help with most ADLs, alleged that a CNA hit them during care. The abuse investigation lacked statements from the resident, the reporting LPN, and the CNA identified as the perpetrator, and the administrator confirmed those interviews and written statements were not completed.
Opened multidose vials of Tuberculin PPD were found in the med storage room without the date of first use. An LPN confirmed that opened vials should be dated when opened, consistent with the facility’s policy for dating and discarding multidose vials.
A resident with severe cognitive impairment and a documented history of wandering was able to exit the facility unsupervised, despite being identified as high risk for elopement. Staff interviews revealed inconsistent awareness of the resident's elopement history and confusion about monitoring procedures. Documentation showed repeated exit-seeking behaviors, but there was no record of an elopement drill at the time of the incident, and not all staff had been educated on elopement protocols.
A facility failed to ensure privacy during personal care for a resident with severe cognitive impairment. A CNA provided incontinent care without using the privacy curtain, despite the presence of the resident's roommate. The facility's policy requires the use of a privacy curtain to ensure full visual privacy, which the CNA acknowledged but did not follow.
A resident with severe cognitive impairment and muscle weakness did not receive thorough incontinent care. A CNA partially removed the soiled brief and cleansed the buttocks but failed to clean the front peri-area, leaving fecal matter on the resident's labia. The CNA acknowledged the oversight when prompted.
A CNA failed to maintain infection control during incontinent care for a resident with severe cognitive impairment. The CNA did not change gloves appropriately while handling soiled materials and cleaning the resident, resulting in contamination of a new brief. The CNA acknowledged the need for more frequent glove changes and cited a lack of plastic bags for disposal as a contributing factor.
A facility failed to assess and update fall prevention interventions for residents at high risk for falls, resulting in repeated injuries. One resident with a history of falls and high fall risk experienced multiple falls with injuries, including a major head injury, without changes to their care plan. Another resident's room contained fall hazards, and specified interventions were not implemented. Staff confirmed the lack of intervention changes and presence of hazards.
The facility failed to submit accurate PBJ staffing data to CMS for FY quarter 1 2024, missing RN hours on several dates and lacking 24-hour licensed nursing coverage on specific days. A Corporate Nurse Consultant admitted the hours were available but not reported, and the Operations Manager later provided documentation of coverage.
The facility failed to provide a SNF ABN to a resident discharged from Medicare Part A services, despite having benefit days remaining. The Regional MDS Specialist identified 12 residents in similar situations over the past six months. Specifically, a resident admitted to Part A skilled services and later discharged did not receive the required notice, as confirmed by the Regional MDS Specialist.
A facility failed to maintain a clean environment in a resident's room, where a strong urine odor persisted despite daily cleaning and tile replacement. The issue was observed over several days, and staff confirmed the odor had been ongoing for months.
A facility failed to complete the cognitive pattern section of the MDS for a resident with multiple diagnoses, including schizophrenia and hypertension. The assessment was left with dashes, indicating it was not filled out, leading to an inaccurate assessment. The intern DON and Regional MDS coordinator confirmed the section should have been completed.
The facility failed to review care plans every three months for three residents, including those with complex medical conditions such as schizophrenia, diabetes, and acute kidney disease. The Regional MDS Coordinator, who has been managing care plans due to a staffing shortage, admitted that nearly all care plans were not current or updated, highlighting a systemic issue in maintaining timely reviews.
The facility failed to change a resident's soiled wound dressing for over six hours, despite visible dried blood and drainage. Additionally, the facility did not document behaviors justifying the administration of PRN antianxiety medication for another resident, as required by physician orders and facility policy.
A resident with significant weight loss and multiple health conditions did not receive timely intervention as recommended by a dietician. The facility delayed implementing an increase in nutritional shakes from twice to three times daily, as the recommendation was not signed by the DON and physician until much later. This delay was acknowledged by the dietary manager and interim DON.
The facility failed to provide adequate staffing and supervision, leading to multiple incidents involving residents. One resident, at high risk for falls, suffered several falls resulting in injuries due to insufficient supervision. Another resident with a non-pressure ulcer had a soiled dressing left unchanged for over six hours. Staff interviews and resident council feedback highlighted the lack of sufficient staff, particularly at night, impacting the quality of care.
The facility did not post required staffing information, as observed on multiple occasions. An operations manager admitted to being unaware of the requirement to post this information on a designated board near the nurses' station. The facility housed 51 residents during these observations.
The facility administered influenza vaccines to several residents before obtaining their consent. The consent forms for these residents were dated after the vaccines were given, contrary to facility policy. A Regional Nurse Consultant confirmed that vaccines should not be administered before education and consent are obtained, but documentation showed this was not adhered to.
The facility administered COVID-19 vaccines to three residents without providing education or obtaining consent. The Regional Nurse Consultant confirmed that no documentation of education or consent was found in the residents' records, indicating a failure to follow proper procedures.
A resident was discharged into the community without proper discharge planning, as the facility failed to arrange necessary medical and pharmacy services before the discharge. The resident left with medications, but scripts were transferred only afterward. Concerns about the resident's safety led to reports filed with adult protective services and the police. The social service director was responsible, but no documentation of pre-discharge planning was found.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure a medication cart was supervised and locked for 1 of 2 medication carts observed. On 05/19/26 at 4:43 p.m., medication cart #1 on the south hall by the nurse's station was observed unlocked and unattended, with no staff in sight. At 4:44 p.m., the ADON walked to the unlocked cart and left without locking it. At 4:45 p.m., CMA #1 was observed leaving a resident's room on the north hall and going to medication cart #1, which remained unlocked and unattended while the CMA was away from it. The facility policy titled Security of Medication Cart, revised April 2007, stated that medication carts must be securely locked at all times when out of the nurse's view. CMA #1 stated the cart should have been locked and supervised at all times and acknowledged forgetting to lock it and leaving it unlocked while helping another resident. The ADON stated anyone could have taken the medications from the cart and that the cart was to be locked and supervised.
Failure to Ensure Informed Consent for Arbitration Agreements
Penalty
Summary
The facility failed to ensure residents or their representatives understood what a binding arbitration agreement was, understood that signing it was not a condition of admission or continued care, and were explicitly informed of the right to rescind the agreement within 30 calendar days of signing. The deficiency involved 8 of 8 sampled residents reviewed for arbitration agreements, and the administrator stated that 51 residents resided in the facility and that all 51 had entered into a binding arbitration agreement. During observation, the social services director was seen using Docusign to click through sections of the admission agreement, with each enter action signing a section and moving to the next, including the arbitration agreement in the admission packet. The Dispute Resolution Plan stated disputes would be resolved through mandatory mediation and/or binding arbitration under the FAA. In interviews, several residents stated they did not know what an arbitration agreement was or did not remember signing one, one resident said they did not sign any of the paperwork, and another said they knew what an arbitration agreement was but were unaware that refusing to sign would not affect care or admission. The social services director stated the admission packet was reviewed section by section and that there had not been a problem with people agreeing to sign, while the ADON stated it did not sound like all residents understood the agreement.
Arbitration Agreement Lacked Neutral Arbitrator and Convenient Venue
Penalty
Summary
The facility failed to ensure its arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue convenient to both parties. The administrator identified 51 residents living in the facility, and the social services director stated that all 51 residents had entered into a binding arbitration agreement. The undated Dispute Resolution Plan in the Admissions Agreement stated that any mediation or arbitration would be governed by the FAA and administered by Dispute Solutions, Inc. During interview, the social services director stated that each area of the admission packet was reviewed separately and that there had not been a problem with people agreeing to sign the arbitration agreement.
Incomplete Advance Directive Acknowledgements
Penalty
Summary
The facility failed to complete the Advance Directive Acknowledgement for 3 of 13 sampled residents reviewed for advance directive acknowledgements. The facility policy stated that prior to or upon admission, social services or designee would inquire about the existence of any written advance directives and that this information should be displayed prominently in the medical record. The acknowledgement form required the resident to check one statement indicating either that they had executed an advance directive or had not executed one. For Resident #1, Resident #2, and Resident #42, the Advance Directive Acknowledgement forms were docusigned but the section indicating whether the resident had or had not executed an advance directive was left blank. Resident #1 and Resident #2 had BIMS scores of 15 on admission assessments, and Resident #42 had a BIMS score of 14, indicating they were cognitively intact. The social services director stated that if nothing was marked, it was assumed the resident did not have an advance directive, and the ADON stated that an acknowledgement form with nothing marked was not completed.
Unsafe Storage of Ice Machine and Freezers in Dining Area
Penalty
Summary
The facility failed to store and maintain food and ice in a safe manner for one ice machine and 2 of 3 freezers located in the dining room. During an observation of the kitchen and dining room, the three freezers and the ice machine were seen in the corner of the dining area, and two of the three freezers and the ice machine were not locked. Residents were walking around in the dining area waiting for the noon meal, and there was no signage indicating staff use only. Facility policies stated that access to ice machines and ice storage chests should be limited to employees only and that only authorized personnel should have access to food preparation and storage areas. The DM stated they did not know the facility policy regarding the freezers and ice machine being locked and said it was sufficient to dummy lock the freezers. The corporate DM later stated the ice machine and freezers in the resident dining area should always be locked because the area was accessible to residents and visitors, and the administrator stated they should be locked and for staff access only.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving Resident #59. The resident’s record showed diagnoses of hemiplegia and hemiparesis following cerebral infarction, aphasia, and diabetes, and an admission assessment showed the resident had a BIMS of 15 and was cognitively intact, with substantial assistance needed from staff for most ADLs. A facility policy titled Abuse Investigation and Reporting required all reports of abuse to be promptly reported and thoroughly investigated, including interviews of the person reporting the incident, the resident as medically appropriate, staff members on all shifts who had contact with the resident during the alleged incident period, and written witness statements. An OSDH incident report documented an allegation that Resident #59 reported to an LPN during care that CNA #1 hit them. The investigative documentation did not include a statement from the resident, the LPN who reported the incident to the administrator, or CNA #1, who was identified as the perpetrator. The resident later discharged from the facility with family. During review, the administrator acknowledged that statements from the reporter, the victim, the perpetrator, and other staff working at the time of the incident had not been completed. The LPN stated the resident reported that CNA #1 hit their right arm during care and that the incident was reported immediately, but no written statement was completed. CNA #1 stated they reported the incident to the nurse and administrator and were not asked to document a statement.
Opened PPD Vials Were Not Dated
Penalty
Summary
The facility failed to ensure two opened multidose vials of Tuberculin PPD solution were labeled with the date of first use. During an observation of the medication storage room with LPN #3, surveyors found two opened multidose vials of PPD that were not dated. The facility policy titled "Dating and Discarding of Multidose Parenteral Vials," dated 06/21/17, stated that when a multidose vial has been opened or accessed, it should be dated and discarded within 28 days. When asked about the policy, LPN #3 stated that opened vials should have a date on them when they were opened.
Failure to Prevent Elopement for High-Risk Resident with Dementia
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent an elopement for a resident with a known history of wandering and severe cognitive impairment. The resident had been assessed as high risk for wandering and exit-seeking behaviors, with documentation showing repeated attempts to exit the facility and a BIMS score indicating severe cognitive impairment. Despite these known risks, the resident was able to leave the facility unsupervised, as confirmed by nurse notes and a state reportable incident, which indicated that the resident was found outside by neighbors and brought back into the facility. Staff interviews revealed inconsistent awareness and understanding of the resident's elopement history and the reasons for frequent monitoring. Several staff members were not aware that the resident had actually eloped, and there was confusion regarding the implementation and documentation of elopement drills. The facility's elopement policy required specific interventions and monitoring for high-risk residents, but there was no documentation to show that an elopement drill was conducted at the time of the incident, and not all staff had been educated on the procedures following the event. Observations and record reviews further indicated that the resident continued to exhibit wandering and exit-seeking behaviors both before and after the elopement incident. The facility had coded doors with alarms, but the resident was able to exit through a door that alarmed, and staff did not immediately locate the resident. The lack of consistent documentation, staff awareness, and immediate response contributed to the failure to prevent the resident's elopement, resulting in a deficiency related to supervision and accident prevention.
Removal Plan
- Educate all staff on the Elopement Policy on hire, annually, and periodically as a reminder.
- Complete in-service with all staff over the Elopement Policy, including interventions to prevent elopement: place any resident determined to be a wanderer on admission on Elopement Risk on their profile and conduct frequent Q 15 minute visual checks to monitor for exit seeking behaviors for 4 weeks and then re-evaluate. If no exit seeking behaviors have been noted, remove elopement risk status.
- Institute 1:1 monitoring or Frequent Visual Checks charting Q 15 minutes or as indicated if a resident with Dementia is having any exit-seeking behaviors or attempts to go out without supervision, until no longer deemed at risk.
- Re-evaluate at least quarterly for wandering and exit seeking and revise plan for monitoring according to resident's risk.
- Institute other interventions as needed for residents with exit seeking behaviors to re-direct or distract resident from exit seeking behaviors such as: camouflaging doors with wallpaper or curtains, stop signs on exit doors, encouraging family members to visit, and diversional activities during times of restlessness.
- Maintain location of the Elopement Risk book that has a list and information for all residents on Elopement Risk.
- Post a list of residents at risk for elopement in each charge nurse's report book.
- Provide agency staff with in-service materials.
- In-service any staff on vacation or unable to reach before working their next shift.
- Ensure all residents considered high risk for elopement have an identifier on the resident's profile to alert staff.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during the provision of personal care, as required by their policy. A certified nursing assistant (CNA) entered the room of a resident with severe cognitive impairment and diagnoses including generalized muscle weakness and cerebral infarction, to provide incontinent care. Although the CNA closed the door, they did not utilize the privacy curtain, despite the presence of the resident's roommate in the room. The facility's policy mandates the use of a privacy curtain to ensure full visual privacy during such care. The CNA acknowledged the policy but admitted to not pulling the privacy curtain during the care provided.
Failure to Provide Thorough Incontinent Care
Penalty
Summary
The facility failed to provide thorough incontinent care for a resident with severe cognitive impairment and diagnoses including generalized muscle weakness and cerebral infarction. The resident's care plan required total assistance with toileting. During an observation, a CNA entered the resident's room to provide incontinent care, partially removed the soiled brief, and cleansed the resident's buttocks. However, fecal matter was observed on the resident's labia, and the CNA did not clean the front peri-area. When asked to observe the area, the CNA acknowledged not seeing the fecal matter and confirmed that they were supposed to clean the front peri-area.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the provision of incontinent care for a resident with severe cognitive impairment and diagnoses including generalized muscle weakness and cerebral infarction. During the care, a CNA did not change gloves appropriately while handling soiled materials and cleaning the resident. The CNA initially removed the resident's soiled brief and placed a soiled pad on the floor mat without changing gloves. They then put a new brief on the resident without noticing fecal matter in the peri-area, which resulted in the new brief being soiled. The CNA continued to use the same gloves to search for wipes and a new brief in the resident's drawers, and only changed gloves after leaving the room to locate the necessary supplies. Upon returning, the CNA donned new gloves, cleansed the resident's peri-area, and put on another new brief, but again did not change gloves before completing the care and handling other items in the room. The CNA acknowledged they were supposed to change gloves three times during the care but only did so twice, citing a lack of plastic bags for disposing of soiled materials as a contributing factor.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adequately assess and implement interventions to prevent falls for a resident with a history of falls and high fall risk. The resident, diagnosed with schizophrenia, dementia, and other conditions, experienced multiple falls resulting in injuries, including a major head injury in December 2023. Despite the resident's care plan indicating a high risk for falls, the facility did not evaluate the causes of these falls or update the care plan with new interventions after each incident. Observations noted the resident ambulating unsteadily without assistive devices, contrary to care plan recommendations. Another resident experienced falls with injuries, and the facility failed to implement care plan interventions designed to mitigate fall risks. Observations revealed that the resident's room contained fall hazards, such as throw rugs, and lacked a fall mat at the bedside, which were specified interventions in the care plan. The operations manager acknowledged these deficiencies upon inspection of the resident's room. The facility's failure to evaluate falls and update care plans for residents at high risk for falls resulted in repeated incidents and injuries. Staff interviews confirmed the lack of intervention changes and the presence of environmental hazards in residents' rooms, indicating a systemic issue in addressing fall risks and implementing preventive measures.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate payroll-based journal (PBJ) staffing data to CMS for the first quarter of fiscal year 2024. The PBJ Staffing Data Report for the period from October 1, 2024, to December 31, 2024, indicated that the facility lacked registered nurse (RN) hours on multiple dates, including October 22, 23, November 3, 10, 17, 30, December 1, 4, 7, 8, 9, 10, 22, 23, 24, 25, and 30, 2024. Additionally, the report documented that the facility did not have licensed nursing coverage for 24 hours a day on December 9, 10, 23, and 24, 2024. During an interview on May 23, 2024, a Corporate Nurse Consultant acknowledged that the hours were available but were not included in the report. Later that day, the Operations Manager provided documentation of coverage for the specified dates.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who was discharged from Medicare Part A covered services. The Regional MDS Specialist identified that 12 residents had been discharged from a Medicare Part A covered stay with benefit days remaining in the past six months. Specifically, Resident #206 was admitted to Part A skilled services on November 16, 2023, and discharged on December 5, 2024. However, there was no documentation indicating that a SNF ABN was provided to this resident. On May 20, 2024, the Regional MDS Specialist confirmed that they had completed the SNF benefit review and acknowledged that Resident #206 did not receive the required notice.
Persistent Urine Odor in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in room [ROOM NUMBER], as evidenced by a persistent strong odor of urine. This issue was observed over several days, from May 19 to May 23, 2024, with the odor detectable down the hall approximately six feet from the room. Housekeeper #1 reported that the odor had been present since they began working at the facility in March 2024, despite the room being cleaned twice daily and the bathroom tile being replaced. The Housekeeping Supervisor confirmed that the room was cleaned twice a day using chemicals to eliminate odors, but the strong urine smell persisted. The operations manager acknowledged awareness of the ongoing issue, which had been present before their tenure at the facility.
Incomplete Cognitive Assessment in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's cognitive pattern, as required by the minimum data set (MDS). The resident, who had multiple diagnoses including schizophrenia, angina, cerebral infarction, restlessness and agitation, hypertension, acute kidney disease, psychosis, and diabetes mellitus, had a quarterly assessment with section C, cognitive patterns, left incomplete. The assessment contained dashes in every box of section C, indicating that no answers were documented for the cognitive assessment questions. Interviews with the intern Director of Nursing (DON) and the Regional MDS coordinator confirmed that section C should have been completed and that the absence of this information rendered the assessment inaccurate.
Failure to Review Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans were reviewed every three months for three residents out of the 13 care plans reviewed. Resident #12, who had diagnoses including an unspecified skin condition, peripheral vascular disease, and non-pressure ulcers, had their care plan last reviewed on March 11, 2023. Resident #42, with diagnoses such as schizophrenia, angina, cerebral infarction, restlessness and agitation, hypertension, acute kidney disease, psychosis, and diabetes mellitus, had their care plan last reviewed on May 4, 2023. Resident #48, diagnosed with schizophrenia, diabetes mellitus, unspecified psychosis, abnormal coagulation, and acute kidney failure, had their care plan last reviewed on August 14, 2023. The Regional MDS Coordinator, who has been handling care plans for over a year due to the absence of a full-time care plan coordinator, acknowledged that care plans should be reviewed quarterly and annually comprehensively. However, they admitted that nearly all care plans were not current or updated, indicating a systemic issue in maintaining timely reviews.
Deficiencies in Wound Care and Medication Documentation
Penalty
Summary
The facility failed to ensure proper wound care for a resident with a trauma wound on the left second toe. The resident, diagnosed with an unspecified skin condition, peripheral vascular disease, and non-pressure ulcers, had specific physician orders for wound care, including cleansing and dressing changes. However, observations revealed that the resident's dressing was visibly soiled with dried blood and drainage for over six hours without being changed. Despite multiple observations throughout the day, the dressing remained unchanged until after 2:00 p.m., when an LPN finally addressed it. The LPN admitted that the dressing should have been changed earlier but was unaware of its condition. Additionally, the facility failed to accurately document behaviors to support the administration of as-needed antianxiety medication for another resident. The resident had a physician's order for Vistaril to be administered as needed for anxiety. However, the medication administration records and progress notes did not document any behaviors warranting the use of the medication on the dates it was given. Interviews with staff confirmed that the medication should only be administered after unsuccessful attempts to redirect or calm the resident, and such episodes should be documented to assess the need for continued medication use. The lack of documentation suggests that the medication may have been administered without proper justification.
Failure to Timely Implement Weight Loss Intervention
Penalty
Summary
The facility failed to implement a weight loss intervention for a resident who was at risk for weight loss and had a history of severe weight loss. The resident, who had diagnoses including Schizophrenia, Diabetes Mellitus, unspecified psychosis, abnormal coagulation, and acute kidney failure, experienced a severe weight loss of 32 pounds over 180 days and 11 pounds over 30 days. A care plan updated in May 2023 indicated the need for a registered dietician to evaluate and make dietary recommendations. On April 1, 2024, a consulting dietician recommended increasing the resident's intake of house shakes from twice a day to three times a day due to significant weight loss. However, the facility did not act on this recommendation in a timely manner. The recommendation was not signed by the facility's director of nursing and physician until May 14, 2024, and the resident did not begin receiving the shakes three times a day until that date. The dietary manager and the interim director of nursing acknowledged that the facility failed to implement the dietician's recommendations promptly, leading to a delay in addressing the resident's weight loss.
Insufficient Staffing and Supervision in LTC Facility
Penalty
Summary
The facility failed to provide sufficient staffing and supervision to meet the needs of its residents, as evidenced by multiple incidents involving two residents. One resident, diagnosed with schizophrenia, dementia, and other conditions, was at high risk for falls. Despite a care plan that included regular checks and reminders to use a walker, the resident experienced several falls, resulting in injuries such as a subdural hematoma and head lacerations. Staff interviews revealed that the facility was understaffed, with only two aides and one nurse on duty at night, making it difficult to supervise residents adequately and provide necessary care. Another resident, with a diagnosis including peripheral vascular disease and non-pressure ulcers, was observed with a soiled dressing on their left toe for over six hours without it being changed, despite visible dried blood and drainage. The dressing was not changed until after 2:00 p.m. due to staffing constraints. During a resident council interview, multiple residents reported that there were not enough staff to provide timely care, particularly at night.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted with the required components and was accessible to all residents. Observations on multiple occasions revealed that no staff information was posted in the facility. Specifically, on May 19, 2024, at 8:00 a.m., and on May 20, 2024, from 8:00 a.m. through 2:30 p.m., no staffing information was observed. Additionally, on May 21, 2024, at 6:15 a.m., the absence of posted staff information was again noted. An operations manager acknowledged that the staffing information should have been posted on a large white dry erase board near the nurses' station but admitted they were unaware of the requirement to post this information. The facility housed 51 residents at the time of these observations.
Failure to Obtain Consent Before Vaccination
Penalty
Summary
The facility failed to provide education and obtain consent before administering the influenza vaccine to four residents. Specifically, the signed consent forms for these residents were dated after the vaccines were administered. For example, Resident #12 received the influenza vaccine on 10/03/23, but their consent form was dated 10/04/23. Similarly, Resident #15's consent form was dated 04/19/24, while the vaccine was administered on 10/03/23. This pattern was consistent for Residents #23 and #32 as well. During an interview, the Regional Nurse Consultant confirmed that, according to facility policy, vaccines should not be administered before education and consent are obtained. However, the documentation reviewed indicated that this policy was not followed, as the vaccines were given prior to obtaining the necessary consents.
Failure to Obtain Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to provide necessary education and obtain consent before administering the COVID-19 vaccine to three residents. Specifically, the immunization records for these residents showed that they received the vaccine, but there was no documentation of signed consent or evidence that education on the risks and benefits of the vaccine had been provided to them or their representatives. This deficiency was identified during a review of the clinical records for these residents. During an interview, the Regional Nurse Consultant confirmed that the standard procedure is to educate residents or their representatives about the vaccine upon admission or when boosters are available. However, upon reviewing the records, the consultant acknowledged that no education or consent forms were found for the residents in question, indicating that the vaccines were administered without proper consent.
Failure in Discharge Planning for a Resident
Penalty
Summary
The facility failed to ensure proper discharge planning for a resident who was discharged into the community. The resident expressed a desire to leave the facility and live with a friend, but there was no documentation in the clinical record indicating that the facility arranged for necessary medical services, pharmacy services, or follow-up appointments prior to the discharge. The resident was discharged with all belongings and medications, but the facility only transferred medication scripts to a local pharmacy after the discharge. Following the discharge, the facility filed a report with adult protective services and the local police department due to concerns about the safety of the resident's new living situation. The social service director was responsible for discharge planning, but there was no evidence that services were set up before the resident left the facility. The corporate human resource specialist confirmed that there was no documentation of discharge planning prior to the resident's departure, and efforts to complete necessary arrangements were made only after the discharge.
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Illustrative
What surveyors actually found near you
We read the 221 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
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Illustrative
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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) |
|---|---|---|---|---|
| Windsor Hills Nursing Center | 1.1 mi | ★★★★★ | 12 | 0 |
| North Winds Living Center | 1.3 mi | ★★★★★ | 0 | 0 |
| The Grand At Bethany Skilled Nursing And Therapy | 1.6 mi | ★★★★★ | 9 | 0 |
| Heritage Park | 2 mi | ★★★★★ | 0 | 0 |
| Warr Acres Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
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