Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Higher Call Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its food labeling, storage, and monitoring policies. In the main kitchen refrigerator, several prepared food items, including pudding-type desserts and turkey sandwiches, lacked labels and dates, an opened container of Caesar dressing was kept past its manufacturer use-by date, and fresh produce such as zucchini and iceberg lettuce was wilted, soft, and discolored. In a south community refrigerator, opened mayonnaise and barbeque sauce were stored beyond their manufacturer expiration dates, and an opened carton of lactose-free reduced-fat milk had no open or use-by date. The temperature log for this community refrigerator had no entries for multiple consecutive days, despite facility policy requiring daily temperature checks and proper dating of all food items. A total of 41 residents were identified as receiving meals from the kitchen.
A resident experienced a documented fall from bed with reported shoulder and knee pain and observable knee swelling, and the fall was incorporated into the resident’s care plan with fall-prevention interventions. However, the subsequent annual MDS assessment incorrectly indicated that the resident had no falls since admission or the prior assessment. During later review, the MDS coordinator confirmed that the fall history on the annual MDS was inaccurately coded, resulting in a non-comprehensive and inaccurate assessment of the resident’s status.
A nurse failed to follow proper infection prevention practices during wound care for a resident with lower extremity wounds. While performing dressing changes, the RN placed gloved hands on the floor, then used the same gloves to touch the resident’s skin and apply dressings, exited the room wearing the same gown to use hand sanitizer, and handled wound dressings and a pen with partially donned gloves before completing the dressing change. Facility policy required wound care to be performed using clean or sterile technique, but the RN later admitted not changing gloves correctly and not feeling skilled or routine in performing dressing changes, while the DON noted the nurse was nervous and inadequately prepared.
The facility failed to ensure that residents did not receive unnecessary psychotropic medications. One resident receiving an antianxiety medication had no documented side-effect monitoring, and another resident with a PRN order for lorazepam did not have frequent evaluations of the PRN order. Staff interviews confirmed the lack of required documentation.
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Temperature logs for refrigerators, freezers, and dish machines were not recorded, and open food packages were undated. Bulk containers were left open with scoops inside, and trash cans were uncovered. Cook #1 confirmed these lapses in protocol.
The facility failed to complete a Skilled Nursing Facility Advance Notice of Beneficiary Notice of Non-coverage (SNFABN) form before having a resident sign it. The form lacked essential information such as the services to be charged, the reason Medicare may not pay, and the estimated costs. The resident's decision to continue or discontinue the services was also not indicated. The BOM confirmed the document should have been completed accurately before obtaining the resident's signature.
The facility failed to assess a resident for safe bed rail use and obtain informed consent before using bed rails. The resident required substantial assistance and had moderate cognitive impairment, but no documentation of assessment or consent was found. The DON confirmed the staff did not follow the proper procedure.
The facility failed to follow infection control protocols during wound care for a resident with MRSA and stage 3 pressure ulcers. An LPN did not perform hand hygiene between glove changes and supported the resident's uncovered heels on their uniform pants. Interviews confirmed these actions were against facility policy.
A resident with multiple health conditions repeatedly stated they did not feel well and did not want to go to the dining hall for a meal. Despite these refusals, an LPN physically removed the resident from their room and moved them to the dining room using a gait belt. Multiple staff members corroborated the incident, and the DON confirmed that the resident's rights were violated.
An Immediate Jeopardy situation was identified due to an LPN's failure to prevent mental and physical abuse of a resident. The LPN forcefully walked the resident using a gait belt despite the resident's complaints of feeling unwell, leading to multiple falls and the resident becoming unresponsive. Three staff members witnessed the abuse but did not intervene.
A resident with multiple diagnoses, including heart disease and Alzheimer's, became unresponsive after multiple falls. The LPN failed to assess the resident immediately and did not initiate CPR, mistakenly believing the resident was a DNR. CPR was eventually performed improperly, leading to a deficiency identified by surveyors.
A resident with multiple diagnoses, including Alzheimer's Disease and generalized muscle weakness, was forced by an LPN to walk to the dining room using a gait belt, despite the resident's repeated statements of feeling unwell and not wanting to leave their room. Multiple staff members observed the resident's distress and instability, and the Director of Nursing confirmed that the gait belt was used as a physical restraint.
A resident with multiple diagnoses was forced by an LPN to walk to the dining room despite feeling unwell, leading to repeated falls and eventual death. The facility delayed investigating the incident and did not immediately suspend the LPN, potentially exposing other residents to further risk.
A facility failed to notify a resident's family of a significant weight loss, as required by policy. The resident experienced a 22.28% decline in body weight over one month, and the family only learned of the change through a family friend. The DON confirmed the lack of documentation and acknowledged that staff did not follow the notification policy.
The facility failed to conduct and document skin and wound assessments as ordered by a physician for a resident with pressure ulcers and quadriplegia. Multiple daily skin assessments and weekly wound assessments were missing from the resident's electronic medical record. Both an LPN and the DON confirmed the assessments were not completed as required.
Failure to Label, Discard, and Monitor Food Items and Refrigerator Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to follow its own food labeling, storage, and monitoring policies for food served to residents. Surveyors observed in the main kitchen refrigerator multiple prepared food items without required labels, preparation dates, or use-by dates, including five covered containers with a white pudding-type substance and two prepared turkey sandwiches wrapped in plastic. They also found an opened one-gallon container of Caesar dressing with a manufacturer use-by date that had already passed, as well as fresh produce (zucchini squash and iceberg lettuce) that was wilted, soft to the touch, and discolored. The facility’s policy required all food containers to be labeled with the common name of the food, date prepared or opened, discard date, and staff initials, and the dietary manager acknowledged that staff had not consistently labeled and dated items and that fresh food should be checked and discarded if not fresh. In a south community refrigerator, surveyors observed additional failures to manage food items and temperature monitoring as required. They found an opened container of mayonnaise and an opened container of barbeque sauce, both past the manufacturer’s expiration dates, and an opened carton of lactose-free reduced-fat milk without an open or use-by date. The refrigerator temperature log posted on this community refrigerator had no dates or temperatures recorded for three consecutive days. Facility policy for LTC resident refrigerators required staff to document the date received, date opened, expiration date, and resident name on each food item, and to maintain the refrigerator at or below 40°F. The administrator stated that housekeeping was responsible for checking community refrigerator temperatures daily and outdated food weekly, and acknowledged that the temperature checks for the south community refrigerator had not been completed as required. A total of 41 residents were identified as receiving meals from the kitchen during this period.
Inaccurate MDS Coding of Resident Fall History
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment of a resident’s fall history. A progress note dated 07/30/25 at 3:45 a.m. documented that Resident #36 reported rolling out of bed onto the floor, with complaints of left shoulder pain and right knee pain, and observation that the right knee appeared slightly larger than the left. A care plan initiated the same day documented that the resident had a fall on 07/30/25 and included interventions such as use of a fall mat next to the bed and education not to sleep on the edge of the bed. Despite this documented fall and related care plan, the resident’s annual MDS assessment dated 10/15/25 indicated that the resident had not had any falls since admission, entry, reentry, or the prior assessment. On 01/08/26, during review of the annual assessment, the MDS coordinator acknowledged that the annual assessment was not accurately coded regarding the resident’s fall history, demonstrating that the facility did not complete a comprehensive and accurate assessment as required by its MDS 3.0 Completion policy and federal regulations.
Inadequate Infection Control During Wound Care Procedure
Penalty
Summary
The deficiency involves the facility’s failure to maintain infection control practices during wound care for one resident receiving treatment to multiple lower extremity wounds. During observation of a wound dressing change, an RN providing care knelt on the tiled floor and placed both gloved hands on the floor, then used the same contaminated gloves to touch the resident’s bare skin and apply a gauze dressing to the left shin. The RN then exited the room while still wearing the gown to use hand sanitizer from a container outside the room, partially donned new gloves, reached into a pocket to retrieve a pen, and with those partially donned gloves handled gauze soaked in Dakin’s solution and placed it onto a wound on the right heel. The RN then fully donned the gloves and used the same gloved hands to write the date on the dressing, insert iodoform gauze soaked in Dakin’s solution into the right heel wound, and apply a border gauze dressing. Facility policy required that wound care be performed by licensed nursing staff using clean or sterile technique as ordered. The RN later acknowledged not realizing they had not changed gloves correctly and stated they were not very skilled at dressing changes and did not feel they had an established routine, while the DON reported the RN was nervous and should have better prepared for the wound care. The Director of Nursing identified that a total of 15 residents in the facility were receiving wound care, and the cited deficient practice was observed in one of two sampled residents reviewed for wound care during the survey.
Failure to Monitor Psychotropic Medication Side Effects and PRN Orders
Penalty
Summary
The facility failed to ensure that residents did not receive unnecessary psychotropic medications. Resident #5, who had diagnoses including depressive episodes and hip pain, was receiving an antidepressant and an antianxiety medication. However, there was no documentation of side-effect monitoring for the antianxiety medication in the resident's health record. Similarly, Resident #19, who had diagnoses including anxiety and depression, had a PRN order for lorazepam. The facility did not document frequent evaluations of the PRN order for this psychotropic medication. Interviews with RN #1 and the DON confirmed that side-effect monitoring and frequent evaluations of PRN orders for psychotropic medications were not consistently documented as required.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. During an observation on 05/13/24, it was noted that the refrigerator and freezer temperature logs had not been recorded since 05/06/24. Additionally, open packages of sliced ham, shredded cheese, and chicken noodle soup were found in a reach-in cooler without any dates. Bulk containers of sugar and flour were left open with scoops inside, and all four trash cans in the kitchen were uncovered. The dish machine temperature log also lacked documentation of temperature and sanitizer concentration for the first 13 days of May. Furthermore, the food temperature log had not recorded any meal temperatures since the noon meal on 05/06/24. Cook #1 confirmed that the temperature logs for the freezers and coolers should be recorded by the cook on duty and that open containers of food should be closed and dated. They also stated that scoops should not be left in bulk containers and that meal temperatures should be recorded prior to serving. The person washing dishes was responsible for monitoring the dish machine, and the temperature and chemical concentration should be recorded three times a day. The DON identified 37 residents who received meals from the kitchen, indicating a widespread impact of these deficiencies.
Incomplete SNFABN Form
Penalty
Summary
The facility failed to properly complete a Skilled Nursing Facility Advance Notice of Beneficiary Notice of Non-coverage (SNFABN) form before having a resident sign it. Specifically, the form for Resident #20, who was admitted and later discharged, was signed on 05/01/24 but lacked essential information. The sections where the services to be charged, the reason Medicare may not pay, and the estimated costs were supposed to be listed were left blank. Additionally, the area where the resident was to indicate whether they wanted to continue or discontinue the services was also not filled out. The Business Office Manager (BOM) confirmed that the document should have been completed with accurate information before obtaining the resident's signature.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was assessed for their ability to safely use bed rails and that informed consent was obtained from the resident or their representative prior to the use of bed rails. The facility's policy required an assessment and informed consent before bed rails could be used. A quarterly assessment documented that the resident required substantial assistance to reposition themselves in bed and had moderate cognitive impairment. However, a review of the resident's medical record did not find documentation of an assessment or informed consent for bed rail use. Observations confirmed that the resident's bed had half rails in the up position, and the resident stated they needed the rails for support. The DON confirmed that the staff had not followed the proper procedure as per the facility's policy.
Infection Control Protocols Not Followed During Wound Care
Penalty
Summary
The facility failed to ensure infection control protocols were followed during wound care for one resident with MRSA and stage 3 pressure ulcers on both heels. During an observation, an LPN was seen changing the resident's wound dressings without performing hand hygiene between glove changes on three occasions. Additionally, the LPN supported the resident's uncovered heels directly on their uniform pants while changing the dressings. Interviews with a CNA and the DON confirmed that hand hygiene should be performed when changing gloves and that it was unacceptable to rest an uncovered wound on a uniform.
Violation of Resident's Right to Refuse Care
Penalty
Summary
The facility failed to ensure a resident's right to remain in their bed and to decline a meal. Resident #1, who had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness, repeatedly stated they did not feel well and did not want to go to the dining hall for a meal. Despite these refusals, LPN #1 physically removed Resident #1 from their room and moved them to the dining room using a gait belt. This incident was captured on a facility video recording dated 11/02/23, showing LPN #1 walking Resident #1 from their room to the dining room at 8:22 a.m. Multiple staff members corroborated the incident. CNA #2 stated that Resident #1 had informed them and LPN #1 that they did not want to get out of bed as they did not feel well. CNA #1 observed LPN #1 walking behind Resident #1 in the hallway and heard the resident state they were out of breath and did not want to continue. CMA #1 observed LPN #1 bringing Resident #1 into the dining room using a gait belt and stated that LPN #1 was basically dragging the resident through the dining room. The Director of Nursing (DON) confirmed that by not allowing Resident #1 to remain in bed, LPN #1 had violated the resident's rights.
Removal Plan
- Grievance book has been established to ensure issues are being taken care of in a timely manner.
- Discussed policy on the residents' right to refuse any care, activities, or anything they want to refuse.
- In-service staff on Self Determination.
- Risk management will monitor the facility issues weekly during regularly scheduled meetings.
- QAPI will monitor quarterly.
Failure to Prevent Resident Abuse and Neglect
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified at the facility due to the failure to prevent mental and physical abuse of a resident. The incident involved a Licensed Practical Nurse (LPN) who used a gait belt to forcefully walk a resident from their room to the dining hall despite the resident's repeated statements of feeling unwell and not wanting to leave their room. The resident, who had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness, fell multiple times during the incident and ultimately became unresponsive. The LPN did not perform CPR, mistakenly believing the resident was a Do Not Resuscitate (DNR) order, when in fact the resident was a full code. Three staff members witnessed the abuse but did not intervene to stop it. The facility's video recording documented the LPN walking the resident using a gait belt, the resident falling multiple times, and being picked up by the LPN before finally being placed in a wheelchair by three staff members and removed from the dining room. Progress notes and staff interviews revealed that the resident had informed staff of feeling dizzy, cold, and unwell, but the LPN dismissed these complaints and insisted on moving the resident to the dining room. The LPN's actions included physically lifting the resident multiple times despite their protests and visible instability, and making derogatory comments towards the resident. Staff interviews further corroborated the events, with witnesses describing the resident's unstable condition and the LPN's forceful handling of the resident. The Director of Nursing (DON) confirmed that the LPN's conduct was abusive and violated the facility's abuse prevention policy. The incident highlights a severe lapse in protecting the resident's right to be free from abuse and neglect, as well as a failure in staff intervention and adherence to proper care protocols.
Removal Plan
- Grievance book has been established to ensure issues are being taken care of.
- Discussed policy on not allowing abuse or neglect in the facility.
- In-service staff on abuse and neglect.
- Monitoring will happen in Risk management and in QAPI through regularly scheduled meetings.
Failure to Provide Timely CPR to Unresponsive Resident
Penalty
Summary
The facility failed to ensure that a resident who had become unresponsive was immediately assessed by a licensed nurse and received cardio-pulmonary resuscitation (CPR) according to standards of practice. The resident, who had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness, was documented as a full code. Despite this, the resident did not receive timely CPR when they became unresponsive after multiple falls while being walked to the dining room by an LPN. The LPN, along with other staff members, transferred the unresponsive resident to a wheelchair and then to their bed without performing an immediate assessment or initiating CPR. The LPN incorrectly believed the resident was a do-not-resuscitate (DNR) and did not perform CPR until much later, after being informed by the Director of Nursing (DON) that the resident was a full code. By the time CPR was initiated, it was performed improperly, with the resident in a bed without a backboard and compressions being too deep, as observed by the DON. The incident was captured on a facility video recording, which showed the resident falling multiple times and being transferred to a wheelchair by the LPN, a physical therapist (PT), and a certified medication aide (CMA). The video also recorded the LPN and other staff members standing over the resident without performing an assessment or initiating CPR. Witnesses, including CNAs and the PT, confirmed that the resident appeared unresponsive and had blue lips, indicating a lack of oxygen. Despite these signs, the LPN did not perform CPR immediately and instead moved the resident to their room, where they were placed in bed and left unattended for a period. Interviews with staff members revealed that the LPN had a mistaken belief about the resident's code status, which led to a delay in initiating CPR. The DON confirmed that the LPN did not follow facility policy during the incident and that the CPR performed was inadequate. The LPN's actions and inactions, including the failure to assess the resident immediately and the improper execution of CPR, contributed to the deficiency identified by the surveyors.
Removal Plan
- LPN #1 was terminated.
- The DON or designee educating all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident.
- RN shift supervisor given responsibility to direct/assign staff roles during code/initiation of code.
- A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted.
- DON or designee will audit new admissions to compare the resident's advance directives to the physician orders for accuracy.
- DON or designee performed a Code Blue drill and was performed with licensed nursing staff on all shifts until every nurse had participated at least once. Code Blue drills will continue to be held.
Improper Use of Gait Belt as Physical Restraint
Penalty
Summary
The facility failed to prevent the use of a gait belt as a physical restraint for a resident diagnosed with atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. On the specified date, a video recording showed an LPN walking behind the resident, who was hunched over a walker, while holding a gait belt secured around the resident's lower chest. Despite the resident's repeated statements of not wanting to leave their room and feeling unwell, the LPN used the gait belt to force the resident to the dining room. The progress note written by the LPN confirmed that the resident had declined to leave their room, but the LPN ignored the resident's statements and used the gait belt to remove them from their room and take them to the dining room. Multiple staff members, including two CNAs and a CMA, observed the incident and reported that the resident expressed feeling dizzy, out of breath, and unstable. The LPN continued to force the resident to walk using the gait belt, despite the resident's visible distress and statements of being unable to walk. The Director of Nursing later confirmed that the way the LPN used the gait belt on the resident constituted a physical restraint.
Delayed Investigation of Potential Abuse
Penalty
Summary
The facility failed to protect residents from potential abuse by delaying an investigation of possible abuse for one resident. The resident had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. A video recording showed an LPN walking the resident to the dining room using a gait belt, despite the resident's complaints of not feeling well, being cold, having tremors, and being dizzy. The resident fell repeatedly and was eventually placed in a wheelchair and removed from the dining room. The resident later died, and the LPN was found performing chest compressions alone without a crash cart or backboard. The DON was informed of the incident but did not start an investigation until several days later, despite receiving information from CNAs and a family member about the resident being forced to walk to the dining room against their will. The DON and ADON were informed by CNAs that the LPN had made the resident get up from bed against their will and that the resident had died in the dining room. The DON did not start the investigation over the weekend because the weekend staff was not on duty when the resident died. The LPN was not instructed to stay away from the facility until the investigation began on Monday, allowing the LPN to have access to residents before being suspended. The delay in starting the investigation and the failure to immediately suspend the LPN potentially exposed other residents to further risk of abuse.
Failure to Notify Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's family of a significant weight loss. A review of records and interviews revealed that one resident experienced a 22.28% decline in total body weight from January 2024 to February 2024, dropping from 124.8 pounds to 97.0 pounds. Despite the facility's policy requiring notification of significant changes in a resident's condition, the family was not informed. A family member only became aware of the weight loss through a family friend who visited the resident. The Director of Nursing (DON) confirmed the lack of documentation indicating that the family had been informed and acknowledged that staff did not follow the policy in this situation.
Failure to Conduct and Document Required Skin and Wound Assessments
Penalty
Summary
The facility failed to conduct and document skin and wound assessments as ordered by a physician for a resident diagnosed with pressure ulcers and quadriplegia. The physician's orders required daily skin assessments starting on 01/23/24 and weekly wound assessments on Thursdays starting on 01/25/24. However, a review of the resident's electronic medical record revealed missing daily skin assessments on multiple dates and missing weekly wound assessments on several Thursdays. Both an LPN and the Director of Nursing confirmed that the assessments were not documented and likely not completed as required.
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 88 citations issued within 25 miles in the last 12 months — including the 4 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 Quapaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastwood Manor | 4.9 mi | ★★★★★ | 0 | 0 |
| Windridge Nursing And Rehabilitation Center | 5.3 mi | ★★★★★ | 1 | 0 |
| Miami Nursing Center, Llc | 7.8 mi | ★★★★★ | 14 | 2 |
| Quaker Hill Manor | 8.2 mi | ★★★★★ | 20 | 0 |
| Galena Nursing & Rehab Center | 12 mi | ★★★★★ | 3 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.