Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Leisure Village Health Care Center during CMS and state inspections, most recent first.
Surveyors found multiple food safety failures involving dish machine sanitation logs, hand hygiene, and refrigerator labeling. Dietary staff did not consistently record sanitizer levels or rinse temperatures for the dish machine, were observed touching their face, hair, glasses, dirty dishes, and clean food without washing or sanitizing their hands, and several food items in refrigerators were missing dates or had incorrect dating.
Infection control and medication handling failures were observed involving staff not completing annual N95 fit testing, improper handling and disinfection of glucometers during FSBS checks and insulin administration for two residents with diabetes, and a CMT touching tablets with bare hands during medication pass. Staff interviews confirmed inconsistent practices, including lack of fit testing, no barrier use for equipment placement, and direct hand contact with medications.
Failure to notify the physician when a resident’s scheduled hydroxyzine was repeatedly not administered before dialysis. The resident had ESRD and dialysis dependence, and the order directed hydroxyzine before dialysis on dialysis days. MAR review showed multiple missed doses over several months because the resident was out of the facility, while staff said the overnight shift was responsible for giving the medication before the resident left and that recurring missed doses should have been communicated.
A facility failed to ensure nighttime snacks were provided to residents on South Hall as required by policy. Residents reported that snacks were left at the main nurses' station, were picked over, and often were not available by the time they got there. Staff confirmed that dietary delivered snack trays to the station and nursing was responsible for distributing them, but South Hall residents still often did not receive snacks.
Failure to Offer and Document Pneumococcal Vaccinations: The facility did not ensure that pneumococcal vaccination was offered to 3 residents reviewed for immunizations. Their EMRs were blank in the immunization section, and MDS assessments showed the vaccine was not up to date because it had not been offered. Interviews with the residents and staff confirmed there was no documentation of an offer, refusal, or receipt of the vaccine.
Failure to Offer and Document COVID-19 Vaccinations: The facility failed to offer the COVID-19 vaccine to three sampled residents and failed to document their vaccination status. The residents had diagnoses including COPD, CHF, emphysema, cerebral palsy, and acute respiratory failure, and their MDS assessments showed COVID-19 vaccination was not up to date. EMR immunization sections were blank or lacked evidence of an offer or refusal, and interviews with the residents and staff confirmed no documentation could be found.
Uneven Meal Service at Shared Tables: Three residents seated together were not served their meals at the same time during meal observations. One resident was eating while two others at the same table had not yet received food, and on another observation one resident had eaten most of the meal while the other two still had not been served. Staff stated residents should be served together, but meal delivery followed the cook's flow and was not being monitored for table-by-table service.
Damaged wheelchair armrests left unrepaired. A resident with dementia, muscle weakness, unsteadiness on feet, and severe cognitive impairment used a wheelchair for mobility, but the chair’s armrests were observed with cracked and torn areas, including exposed foam. Staff stated damaged equipment should be reported, yet the Maintenance Supervisor knew about the issue and had not fixed it, and the Administrator found no prior maintenance system entries for the wheelchair.
Respiratory Care Provided Without Order and Equipment Stored Improperly: A resident with COPD and SOB was observed receiving oxygen via nasal cannula from a concentrator set at 3.5 LPM even though no physician order for supplemental oxygen was found in the EMR or MARs. The resident’s nebulizer mouthpiece and tubing were repeatedly left uncovered on the nightstand instead of being stored in a labeled bag, and the ordered oxygen humidifier bottle was not present during observations.
A resident receiving HD had no physician order or care plan for dialysis services or HD catheter care, and the record lacked documented post-dialysis assessment and monitoring. The resident had ESRD on HD, returned with a new chest HD catheter, and facility staff acknowledged that post-HD vital signs, catheter monitoring, and dialysis communication documentation were expected but not found in the chart.
A facility’s medication error rate was above the required threshold after an LPN prepared NovoLog and Lantus insulin pens for a resident with type 2 DM and moderate cognitive impairment without first performing the insulin pen safety test. The LPN dialed the ordered doses but did not prime the pens with 2 units before administration, and later stated she had not been shown how to prime them. Facility policy and staff interviews confirmed that insulin pens were expected to be primed before use, and the overall medication error rate was 7.41%.
The facility failed to maintain comfortable water temperatures in all shower rooms, resulting in water that quickly became uncomfortably cold during use. Temperature checks by surveyors showed significant drops from initially warm or hot water to much cooler levels within minutes in multiple shower rooms. A resident reported that shower water became "ice cold" after a brief period and that they avoided showers, while others described the water as "freezing" and "frigid." CNAs reported that water turned very cold within a few minutes, forcing them to rush bathing and leading some residents to refuse showers. Staff stated they had reported the issue to maintenance several times, but the maintenance supervisor admitted there were no routine water temperature checks or logs, and the administrator acknowledged the water was too cold for them to take a shower.
Surveyors found that dietary staff lacked proper training and competency to operate the low-temperature dish machine. Two dietary aides relied on the presence of suds and visual checks of a temperature gauge instead of using required test strips or documented temperature checks, and one aide stopped the dish machine mid-cycle and walked away. One aide reported receiving informal training from another staff member and had not been taught how to check temperatures or use test strips, despite frequent use of the machine. The DM could not produce quarterly training records, 90-day nutrition services training, or annual competency documentation for dietary staff and acknowledged that, although procedures were reviewed in orientation, staff did not understand or follow the required dish machine testing process.
The facility failed to ensure proper sanitation and monitoring of dishware and cooking utensils for residents receiving meals from the kitchen. Surveyors observed a low-temp dishwasher stopped mid-cycle with suds in the reservoir and a temperature around 140°F, while the warewashing log lacked required daily documentation for multiple days. Staff reported hot water problems, use of three plastic tubs with heated water from the stove, and reliance on paper products, but the dietary manager and other dietary staff did not check or document water or sanitizer temperatures as required. One dietary aide relied only on the dishwasher gauge and visible suds and did not use test strips, while another had not been trained to test the machine. The administrator and dietary manager acknowledged uncertainty and lack of documentation regarding required daily dishmachine testing.
The facility did not consistently notify resident representatives of significant changes in condition for two residents, including new diagnoses, medication changes, and a fall. Documentation and interviews revealed that while physicians were informed, representatives were not always notified, and staff had inconsistent understanding of notification requirements.
A resident with hypertension and intact cognitive status frequently left the facility independently in a motorized wheelchair, sometimes signing out and sometimes requiring staff assistance. The care plan did not address the resident's ability to sign out, their preference for outdoor activities, or the need for staff involvement in the sign-out process, despite facility policy and observed behaviors. Staff confirmed these elements were not included in the care plan.
A resident in a long-term care facility was verbally abused by a staff member, as reported by the resident's roommate who overheard the staff member cursing. The facility's investigation substantiated the verbal abuse incident.
The facility experienced a 12% medication error rate due to errors in administering medications to two residents. One resident did not receive their prescribed medications for GERD and constipation, while another received the wrong ophthalmic solution at an incorrect time. The errors were attributed to CMAs forgetting to review the MAR and administering medication at the resident's request.
The facility failed to ensure medications were labeled and dated when opened, as observed in four medication and treatment carts. Staff acknowledged the requirement to date medications upon opening, yet several items, including insulin pens and inhalers, were found without dates. Additionally, some medications lacked proper labeling with the resident's name and dosage information.
A resident with multiple diagnoses, including multiple sclerosis and chronic pain, had a physician's order for a catheter privacy bag to be in place every shift. However, observations revealed the catheter bag was visible from the hallway without a privacy bag. The resident preferred the bag to be covered, but staff only did so upon request. A CNA admitted the oversight, and the DON expected privacy bags for all residents with indwelling catheters.
A resident with contractures did not receive recommended restorative services for contracture management, as indicated by a PT evaluation. Despite a physician's order for hand roll use and observations of positioning aids, there was no documentation of restorative services being provided. The DON and corporate RN could not locate records of the program's initiation or follow-up, and the former DON noted the resident was not agreeable to therapy.
A facility failed to properly position a urinary catheter bag for a resident, as it was observed on the floor on two occasions. A CNA confirmed the improper placement, and the DON acknowledged the absence of a policy regarding catheter bag positioning.
The facility failed to label, date, and store food items according to policy, affecting 77 residents. Surveyors found unlabeled and undated frozen biscuits and cookies, as well as an unsecured bag of lettuce without a label or date. The DM confirmed that all leftover food should be securely closed and labeled with a date.
A facility failed to implement enhanced barrier precautions during peg tube care for a resident with dysphasia. Despite signage and supplies being present, an LPN administered medication without wearing a gown, and stated the resident was not on infection control precautions. The infection preventionist and DON confirmed that such precautions should be used, but a policy had not been implemented.
A facility failed to ensure the required two-person assist during a mechanical lift transfer for a resident with a femur fracture and dementia, resulting in the resident falling. Despite training, only one CNA was present during the transfer, contrary to the care plan and safety protocols.
A resident with cognitive decline and dementia was left upset and partially clothed after a CNA improperly performed perineal care by picking off dry material with their hands instead of using wipes and cleanser. The CNA did not inform other staff of the resident's condition, leaving the resident without proper assistance and with the door open. The DON confirmed the CNA did not follow facility policy.
A CNA failed to provide perineal care according to accepted standards for a resident. The CNA found the resident with vaginal discharge and, instead of using a cleanser and wipes, attempted to pick the dry discharge off with their hands, causing discomfort. The DON confirmed this was substandard care.
The facility failed to provide showers for two residents who required assistance with activities of daily living. One resident, with COPD and Parkinson's, reported not having a shower in over a week due to staffing issues. Another resident stated they only received showers when they had a doctor's appointment. CNAs confirmed time constraints and inconsistent documentation of showers. The DON acknowledged the issue and mentioned plans to hire bath aides.
The facility failed to answer call lights promptly, as documented in resident council minutes and grievance logs. Residents reported waiting up to an hour, with one experiencing a colostomy bag burst due to delays. Staff acknowledged call lights should be answered within 5-10 minutes, but no written policy existed to enforce this standard.
A CMA was observed using bare fingers to break a potassium pill before giving it to a resident, acknowledging that gloves and a pill cutter should have been used, indicating a breach in infection control practices.
Food Safety Failures in Dish Machine Logs, Hand Hygiene, and Refrigerator Labeling
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Surveyors found that daily documentation was missing for the dish machine sanitation test strip levels and rinse temperature levels, dietary staff did not perform hand hygiene during meal service, and food in facility refrigerators was not labeled and dated appropriately. For the dish machine, the facility policy required test strips to be available and results to be checked and recorded daily. The Low Temperature Dish Machine Log for May 2026 showed no documented wash or rinse temperatures for breakfast, lunch, or dinner on 05/30/2026 and 05/31/2026, and no sanitizer levels were recorded for the entire month. The June 2026 log also showed no sanitizer levels recorded from 06/01/2026 through the morning of 06/10/2026. During observations and interviews, dietary staff gave conflicting information about whether the machine was high temperature or low temperature, and staff confirmed sanitizer levels were not being recorded. One dietary aide stated the sanitizer strips had not been available since 06/08/2026. During meal service and kitchen activities, surveyors observed dietary staff touching their face, hair, glasses, dirty dishes, and clean food items without performing hand hygiene. Staff continued placing covers on plated food, sorting diet tickets, delivering food and beverages, putting plates into carts, and cooking eggs without washing or sanitizing their hands after those contacts. In the refrigerator observations, leftover foods such as chicken noodle soup, ketchup, chocolate pudding, tomato soup, grapes, brown sugar, watermelon, a pickle spear, and ranch dressing were found with incorrect dates, missing dates, or only a best-use-by date. Staff interviews confirmed that some items were dated with the open date, some were dated incorrectly, and some items in non-kitchen refrigerators were not labeled with an expiration date.
Infection Control and Medication Handling Failures
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program when it did not complete annual fit testing for N95 respirators for staff. During interviews, the Regional Nurse Consultant stated the facility did not have a fit testing policy and followed CDC guidance, while multiple staff members, including the ADON/Infection Preventionist, a CMT, a CNA, and the Rehabilitation Director, stated they had not been fit tested at the facility. The Regional Nurse Consultant also stated the facility was not fit testing staff at that time and had not done so during the prior annual skills fair. The facility also failed to follow infection control practices during blood glucose monitoring and insulin administration for two residents with diabetes. Resident #66 had type 2 diabetes mellitus, intact cognition, and active orders for insulin aspart on a sliding scale. During observation, an LPN checked the resident’s FSBS, removed gloves, used bare hands to place the glucometer under her arm, then cleaned the glucometer with an alcohol pad before placing it in the resident-labeled plastic bag. The LPN stated she always used alcohol pads to clean the glucometer because each resident had their own glucometer. Resident #83 had type 2 diabetes mellitus, moderate cognitive impairment, and active orders for insulin glargine and insulin aspart. During observation, an LPN placed insulin pens and a glucometer on a tray table without first using a barrier, then used the glucometer for FSBS and administered insulin. After removing gloves, the LPN carried the glucometer with bare hands and placed it directly on a medication cart without first placing a barrier on the cart. She stated she had not received education on barrier use after using the glucometer. The ADON/Infection Preventionist and DON stated they expected staff to use a barrier, perform hand hygiene, wear gloves, and disinfect the glucometer with a Super Sani wipe. The facility also failed to follow its medication administration policy when a CMT handled medications with bare hands during administration to Resident #9. Resident #9 had chronic pain and vertigo and intact cognition. During observation, the CMT used her fingers to remove acetaminophen tablets and a meclizine tablet from the medication bottle lids and placed them in a medication cup before administering them to the resident. The CMT stated she routinely touched medications with her fingers, and the Pharmacy Consultant and ADON/Infection Preventionist stated staff should not touch medications with their fingers.
Failure to Notify Physician When Scheduled Hydroxyzine Was Missed Before Dialysis
Penalty
Summary
The facility failed to notify the physician when Resident #41’s ordered hydroxyzine was not administered as scheduled before dialysis. Resident #41 was admitted with end stage renal disease and dependence on renal dialysis, had intact cognition with a BIMS score of 15, and had care plan interventions directing staff to give an anti-anxiety medication before dialysis. The physician’s order directed hydroxyzine 10 mg by mouth every Tuesday, Thursday, and Saturday before dialysis, and the MAR scheduled the medication for 6:15 AM on those days. Record review showed repeated missed administrations over several months. The MAR documented multiple occasions in January, February, March, April, May, and June 2026 when hydroxyzine was not given because the resident was out of the facility for dialysis, and on some days the dose was documented as held. Staff interviews indicated that the resident typically left for dialysis before the day shift began, that the medication should have been given before the resident left, and that the overnight staff was responsible for administering it. Staff also stated that they routinely documented the resident as out of the facility when the medication was not given. Interviews with nursing staff, the DON, the Administrator, and the Medical Director showed awareness that the resident should have received the medication as ordered and that recurring missed doses should have been communicated. The DON stated that an adjustment should have been made to ensure medications were given as ordered, and the Medical Director stated that the concern should have been addressed and reported. The facility policy required medications to be administered according to physician orders and stated that the physician must be notified when a scheduled dose was not given.
Nighttime Snacks Not Distributed to South Hall Residents
Penalty
Summary
The facility failed to ensure nighttime snacks were provided to residents on South Hall in accordance with resident needs, preferences, and requests. Facility policy stated that an evening snack shall be provided by Nutritional Services and offered to residents by Nursing, and that additional snacks shall be provided between meals as ordered or per resident preference or request. A facility snack delivery log also indicated snacks were to go out every night between 6:30 PM and 7:00 PM, including nutritionally dense frozen snack cups, health shakes, and peanut butter and jelly sandwiches. Resident interviews showed that snacks were not being reliably distributed on South Hall. One resident with intact cognition, supervision or touching assistance with eating, and no therapeutic diet stated the facility did not make or provide enough snacks and that residents had to get them from the nurses' station themselves. Another resident with type 2 diabetes mellitus, mild protein-calorie malnutrition, moderate cognition, partial to moderate assistance with eating, a mechanically altered diet, and use of a walker or wheelchair stated they did not get nighttime snacks and that by the time they reached the nurses' station, the snacks were usually gone. Staff interviews confirmed inconsistent delivery and distribution practices. CNAs and LPNs stated snacks were brought to the main nurses' station, often before South Hall staff were notified, and that residents or staff would then try to obtain them from the station. One CNA stated South Hall residents did not receive nighttime snacks and that complaints had been made for months. The Dietary Supervisor stated dietary staff delivered snack trays to the main nurses' station and nursing was responsible for distributing them to the halls, while the Registered Dietician stated the number of snacks should allow at minimum one snack per person and that nursing was responsible for distribution after dietary handoff. The Administrator stated his expectation was that staff were following the established process.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccination was offered to 3 of 5 sampled residents reviewed for immunizations. The facility policy titled, Pneumococcal Vaccine, stated that the opportunity to receive the pneumococcal vaccine would be extended to all residents and that the facility would provide information regarding the risks and benefits of receiving the vaccine, with immunization details to be documented in the medical record. However, the immunization sections in the EMRs for Residents #7, #44, and #77 were blank and did not show that the vaccine had been offered or refused. Resident #7 was admitted with diagnoses including COPD without exacerbation, emphysema, and acute respiratory failure with hypoxia, and had a BIMS score of 12 indicating moderate cognitive impairment. Resident #44 was admitted with diagnoses including COPD and cerebral palsy and had a BIMS score of 15 indicating intact cognition. Resident #77 was admitted with diagnoses including heart failure and type 2 diabetes mellitus and had a BIMS score of 12 indicating moderate cognitive impairment. For each resident, the MDS indicated the pneumococcal vaccine was not up to date and had not been received because it was not offered. During interviews, Resident #7 said the vaccine had not been offered and they would not have been interested, while Residents #44 and #77 said they had not been offered the immunization and would have liked to have been offered. Staff interviews confirmed there was no documentation that the residents declined or received the pneumococcal vaccine, and the RNC stated the facility would begin offering pneumococcal immunizations going forward.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that 3 of 5 sampled residents reviewed for immunizations were offered the COVID-19 vaccine. A facility policy titled, COVID Vaccine, revised 09/04/2024, stated that the facility would offer the COVID vaccine to employees and residents and maintain documentation for all residents and employees on COVID-19 vaccination. However, the Immunizations sections in the EMRs for Residents #7, #14, and #44 were blank or did not show that the vaccine had been offered or refused. Resident #7 was admitted with diagnoses including COPD without exacerbation, emphysema, and acute respiratory failure with hypoxia, and had a BIMS score of 12 indicating moderate cognitive impairment; the MDS showed the resident's COVID-19 vaccination was not up to date. Resident #14 was admitted with chronic systolic CHF and COPD and had a BIMS score of 14, indicating intact cognition; the MDS also showed the resident's COVID-19 vaccination was not up to date. Resident #44 was admitted with COPD and cerebral palsy and had a BIMS score of 15, indicating intact cognition; the MDS likewise showed the resident's COVID-19 vaccination was not up to date. During interviews, each resident stated they had not been offered the vaccine or did not recall being offered it, and the ADON/IP and RNC stated they could not find documentation showing the residents had declined or received COVID-19 vaccination.
Uneven Meal Service at Shared Tables
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents when meal service was not provided to everyone seated at the same table at the same time during two meal observations. On 06/08/2026, Resident #13 was eating while Resident #80 and Resident #77, who were seated at the same table, had not yet been served; 23 minutes after Resident #13 was served, Resident #80 still had not received a meal, and Resident #77 also remained without lunch. On 06/11/2026, the same three residents were again seated together for breakfast, and Resident #77 had a meal while Resident #13 and Resident #80 had not been served; later, Resident #77 had eaten 75% of the meal while the other two residents still did not have theirs. Resident #80 had intact cognition, required supervision or touching assistance with eating, and had diagnoses including iron deficiency anemia and a history of peptic ulcer disease. Resident #77 had moderate cognitive impairment, required partial to moderate assistance with eating, and required a mechanically altered diet; diagnoses included type 2 diabetes mellitus and mild protein-calorie malnutrition. Resident #13 had moderate cognitive impairment, required partial to moderate assistance with eating, and required a mechanically altered diet; diagnoses included protein calorie malnutrition, anxiety, and depression. Staff interviews confirmed that residents should be served at the same time at the same table, but the Dietary Supervisor stated staff were to serve the whole table at the same time and organize meal tickets by table, while a Dietary Aide stated he followed the cook's flow when delivering meals. The DON stated the facility was not monitoring to ensure residents were served at the same time when sitting at the same table.
Damaged wheelchair armrests left unrepaired
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for a resident who used a wheelchair when Resident #88’s wheelchair armrests were found damaged and there was no documented evidence that repair efforts had been made, despite the Maintenance Director being aware of the issue. Resident #88 was admitted on 06/24/2025 and had diagnoses including dementia, muscle weakness, unsteadiness on feet, and a history of falling. A significant change MDS with an ARD of 06/03/2026 showed a BIMS score of 4, indicating severe cognitive impairment, and documented that the resident used a wheelchair for mobility. During observation, the resident’s wheelchair had a cracked left armrest with exposed foam measuring approximately 3 inches by 1 inch, and the right armrest had torn lining over an area of about five square inches. A CMT stated damaged equipment should be reported to the charge nurse and acknowledged she should have noticed the torn armrests and brought them to someone’s attention. The Maintenance Supervisor stated he was familiar with the issue and had not fixed it yet, while the Administrator stated he first learned of the armrest problem on 06/10/2026 and found no prior maintenance system entries for the wheelchair. The DON stated nursing staff were to notify maintenance when damaged equipment was noticed, and unsafe equipment was to be removed immediately.
Respiratory Care Provided Without Order and Equipment Stored Improperly
Penalty
Summary
Resident #14, who had diagnoses including COPD, encephalopathy, and chronic systolic heart failure, was readmitted to the facility on 12/11/2025 and had a quarterly MDS showing intact cognition with active diagnoses of COPD and shortness of breath. The resident’s care plan directed staff to administer medication for shortness of breath and wheezing as ordered, monitor for respiratory distress, change the humidifier bottle and oxygen tubing weekly, change the nebulizer mask and tubing weekly if in use, and provide oxygen per orders as needed. However, the resident’s active order summary did not include an order for supplemental oxygen, and the MARs for 05/2026 and 06/2026 did not show oxygen treatment. Despite the absence of a physician’s order for supplemental oxygen, the resident was observed on multiple occasions receiving oxygen via nasal cannula from an oxygen concentrator set at 3.5 LPM. During these observations, the resident was in bed and the concentrator was running without a documented oxygen order in the record. A nurse reviewed the electronic medical record and confirmed she did not see an order for supplemental oxygen, while other nurses stated the resident had been on oxygen since arrival or was on continuous oxygen. The DON stated that if a resident had no oxygen order and was receiving oxygen, staff were expected to ensure the physician’s orders were in the EMR and followed. The resident’s nebulizer mouthpiece and tubing were also repeatedly observed on the nightstand uncovered and not stored in a bag, despite the care plan and staff statements indicating the equipment should be stored in a labeled, dated plastic bag. In addition, the resident’s oxygen humidifier bottle was not present during observations even though an order existed to change the humidifier bottle on the oxygen concentrator weekly. The resident stated staff never put the water bottle on the oxygen concentrator and that the nebulizer mouthpiece and tubing were not placed in a bag until that day.
Missing dialysis orders, care plan, and post-HD monitoring
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care/services for a resident receiving hemodialysis. Resident #58 was readmitted with a history that included acute kidney failure, type 2 diabetes mellitus with diabetic chronic kidney disease, and later documentation of end stage renal disease on hemodialysis. Hospital records showed the resident was started on dialysis and was to continue outpatient dialysis three times weekly, and a later discharge summary noted the resident had been admitted from the dialysis center for altered mental status and somnolence that prevented a scheduled dialysis session. After the resident returned to the facility with a new hemodialysis catheter in the right chest, the record contained no physician order for dialysis services or for care of the HD catheter, and no care plan addressing dialysis treatment or catheter monitoring. The resident’s MDS did not indicate dialysis, and there was no documented evidence in the MARs or TARs of dialysis-related monitoring. Facility policy required post-dialysis review of communication documents, vital signs per physician order, and specific care for external catheters, but staff interviews indicated the resident should have been monitored after dialysis and the dialysis transfer communication form should have documented the assessment. The DON, ADON, RNC, and Administrator all acknowledged expectations for post-dialysis care and physician orders, and the NP stated she expected there to be an order for dialysis and that the facility had dropped the ball.
Medication Error Rate Exceeded Threshold During Insulin Administration
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent for 1 of 8 residents observed during medication administration. During a concurrent observation, an LPN prepared NovoLog and Lantus insulin pens for a resident with type 2 diabetes mellitus, a BIMS score of 12 indicating moderate cognitive impairment, and active orders for 5 units of NovoLog with meals and 25 units of Lantus daily. The LPN dialed the ordered doses and began to go to the resident’s room without first performing the required insulin pen safety test/priming step. The LPN stated she had not primed the insulin pens with 2 units and said she had not been shown how to prime them. She then left to receive education from the DON before returning. Facility policy and standardized priming instructions required priming before every injection, and the ADON/IP, pharmacy consultant, DON, and medical director all stated that insulin pens should be primed or dosed accurately according to manufacturer instructions. The facility’s overall medication error rate was 7.41%, reflecting 2 medication errors in 27 opportunities.
Failure to Maintain Comfortable Shower Water Temperatures
Penalty
Summary
The facility failed to maintain comfortable water temperatures in all five shower rooms, affecting residents' right to a safe, clean, comfortable, and homelike environment. Surveyors measured water temperatures in multiple shower rooms over two days and found that while initial temperatures were within or near a comfortable range, they dropped significantly within minutes. In the large South shower, water started at 100.4°F and fell to 77.4°F within 11 minutes. In the small East shower, water began at 107.4°F and dropped to 85.2°F within eight minutes. The large East shower showed a relatively stable temperature (97.6°F to 98.4°F within one minute), but the North shower dropped from 81.3°F to 70.5°F within two minutes, and the small South shower decreased from 104.6°F to 85.8°F within five minutes. Facility policy on ADL bathing required ensuring the bathing area was at a comfortable temperature, and a maintenance document dated 11/17/25 noted that hot water was not working on the north hall. Residents and staff reported ongoing problems with shower water becoming uncomfortably cold. One resident stated the shower water was warm for about two minutes and then became "ice cold," leading them to avoid taking many showers. Another resident reported that within five minutes the water became "freezing" and described it as "frigid," while another said the water on the north hall became freezing within a minute. CNAs reported that when they started showers, the water turned very cold within about three minutes, forcing them to hurry to rinse soap off residents and resulting in residents feeling their showers were cut short or refusing showers because they knew the water would get cold quickly. Staff also stated they had reported the cold water issue in the shower rooms to the maintenance supervisor several times. The maintenance supervisor acknowledged they did not perform routine water temperature checks and had no temperature logs, and the administrator stated that after feeling the water from the north hall shower, they personally would not take a shower in that water because it was too cold.
Inadequate Training and Competency of Dietary Staff in Dish Machine Operation
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure dietary staff were properly qualified and competent to operate the dishwashing equipment and carry out food and nutrition services. The DON reported that 81 residents received nutrition from the kitchen, and the DM reported there were 11 dietary staff members. During observation, two dietary aides were seen operating a low-temperature dish machine when one aide stopped the machine mid-wash cycle and walked away. One aide stated they determined the water was not hot enough by observing suds in the side tank and would wait and then try running the dishwasher again, rather than using the temperature gauge or test strips. The same aide reported working at the facility for about a month and stated they had been trained by another staff member but had not been instructed on checking the dish machine temperature or using test strips, despite using the machine several times a day. The other aide stated they checked the temperature gauge to ensure it was between two green lines and knew there were strips to check the machine but did not know where they were kept and did not usually worry about testing or documentation, instead relying on the presence of suds to judge water temperature. The DM later stated they were unable to locate quarterly training documents, 90-day nutrition services training, or annual competencies for dietary staff, and although they reported reviewing dish machine temperature and sanitation strip procedures during orientation, they acknowledged staff were not following or understanding the required testing process or frequency.
Failure to Ensure Proper Dishwashing Sanitation and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper sanitation of dishware and cooking utensils in accordance with professional standards and its own warewashing policy. Surveyors observed a low-temperature dishwasher being stopped mid-cycle by a dietary aide, with visible suds in the reservoir and a gauge reading around 140°F. The facility’s warewashing policy required dishware to be washed in a three-sink unit with sanitizer or disposable dishware to be used if the dish machine was not working or not meeting regulatory requirements, and required daily checks and documentation of sanitizer test strip results. The warewashing log for the dishmachine showed entries marked through one date with a note that hot water was being installed, and no documentation of testing or results for several subsequent days, despite the Director of Nursing identifying that 81 residents received nutrition from the kitchen. Staff interviews revealed that hot water had been an issue and a new hot water tank was being installed, during which time staff reported washing dishes in tubs, heating water on the stove for pots, pans, and utensils, and using paper plates and containers for resident meals. The dietary manager and cook stated they were using three plastic tubs and sanitizer but did not know they needed to check or document water or sanitizer temperatures in the tubs. One dietary aide stated they only checked that the dishwasher gauge was between two green lines, knew test strips existed but did not know their location, and did not usually worry about testing or documentation, instead relying on the presence of suds to judge water temperature. Another dietary aide reported not being shown how to check water temperature or use test strips and had been trained only by another staff member. The administrator acknowledged being unsure whether staff were completing dish machine testing due to lack of documentation, and the dietary manager later confirmed that temperature and sanitizer checks and documentation had not been completed for several days, attributing this to miscommunication among staff.
Failure to Notify Resident Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure that resident representatives were notified of significant changes in condition for two of four sampled residents. For one resident with diagnoses including congestive heart failure and obstructive sleep apnea, documentation showed that the physician was notified and new medications were ordered following complaints of nausea and an elevated A1C level, which led to a new diagnosis of type II diabetes mellitus. However, there was no documentation that the resident's representative was informed of the new medications, abnormal laboratory results, or the new diagnosis. The resident's representative confirmed limited contact from the facility since admission. For another resident with diabetes mellitus and muscle weakness, a nurse note indicated that after a fall from the bed, the physician, DON, and family member were reportedly notified. However, the family member stated they were not informed of the fall. Interviews with nursing staff revealed inconsistent understanding of when to notify resident representatives, particularly for cognitively intact residents, with some staff believing notification was not always necessary unless requested by the representative.
Failure to Develop Comprehensive Care Plan for Resident's Independent Outings
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident who was cognitively intact and had a diagnosis of hypertension. The resident was able to leave the facility independently in a motorized wheelchair and enjoyed spending time outside. Facility policy required residents to sign out when leaving the premises, but documentation showed that the resident sometimes signed themselves out, while at other times staff signed out on their behalf. There were instances where the resident left the facility without signing out or alerting staff, as noted in nurse documentation and staff interviews. Despite the resident's established pattern of independent outings and the need for adherence to the sign-out protocol, the care plan did not address the resident's ability to sign out, their enjoyment of outdoor activities, or the need for staff involvement in the sign-out process. Interviews with staff, including the DON and care plan coordinator, confirmed that these aspects were not included in the resident's care plan, and the care plan coordinator acknowledged the omission.
Verbal Abuse Incident in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from abuse, specifically in the case of a resident who was verbally abused by a staff member. The incident was reported by the resident's roommate, who overheard the staff member cursing while speaking to the resident. This verbal abuse was substantiated by the facility's investigation, which confirmed the occurrence of the incident.
Medication Administration Errors Lead to 12% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 12% error rate during medication administration. This was observed over 25 opportunities, with three medication errors identified. One incident involved a resident with diagnoses of GERD and constipation, who did not receive their prescribed medications, docusate sodium and famotidine, during a medication pass. The Certified Medication Aide (CMA) responsible for administering the medications admitted to forgetting to review the Medication Administration Record (MAR) to obtain the medications from the house stock supply. Another incident involved a resident with glaucoma, who was prescribed bimataprost ophthalmic solution to be administered at bedtime. Instead, the CMA administered latanoprost ophthalmic solution earlier than the prescribed time, at the resident's request. The Director of Nursing (DON) confirmed that the medication was administered at the wrong time, despite the medications being considered interchangeable. The Assistant Director of Nursing (ADON) stated that they monitored medication administration three times a week but had not observed these specific errors.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated when opened, as observed in four medication and treatment carts. During the survey, it was noted that medications on the north hall medication cart, east hall treatment cart, south hall medication cart, and south hall treatment cart were opened but not dated. Staff members, including CMAs and LPNs, acknowledged that medications should be dated upon opening, yet several items were found without dates. These included a bottle of milk of magnesia, glucometer check strips, insulin pens, inhalers, and nasal sprays. Additionally, some medications lacked proper labeling with the resident's name and dosage information, as required. The DON confirmed that medications should be dated when opened and should have a pharmacy label with the resident's name and dosage. The failure to adhere to these protocols was observed across multiple carts, indicating a systemic issue in the facility's medication management practices.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to maintain a resident's dignity by not using a privacy bag over an indwelling catheter bag for one of the residents reviewed for dignity. The resident, who was admitted with multiple diagnoses including multiple sclerosis, anxiety, depression, urogenital implants, and chronic pain, had a physician's order to verify the dignity bag was in place every shift. Despite this order, observations on multiple occasions revealed that the resident's catheter bag was visible from the hallway without a privacy bag in place. The resident expressed a preference for the catheter bag to be covered, indicating that staff only covered it upon request. A CNA acknowledged that the resident should have a catheter privacy bag in place at all times but admitted it was missed because the resident had not been getting out of bed as much. The Director of Nursing also stated that they would expect any resident with an indwelling catheter to have a privacy bag in place, highlighting a lapse in adherence to the facility's dignity policy.
Failure to Provide Recommended Restorative Services for Contracture Management
Penalty
Summary
The facility failed to provide range of motion (ROM) services to a resident with contractures, as recommended by a physical therapist (PT). The resident had diagnoses including contracture to the right elbow, wrist, and hand. A PT evaluation dated 03/30/24 indicated that the resident was not a candidate for skilled PT but would benefit from a restorative program for geri chair positioning and contracture management. Despite this recommendation, there was no documentation in the clinical record that the resident received restorative services. A physician's order dated 07/19/24 instructed the use of a hand roll for the left hand daily, and the resident was observed with hand rolls and positioning pillows. However, the Director of Nursing (DON) and corporate RN could not find documentation that the restorative program was initiated or followed up on, and the former DON indicated the resident was not agreeable to restorative therapy at that time.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure proper positioning of a urinary drainage bag for a resident with a urinary catheter. On two separate occasions, the resident was observed in bed with the urinary catheter bag placed on the floor. A Certified Nursing Assistant (CNA) acknowledged that the urinary catheter bag should not be on the floor. Additionally, the Director of Nursing (DON) confirmed that the facility did not have a policy regarding the positioning of urinary catheter bags, but agreed that the bag should not have been on the floor.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were labeled, dated, and stored according to its policy, which affected 77 residents receiving services from the kitchen. During an observation, surveyors found an unlabeled and undated zip lock freezer bag containing frozen biscuits and another with frozen cookies in the freezer. Additionally, an opened and unsecured bag of lettuce was observed without a label or date. The facility's policy, revised on 08/21/24, requires all leftovers to be labeled and dated with an expiration date. The Dietary Manager (DM) confirmed that all leftover food should be securely closed and labeled with a date.
Failure to Implement Enhanced Barrier Precautions for Peg Tube Care
Penalty
Summary
The facility failed to ensure the use of enhanced barrier precautions during peg tube care for a resident diagnosed with dysphasia. On August 20, 2024, enhanced barrier precautions signage and supplies were observed on the resident's door. However, an LPN was observed administering medication via the peg tube without wearing a gown. The LPN stated that the resident was not on infection control precautions. On August 23, 2024, the infection preventionist confirmed that enhanced barrier precautions should be used for peg tube care, among other procedures. The Director of Nursing also acknowledged that enhanced barrier precautions should be used for peg tube care and admitted that an enhanced barrier precaution policy had not yet been implemented.
Failure to Ensure Adequate Staffing During Mechanical Lift Use
Penalty
Summary
The facility failed to ensure the required number of staff were present when operating a mechanical lift for a resident with a history of a left femur fracture and dementia. The resident's care plan specified the need for a two-person assist during transfers using a mechanical lift. However, an incident occurred where the resident was found on the floor next to the Hoyer Lift with the sling still under her, indicating that the lift was operated by only one staff member at the time of the incident. Interviews with multiple CNAs confirmed that they had been trained and inserviced on the proper use of the Hoyer Lift, which requires two staff members to operate. Despite this training, the incident report and the resident's account revealed that only one CNA was present during the transfer when the resident fell. This deficiency highlights a failure in adhering to the care plan and established protocols for safe mechanical lift operation, leading to the resident's fall.
Failure to Maintain Resident Dignity During Perineal Care
Penalty
Summary
The facility failed to maintain the dignity of a resident during and after perineal care. A CNA attempted to clean a resident's vaginal area by picking off dry material with their hands instead of using wipes and cleanser, which upset the resident and caused them to cry. The CNA did not complete the care properly, as they left the resident partially clothed and did not close the door upon leaving the room. Furthermore, the CNA did not inform other staff members of the resident's condition, leaving the resident without proper assistance. The incident involved a resident with age-related cognitive decline and dementia, highlighting their vulnerability. Other CNAs observed the resident's condition after the initial CNA left, noting that the resident was only partially dressed and the door to their room was open. The Director of Nursing confirmed that the CNA did not follow the facility's policy, which requires informing other staff members of a resident's condition and using appropriate cleaning methods during perineal care.
Inadequate Perineal Care by CNA
Penalty
Summary
The facility failed to ensure that a CNA provided perineal care in accordance with accepted standards for one resident. During an inspection, CNA #1 was asked to supervise the memory care unit and found a resident lying on their bed fully clothed. Upon detecting a foul smell, CNA #1 removed the resident's jeans and instructed them to remove their briefs, finding the resident dry but with visible vaginal discharge. Instead of using a cleanser and wipes as per the facility's Incontinent Care policy, CNA #1 attempted to pick the dry discharge off the resident's vaginal area with their hands, causing discomfort to the resident. The Director of Nursing later confirmed that CNA #1's actions were substandard and indicated a need for further training.
Failure to Provide Showers for Residents
Penalty
Summary
The facility failed to provide showers for two residents who required assistance with activities of daily living. Resident #5, diagnosed with COPD and Parkinson's disease, reported not having had a shower in over a week and feeling dirty. The resident mentioned that staff cited insufficient staffing as the reason for not receiving showers. Similarly, Resident #6 stated they had not received a shower in over a week and only received one when they had a doctor's appointment. Interviews with CNAs revealed that they often ran out of time to complete baths and that documentation for showers was inconsistent, with showers being documented as completed when they were not. The Director of Nursing acknowledged the issue and mentioned they were in the process of hiring bath aides to address the problem.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, as documented in various reports and interviews. The Resident Council Minutes from January and February 2024 highlighted concerns about call lights not being answered or taking too long to be addressed. Additionally, the Grievance/Missing Property Monthly Tracking Log from March 2024 noted similar issues. A Device Activity Report from early June 2024 recorded multiple instances where call lights were activated for extended periods, ranging from 23 to 60 minutes, indicating a pattern of delayed responses. Interviews with residents and staff further corroborated these findings. Residents reported waiting times of up to an hour for call lights to be answered, with one resident experiencing a colostomy bag burst due to the delay. Staff members, including CNAs and LPNs, acknowledged that call lights should be answered within 5 to 10 minutes, yet there was no written policy in place to enforce this standard. The Director of Nursing confirmed the absence of a formal policy, stating that it is everyone's responsibility to answer call lights promptly.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration. On June 19, 2024, at 10:20 a.m., a Certified Medication Aide (CMA) was observed using bare fingers to break a potassium pill in half before administering it to a resident. The CMA acknowledged that gloves and a pill cutter should have been used during this process.
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 139 citations issued within 25 miles in the last 12 months — including the 5 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 Tulsa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tulsa Nursing Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Emerald Care Center Tulsa | 1.4 mi | ★★★★★ | 4 | 0 |
| Gracewood Health & Rehab | 2.8 mi | ★★★★★ | 9 | 0 |
| Trinity Woods, Inc. | 3.8 mi | ★★★★★ | 3 | 0 |
| Tulsa Center For Rehabilitation And Healthcare | 4.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.