Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcloud Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure RN coverage for eight consecutive hours a day, seven days a week. A review of the Nursing Department Schedule revealed no RN was present on certain shifts, and the administrator confirmed the absence of an RN on specific days. The facility did not use staffing agencies to address this issue, affecting the care of 43 residents.
The facility failed to maintain proper food storage and sanitation practices, with a malfunctioning refrigerator storing perishable items at unsafe temperatures and unsanitary kitchen conditions. Despite awareness of these issues, staff continued to use the faulty equipment and serve inadequately heated food, violating facility policies.
The facility failed to provide a SNF ABN for two residents discharged from Medicare Part A skilled services. One resident was admitted and discharged without receiving the required notice, and another resident experienced the same oversight. The social service director was unaware of the requirement to complete the SNF ABN form for residents discharged from Part A services.
The facility failed to conduct a new PASARR Level I screening for a resident with a new serious mental illness diagnosis and did not update another resident's PASARR Level I screening to reflect their serious mental illness diagnosis. The MDS coordinator was unaware of the need for a new screening, and the DON confirmed the incorrect completion of the PASARR Level I screening.
A facility failed to update a resident's care plan to include oxygen therapy and enhanced barrier precautions (EBP). The resident, with asthma, urinary retention, and a stage four pressure ulcer, had a physician's order for oxygen therapy, but the care plan lacked details on oxygen use and EBP. The MDS coordinator confirmed the care plan should have been updated, leading to the identified deficiency.
A resident with psychotic disorder and dementia was found using a portable electric space heater in their room, contrary to the facility's policy prohibiting such devices. The resident used the heater due to feeling cold and had covered the vent blowing cold air. The administrator confirmed the heater did not meet safety guidelines.
The facility did not post the required daily nurse staffing information. Observations showed that the dry erase board at the nurses' station was not filled out, and the schedule book lacked the current census. The DON confirmed the omission, affecting the facility with 43 residents.
The facility failed to ensure psychotropic medications were necessary for two residents. A resident received Lexapro, Buspirone, and Seroquel without documented diagnoses of depression, anxiety, or psychosis. Another resident's physician declined a pharmacist's request for a gradual dose reduction of Seroquel without providing a rationale.
The facility failed to ensure the Dietary Manager (DM) met state certification requirements. The DM, transferred to the kitchen in 2020, lacked documentation of certification. By mid-2024, the DM had completed training but had not taken the certification test, affecting all 43 residents receiving meals from the kitchen.
The facility failed to adhere to infection control protocols, including improper storage of nebulizer masks, inadequate hand hygiene during wound care, and lack of enhanced barrier precautions for residents with IV access or wounds. Staff were not fully educated on necessary precautions, leading to multiple deficiencies in care.
A facility failed to maintain a comfortable hot water temperature in a resident's room, as required by policy. The water temperatures were not monitored in May and June, and checks confirmed the water was significantly below a comfortable level. The resident expressed dissatisfaction with the water temperature.
A resident with multiple physical health issues was prescribed Lexapro, Buspirone, and Seroquel without documented diagnoses of anxiety, depression, or psychosis. Despite being cognitively intact and showing no signs of psychosis, the resident received these medications, and the DON confirmed the absence of supporting diagnoses, indicating a failure in professional standards of medication management.
A resident was discharged home with medication and belongings, but the facility failed to complete a discharge summary with a recapitulation of stay. The absence of this documentation was confirmed by the DON during an interview.
A facility failed to secure a urinary catheter for a resident with urinary retention, as required by policy. The catheter tubing was not anchored, and the catheter bag was observed hanging below the bladder. During pericare, an LPN noted that the catheter appeared to have pulled, causing the tubing to be in the crease of the resident's leg, which may have led to dark reddish-colored dried drainage on the resident's vulva area.
A facility failed to ensure a medication had a diagnosis for use for a resident with MDD, dementia, and a psychotic disorder. Lamictal was prescribed without a documented diagnosis, as confirmed by the DON, despite a nurse practitioner's note referencing a recent assessment.
The facility failed to convey remaining funds to the legal representatives of two deceased residents within 30 days as required by policy. The corporate BOM admitted that the funds were processed late and 'just fell between the cracks.'
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. The deficiency was identified through a review of the Nursing Department Schedule as Worked, dated 06/08/24, which documented the absence of an RN on the day, evening, or night shift. The facility's administrator confirmed that no RN was scheduled to work on 06/08/24 and 06/09/24, and acknowledged that an RN had not worked on 06/08/24. Additionally, the administrator stated that the facility did not utilize staffing agencies to fill the gap in RN coverage. This deficiency affected the care of 43 residents residing in the facility.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food service sanitation and storage requirements, as evidenced by multiple observations and interviews. The refrigerator used for storing food was consistently operating at temperatures above the recommended 40 degrees Fahrenheit, with recorded temperatures ranging from 44.4 to 54 degrees Fahrenheit over a nine-day period. Despite the refrigerator's malfunction, it was still in use, storing various perishable items such as cut fruits, mixed vegetables, and thawing meat, which were found to be at unsafe temperatures. The refrigerator also emitted a foul odor, and the staff acknowledged the issue but continued to use it. Additionally, the kitchen environment was observed to be unsanitary, with calcification and debris present under and behind the ice machine, and black build-up on the oven and stove. Wet blankets were used to address a leaking pipe behind the ice machine, contributing to the unsanitary conditions. The facility's policies on food storage and handling were not followed, as evidenced by the presence of a styrofoam cup in a flour bin and a cracked container used for thickening food. The facility also failed to maintain proper food temperatures on the steam table, with items such as pureed eggs and sausage not held at the required 135 degrees Fahrenheit. Despite being aware of the temperature requirements, the staff continued to serve the inadequately heated food. The dietary manager confirmed the issues with food storage, handling, and equipment cleanliness, acknowledging that the cleaning schedule was not adhered to and that the staff was aware of the refrigerator's malfunction.
Failure to Provide SNF ABN for Discharged Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for two residents who were discharged from Medicare Part A skilled services. Resident #1 was admitted to Part A skilled services on March 26, 2024, and discharged on May 30, 2024, without documentation of a SNF ABN being provided. Similarly, Resident #42 was admitted on May 8, 2024, and discharged on June 6, 2024, also without receiving a SNF ABN. The Director of Nursing identified 17 residents who had been discharged from a Medicare Part A covered stay with benefit days remaining in the past six months. The social service director stated they were unaware of the requirement to complete the SNF ABN form for residents discharged from Part A services, resulting in the oversight for these two residents.
Failure to Conduct and Update PASARR Level I Screenings
Penalty
Summary
The facility failed to conduct a new PASARR Level I screening for a resident who received a new diagnosis of serious mental illness. The resident was diagnosed with unspecified psychosis not due to a substance or known physiological condition, but the MDS coordinator was unaware of the requirement to submit a PASARR Level I for this new diagnosis. Additionally, another resident had diagnoses of major depressive disorder and psychotic disorder with delusions due to a known physiological condition. However, the PASARR Level I screening submitted did not reflect the diagnosis of serious mental illness. The DON acknowledged that the PASARR Level I screening was not completed correctly and lacked documentation of a corrected submission.
Failure to Update Care Plan for Oxygen Therapy and EBP
Penalty
Summary
The facility failed to update the care plan for a resident to include oxygen therapy and enhanced barrier precautions (EBP). The resident had diagnoses of asthma, urinary retention, and a stage four pressure ulcer. A physician's order was documented to administer oxygen at 3 liters via nasal cannula as needed for shortness of breath. However, the care plan did not reflect the use of oxygen therapy or the necessary details such as the flow rate and monitoring for shortness of breath. Additionally, the care plan was not updated to include EBP, which was necessary due to the resident's open wound and catheter. The resident's annual assessment indicated severe cognitive impairment and a need for substantial assistance with daily activities. The resident was observed with a catheter and using oxygen, yet these were not documented in the care plan. The MDS coordinator confirmed that the care plan should have included the oxygen therapy details and EBP, but it had not been updated accordingly. This oversight in updating the care plan led to the deficiency identified during the survey.
Use of Prohibited Space Heater in Resident Room
Penalty
Summary
The facility failed to ensure compliance with its policy prohibiting the use of portable electric space heaters in resident rooms, leading to a deficiency. A resident with diagnoses including psychotic disorder with hallucinations and dementia was observed using a portable electric space heater in their room. The resident explained that they used the heater because they felt cold and had covered the heat and air vent due to it blowing cold air. Despite the facility's policy stating that portable space heaters are not permitted, the heater was found plugged in and turned on during an observation. The administrator acknowledged that the space heater did not meet safety guidelines as per the facility's policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information. Observations on multiple dates revealed that the white dry erase board at the nurses' station, intended for displaying staffing information, was not filled out. Additionally, the schedule book at the nurses' station did not document the current census. The Director of Nursing (DON) confirmed that the required information was not documented on the dry erase board. This deficiency affected the facility, which housed 43 residents at the time of the survey.
Failure to Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were necessary for specific conditions as indicated in the clinical records for two residents. Resident #42 was prescribed Lexapro, Buspirone, and Seroquel without documented diagnoses of depression, anxiety, or psychosis. Despite being cognitively intact and having no behaviors or indications of psychosis, the resident was receiving these medications. The Director of Nursing (DON) confirmed that there was no diagnosis supporting the use of these medications for Resident #42. Additionally, the facility did not document a rationale for declining a gradual dose reduction of Seroquel for Resident #3, who had a diagnosis of a psychotic disorder with hallucinations. The pharmacist had requested a dose reduction, but the physician disagreed without providing a documented explanation. This lack of documentation for the physician's decision was acknowledged by the DON.
Dietary Manager Certification Deficiency
Penalty
Summary
The facility failed to ensure that the designated Dietary Manager (DM) met the state requirements for certification. The DM was transferred to the kitchen on November 16, 2020, but there was no documentation provided to confirm that the DM had obtained the necessary certification. On June 12, 2024, the Director of Nursing (DON) stated that the DM had completed their training and was waiting to take the certification test. However, later that day, the DM confirmed that they were not yet certified and still needed to take the test. This deficiency affected all 43 residents who received their meals from the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, leading to several deficiencies. Two residents receiving nebulizer treatments had their masks improperly stored, with one mask left on a nightstand and another on a counter, both without being placed in a bag as required by facility policy. The masks were also not changed weekly as stipulated. The Director of Nursing (DON) acknowledged the improper storage and the need for weekly changes. In another instance, a resident with a stage four pressure ulcer did not receive proper wound care. An LPN performed wound care without wearing an isolation gown and failed to perform hand hygiene after removing gloves. The LPN admitted to not being educated on enhanced barrier precautions and was unaware of which residents required such precautions. Additionally, there was no signage indicating the need for enhanced barrier precautions for this resident. Further deficiencies were noted with residents requiring IV therapy and wound care. One resident's IV tubing was not changed every 24 hours as per facility policy, and there was no signage or PPE available for enhanced barrier precautions. The DON admitted to a misunderstanding of the guidance regarding enhanced barrier precautions and acknowledged the need for re-education of staff. Another resident receiving wound care also lacked signage and PPE for enhanced barrier precautions, and the LPN did not wear a gown during care.
Failure to Maintain Comfortable Hot Water Temperature
Penalty
Summary
The facility failed to ensure that the hot water in a resident's room was at a comfortable temperature, as required by their policy. The policy, revised in December 2009, mandates that maintenance staff conduct periodic tap water temperature checks. However, the temperature logs revealed that the water temperatures for the resident's room were not monitored in May and June 2024. On June 9, 2024, a family member of the resident reported that there was no hot water at the sink faucet. Subsequent checks on June 12 and June 13, 2024, confirmed that the water temperature was significantly below a comfortable level, with readings of 71.2 degrees F and 68 degrees F, respectively. The resident expressed that the hot water had never been warm and desired it to be warmer.
Failure to Ensure Professional Standards in Medication Management
Penalty
Summary
The facility failed to ensure that professional standards of quality were met concerning the mental health diagnoses and medication management for a resident. The resident had multiple diagnoses, including myocardial infarction, acute respiratory distress, and chronic obstructive pulmonary disease, among others. Despite being cognitively intact and showing no behaviors or indications of psychosis upon admission, the resident was prescribed Lexapro for depression and anxiety, Buspirone for anxiety, and Seroquel for sleep and later for psychosis. However, there was no documented diagnosis of anxiety disorder, depression, or psychotic disorder to justify the use of these medications. The care plan and physician orders were inconsistent with the resident's documented mental health status, as the resident was described as pleasant and cooperative, with no concerns verbalized during an interview. The Director of Nursing (DON) confirmed upon review of the clinical records that there was no diagnosis supporting the use of the antidepressant, antianxiety, or antipsychotic medications. This discrepancy indicates a failure in adhering to professional standards of medication management and diagnosis documentation, leading to the unnecessary administration of psychotropic medications.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary with a recapitulation of stay for a resident who was discharged. The resident was discharged home with medication and belongings via family transport on home health. However, there was no documentation in the clinical record indicating that a discharge summary was completed for this resident. The Director of Nursing confirmed the absence of a discharge summary for the resident during an interview.
Failure to Secure Urinary Catheter
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to a deficiency. The facility's policy required that catheters be secured with a leg strap to prevent movement and friction at the insertion site. However, during an observation, it was noted that the catheter tubing for a resident with urinary retention was not anchored, and the catheter bag was hanging below the bladder. This lack of proper securing was observed during pericare provided by an LPN, who noted that the catheter appeared to have pulled, causing the tubing to be in the crease of the resident's leg. This may have resulted in a small amount of dark reddish-colored dried drainage on the resident's vulva area, which looked like old blood.
Medication Prescribed Without Diagnosis
Penalty
Summary
The facility failed to ensure that a medication prescribed to a resident had an appropriate diagnosis for its use. The resident in question had diagnoses including major depressive disorder (MDD), dementia, and a psychotic disorder with hallucinations. A physician's order dated May 14, 2024, instructed the administration of Lamictal 25 mg twice daily, but there was no documented diagnosis justifying the use of this medication. On June 13, 2024, the Director of Nursing (DON) confirmed that there was no diagnosis for Lamictal, despite a nurse practitioner's note referencing an assessment from the previous week.
Failure to Timely Convey Resident Funds
Penalty
Summary
The facility failed to convey remaining funds to the legal representatives of deceased residents within 30 days for two of the three sampled residents reviewed for finances. The policy titled 'Conveyance of Resident Funds' mandates that personal funds and a final accounting of funds be returned to the resident, the resident's representative, or the resident's estate within thirty days from the date of discharge, eviction, or death. Resident #1 was admitted and later discharged, with a check request date documented, but the check was sent late. Similarly, Resident #2 was admitted and discharged, with a check request date documented, but the check was mailed late. During a telephone interview, the corporate BOM acknowledged that the remaining funds for the residents were processed late and admitted that they 'just fell between the cracks.'
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mcloud
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrah Nursing Center | 6.7 mi | ★★★★★ | 1 | 0 |
| The Wolfe Living Center At Summit Ridge | 9.7 mi | ★★★★★ | 0 | 0 |
| Shawnee Care Center | 10 mi | ★★★★★ | 1 | 0 |
| Shawnee Colonial Estates Nursing Home | 10.6 mi | ★★★★★ | 0 | 0 |
| The Golden Rule Home | 11 mi | ★★★★★ | 0 | 0 |
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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 June 2026) and official state health department websites.