Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 North County Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A CMA was observed administering oral medications to multiple residents consecutively without performing hand hygiene between each resident, despite facility policy and prior training requiring handwashing before medication administration. This lapse was noted during the preparation and administration of various medications, including pain relievers, muscle relaxants, and gastric agents.
A resident was prescribed and administered Seroquel, an antipsychotic, for unspecified dementia with behavioral disturbances and anxiety, despite facility policy requiring antipsychotics only for specific, indicated conditions. Staff interviews confirmed the medication was used for dementia-related behaviors, and the DON acknowledged it was not approved for this diagnosis, resulting in a deficiency for unnecessary medication use.
A resident's MDS discharge assessment was completed but not transmitted to the CMS QIES ASAP system within the required 7-day period. The MDS coordinator acknowledged the oversight, and the DON reported not monitoring the export status of MDS records due to limited training. This resulted in a failure to comply with facility policy and federal regulations regarding timely MDS data transmission.
A resident with severe cognitive impairment and multiple diagnoses was denied re-entry to the facility after an overnight stay with family, despite only being provided 24 hours of medication and not intending a permanent discharge. The administrator refused to allow the resident to return, there was no discharge documentation, and the resident was left without appropriate notice or placement, resulting in a deficiency for improper discharge procedures.
A facility failed to manage controlled medications properly, resulting in the misappropriation of narcotics for three residents. Despite policies requiring reconciliation, numerous lapses in procedure were found, including missing counts and improper staff signatures. The DON acknowledged the issues but failed to monitor compliance effectively, allowing the deficiencies to persist.
The facility failed to complete baseline care plans within 48 hours of admission for three residents, citing reasons such as staff absence and weekend admissions. This resulted in delays and, in one case, a complete lack of a baseline care plan.
The facility failed to develop comprehensive care plans for the use of bed rails for four residents, despite physician orders allowing therapeutic devices. The care plans were not completed in a timely manner, and one resident's comprehensive care plan was entirely missing due to staff shortages.
The facility failed to attempt alternative interventions and assess the risk of entrapment before using bed rails for three residents. The DON confirmed that staff did not follow the policy requiring these steps.
The facility failed to complete the required yearly performance reviews for two CNAs. The last documented skills performance for both CNAs was completed in 2022. The DON confirmed that no skills performance checks had been completed for the year 2023 and was unaware of the requirement.
The facility failed to maintain an infection prevention and control program, including proper catheter and incontinent care, and did not implement a water treatment program to prevent Legionella. Staff did not follow hand hygiene protocols, and the water management program was not instituted.
The facility failed to ensure two residents were offered the choice to formulate advanced directives. One resident had chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy, and chronic respiratory failure with hypoxia, while the other had embolism and thrombosis of an unspecified vein, edema, hypokalemia, and cerebral fluid drainage. The clinical records for both residents did not document that they or their representatives were offered the choice to formulate an advanced directive.
The facility failed to complete an admission assessment for a resident with multiple diagnoses, including congestive heart failure and dementia, within the required timeframe. The MDS coordinator cited a backlog due to a staff nurse's family emergency.
The facility failed to complete quarterly assessments within the required time frame for two residents. One resident with respiratory failure, congestive heart failure, and cerebrovascular disease had an incomplete assessment, and another resident with dementia, schizoaffective disorder, and auditory hallucinations also had an overdue assessment.
The facility failed to submit a resident's assessment data to CMS within the required seven days. A resident with urinary tract infection and cellulitis had their quarterly assessment completed but not submitted until over a month later. The MDS coordinator was unaware of the delay's cause.
The facility failed to develop a discharge summary for a resident, including a recapitulation of the stay, medication reconciliation, and a post-discharge plan. The resident had multiple diagnoses and was discharged to another facility, but the necessary documentation was missing.
The facility failed to notify the physician and implement interventions for a resident with significant weight loss. Despite a dietary order for daily supplements, the resident experienced weight loss and was observed eating without being offered the prescribed supplements. The MDS Coordinator confirmed the physician was not informed of the weight loss.
The facility failed to ensure a resident's nutritional issues were supervised by a physician, resulting in significant weight loss. Despite a dietary order for supplements, the resident was observed eating without being offered the prescribed supplement, and the physician was not notified of the weight loss.
The facility failed to maintain an ice machine in a sanitary condition. An observation revealed a black substance inside the ice machine used by all 44 residents. The machine was cleaned only every six months, and there was no regular monitoring or documentation of its cleanliness.
The facility failed to conduct regular inspections of beds and bed rails for three residents, contrary to their policy. One resident with severe cognitive impairment had an assist bar attached, while two residents with intact cognition had bed rails but were unaware of any safety assessments. The Maintenance Supervisor confirmed no routine inspections were conducted.
The facility failed to follow physician orders for wound care for a resident with a sacral pressure ulcer. The wound vac was observed not in use, and the resident reported it had been off since Saturday due to a nurse's unfamiliarity with its operation. Staff confirmed the wound vac frequently came off and was not always reapplied promptly.
A resident with impulse disorder and dementia exhibited multiple instances of verbally abusive behavior towards other residents. Despite these documented behaviors, the DON and the administrator did not classify these incidents as verbal abuse and failed to implement the facility's abuse policy, leading to a failure in protecting other residents.
The facility failed to report allegations of verbal abuse involving a resident with impulse disorder and dementia to the administrator and OSDH as required by their abuse policy. Multiple incidents of the resident's verbally abusive behavior were documented, but notifications to the administrator or DON were not consistently recorded, and reports were not submitted to OSDH within the mandated timeframe.
The facility failed to provide abuse training upon hire for four employees, including three CNAs and one housekeeper, as required by their abuse policy. The DON and administrator confirmed that no abuse training had been provided since the facility changed ownership.
Failure to Perform Hand Hygiene Between Residents During Medication Administration
Penalty
Summary
Facility staff failed to follow infection control practices during medication administration for three of eight sampled residents. On multiple occasions, a Certified Medication Aide (CMA) was observed preparing and administering oral medications to residents without sanitizing or washing hands between residents. The CMA prepared medications for one resident, assisted with administration, and then proceeded to prepare and administer medications to subsequent residents without performing hand hygiene. This sequence was observed with three different residents, each receiving various prescribed oral medications, including pain medication, muscle relaxants, anticonvulsants, expectorants, and gastric protective agents. Facility policy required staff to wash their hands prior to administering medications and after handling items potentially contaminated with blood, body fluids, or secretions. Despite this, the CMA did not adhere to these protocols, as confirmed by direct observation. The Director of Nursing (DON) stated that all CMAs had completed training on medication administration and infection control, including the requirement for hand hygiene between residents.
Unnecessary Antipsychotic Medication Prescribed for Dementia
Penalty
Summary
A deficiency was identified when a resident was prescribed and administered Seroquel, an antipsychotic medication, for the diagnosis of unspecified dementia with behavioral disturbances and anxiety. Facility policy states that antipsychotic medications should only be used when necessary to treat specific, indicated conditions. However, the medication administration record showed the resident received Seroquel twice daily over several days for dementia, a diagnosis for which the medication is not approved. Staff interviews revealed that the primary behaviors observed were attempts by the resident to leave the facility and statements about needing to go to work. Further interviews with a certified medication aide, an LPN, and the DON confirmed that the medication was being used for dementia-related behaviors and anxiety. The DON acknowledged awareness that CMS does not approve Seroquel for the treatment of dementia and that the resident had been on the medication since admission for these behaviors. The documentation and staff responses did not indicate a specific, approved psychiatric diagnosis justifying the use of the antipsychotic, resulting in the finding of unnecessary medication use.
Failure to Transmit MDS Discharge Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment record was transmitted within the required 7-day timeframe for one of the sampled residents. According to facility policy, all MDS assessments, including discharge records, are to be completed, encoded, and transmitted to the CMS QIES ASAP system in accordance with OBRA regulations. Record review showed that a resident was discharged on 03/01/25, and while the MDS discharge record was completed, it was not transmitted as required. The MDS coordinator acknowledged that the record had been completed but not exported, attributing the failure to an error on their part. Further interviews revealed that the DON reviewed and signed MDS assessments as they became due but did not monitor whether records had been exported or were incomplete, citing minimal training in the MDS process. The corporate nurse consultant, new to their role, had planned to audit two medical records weekly but indicated a need to reconsider this approach after learning of the missed transmission. The deficiency was identified through record review and staff interviews, confirming the lapse in timely MDS data transmission.
Resident Denied Re-Entry After Overnight Absence Without Proper Discharge Notice
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, anoxic brain damage, PTSD, and bipolar disorder was not allowed to return to the facility after an overnight stay with family. The resident had signed out of the facility for an overnight visit, was provided with 24 hours of medication, and was expected to return the following day. Upon attempting to return, the resident was informed by the DON that they were no longer considered a resident, based on information from the administrator, despite the resident's statement that they had not intended to discharge themselves permanently. There was no documentation of a formal discharge for the resident, and the facility was unable to produce any discharge paperwork. The administrator refused to allow the resident to re-enter the facility, even after being informed by police that the resident had nowhere else to go. The administrator paid for a one-night hotel stay for the resident, but did not facilitate their return to the facility or provide the required discharge notice and documentation as outlined in the facility's policy and regulatory requirements. Interviews with staff confirmed that the resident had only planned an overnight stay and had not expressed intent to leave the facility permanently. The facility's failure to provide proper discharge notice, documentation, and to allow the resident to return after a temporary absence resulted in a deficiency related to improper discharge procedures.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure the proper management and reconciliation of controlled medications, leading to the misappropriation of narcotics for three residents. Resident #4, who had diagnoses including abnormal posture and weakness, was missing 60 tablets of Hydrocodone. The medication was delivered by the pharmacy, but discrepancies were found during a routine check. Similarly, Resident #8, diagnosed with chronic pain, was missing 30 tablets of Hydrocodone. The medication was delivered, but the facility could not account for the missing quantity. Resident #7, with cervical disc degeneration, was also affected, with 56 tablets of Hydrocodone unaccounted for, despite the medication being delivered months earlier. The facility's Controlled Substances policy required reconciliation of medications upon receipt, administration, and at the end of each shift. However, the review of Controlled Substance Card Count Sheets revealed numerous instances where medications were not counted, and staff signatures were missing or improperly recorded. The same employee often signed as both the on-coming and off-going staff member, indicating a lack of proper oversight and accountability. These lapses in procedure contributed to the misappropriation of medications. The Director of Nursing (DON) acknowledged the issues, stating that they were first made aware of the misappropriation when staff reported missing medications. Despite initial investigations and reconciliation efforts by a consultant pharmacist, further discrepancies were discovered. The DON admitted to not monitoring staff compliance with medication reconciliation procedures, which allowed the deficiencies to persist. The administrator confirmed that the DON was responsible for ensuring residents were free from medication misappropriation by reviewing count sheets, but this oversight was not effectively implemented.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for three residents. Resident #31, who had multiple diagnoses including osteomyelitis, stage four pressure ulcer, diabetes, and hypertension, was admitted on [DATE], but the baseline care plan was completed six days later. The care plan coordinator acknowledged the delay, attributing it to their absence from work. Similarly, Resident #45, admitted with diagnoses such as non-traumatic intracranial hemorrhage and dementia, had their baseline care plan initiated four days after admission. The MDS coordinator explained that the delay was due to the admission occurring over a weekend, and the baseline care plan was not initiated until the care plan staff member returned to work. They also mentioned that any nurse could initiate a baseline care plan, but it was typically completed by the MDS/Care plan staff nurse. Resident #246, who had diagnoses including congestive heart failure, dementia, and anxiety, was admitted on [DATE], but there was no documentation of a baseline care plan in the EHR. The MDS coordinator stated that they had been helping with the baseline care plans but had fallen behind, resulting in the failure to complete a baseline care plan for this resident. These findings indicate a systemic issue in the timely completion of baseline care plans, particularly when admissions occur over weekends or when key staff members are absent.
Failure to Develop Comprehensive Care Plans for Bed Rails
Penalty
Summary
The facility failed to develop a comprehensive care plan to include the use of bed rails for four residents reviewed for accident hazards. Resident #16, diagnosed with primary osteoarthritis, had an assist bar attached to their bed that was not care planned until 04/02/24, despite a physician's order dated 11/21/23 allowing the use of therapeutic devices. Resident #23, diagnosed with multiple sclerosis and generalized muscle weakness, had half-size bed rails on each side of their bed since admission, but these were not care planned until 04/02/24, even though a physician's order dated 07/25/23 permitted the use of therapeutic devices. Resident #146, diagnosed with a broken internal joint prosthesis, had side rails attached to their bed since admission, but these were not care planned until 04/03/24, despite a physician's order dated 01/30/24 allowing the use of therapeutic devices. Resident #246, diagnosed with congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome, was admitted to the facility, but there was no documentation of a comprehensive care plan available. The MDS stated that the other person helping with assessments and care plans had been out, causing delays in completing the care plans. The DON confirmed that the bed side rails had not been care planned for residents #16, 23, and #146 in a timely manner or in accordance with facility policy.
Failure to Attempt Alternatives and Assess Risks Before Using Bed Rails
Penalty
Summary
The facility failed to attempt alternative interventions before using bed rails for three residents and did not assess the risk of entrapment for two of these residents. Resident #16, who had severe cognitive impairment and chronic pain, was observed with an assist bar attached to their bed without documentation of alternative interventions or a risk assessment. Similarly, Resident #23, who had multiple sclerosis and intact cognition, was found with half-size bed rails on each side of their bed without any documented attempts at alternative interventions. Resident #23 confirmed that no alternatives were tried before the bed rails were used. Resident #146, who had a broken internal joint prosthesis and intact cognition, also had bed rails attached to their bed without documentation of alternative interventions or a risk assessment. The DON confirmed that alternative interventions were not attempted and risk assessments were not performed for residents #16 and #146 before the use of bed rails. The facility staff did not follow the policy related to the use of bed rails, which requires attempts at alternative interventions and risk assessments before installation.
Failure to Complete Yearly Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete the required yearly performance reviews for two certified nurse aides (CNAs), specifically CNA #2 and CNA #4. The last documented skills performance for both CNAs was completed on 09/22/22. During an interview on 04/04/24, the Director of Nursing (DON) reviewed the skills performance checklists and confirmed that no skills performance checks had been completed for the year 2023 for any current CNAs. The DON admitted to being unaware of the requirement for yearly performance reviews.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of infections. For one resident with a catheter and multiple pressure ulcers, a CNA did not follow the enhanced barrier precautions posted on the resident's door. The CNA did not wear a gown and failed to wash their hands between glove changes while providing catheter care and repositioning the resident. The Director of Nursing confirmed that the CNA should have used the appropriate PPE and followed proper hand hygiene protocols. Another resident, who was incontinent of bowel and bladder, did not receive proper infection control measures during incontinent care. The CNA assisting the resident did not change gloves or wash hands between removing the soiled undergarment and placing a clean one on the resident. The CNA later acknowledged that they should have changed gloves and washed hands during the care process. Additionally, the facility did not implement a water treatment program to prevent Legionella. The administrator admitted that the new water management program provided by the corporation had not been instituted. There was no documentation of preventive measures such as flushing toilets in unoccupied rooms, and no risk assessment or water management team had been established. The maintenance supervisor confirmed that no assessment of the facility's piping had been conducted to identify potential areas of standing water.
Failure to Offer Advanced Directives
Penalty
Summary
The facility failed to ensure residents were offered the choice to formulate advanced directives for two residents. Resident #4, who had diagnoses including chronic kidney disease - stage 3, type 2 diabetes mellitus with diabetic neuropathy, and chronic respiratory failure with hypoxia, did not have documentation in their clinical records indicating that they or their representative were offered the choice to formulate an advanced directive. Similarly, Resident #7, with diagnoses including embolism and thrombosis of unspecified vein, edema, hypokalemia, and cerebral fluid drainage, also lacked documentation in their clinical records showing that they or their representative were offered the choice to formulate an advanced directive. The Director of Nursing identified that 41 residents resided in the facility at the time of the survey.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility failed to ensure an admission assessment for a resident was completed within the required timeframe. The resident, who had diagnoses including congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome, was admitted to the facility, but the Electronic Health Record (EHR) did not document an admission assessment. The MDS coordinator stated that the staff nurse responsible for completing the MDS assessments had been out for a family emergency, causing a backlog in assessments.
Failure to Complete Quarterly Assessments on Time
Penalty
Summary
The facility failed to complete quarterly assessments within the required time frame for two residents out of 13 whose assessments were reviewed. Resident #32, who had diagnoses including respiratory failure, congestive heart failure, and cerebrovascular disease, had a quarterly assessment dated 12/15/23 completed, but the subsequent assessment dated 03/15/24 was still in progress as of 04/03/24. The MDS coordinator confirmed that the assessment was not completed on time. Similarly, Resident #14, with diagnoses including dementia, schizoaffective disorder, and auditory hallucinations, had a quarterly MDS assessment with an ARD date of 03/12/24 that was still in progress as of 04/02/24. The MDS coordinator acknowledged that this assessment was also not completed and submitted on time.
Failure to Submit Assessment Data Timely
Penalty
Summary
The facility failed to ensure assessments were encoded and submitted to CMS within seven days of completion for one of the 13 residents whose assessments were reviewed. Resident #16, who had diagnoses including urinary tract infection and cellulitis, had a quarterly assessment completed on 02/27/24, but it was not submitted until 04/03/24. During the survey, the resident was observed in a manual wheelchair and mentioned they had been receiving an antibiotic for cellulitis but were unsure if they were still taking it. The MDS coordinator stated that someone at the corporate offices submitted the assessment on 04/03/24 and did not know why it had not been submitted within the required timeframe.
Failure to Develop Discharge Summary
Penalty
Summary
The facility failed to develop a discharge summary for a resident, including a recapitulation of the resident's stay, a reconciliation of the resident's medications, and a post-discharge plan of care. The resident had diagnoses including a fracture of the right fibula, osteoarthritis, chronic stage four kidney disease, and diabetes. An admission assessment documented the resident was cognitively intact. A discharge assessment indicated the resident was discharged to another facility in a different state. However, the MDS coordinator confirmed that the discharge summary was not documented in the nursing notes, and there was no summary of the resident's stay, interventions, or medication reconciliation.
Failure to Notify Physician and Implement Interventions for Weight Loss
Penalty
Summary
The facility failed to ensure the physician was notified of significant weight loss and did not implement interventions to maintain or prevent further weight loss for a resident diagnosed with tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis. The resident's care plan indicated that supplements or alternates should be offered if the resident ate less than 50% of meals or refused meals. Despite a dietary order for a house supplement every day shift for weight loss, the resident experienced a weight loss from 145.2 lbs to 137.4 lbs. Observations on multiple occasions showed the resident eating without being offered the prescribed supplements. Additionally, the MDS Coordinator confirmed that the physician was not notified of the significant weight loss.
Failure to Supervise Nutritional Issues by Physician
Penalty
Summary
The facility failed to ensure that a resident's nutritional issues were supervised by a physician, leading to a significant weight loss. The resident, who had diagnoses including tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis, was admitted with a care plan that included offering supplements if the resident ate less than 50% of meals or refused meals. Despite a dietary order for a house supplement every day shift for weight loss, the resident's weight dropped from 145.2 lbs to 137.4 lbs over a month. Observations on multiple occasions showed the resident eating without being offered the prescribed supplement. Additionally, the MDS Coordinator confirmed that the physician was not notified of the significant weight loss, indicating a lapse in communication and adherence to the care plan.
Facility Failed to Maintain Ice Machine Sanitation
Penalty
Summary
The facility failed to maintain an ice machine in a sanitary condition. During an observation, a staff member wiped the inside of an ice machine located in an employee-only hallway next to the kitchen, and the cloth came back with a black substance. The Director of Nursing (DON) confirmed that all 44 residents received ice from this machine. The facility's Sanitation policy, dated November 2022, required the food service area to be maintained in a clean and sanitary manner. The Dietary Manager (DM) stated that the ice machine was cleaned once every six months. The administrator provided documentation of cleanings for two ice machines, dated December 29, 2023, and January 31, 2024, but no other documentation was available. The DM later stated that the dirty ice machine had been turned off and the second machine had not been working for several weeks and was due for repair. The facility did not monitor the ice machines for cleanliness on a schedule and did not document inspections of the ice machines.
Failure to Conduct Regular Bed and Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of resident beds and did not inspect beds for safety prior to the attachment and use of bedrails for three residents. The facility's policy, dated August 2022, required bed frames, mattresses, and bed rails to be checked for compatibility and size before use, and for maintenance staff to routinely inspect all beds and related equipment. However, observations and interviews revealed that these inspections were not being performed. Resident #16, with severe cognitive impairment, was observed with an assist bar attached to their bed. Resident #23, with intact cognition, had half-size bed rails on each side of their bed and was unaware of any safety assessments or inspections. Resident #146, also with intact cognition, had side rails attached to their bed and did not recall any assessments or inspections prior to their use of the bed. The Maintenance Supervisor confirmed that they had not been informed about the need for routine inspections or pre-use inspections of bed rails and had not conducted any such inspections. The Director of Nursing (DON) acknowledged that the facility had not been following the policy regarding bed and bed rail inspections. The report documented that 17 residents at the facility used bed rails, and the facility had a total of 44 residents. The lack of adherence to the policy and the absence of routine inspections posed potential safety risks for the residents using bed rails. The DON stated that they would ensure compliance with the policy in the future, but no corrective actions were documented in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure physician orders were followed for wound care for Resident #7, who had a pressure ulcer of the sacral region and diabetes mellitus. The physician's order dated 02/20/24 required the sacral wound to be cleaned with normal saline and a wound vac to be applied. However, on 03/26/24, the wound vac was observed at the resident's bedside but not in use. The resident reported that the wound vac had been off since Saturday because the nurse on duty was unfamiliar with its operation and did not return to reapply it. LPN #1 confirmed that the wound vac sometimes comes off or gets soiled and that the nurse on duty might not be able to reapply it. Additionally, LPN #1 was unsure if the wound vac was supposed to have been discontinued on 03/14/24 and stated they would contact the wound physician for clarification. The DON stated that the nurse accompanying the wound physician was responsible for entering orders into the resident's medical record, and the charge nurses were responsible for ensuring the wound vac was in place and functioning properly. It was later confirmed that the wound vac had not been discontinued until 03/26/24. CNA #1, who provided care for Resident #7 on 03/26/24, also confirmed that the wound vac had not been in place all day and mentioned that it frequently came off. The DON reiterated that the charge nurses were responsible for ensuring the wound vac was in place and functioning properly. This failure to follow physician orders and ensure proper wound care led to a deficiency in the care provided to Resident #7.
Failure to Implement Abuse Policy for Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse policy for verbal abuse in the case of a resident with impulse disorder and dementia. The resident exhibited multiple instances of verbally abusive behavior towards other residents, including cursing, yelling, making derogatory comments, and threatening physical harm. Despite these documented behaviors, the Director of Nursing (DON) and the administrator did not classify these incidents as verbal abuse and therefore did not implement the facility's abuse policy. The DON and the administrator reviewed the incidents as behavioral issues rather than abuse, leading to a failure in policy implementation. The resident's care plan noted their tendency to become moody and verbally abusive, with interventions suggested to manage these behaviors. However, the facility's staff, including the DON and the administrator, did not follow the abuse policy despite multiple documented incidents of verbal abuse. The DON admitted to lacking experience with verbal abuse and misclassifying the incidents, while the administrator acknowledged the oversight and failure to implement the abuse policy. This resulted in a failure to protect other residents from verbal abuse by the resident in question.
Failure to Report Verbal Abuse Incidents
Penalty
Summary
The facility failed to ensure allegations of verbal abuse were reported to the administrator and the Oklahoma State Department of Health (OSDH) for one resident who was reviewed for abuse. The facility's abuse policy required employees to report all incidents of possible abuse immediately to their supervisor, who would then report to the administrator or person on call. The policy also mandated that the nursing facility must report allegations to OSDH immediately, but not later than two hours after the allegation is made. Despite this policy, multiple behavior notes documented incidents where Resident #6 exhibited verbally abusive behavior towards other residents, but there was no documentation that the administrator or Director of Nursing (DON) had been notified in some instances, and reports were not submitted to OSDH as required. Resident #6, who had diagnoses including impulse disorder and dementia, displayed a pattern of verbally abusive behavior towards other residents. Incidents included cursing, name-calling, and making derogatory comments. On several occasions, the behavior notes indicated that the administrator or DON were notified, but there were also instances where this notification was not documented. Interviews with staff revealed that while some reported incidents to the administrator or DON, they failed to document these notifications. The DON admitted that they had not reported the incidents to OSDH, acknowledging that they should have done so. The administrator also confirmed that they had not submitted reports to OSDH for the verbal abuse incidents involving Resident #6, indicating a failure to follow the facility's abuse reporting policy.
Failure to Provide Abuse Training Upon Hire
Penalty
Summary
The facility failed to ensure that staff received abuse training upon hire for four employees (three CNAs and one housekeeper) out of five employee files reviewed. The facility's abuse policy, dated 02/17/22, mandates that all new employees receive in-service training on abuse prohibition before working a shift. However, a review of the employee files for CNA #1, CNA #2, CNA #3, and housekeeper #1, who were hired between 11/11/23 and 01/04/24, revealed that they had not received the required abuse training. The Director of Nursing (DON) confirmed that the facility had not provided abuse training upon hire since the ownership change several months ago. The administrator also acknowledged that no employee abuse training had been provided since the new company took over in September 2023.
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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 Collinsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequoyah Pointe Living Center | 5.9 mi | ★★★★★ | 0 | 0 |
| The Highlands At Owasso | 5.9 mi | ★★★★★ | 5 | 1 |
| Baptist Village Of Owasso | 7.4 mi | ★★★★★ | 0 | 0 |
| Skiatook Nursing Home,llc | 8.6 mi | ★★★★★ | 2 | 0 |
| Green Country Care Center | 12.3 mi | ★★★★★ | 1 | 1 |
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