Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northwest Nursing Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including mobility impairment, was injured during van transport to dialysis when they slid out of their wheelchair despite being secured with a seat belt and straps as per facility policy. The CNA driving the van observed the resident sliding out and found them on the floor with a leg laceration, even though the seat belt remained attached to the wheelchair. Staff interviews and documentation confirmed the resident was not adequately secured, leading to the accident and injury.
The facility did not ensure proper care for a resident with a dehisced surgical incision by failing to notify the surgeon and inconsistently documenting the wound's status, resulting in the need for hospital intervention. Additionally, two residents receiving hospice services did not have required physician orders in the facility's records, and coordination of care with hospice providers was inadequate.
Failure to complete significant change assessments when hospice was elected for two residents. One resident had moderate cognitive impairment and a limited life expectancy, and another resident was cognitively intact with a limited life expectancy; both had hospice assessments or orders documented, but the required significant change assessments were not completed when hospice was initially chosen.
Baseline Care Plans Not Completed or Shared Within Required Timeframe: The facility failed to develop baseline care plans within 48 hours of admission for multiple residents, including a resident with depression and psychotic disorder and another with acute respiratory failure, CHF, and trach status. For another resident with a BIMS of 15 and unspecified dementia, the baseline care plan summary was not provided to the resident or representative, and staff acknowledged the missing or delayed care planning and communication.
Incomplete Comprehensive Care Plans: The facility failed to develop comprehensive care plans for 3 residents. One resident with ESRD and intact cognition had multiple triggered care areas identified on the admission assessment, but only a falls care plan was present. Another resident with severe cognitive impairment and limited ROM had a revised care plan that did not address the ROM limitation. A third resident with acute respiratory failure, acute on chronic systolic CHF, and tracheostomy status had no comprehensive care plan initiated or completed.
Failure to provide ROM services for residents with limited mobility and contractures. Two residents with severe cognitive impairment, one with spastic quadriplegic cerebral palsy and aphasia and another with intracerebral hemorrhage and muscle spasm, were observed in bed with contractures/weakness, and their assessments showed no passive or active ROM in the look-back period with no documentation of ROM services. A third resident with severely impaired cognition and limited ROM on both sides had no evidence of assessment or evaluation for ROM services, and the DON stated the facility did not have a restorative program.
Dialysis Assessments Not Completed: The facility failed to ensure a resident with ESRD received documented pre- and post-dialysis assessments. The resident was on a regular dialysis schedule and had a fistula monitored each shift, but the record did not show assessments before and after dialysis. Dialysis communication forms were incomplete or missing key documentation, and staff interviews confirmed the facility had not monitored whether the required dialysis assessments were being completed.
Anticoagulant monitoring was not completed for a resident receiving Apixaban for a high-risk medication regimen. The resident had multiple serious diagnoses, including respiratory failure, CHF, and tracheostomy status, and the EMR showed no documented monitoring for side effects after the anticoagulant order began. An LPN stated monitoring should have been in the EMR but could not locate it and later said there was nothing available.
The facility did not promptly notify the nurse aide registry of an abuse allegation involving a CNA who was reported to have physically and emotionally mistreated several residents with varying cognitive and physical conditions. The delay in reporting was contrary to facility policy, as the notification was only made after the initial incident report had already been submitted to the state agency.
A resident with end stage renal disease, who was cognitively intact, was transferred to the hospital without being provided notification of the facility's bed hold policy at the time of transfer. Staff interviews indicated confusion about who was responsible for this notification, and the administrator confirmed that such information was only given at admission, not during transfers.
A resident with diabetes and intact cognition did not receive a timely annual comprehensive assessment, as required, due to the absence of an on-site MDS coordinator and reliance on corporate staff, resulting in the assessment being completed late.
A resident with impaired mobility and intact cognition did not receive scheduled showers on multiple occasions, despite being care planned for assistance and never refusing care. Staff interviews and documentation confirmed the missed care, and no records were found to indicate the resident declined bathing.
A resident’s SNF Part A discharge assessment was completed late and not transmitted within the required timeframe. The resident had a BIMS score of 12, indicating moderate cognitive impairment, and the MDS validation report identified the assessment as late because completion occurred more than 14 days after the ARD. The administrator said late assessments occurred during a transition of MDS coordinators.
A resident’s MDS was inaccurate because it did not reflect a schizophrenia diagnosis or antipsychotic medication use. Record review showed the resident had been discharged from a behavioral health facility with schizophrenia and later received Paliperidone ER and Zyprexa for schizophrenia, but the quarterly MDS listed different psych dx and indicated no antipsychotic meds. The MDS coordinator acknowledged the questions were answered incorrectly.
A resident discharged from behavioral health with schizophrenia had inconsistent PASARR documentation on admission, with the MDS listing depression and psychotic disorder other than schizophrenia and indicating the resident was not considered for state level 2 PASARR review. A psych exam and MAR showed the resident was receiving Paliperidone for schizophrenia, and the MDS coordinator acknowledged the PASARR question was not answered correctly.
Care plan not updated after liquid protein was discontinued. A resident with DM and moderate cognitive impairment still had liquid protein listed on the care plan even though the dietician had stopped it, and the nutrition section had not been revised for months. The MDS coordinator and corporate nurse consultant stated the care plan was not fully updated to reflect the resident’s current needs.
Medication administration was not completed as ordered for a resident with acute respiratory failure with hypoxia, CHF, and tracheostomy status. Physician orders for Guaifenesin and Ipratropium-Albuterol were documented, but the MAR had blank entries for multiple scheduled doses. An LPN stated the blanks meant the doses were missed and did not see where the medications were administered as ordered.
A facility failed to maintain infection control during incontinent care and EBP care. A CNA provided incontinent care to a resident with severe cognitive impairment, total incontinence, and a feeding tube without observed hand hygiene, glove changes, or a gown, and placed soiled linen on the floor. An LPN also performed wound care for another resident on EBP without a gown and reused scissors from dressing removal to cut collagen without cleaning them first.
A resident was not documented as having been offered the influenza vaccine, despite the facility policy stating that residents without medical contraindications would be offered the vaccine annually. Review of the resident’s care plan and interview with the infection preventionist confirmed there was no supporting documentation that the vaccine had been offered.
The facility failed to ensure the COVID-19 vaccine was offered to 3 of 5 sampled residents reviewed for immunization. Record review showed no documentation that the vaccine had been offered to three residents, despite the facility policy stating residents would be offered vaccines unless medically contraindicated or already vaccinated. The IP stated there was no supporting documentation that the residents had been offered the COVID-19 vaccine.
The facility failed to document meal consumption percentages and weights for residents experiencing weight loss. One resident with dysphagia had multiple instances of missing weight documentation, while another with protein calorie malnutrition had missing meal consumption and weight records. A third resident with dementia had no weight recorded for a month despite weight loss, and a fourth resident with dysphagia had multiple instances of missing meal consumption documentation.
A facility failed to notify a physician in a timely manner about a resident's abnormal lab results, despite policy requirements. The lab report showed a high potassium level, but there was no documentation of physician notification until several days later.
Resident Injury During Van Transport Due to Inadequate Securing
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, schizophrenia, seizures, altered mental status, muscle weakness, and mobility abnormalities was being transported by facility van to dialysis. The facility's policy required that wheelchair users be secured with four straps and a seat belt during transport. On the day of the incident, the resident was placed in the van, and the seat belt was applied by an LPN/charge nurse, while a CNA was responsible for driving and ensuring the resident was secured. During transport, the CNA observed the resident sliding out of the wheelchair via the rearview mirror. Upon stopping the van, the resident was found on the floor with a laceration to the right leg, requiring EMS transport to the emergency room and subsequent sutures. Review of documentation and staff interviews confirmed that the seat belt was still connected around the wheelchair after the incident, but the resident had nonetheless slid out of the chair. The facility's maintenance supervisor demonstrated the van's securing process and stated that, if the seat belt was placed correctly, the resident could not fall out. However, the incident report and staff statements indicated that the resident was not adequately secured, resulting in the accident and injury. The administrator acknowledged that the in-service training provided after the incident did not address the specific concern of the resident sliding out of the wheelchair during transport.
Failure to Ensure Appropriate Care for Surgical Wound and Hospice Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' preferences and goals in several instances. For one resident with a dehisced surgical incision, there was no documentation that the facility contacted the surgeon as directed in the physician's progress note, nor was the dehiscence consistently documented in nursing notes. The resident was later observed interfering with the wound and required hospital intervention for wound closure. Interviews with nursing staff indicated a lack of awareness of the wound's dehiscence prior to the resident's hospitalization, and the corporate nurse consultant confirmed that the facility should have clarified the physician's note and notified the surgeon. Additionally, the facility failed to ensure that two residents receiving hospice services had appropriate physician orders for hospice care. One resident switched hospice providers, but there was no order for the initial hospice admission, and coordination of care with the first hospice provider was lacking due to their irregular visit times. Another resident was assessed and care planned for hospice services, but a physician's order for hospice was not present in the clinical record until months after hospice admission. Staff interviews confirmed reliance on hospice company hard charts rather than facility physician orders to identify hospice status.
Failure to Complete Significant Change Assessments When Hospice Was Elected
Penalty
Summary
The facility failed to ensure a significant change assessment was completed when hospice services were elected for 2 residents. For Resident #75, a progress note showed the resident wanted to switch hospice companies, and a physician order directed evaluation by the resident’s hospice of choice. A significant change assessment was later completed and documented the resident had a BIMS score of 12, indicating moderate cognitive impairment for daily decision making, and a life expectancy of less than 6 months, with portions of the assessment completed later. The administrator stated the resident had elected the hospice benefit in February or March 2025 with the first hospice company and that a significant change assessment should have been completed when hospice was initially elected. For Resident #4, an initial hospice assessment showed the resident had been assessed by the hospice RN, and a later significant change assessment documented a BIMS score of 14, indicating the resident was cognitively intact for daily decision making, and a life expectancy of less than 6 months, with portions of the assessment completed later. The MDS coordinator stated they noticed in June that a significant change assessment had not been completed when the resident elected the hospice benefit. The administrator stated the assessment had not been completed at that time because the facility was transitioning MDS coordinators.
Baseline Care Plans Not Completed or Shared Within Required Timeframe
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours of admission for 3 of 18 sampled residents reviewed for baseline care plans. For Resident #20, an admission MDS dated 02/19/25 showed admission to the facility with diagnoses including depression and psychotic disorder other than schizophrenia, but the medical chart did not show a baseline care plan was developed within 48 hours of admission. During interview on 07/16/2025, the MDS coordinator stated the baseline care plan should be developed within 48 hours and acknowledged that Resident #20's care plan was not completed until May, adding that the resident did not have a baseline care plan in place. For Resident #69, an order summary listed diagnoses including acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status, and the electronic medical record did not show a baseline care plan had been completed. The resident's admission assessment dated 04/07/25 showed an admission date of 03/29/25. The MDS coordinator stated there was not a baseline care plan for the resident and said they started in May and had to catch things up, noting there was no coordinator since February and corporate was doing them during that time. For Resident #29, the baseline care plan dated 05/19/25 did not show that the resident or representative had been provided a summary of the plan; the admission assessment dated 05/23/25 showed a BIMS score of 15 and a diagnosis of unspecified dementia. The MDS coordinator stated baseline care plans were completed in the electronic record within 48 hours, but they had not provided residents or representatives with a summary, and corporate nurse consultant later confirmed social services had not provided a baseline care plan summary to Resident #29 or the representative.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for 3 of 18 sampled residents reviewed for care plans. For Resident #73, an admission assessment dated 02/20/25 showed a BIMS score of 15 and a diagnosis of end stage renal disease. The care area assessment summary identified multiple triggered care areas, including visual function, ADL function, urinary incontinence/indwelling catheter, psychosocial well-being, activities, falls, nutritional status, pressure ulcer, psychotropic drug use, pain, and return to the community referral, and care planning decisions were documented as completed by the VP of reimbursement on 02/28/25. However, when the care plan was reviewed on 06/09/25, it only showed a falls care plan and did not include the other triggered areas. For Resident #61, a significant change assessment dated 06/12/25 showed severe cognitive impairment for daily decision making and limited range of motion in both upper and lower extremities, but the revised care plan dated 07/14/25 did not address the limited range of motion. For Resident #69, an admission/discharge return anticipated assessment dated 04/07/25 showed an admission date of 03/29/25 and that the resident went to the hospital, while an order summary showed diagnoses including acute respiratory failure with hypoxia, acute on chronic systolic CHF, and tracheostomy status. A review of the electronic medical record did not show a comprehensive care plan had been initiated or completed for this resident.
Failure to Provide Range of Motion Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide range of motion services for residents with limited mobility and contractures. Resident #2, who had spastic quadriplegic cerebral palsy, aphasia, severely impaired cognition, and impairment of both upper and lower extremities, was observed in bed with contracted upper and lower extremities. The quarterly assessment showed no passive or active range of motion was performed in the 7-day look-back period, and there was no documentation that range of motion services were provided. Resident #13, who had diagnoses including nontraumatic intracerebral hemorrhage and muscle spasm, was observed in bed with right-sided weakness and a contracted left hand. The quarterly assessment showed severely impaired cognition, impairment on one side of the upper and lower extremities, and no passive or active range of motion performed in the 7-day look-back period, with no documentation of range of motion services. Resident #61 had a significant change assessment showing severely impaired cognition and limited range of motion on both sides of the upper and lower extremities, but the care plan did not show limitation in the upper or lower extremities. Review of the physician orders, care plan, assessments, and scanned documents did not show the resident had been assessed or evaluated for range of motion services. A family member stated the resident had refused therapy in the past but wanted the resident assessed for exercises of the joints. The DON stated nurses periodically assessed for range of motion services, but also stated they did not know how they ensured residents with limited range of motion did not experience further decline and that the facility did not have a restorative program, only physical therapy.
Dialysis Assessments Not Completed
Penalty
Summary
The facility failed to ensure that a resident who received dialysis services was assessed before and after dialysis. Resident #7 had end stage renal disease, a BIMS score of 12 indicating moderate cognitive impairment for daily decision making, and was scheduled for dialysis on Monday, Wednesday, and Friday at 1:30 p.m. The resident’s treatment record showed the fistula was monitored every shift, and the care plan identified the need for dialysis services. Review of the electronic clinical record for the period from 06/01/25 through 07/16/25 did not show that Resident #7 had been assessed before and after dialysis. A dialysis communication form dated 07/18/25 showed vital signs had been obtained by facility staff, while the bottom of the form indicated the dialysis center obtained vital signs. Another form dated 07/21/25 showed vital signs had been obtained by dialysis staff, but the form did not have the resident’s name on it and facility staff had not documented the pre-dialysis vital signs. Staff interviews showed the nurse documented pre-dialysis vital signs in the dialysis communication book or a progress note, but corporate nurse consultant #1 stated the nurses were to document in the dialysis communication book before and after the resident returned from dialysis, including vital signs and assessment of the dialysis access site. The administrator stated the dialysis center did not always return the dialysis communication forms, and corporate nurse consultant #1 stated the facility had not monitored to ensure pre- and post-dialysis assessments were being completed.
Anticoagulant Monitoring Not Completed
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when the facility failed to ensure anticoagulant monitoring was in place for one resident receiving a high-risk medication. Resident #69 had diagnoses including acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status. The resident had physician orders for Apixaban 5 mg twice daily beginning 03/28/25, which was discontinued on 04/09/25, and then again ordered on 04/15/25 and discontinued on 06/22/25. Review of the electronic medical record showed no order or monitoring for side effects of anticoagulant therapy was completed since the start of the 03/28/25 order. During interview, an LPN stated anticoagulant monitoring was done in the EMR and there was something they had to follow, but after reviewing the order list the LPN could not locate it and later requested help from the corporate nurse consultant; the LPN then stated they did not have anything.
Failure to Timely Report Abuse Allegation to Licensing Board
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse and mistreatment to the appropriate licensing board for five out of six sampled residents. According to the facility's policy, mechanisms should be in place for reporting, investigating, and monitoring abuse, neglect, and misappropriation of property. An initial incident report documented that a CNA was alleged to have physically and emotionally abused multiple residents, including rolling them roughly into walls and slamming a food tray in front of a resident. The initial report did not indicate that the nurse aide registry was notified of the abuse allegation at the time the incident was reported to the state agency. The residents involved had varying degrees of cognitive impairment and medical conditions, including severe obesity, hearing loss, dementia, anxiety disorder, and hemiplegia. Despite the serious nature of the allegations and the facility's policy requirements, the notification to the nurse aide registry was delayed and only documented in a final incident report two days after the initial report. The administrator confirmed that the nurse aide registry should have been notified when the initial incident was reported.
Failure to Notify Resident of Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to provide required notification of its bed hold policy to a resident upon transfer to the hospital. Record review showed that a cognitively intact long-term care resident with end stage renal disease was transferred to the emergency room for evaluation and treatment. Documentation did not indicate that the resident was notified of the bed hold policy at the time of transfer. Interviews with staff revealed uncertainty about who was responsible for providing this notification, and the administrator confirmed that while residents signed bed hold information upon admission, the facility did not provide notification at the time of hospital transfer.
Late Completion of Annual Comprehensive Assessment
Penalty
Summary
The facility failed to complete an annual comprehensive assessment for one resident within the required 366-day timeframe. Record review showed that the resident, who was cognitively intact and had a diagnosis of diabetes mellitus, had an annual assessment completed late, with no prior assessment found within the mandated period. The administrator confirmed that the delay occurred because the facility did not have an MDS coordinator and was relying on a corporate MDS coordinator, resulting in late completion of assessments.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide scheduled bathing assistance to a resident who required partial to moderate help with bathing due to impairment on one side of their upper and lower extremity. The resident's assessment indicated intact cognition and a need for assistance from one person for bathing. Facility policy required showers to be provided per resident request or facility schedule, based on safety. Documentation for July showed that bathing did not occur, or was provided by family or non-facility staff, on three separate dates. There was no documentation indicating that the resident refused showers on those dates. During interviews, CNAs confirmed that the resident was scheduled for showers three times a week and stated that the resident never refused a shower. The DON was unable to locate any shower sheets to show refusals for the dates in question. The deficiency was identified after the resident was mentioned in a group meeting as not having received scheduled showers.
Late Transmission of Resident Assessment Data
Penalty
Summary
The facility failed to ensure that resident assessment data were transmitted to the State within the required timeframe for 1 of 19 sampled residents, Resident #7. Record review showed a SNF Part A discharge assessment dated 02/26/25 for Resident #7, whose BIMS score was 12, indicating moderate cognitive impairment for daily decision making, and whose Part A skilled services ended on 02/26/25. The assessment sections were completed on 06/02/25, and the MDS 3.0 NH Final Validation Report dated 06/05/25 identified the assessment as completed late because the assessment completion date was more than 14 days after the assessment reference date. On 07/23/25, the administrator stated the corporate MDS coordinator had been completing assessments, but some were late due to the transition of MDS coordinators in the facility.
Inaccurate MDS for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure Resident #20’s assessment was accurate. A Transition Plan dated 11/21/24 showed the resident was discharged from an inpatient behavioral health facility with a diagnosis of schizophrenia. However, the Quarterly MDS dated 05/22/25 listed diagnoses including depression and psychotic disorder other than schizophrenia, and indicated the resident did not receive antipsychotic medications. Review of the MAR showed the resident received Paliperidone ER 6 mg daily in February and March 2025 and Zyprexa 5 mg daily in March, April, and May 2025, both documented for schizophrenia. When asked on 07/16/25, the MDS coordinator stated the quarterly MDS did not reflect the resident’s schizophrenia diagnosis or antipsychotic medication use and acknowledged the questions were answered incorrectly.
Inaccurate PASARR Documentation for Resident with Schizophrenia
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for Resident #20. The resident was discharged from an inpatient behavioral health facility with a diagnosis of schizophrenia, and the admission MDS later listed depression and psychotic disorder other than schizophrenia. The MDS also indicated the resident was not considered by the state level 2 PASARR process to have serious mental illness and/or intellectual disability or a related condition. A psychiatric exam documented that the resident was taking Paliperidone and had a diagnosis of schizophrenia, and the February 2025 MAR showed daily Paliperidone ER 6 mg for schizophrenia. During interview, the MDS coordinator stated that residents with diagnoses such as bipolar disorder or schizophrenia, or those taking antipsychotic medications, would prompt a state level 2 PASARR, and acknowledged that the PASARR question was not answered correctly for this resident. The coordinator later stated that the resident did not actually have a level 2 PASARR in progress.
Care Plan Not Updated After Liquid Protein Discontinued
Penalty
Summary
The facility failed to ensure Resident #7’s care plan was revised to reflect current needs after the dietician discontinued liquid protein. A Nutrition Services Note dated 04/02/25 showed the liquid protein was discontinued, and an annual assessment dated 04/12/25 showed the resident had a BIMS score of 12, indicating moderate cognitive impairment for daily decision making, and a diagnosis of diabetes mellitus. However, a care plan reviewed on 07/14/25 still identified a nutritional problem and directed that the resident receive 30 milliliters of liquid protein each day. On 07/23/25, the MDS coordinator stated the care plan had been reviewed on 07/13/25 but the nutrition portion had not been revised since 09/04/24, and the liquid protein should not have remained on the care plan. The corporate nurse consultant stated care plans were to be reviewed and revised daily for acute needs and quarterly, and did not know why the care plan had not been updated to reflect the resident’s current needs.
Medication Administration Not Completed as Ordered
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when medication was not administered according to physician orders for one resident. The resident had diagnoses including acute respiratory failure with hypoxia, acute on chronic systolic congestive heart failure, and tracheostomy status. Physician orders were entered for Guaifenesin three times daily and Ipratropium-Albuterol three times daily for wheezing and shortness of breath, but the medication administration record contained blank boxes for multiple scheduled doses of both medications. During interview, an LPN stated the blanks meant the doses were missed and should have been marked refused, and also stated they did not see where the albuterol or guaifenesin were administered as ordered.
Infection Control Lapses During Incontinent Care and EBP Wound Care
Penalty
Summary
The facility failed to maintain infection control during incontinent care for one resident who was always incontinent of bladder and bowel, dependent for toileting mobility, severely cognitively impaired with a BIMS of 5, and had a feeding tube. During observation, a CNA checked the resident’s brief, found it wet, left the room to gather supplies without observed hand hygiene, and returned to provide care without changing gloves or performing hand hygiene as expected. The CNA wiped gloved hands with clean wipes during care, placed a soiled pad on the floor next to the trash, and then continued care without observed glove changes or hand hygiene. The resident was also observed with an EBP sign posted at the door, but there was no order located for enhanced barrier precautions. The CNA stated the resident was on EBP for the feeding tube, yet no gown was worn during the incontinent care. The corporate nurse consultant stated that for an incontinent resident on EBP, gown and gloves were expected, and that the PPE was stored on the carts. The consultant also stated it was not appropriate to place soiled linen on the floor or to wipe gloved hands with a clean wipe used for incontinent care instead of changing gloves or performing hand hygiene. The facility also failed to ensure appropriate PPE was worn during wound care for another resident on EBP. An LPN provided dressing care to a resident with schizophrenia, mild protein-calorie malnutrition, abnormal gait and mobility, and diabetes mellitus, and used scissors to remove the old dressing without cleaning them before using the same scissors to cut the collagen strip for the wound. The LPN did not wear a gown during the wound care and later stated they forgot to bring an alcohol wipe to clean the scissors between dirty and clean dressing areas and that they should have been wearing a gown and gloves for the wound care per EBP.
Failure to Document Offering Influenza Vaccine
Penalty
Summary
The facility failed to ensure that the influenza vaccine was offered to Resident #4, one of five sampled residents reviewed for immunization. The facility’s Influenza Vaccine policy, dated 2001, stated that all residents and employees without medical contraindications would be offered the influenza vaccine annually. A care plan revised on 06/09/25 showed that Resident #4 was admitted on [DATE], but there was no documentation that the resident had been offered an influenza vaccine. On 07/23/25 at 6:14 p.m., the infection preventionist stated there was no supporting documentation that Resident #4 had been offered the influenza vaccine.
COVID-19 Vaccine Not Offered or Documented for Three Residents
Penalty
Summary
The facility failed to ensure the COVID-19 vaccine was offered to residents for 3 of 5 sampled residents reviewed for immunization, identified as Residents #4, #29, and #61. The facility’s Vaccination of Residents policy stated that all residents would be offered vaccines that aid in preventing infectious diseases unless medically contraindicated or already vaccinated. Record review showed Resident #4 had a care plan revised on 06/09/25, Resident #29 had an admission resident assessment dated 05/23/25, and Resident #61 had a care plan dated 07/14/25. For each of these residents, there was no documentation that the COVID-19 vaccine had been offered. On 07/23/25 at 6:14 p.m., the infection preventionist stated there was no supporting documentation that the residents had been offered the COVID-19 vaccine.
Failure to Document Meal Consumption and Weights for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure proper documentation of meal consumption percentages and weights for residents experiencing weight loss. Specifically, Resident #2, who had diagnoses including dysphagia and cerebral infarction, had multiple instances where weights were not documented as ordered by the physician. The November 2023, December 2023, January 2024, and February 2024 Treatment Administration Records (TARs) showed blanks for the resident's weight on several dates, indicating that the weights were not completed as required. The Assistant Director of Nursing (ADON) confirmed that the weights were not documented as ordered. Resident #3, diagnosed with protein calorie malnutrition and muscle wasting, also had missing documentation for meal consumption amounts and weights. There were several instances in January, February, and March 2024 where meal consumption was not recorded, and the March and April 2024 TARs showed blanks for the resident's weight on specific dates. The ADON and Certified Nursing Assistant (CNA) confirmed the lack of documentation. Similarly, Resident #5, with diagnoses including dementia and heart disease, had no weight recorded for January 2024 despite experiencing weight loss. The ADON stated that the resident was not on weekly weight monitoring as required. Resident #7, diagnosed with dysphagia and protein calorie malnutrition, also had multiple instances of missing meal consumption documentation across January, February, and March 2024. The CNA and Director of Nursing (DON) confirmed the lack of documentation for meal consumption on the specified dates for Resident #7.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding abnormal lab results for a resident reviewed for weight loss. The facility's Test Results policy mandates that the attending physician be promptly notified of abnormal test results. A physician's order required a basic metabolic panel (BMP) to be checked, and the lab report showed a high potassium level. However, there was no documentation that the physician was notified of this abnormal result. The DON confirmed that the physician should have been notified immediately, and the ADON acknowledged that the nurse on duty should have informed the physician upon receipt of the lab report. The physician was eventually notified several days later, indicating a delay in communication.
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 236 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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 Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lodge At Brookline | 0.8 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Okc, Llc | 1.1 mi | ★★★★★ | 9 | 0 |
| Bellevue Health & Rehabilitation Center | 1.2 mi | ★★★★★ | 8 | 0 |
| North Winds Living Center | 2 mi | ★★★★★ | 0 | 0 |
| Tuscany Village Nursing Center | 2.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Northwest Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.