Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ranchwood Nursing Center during CMS and state inspections, most recent first.
A resident with multiple serious medical conditions, including acute kidney injury, sepsis, and diabetes, experienced repeated episodes of abnormal vital signs such as very low blood pressure, low oxygen saturation, and bradycardia. On more than one occasion, there was no documentation that the physician or NP was notified of these changes, nor that the NP evaluated the resident, despite facility policy requiring notification for significant changes in condition. The resident’s family reported they were not informed by the facility about the resident’s deteriorating condition and instead learned of it from the emergency room. The resident was later found unresponsive, transferred to the ER in critical condition, returned while actively dying, and subsequently died, with the death certificate citing protein calorie malnutrition, cognitive impairment disorder, acute kidney failure, and diabetes mellitus as contributing conditions.
A resident with DM2, acute kidney injury, and a recent history of hypoglycemia-related hospitalizations was admitted without care plan interventions for diabetes or kidney injury and without parameters for PRN Glutose or glucagon. Over several days, no finger stick blood sugars were documented despite ongoing use of Metformin and glimepiride. The resident developed critically abnormal VS, including hypotension, hypoxia, bradycardia, and unresponsiveness, with documentation gaps showing no or unclear provider notification and no recorded interventions for some abnormal readings. Staff later reported they believed they had notified the NP about low VS, but could not find documentation, and the NP stated they had not been notified of these changes and had expected routine blood glucose monitoring. The resident was ultimately found unresponsive with severe hypoglycemia and was transferred to the ED in critical condition, and the situation was cited as an IJ for failure to monitor and intervene for hypoglycemia and acute changes in condition.
The facility failed to develop and update comprehensive care plans for two residents with significant clinical needs. One resident admitted with DM2 and acute kidney injury had a care plan that did not include these diagnoses, despite later being found unresponsive and critically ill with severe hypoglycemia and hypotension, and having acute kidney failure and diabetes documented on the death certificate. Another resident with severe cognitive impairment, severe protein-calorie malnutrition, and notable weight loss had a nutrition therapy assessment and MD orders for weekly weights and specific nutritional interventions, but these were not incorporated into the care plan. The MDS coordinator and DON acknowledged that these conditions and interventions should have been reflected in the residents’ plans of care.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with orders for levothyroxine for hypothyroidism and divalproex for dementia did not receive multiple scheduled doses because the medications were not available in the building. Review of the MAR showed several early-morning levothyroxine doses and morning divalproex doses marked as held due to unavailability or lacking documentation. CMAs reported that medications were ordered when supplies were low and that unavailable medications were left on the MAR while notifying nursing staff, pharmacy, and the DON, while leadership stated medications should be reordered earlier and STAT if needed. These discrepancies in practice led to repeated missed doses of the resident’s prescribed medications.
An LPN left a treatment cart in a hallway with a laptop unlocked and the EMR visible while going into a resident room, leaving the screen facing the hallway. During this time, a resident approached the cart and faced the exposed screen while speaking to the LPN. Facility policy required resident health information to remain private and MAR or EMR information to be closed or covered when not in direct use, but the LPN reported not knowing how to lock the computer screen, resulting in resident medical information being visible in a public area.
A resident who was cognitively intact, occasionally incontinent, and dependent for bed mobility was found to have a bed with a visible urine wet ring on the mattress and wet linens placed on the floor, along with a strong urine odor and a saturated brief in the trash. A CNA reported the resident was wet when being gotten out of bed for therapy and that only the resident’s clothes were changed, not the bed linens. The DON stated staff were expected to check incontinent residents at least every two hours, provide perineal care, and change soiled linens as needed, and confirmed observing the wet linens and wet ring on the bed.
A treatment cart on one hall was left unlocked and unattended in the hallway while an LPN entered a resident room, despite facility policy requiring carts to be locked when out of sight and clearly visible when unlocked. During this time, a resident approached the front of the unattended cart and spoke with the LPN from the doorway while the LPN remained inside the room. In interviews, the LPN minimized the significance of leaving the cart unlocked, and facility leadership, including the regional consultant and DON, confirmed that policy required treatment/medication carts to be locked whenever staff were not in attendance.
A CNA failed to follow infection control and hand hygiene protocols while providing perineal care to a resident who was dependent for toileting, frequently incontinent, and had active UTI and septicemia. After cleaning stool, the CNA wiped feces from a gloved hand onto the bed pad and then continued care, touching the resident, linens, wipes package, and cleaning solution without changing gloves. The CNA then removed the soiled pad, dressed the resident, handled bed covers, and took out the trash without performing hand hygiene, contrary to facility policy requiring glove removal and hand hygiene after feces removal and before applying new gloves and clean linens.
Failure to Identify and Assess a Diabetic Foot Wound: A resident with DM and renal failure developed an unrecognized right plantar diabetic ulcer that was not identified on facility skin assessments. The resident later presented with AMS, sepsis, hypoglycemia, and an infected foot ulcer; the wound grew MRSA, worsened despite treatment, and ultimately required a right BKA after hospital admission and podiatry/vascular evaluation.
Missing Discharge Summary: A resident with paraplegia and anxiety, who was cognitively intact and independent with eating and personal hygiene, was discharged from the facility, but no discharge summary was found in the medical record. A corporate nurse consultant confirmed the discharge summary was not completed.
Inaccurate Smoking Safety Assessment: A resident was found with a vape hidden under a blanket and later observed smoking independently in the smoking area, despite staff reporting that smoking/vaping privileges had been suspended and that the resident's supplies were supposed to be kept by staff. Records showed a physician order suspending smoking privileges due to non-compliance and psychosis, but a later smoking assessment incorrectly stated the resident could smoke unsupervised and request materials from staff.
A resident’s care plan was not updated after smoking/vaping privileges were suspended, even though the resident had a physician order stating the restriction was active and staff reported the resident still had access to vapes. In another case, a resident with moderately impaired cognition had a care plan meeting conducted by the social services director without the legal guardian being invited or documented as participating.
A facility failed to include key resident needs in care plans for anxiety and smoking. One resident had orders for multiple psychotropic medications and documented anxiety disorder, but the care plan had no goals or interventions for anxiety. Another resident had nicotine dependence, tobacco use, and a supervised smoking order, but the care plan did not address smoking or the level of assistance needed.
Missed showers and incontinent care were identified for two residents. One resident had no documentation of showers for an extended period, and a charge nurse stated showers were sometimes missed when staff did not show up. Another resident with bowel and bladder incontinence, severe cognitive impairment, and diagnoses including COPD, DM, and dementia was observed with a urine-soaked brief, urine odor, and unwashed hair; the resident said they had not received a brief change or bath, and a CNA said incontinent care had not been provided during the shift.
Failure to notify a resident's legal guardian of a change in condition and treatment. A resident with moderate cognitive impairment was diagnosed with a UTI and ordered IV Ceftriaxone, but there was no documentation that the guardian was informed. The guardian stated they were not notified, and the DON acknowledged the guardian should have been notified of the diagnosis and antibiotic treatment.
A resident’s baseline care plan was incomplete because it did not include incontinence, ADL assistance, fall risk, or a wound vac despite recent surgery, IV ABX, and mild cognitive impairment. Family members reported repeated falls from bed and episodes of the resident being soaked with urine, and the DON stated the resident’s fall risk, wound vac, and toileting/incontinent care should have been included on the baseline care plan.
Failure to Offload Heel Pressure Ulcer: A resident with a stage III left heel pressure ulcer and impaired cognition was repeatedly observed lying in bed with the heels on the mattress and not offloaded. Although the care plan called for floating the heel in bed and the wound treatment plan included off-loading, the resident’s heels remained unsupported during and after wound care, and no pressure-relieving devices were in place.
Three residents with significant physical or cognitive impairments did not consistently receive scheduled showers or baths, and staff failed to document bathing as required by facility policy. Interviews with residents, family members, and staff confirmed that bathing was not provided on scheduled days and that records were incomplete or missing, making it impossible to verify that care was delivered as planned.
Three residents experienced multiple missed doses of prescribed medications, including antihypertensives, insulin, anticonvulsants, and anticoagulants, with no explanations documented in the medical records. Facility staff confirmed that there was no way to verify if the medications were given, as proper documentation was not completed, resulting in a deficiency in pharmaceutical services.
A resident with intellectual disabilities and reduced mobility fell in the bathroom, sustained a head injury, and was transported to the hospital. Facility staff did not notify the resident's family or representative about the fall or hospital transfer, as required by policy. The family only learned of the incident when contacted by hospital staff, and facility staff cited confusion with the new EHR system as a reason for the failure to notify.
An LPN failed to follow infection control protocols during wound care for a resident with pressure ulcers, including not wearing a gown as required by Enhanced Barrier Precautions, and not performing hand hygiene or changing gloves after incontinent care and between wound sites. The resident had a history of pressure ulcers and malnutrition, and the LPN was not aware of the EBP requirements. The DON confirmed that proper infection control procedures were not followed.
A resident who required significant assistance with bathing did not have any documented evidence of receiving bathing services during their stay. Staff were unaware of the resident's bathing schedule, and the DON could not provide records to show that bathing was performed, resulting in a failure to meet the resident's care needs.
A resident with diabetes and renal disease reported missing doses of Ozempic, a medication they were prescribed weekly. The resident's medication pen, with two doses remaining, went missing after being left out to warm by an RN. The incident was reported to the DON, who did not initiate an investigation or inform the administrator. The administrator later confirmed they were unaware of the incident, leading to a deficiency in the facility's response to the alleged violation.
A resident admitted with type 2 diabetes and a stage 4 pressure ulcer did not have a comprehensive MDS assessment completed within the required time frame. The DON confirmed the absence of this assessment after reviewing the resident's clinical record.
A resident with pneumonia and deep vein thrombosis was mistakenly given medications intended for another resident due to improper identification methods by a CMA. The error involved administering aspirin, buspirone, linezolid, and potassium chloride. The DON acknowledged the incident but lacked documentation of a review or staff training to prevent recurrence.
The facility failed to maintain a homelike environment, with observations of torn carpets, damaged tiles, exposed wires, and strong urine odors. Residents expressed dissatisfaction, and the housekeeping supervisor confirmed the disrepair. The Regional Directors acknowledged the unsafe conditions and lack of adherence to the facility's policy.
The facility failed to ensure safe food handling practices by allowing unwrapped cereal bowls to be stacked on the tray line, leading to potential contamination. A kitchen aide noted that the bowls should have been wrapped, and the dietary manager confirmed the issue as an infection control concern, with no policy in place to address it. The DON reported that 101 residents received meals from the kitchen.
A facility failed to maintain a resident's dignity by not covering their catheter bag with a vanity bag, as required by policy. The resident, admitted with acute respiratory failure and cellulitis, had their catheter bag observed uncovered and visible from the hallway on two occasions. Staff interviews confirmed the policy breach, with a CNA and LPN acknowledging the requirement to cover the bag, while a corporate nurse was unsure of the policy details.
A facility failed to ensure a resident was offered the choice to formulate an advance directive. The policy requires the Director of Admission to complete and scan the Advanced Directive Acknowledgment Form into the resident's EMR during admission. However, a resident with multiple sclerosis and paraplegia had no documentation in their EMR indicating assistance with formulating an advance directive. Corporate Nurse #1 confirmed the absence of an acknowledgment after auditing the charts.
A resident with Hypertensive Chronic Kidney Disease and Anxiety Disorder reported an alleged abuse incident to a CMA, who failed to document it as required by the facility's policy. The incident was reported during a shift change, but no incident report was completed, as confirmed by the DON.
The facility failed to complete quarterly MDS assessments within the required 92-day period for two residents. One resident with morbid obesity and hypotension did not have an assessment completed by the due date following an ARD of 04/25/24. Another resident with epilepsy and major depressive disorder also missed the assessment deadline after an ARD of 04/06/24. A corporate nurse confirmed the oversight.
A facility failed to ensure accurate MDS documentation for a resident's discharge status. The MDS records incorrectly indicated a discharge to the hospital, while nursing notes and physician orders confirmed a discharge home. The MDS Coordinator acknowledged the coding error, and the Administrator noted the absence of a policy for handling such inaccuracies.
A resident with Parkinson's disease, dementia, and bipolar disorder fell due to a torn and frayed carpet in their room, resulting in a skin tear and pain. Despite the facility's policy to investigate and prevent future falls, the intervention plan only included educating the resident to use their walker and did not address the carpet issue. Observations confirmed the carpet had been in disrepair for at least a year, and maintenance was aware but did not complete repairs.
The facility failed to report allegations of abuse, neglect, and resident-to-resident altercations to the OSDH for seven residents. Incidents involving mistreatment by staff and inappropriate behavior were not documented or reported within the required time frames, leading to a significant deficiency in compliance with regulations.
The facility failed to investigate multiple allegations of abuse and neglect reported by residents, including incidents involving staff treatment and resident altercations. Despite documentation of these complaints, the facility did not conduct thorough investigations as required by their policies.
Failure to Notify Physician and Family of Significant Change in Condition and Abnormal Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and the resident’s family of significant changes in condition, including abnormal vital signs, for a resident who ultimately died. The resident was admitted with multiple serious diagnoses, including hypertension, acute kidney injury, multidrug-resistant organisms, urinary tract infection, sepsis, diabetes mellitus, and later was assessed for dehydration with an order for IV normal saline. On one date, the vital sign log documented a blood pressure of 73/47 and oxygen saturation of 84% on room air, but there was no documentation in the health record that the physician was notified of these abnormal findings, and there was no documentation that the nurse practitioner saw the resident that day. Subsequently, nursing documentation showed the resident was unable to be aroused, with a blood pressure of 81/59, pulse of 41, 3+ pitting edema to both arms, and cold, purple fingers. At that time, the physician was notified and ordered a 500 cc normal saline bolus and possible transfer to the emergency room if there was no improvement. On a later date, the vital sign log showed a pulse of 48, but again there was no documentation that the nurse practitioner saw the resident that day or that the physician was notified of this abnormal pulse. A nurse later stated they had notified the nurse practitioner of the low pulse and documented it, but they were unable to locate any such documentation in the chart. The resident was later found unresponsive with a pulse of 28 and was sent to the emergency room, where records showed critically low blood pressure, hypothermia, and a blood glucose level of less than 20, with the resident verbally and physically unresponsive and critically ill. The resident subsequently returned to the facility while actively dying and passed away the following day. The death certificate listed protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure as causes of death, with diabetes mellitus as a contributing condition. The facility’s own change of condition policy required contacting families or appropriate representatives when there is a significant change in condition, yet the resident’s family member reported receiving no communication from the facility about the resident’s physical condition and stated they were first notified of the resident’s condition by the emergency room.
Failure to Monitor and Intervene for Diabetic Resident With Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess, identify, monitor, and intervene when a resident with diabetes mellitus type 2 and acute kidney injury experienced an acute emergent change in condition. The resident had a known history of diabetes, hypoglycemia, and recent hospitalizations for hypoglycemia, including a documented emergency room visit where their finger stick blood sugar was 36 and a subsequent hospital stay for hypoglycemia. Despite these known conditions, the comprehensive admission assessment and care plan did not include interventions for diabetes mellitus type 2 or acute kidney injury. The resident was prescribed Metformin and glimepiride, both blood sugar–lowering medications, as well as PRN Glutose gel and glucagon for low blood sugar, but there were no parameters in the orders specifying at what blood glucose level these PRN medications should be administered. An undated vital sign log showed there was no finger stick blood sugar monitoring for the resident over a multi-day period, even though the resident had diabetes and a recent history of hypoglycemia-related hospitalizations. The DON later acknowledged there were no physician orders to monitor the resident’s finger stick blood sugar, but stated monitoring should have been done because of the diabetes diagnosis. Nursing staff interviews further showed that an LPN did not recall monitoring the resident’s finger stick blood sugar, and the nurse practitioner stated they expected the facility to monitor the resident’s blood sugars given the diagnosis and prior hypoglycemic events. The nurse practitioner also reported that the only notifications of changes in the resident’s condition they received were on days when the resident was seen in person, and they did not recall being notified of abnormally low vital signs on the critical dates. The facility also failed to appropriately respond to and document interventions for the resident’s abnormal and critical vital signs. A vital sign log documented a blood pressure of 73/47 and oxygen saturation of 84% on room air, with no corresponding documentation of any intervention in the health record. Later, a nurse’s note recorded that the resident was unable to be aroused, with a blood pressure of 81/59, pulse of 41, 3+ pitting edema in both arms, and cold, purple fingers; the physician was notified and ordered a 500 cc normal saline bolus with instructions to send the resident to the emergency room if there was no improvement. Another vital sign entry showed a pulse of 48, but there was no documentation that the physician was notified of this abnormal pulse. The LPN stated they would notify a provider for a pulse less than 60 and claimed to have notified the nurse practitioner about the pulse of 48, but could not locate any documentation of this notification and did not notify the family. Subsequently, a nurse’s note documented that the resident was found unresponsive with a pulse of 28 and was sent to the emergency room, where they were found to have a blood pressure of 71/44, temperature of 88.2°F, blood glucose less than 20, and were described as ill-appearing, verbally and physically unresponsive, critically ill with low blood pressure, and with a high likelihood of death. The resident was later identified as actively dying, returned to the facility, and expired, with the death certificate listing protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure as the cause of death, and diabetes mellitus as a significant contributing condition. The facility’s own Change of Condition policy defined an acute change of condition as a sudden, clinically important deviation from baseline that, without intervention, may result in complications or death, and required staff to clearly document symptoms, condition changes, physician notifications, actions taken, and patient responses. However, the record review showed multiple instances where abnormal vital signs and significant changes in condition were either not followed by documented interventions or not accompanied by documented provider notification. The ADON stated they would report a blood pressure less than 110/60 and oxygen saturation less than 90% to a provider and claimed to have notified the nurse practitioner about the resident’s blood pressure of 73/47 and oxygen saturation of 84%, but could not recall whether they spoke directly or left a message and could not recall any resulting orders, and there was no documentation of this notification. These documented omissions and inconsistencies in monitoring, assessment, and communication regarding the resident’s diabetes, hypoglycemia risk, and abnormal vital signs formed the basis of the deficiency. The situation was determined by the state survey agency to constitute immediate jeopardy related to the facility’s failure to adequately monitor finger stick blood sugars and intervene for a resident with diabetes mellitus type 2 who was found unresponsive with hypoglycemia, and also related to the failure to monitor and intervene when the resident experienced a change in condition with abnormal vital signs. The immediate jeopardy determination was based on the facility’s alleged failures in monitoring, assessment, and intervention for this resident’s hypoglycemia and abnormal vital signs, as well as the lack of appropriate documentation and communication with the medical provider regarding these critical changes in condition.
Failure to Develop and Update Comprehensive Care Plans for Diabetes, AKI, and Weight Loss
Penalty
Summary
The facility failed to develop and implement complete care plans addressing all identified needs for two residents. For one resident with documented diagnoses of diabetes mellitus type 2 and acute kidney injury on the comprehensive admission assessment, the care plan dated 01/22/26 did not include these conditions as problems to be managed. Subsequent clinical events showed the resident was found unresponsive with a pulse of 28 and transferred to the emergency room, where the physician documented hypotension, hypothermia, a blood glucose level of less than 20, and critical illness with a high likelihood of death. The Certificate of Death later listed protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure as causes of death, with diabetes mellitus noted as a significant contributing condition. The DON acknowledged that this resident should have had a care plan for monitoring kidney injury/failure and diabetes mellitus type 2. The facility also failed to incorporate recommended nutritional interventions and weight monitoring into the care plan for another resident experiencing weight loss. A Nutrition Therapy Assessment dated 03/25/26 recommended encouraging fluid intake with meals and snacks, providing a frozen nutrition treat, and obtaining weekly weights, and a physician order directed weekly weights on day shift for four weeks or until stable. However, the resident’s care plan did not include these recommended interventions. A weight report showed an 8.5% weight loss over six months, and a quarterly assessment documented severe cognitive impairment (BIMS score of 3) and a diagnosis of severe protein calorie malnutrition. The MDS coordinator stated that care plans were updated when there was a 10% change in weight and acknowledged that the interventions from the nutrition therapy assessment were appropriate but were not added to the care plan.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Ensure Availability of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for one resident. Facility policy dated 01/2024 required medications to be administered as prescribed in accordance with manufacturers’ specifications and good nursing practices. Physician orders for the resident included divalproex 125 mg by mouth every 12 hours for unspecified dementia and levothyroxine 150 mcg by mouth in the early morning for hypothyroidism. Review of the resident’s February 2026 MAR showed multiple instances where levothyroxine doses were held due to unavailability on 02/07, 02/08, 02/14, 02/15, and 02/16 at 6:00 a.m., and one instance on 02/12 at 6:00 a.m. with no documentation. The MAR also showed divalproex doses held on 02/15 and 02/16 at 9:00 a.m. due to unavailability. During interviews, CMA #2 stated the process to ensure medications were available was to order medications daily, typically when the supply was down to five days or less, and to call the pharmacy and notify the nurse if a medication was not in the building. CMA #2 also stated that when a medication was not available, they left the medication up on the MAR and notified the nurse, pharmacy, and then the DON. The DON and regional consultant stated medications should be ordered when down to a seven-day supply and, if not available, the physician and DON should be notified and the medication ordered STAT from the pharmacy. CMA #1 confirmed that an “H” on the MAR indicated a hold and verified that the resident’s levothyroxine and divalproex doses on the specified February dates were held because the medications were unavailable and needed to be ordered STAT, indicating the medications were not in the building at those times.
Unsecured Computer Screen Exposed Resident Medical Records
Penalty
Summary
The facility failed to maintain privacy and confidentiality of residents' medical records when a laptop on a treatment cart in hall 8 was left unlocked with the electronic medical record visible while unattended. During observation, an LPN left the treatment cart positioned in front of a resident room with the computer screen facing the hallway and went inside the room, leaving the screen exposed and displaying resident medical information. While the LPN was inside the room, a resident approached the cart, faced the computer, and spoke to the LPN from the doorway, with the medical record still visible on the screen. The facility’s Medication Administration policy stated that resident health information must remain private and that MAR pages containing resident health information must remain closed or covered when not in direct use. The LPN stated they did not think leaving the screen exposed was a big deal because they returned quickly and also stated they were unsure how to lock the computer screen. The regional consultant and DON later stated that the policy and procedure for securing computers was to minimize or close the screen when not actively in use by staff. The administrator identified that 105 residents resided in the facility at the time of the survey, and the deficiency was cited for 1 of 1 treatment cart observed with an unsecured computer displaying medical records in a public hallway area.
Failure to Provide Timely Incontinent Care and Change Soiled Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and change soiled linens for a resident who required assistance with activities of daily living. Surveyors observed a strong urine odor and an overly urine-saturated brief in the trash can in the resident’s room in the early afternoon. The resident’s bed had a visible wet ring in the center of the mattress, and the blanket, sheet, and cloth pad that had been removed from the bed and placed on the floor were wet. The facility’s perineal care policy required staff to provide perineal care in accordance with standards of practice to prevent skin breakdown and infection, dispose of used supplies, perform hand hygiene, and apply a new brief and change linens as needed. The resident’s admission assessment showed the resident was cognitively intact, occasionally incontinent of bladder, required partial/moderate assistance with toileting, and was dependent for bed mobility. The resident stated they were not soiled and reported staff had gotten them out of bed just before lunch. A CNA reported that when they went to the room around 1:00 p.m. or earlier to get the resident out of bed for therapy, the resident was wet, and the CNA changed the resident’s clothes but did not make the bed afterward. The CNA verified the sheet and linens were wet. The DON stated that staff were expected to check incontinent residents at least every two hours, clean and dry them if soiled, and change linens as needed when soiled, and confirmed observing the wet linens and wet ring on the resident’s bed.
Unattended Unlocked Treatment Cart Left Accessible in Hallway
Penalty
Summary
The facility failed to ensure a treatment cart on hall 8 was secured when staff were not in attendance, contrary to facility policy requiring medication carts to be closed and locked when out of sight of the medication nurse. On 03/04/26 at 12:26 p.m., an LPN left the treatment cart unlocked in the hallway and went inside a resident room, positioning the cart slightly sideways near the wall with the front of the cart facing the hallway. At 12:27 p.m., an unidentified resident approached the front of the unattended, unlocked treatment cart and spoke to the LPN from the doorway while the LPN remained inside the room. The facility’s Medication Administration policy, dated 01/2024, stated that during medication administration the cart must be kept closed and locked when out of sight and must be clearly visible to the personnel administering medications when unlocked. When interviewed at 12:29 p.m., the LPN stated they did not think leaving the cart unlocked was a big deal because they returned quickly. Later, at 2:32 p.m., the regional consultant and the DON confirmed that the policy and procedure for treatment/medication cart storage required carts to be locked anytime staff were not in attendance of the cart. The administrator identified that 105 residents resided in the facility at the time of the survey.
Failure to Follow Hand Hygiene and Glove Protocol During Perineal Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices, specifically hand hygiene and glove use, during perineal care for one resident. During an observation of incontinent care, a CNA performed perineal care on a resident who was dependent for toileting and bed mobility and frequently incontinent of bowel and bladder. After the resident had a bowel movement, the CNA wiped stool from the resident and was observed wiping stool from their gloved hand onto the pad under the resident. Without changing gloves, the CNA then placed a clean brief under the resident, touched the wipes package, placed it on the resident's table, turned the resident, and continued to touch the resident, the wipes package, and a cleaning solution with the same contaminated gloves. The CNA continued the care by fastening the clean brief, removing the soiled pad and placing it at the foot of the bed, and putting clean pants on the resident, all without changing gloves. The CNA then touched the resident's covers and draw sheet with the same gloved hands. At the end of care, the CNA removed their gloves, took the trash, and left the room without performing hand hygiene after glove removal or before handling the trash. There was no observation that hand hygiene was performed at any point. The facility's perineal care policy required staff to remove feces, dispose of gloves and used supplies, perform hand hygiene, and then apply new gloves before placing a new brief and changing linens. The resident involved had active diagnoses of urinary tract infection and septicemia. In a subsequent interview, the CNA stated that gloves were supposed to be changed after cleaning stool and after completing incontinent care and acknowledged they did not think they changed their gloves because they were nervous.
Failure to Identify and Assess a Diabetic Foot Wound
Penalty
Summary
The facility failed to assess and identify a new wound for a resident with diabetes and renal failure, and the resident later developed an infected diabetic foot ulcer that required hospitalization and ultimately a right below-knee amputation. The resident’s quarterly assessment showed intact cognition with a BIMS score of 15, no pressure ulcers or skin issues, and a need for supervision with activities of daily living. A skin assessment on 06/24/25 also documented no skin issues, and the last documented skin assessment before the hospital transfer was on 06/24/25. On 07/07/25, the resident was observed to be drowsy, persistently wanting to lie down and sleep, and was sent to the hospital because of altered mental status. The emergency room record documented mild hypotension responsive to IV fluids and concern for a possible infected right foot diabetic ulcer. The resident was admitted with diagnoses including altered mental status, sepsis, diabetic foot ulcer, and hypoglycemia. Hospital records later documented a right plantar diabetic ulcer first assessed on 07/07/25, and a wound culture from the right foot grew MRSA. After the resident returned to the facility, the record showed an admission skin assessment that documented dry skin but did not identify a diabetic ulcer to the right foot. A treatment record showed ordered daily wound care was not performed on several days because the resident was in the hospital or out to dialysis. On 07/21/25, the resident was again confused and had a blood sugar of 57, was sent back to the emergency room, and family reported the right diabetic foot ulcer was worsening and they were unsure whether wound care had been performed as prescribed. The emergency room described the ulcer as grossly infected, podiatry documented a plantar ulcer with bedside debridement, vascular surgery later noted a non-healing right foot wound requiring amputation, and a right below-knee amputation was performed on 07/29/25.
Missing Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was completed for Resident #129, who was discharged from the facility on 03/21/25. Record review showed the resident’s 01/01/25 quarterly assessment documented diagnoses of paraplegia and anxiety, a BIMS score of 15 indicating cognitive intactness, and that the resident was independent with eating and personal hygiene. A social services discharge note documented the resident’s discharge, but there was no discharge summary located in the medical record. On 09/17/25 at 10:12 a.m., the corporate nurse consultant reported that a discharge summary was not completed for Resident #129.
Inaccurate Smoking Safety Assessment
Penalty
Summary
The facility failed to accurately assess a resident for smoking safety and smoking privileges. Resident #32 was observed in the room with a vape hidden under a blanket and handed it to staff when asked for it. Staff reported the resident's smoking/vaping privileges had been suspended at one time, that staff were supposed to keep the resident's smoking supplies, and that the resident's family continued to bring vapes, with several stored in a large baggie locked in the medication cart. The resident was also later observed smoking a cigarette independently in the designated smoking area/patio with other residents. Record review showed the resident had a quarterly assessment documenting a BIMS of 15, indicating cognitive intactness, and a care plan noting the resident tried to keep vape and other smoking supplies in pockets or hidden in a chair and accused staff of harassment and theft when supplies were removed. A physician order dated 07/12/25 suspended the resident's smoking privileges due to non-compliance with smoking policies and procedures and documented psychosis. However, a smoking assessment dated 09/08/25 stated the resident may smoke unsupervised in designated smoking areas and must request smoking materials from staff. The DON later stated the suspension order was correct and still active, and that the smoking assessment was not correct because the resident should not have smoking privileges.
Care Plan Not Updated for Smoking Restriction; Guardian Not Included in Care Planning
Penalty
Summary
The facility failed to revise and update Resident #32’s care plan after the resident’s smoking privileges were suspended for non-compliance with smoking policies and procedures. Resident #32 had a quarterly assessment on 06/16/25 showing a BIMS of 15 and was described as cognitively intact, with substantial to maximal assistance needed for activities of daily living and independent eating. A care plan dated 07/02/25 addressed the resident’s behavior of trying to keep a vape and other smoking supplies hidden and accusing staff of harassment and theft when items were removed, but it did not address that smoking privileges had been suspended. A physician order dated 07/12/25 documented the suspension of smoking privileges, and the DON confirmed on 09/11/25 that the order was still active and that the care plan should have reflected that the resident was not supposed to smoke. The facility also failed to include Resident #76’s legal guardian in the development and review of the care plan. Resident #76 had a quarterly assessment dated 08/15/25 showing a BIMS of 10, indicating moderately impaired cognition. The guardian stated they had attended only one care plan meeting in March 2025, attended only by the social worker, and had not been invited to the most recent care plan meeting on 08/22/25. The social services director stated they conducted the 08/22/25 care plan meeting alone, forgot to invite the guardian, and there was no documentation showing the guardian had been contacted or participated in the meeting.
Failure to Include Anxiety and Smoking Needs in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with anxiety disorder. Resident #70 had physician orders for sertraline 50 mg daily, duloxetine 30 mg every 12 hours, and Xanax 0.25 mg at bedtime for anxiety disorder and unspecified depression. A quarterly assessment showed intact cognition with a BIMS score of 15 and documented anxiety disorder and antianxiety medication use, but the care plan dated 09/09/25 contained no goals or interventions for the resident's anxiety disorder. The regional nurse consultant stated on 09/17/25 that the resident's anxiety diagnoses should have been included in the care plan. The facility also failed to include smoking in the care plan for a resident who smoked. Resident #16 had a physician order for supervised smoking as needed for nicotine dependence. An annual assessment showed severe cognitive impairment with a BIMS score of 07 and documented tobacco use and nicotine dependence. A smoking risk assessment showed cigarette use and indicated the resident may smoke independently or with setup assistance and may request smoking material from staff, but the care plan dated 09/09/25 had no goal or interventions related to smoking. The regional nurse consultant stated on 09/17/25 that smoking should have been included in the resident's care plan.
Missed showers and incontinent care
Penalty
Summary
The facility failed to provide showers for one resident who was admitted and later discharged from the facility. Review of bath sheet forms showed the resident received showers on 04/16/25, 04/20/25, and 04/23/25, but there was no documentation that showers were provided from 04/03/25 through 04/16/25. An unidentified charge nurse stated there was a shower list at the nurse’s station showing room numbers and scheduled shower days, and that the charge nurse signed off when showers were completed. The charge nurse also stated showers were sometimes missed if staff did not show up to work. A CNA stated residents sometimes refused showers, were encouraged to shower, and refusals were reported to the charge nurse. The facility also failed to provide incontinent care for one resident who was observed in bed during a wound care observation with a brief soaked with urine, a foul odor of urine, and greasy, unwashed hair. The resident’s care plan identified bowel and bladder incontinence and directed staff to check and change the resident and keep them clean and dry. The annual assessment showed severely impaired cognition with a BIMS score of 07, frequent urinary incontinence, and need for partial to moderate assistance with ADLs, along with diagnoses of COPD, diabetes mellitus, and dementia. The resident stated they had not received a brief change or a bath, and a CNA stated they had not been able to perform incontinent care during that shift. The regional nurse consultant stated incontinent care should be offered frequently, at least every two hours.
Failure to Notify Legal Guardian of Change in Condition and IV Antibiotic Treatment
Penalty
Summary
The facility failed to notify the resident's legal guardian of a change in condition and treatment for Resident #76. The resident had a quarterly assessment showing a BIMS score of 10, indicating moderate cognitive impairment, and a physician's order dated 08/20/25 showed the resident was to receive Ceftriaxone 2 g intravenously for a UTI. There was no documentation that the legal guardian was notified of the diagnosis or the IV antibiotic treatment. On 09/10/25, the legal guardian stated they were not notified when the resident was diagnosed with a UTI and needed IV antibiotic treatment, and on 09/11/25 the DON reported the guardian should have been notified of the resident's diagnosis and antibiotic treatment.
Baseline Care Plan Missing Key Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan to provide effective and person-centered care for Resident #126 within 48 hours of admission. The facility’s Care Plan - Process policy stated that a baseline care plan should be initiated and completed within 48 hours of admission based on physician orders and nursing evaluation, and that it should facilitate care until the comprehensive care plan is developed. Resident #126 was admitted with diagnoses including infection and inflammatory reaction due to an internal right knee prosthesis, diabetes, hypertension, urge incontinence, and atrial fibrillation. The baseline care plan dated 09/03/25 identified mild cognitive impairment, physical therapy, and IV antibiotic therapy, but did not address incontinence, ADL assistance needs, fall risk, or the wound vac. Family members reported multiple concerns after admission. One family member stated the resident fell out of bed on 09/07/25 and later reported another fall the following night, with staff saying they would place the bed in the lowest position and obtain a fall mat. The family member also reported the resident had a new surgical wound to the right leg and a wound vac in place, and did not know what the facility was doing to prevent falls. Another family member stated the resident had been found soaking wet on multiple occasions since admission, including being in the same pull-up and clothes later in the day with urine up to the neck while sitting in a recliner. The DON acknowledged that the resident’s fall risk, wound vac, and ADL assistance, including toileting or incontinent care, should have been included on the baseline care plan.
Failure to Offload Heel Pressure Ulcer
Penalty
Summary
The facility failed to ensure care plan interventions were implemented to promote healing of a stage III pressure ulcer for Resident #100, who had moderately impaired cognition with a BIMS score of 12 and two stage III pressure ulcers that were not present on admission. The resident’s quarterly assessment listed pressure reducing devices for bed and chair, pressure ulcer/injury treatment, and application of dressing to the feet. A physician’s order directed treatment to the left heel wound, and a wound physician’s note described the left heel as a stage III pressure wound with a duration greater than 110 days, measuring 1.2 x 0.8 x 0.1 cm, with the objective to heal and maintain and the approach of close monitoring and off-loading. Survey observations showed the resident lying on their back in bed on multiple occasions with the heels on the mattress and not offloaded. During wound care, the ADON treated the left heel wound, but after the care was completed the resident’s heels remained not offloaded and no pressure relieving devices were in place. The care plan dated 09/08/25 included an intervention to float the heel when in bed, and the facility policy stated pillows used to support the entire lower leg may effectively raise the heel from contact with the bed. The regional nurse consultant stated that if offloading was documented in the care plan, the heels should be offloaded, and a CNA stated the resident should have had a pillow under the heels to offload them.
Failure to Provide and Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents dependent on staff for bathing received scheduled showers or baths, as required by their care plans and facility policy. For each of the three residents reviewed, there was a lack of documentation showing that showers or baths were provided on the scheduled days across multiple weeks in February, March, and April. The facility's policy required staff to provide bathing services and document any refusals or missed baths, but records were incomplete or missing. Interviews with residents and family members confirmed that showers were not consistently provided as scheduled, and staff were unable to produce documentation to verify that bathing occurred as required. The residents involved had significant care needs, including hemiplegia, hemiparesis, intellectual disabilities, reduced mobility, heart failure, and muscle weakness. Assessments indicated that these residents required partial to maximum assistance with bathing and were cognitively intact or moderately impaired. Despite these needs, the facility did not maintain adequate records or ensure that scheduled bathing was completed, as confirmed by the DON, staffing coordinator, and administrator, who acknowledged the lack of documentation and inability to verify that care was provided as scheduled.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for three residents who were sampled for timely medication administration. Review of the facility's policy indicated that medications should be given within a defined window of time, and any missed doses should be documented with an explanation. However, medication administration records for all three residents showed multiple missed doses of various prescribed medications, with no explanations documented in the medical records for these omissions. For one resident with diagnoses including hypertensive chronic kidney disease and type II diabetes mellitus, missed doses included antihypertensives, insulin, and other critical medications over several days. Another resident with a history of convulsions, encephalitis, and edema had missed doses of anticonvulsants, diuretics, and statins, again with no documentation explaining the missed doses. A third resident with chronic kidney disease, atrial fibrillation, and insomnia also had several missed doses of anticoagulants, diuretics, and other medications, with no recorded reasons for the omissions. Interviews with facility staff, including the corporate nurse consultant and the DON, confirmed that there was no way to determine if the missed doses were actually administered, as staff were not documenting appropriately on the medication records. The lack of documentation and unexplained missed doses directly contravened facility policy and physician orders, resulting in a deficiency related to pharmaceutical services and medication administration.
Failure to Notify Resident's Representative After Hospital Transfer Due to Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative after the resident experienced a fall that resulted in a head injury and required transport to the hospital. The resident, who had intellectual disabilities, reduced mobility, and was cognitively intact, fell in the bathroom, sustained a swollen area above the left eye, and was subsequently sent to the emergency room for evaluation. The facility's policy required notification of family or representatives in the event of significant injury or transfer to another healthcare setting. Despite this policy, the resident's family was not informed by the facility about the fall or the hospital transfer. Instead, the family was contacted by hospital emergency room staff to pick up the resident after evaluation. Interviews with facility staff revealed confusion regarding the location of emergency contact information in the new EHR system, with multiple staff members assuming others had notified the family. The DON confirmed that staff were looking in the wrong area of the EHR and acknowledged that the family should have been notified according to policy.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to follow infection prevention and control protocols during wound care for a resident with pressure ulcers. The LPN performed hand hygiene and donned gloves prior to starting, but did not wear a personal protective gown as required under Enhanced Barrier Precautions (EBP) for residents with wounds. During the procedure, the resident was found to be incontinent of bowel, and the LPN cleaned the area but did not perform hand hygiene or change gloves before proceeding with wound care on the resident's left lower back and sacrum. The LPN also touched personal items, wrote on wound dressings, applied a new brief, and repositioned the resident without changing gloves or performing hand hygiene between these activities. Facility policies required the use of gowns and gloves during high-contact care activities, such as wound care, under EBP, and specified hand hygiene before and after care, especially when hands become soiled. The resident involved had a history of pressure ulcers and protein-calorie malnutrition, with physician orders for specific wound care procedures. The LPN later acknowledged not being educated on EBP and was unaware of the need for a gown during wound care for residents with pressure ulcers. The Director of Nursing confirmed that EBP should have been followed and that the LPN's actions did not meet infection control standards.
Failure to Provide and Document Bathing Assistance
Penalty
Summary
The facility failed to provide bathing services for a resident who required substantial to maximum assistance with bathing, as documented in their admission assessment. The facility's policy required staff to provide bathing services within standard practice guidelines. During the resident's stay, a CNA was unaware of the resident's shower schedule, and the interim DON was unable to locate any documentation indicating that bathing was provided. This lack of documentation and staff awareness resulted in the failure to ensure the resident received necessary bathing care as required by facility policy and the resident's assessed needs.
Failure to Investigate Missing Medication Doses
Penalty
Summary
The facility failed to conduct a thorough investigation after receiving an allegation of missing doses of medication for a resident diagnosed with type 2 diabetes mellitus and end-stage renal disease. The resident was prescribed Ozempic 2mg via subcutaneous injection every Wednesday. According to the Medication Administration Record (MAR), the medication was administered as ordered in December and early January. However, the resident reported issues with receiving the correct dosage for three weeks in December and mentioned not receiving the medication at all for one week. Additionally, the resident reported that their Ozempic pen, which had two doses remaining, went missing after being left out to warm by a registered nurse (RN). The RN confirmed that the pen was missing and reported the incident to the Director of Nursing (DON), who attempted to locate the pen but did not initiate an investigation or report the incident to the administrator. The pharmacist corroborated that there should have been two doses remaining in the pen based on the prescription fill dates. When questioned, the administrator stated they were unaware of the incident and acknowledged that an investigation should have been initiated. This lack of action and communication led to a deficiency in the facility's handling of the alleged violation.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required time frame for a resident. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an admission assessment must be completed no later than the 14th day of the resident's admission. A resident, who was admitted with diagnoses including type 2 diabetes mellitus and a stage 4 pressure ulcer of the sacral region, did not have a comprehensive MDS assessment documented in their electronic health record (EHR). The Director of Nursing (DON), upon reviewing the resident's clinical record and consulting with the MDS coordinator, acknowledged that no comprehensive MDS assessment had been completed since the resident's admission.
Medication Administration Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident did not receive the wrong medications, affecting one of the three sampled residents reviewed for medication administration. The incident involved a resident with diagnoses of pneumonia and deep vein thrombosis, who was mistakenly given medications intended for another resident. The medications administered in error included aspirin, buspirone, linezolid, and potassium chloride. This error was documented in an incident report and a nurse's note, both dated December 25, 2024. The Director of Nursing (DON) acknowledged the incident but did not provide documentation that the Quality Assurance and Performance Improvement (QAPI) committee reviewed the incident or that staff, including the Certified Medication Aide (CMA) involved, received in-service training to prevent recurrence. The CMA responsible for the error stated that residents are identified using pictures in the Electronic Health Record (EHR), names posted outside doors, and personal familiarity over time. However, this method failed to prevent the medication error.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment, as observed during a survey. The observations revealed several deficiencies, including torn and raised carpets, missing and damaged tiles, peeling wallpaper, exposed wires, and strong odors of urine. These issues were noted in multiple rooms and hallways, indicating a widespread problem. The facility's Resident Room Cleaning policy aimed to provide a clean and safe environment, but the maintenance work order log showed that repairs were not completed, and some issues had persisted for at least a year. Residents expressed dissatisfaction and concern about the unsafe and unclean conditions, with one resident reporting a fall due to the carpet tear. The housekeeping supervisor acknowledged the disrepair and stated that maintenance was aware of the issues but had not effectively addressed them. The Regional Director of Plant Operations and the Regional Director of Operations confirmed the unsafe conditions and admitted that the facility did not maintain a homelike environment, as required by their policy.
Unsafe Food Handling Practices in Tray Line
Penalty
Summary
The facility failed to ensure safe food handling practices during meal preparation and distribution, specifically regarding the sanitary condition of cereal bowls on the tray line. On September 3, 2024, it was observed that bowls of cereal were unwrapped, stacked, and stored in a manner that allowed the bottom of the bowls to come into contact with the cereal product. This practice was contrary to the expected standard, as reported by Kitchen Aide #1, who stated that the bowls were supposed to be wrapped and not stacked on each other. On September 10, 2024, the Dietary Manager acknowledged that the handling of the cereal bowls was an infection control issue and confirmed that there was no existing policy to address this specific issue. The Director of Nursing (DON) indicated that 101 residents received nutritional meals from the kitchen, highlighting the potential impact of this deficiency on a significant number of residents.
Failure to Cover Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering a catheter bag with a vanity bag, as required by their policy. This deficiency was observed in the case of a resident who was admitted with acute respiratory failure with hypoxia and cellulitis. The facility's policy, revised on January 12, 2023, mandates that drainage bags should be covered with a privacy bag as necessary. However, during two separate observations, the resident's catheter bag was found uncovered and visible from the hallway, which was against the facility's policy. Interviews with staff members, including a CNA, an LPN, and a corporate nurse, confirmed the visibility of the uncovered catheter bag from the hallway. The CNA and LPN acknowledged that the facility's policy required the catheter bag to be covered with a vanity bag to maintain the resident's dignity. The corporate nurse, however, was unsure if the policy required the bag to be covered while in the resident's room. This inconsistency in policy understanding and implementation led to the deficiency in maintaining the resident's dignity.
Failure to Offer Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate an advance directive, as evidenced by the case of one resident among a sample of 32 whose advance directive acknowledgments were reviewed. The facility's policy, revised on March 27, 2023, mandates that the Director of Admission complete and scan the Advanced Directive Acknowledgment Form into the resident's electronic medical record (EMR) during the admission process. However, for a resident admitted with diagnoses including multiple sclerosis and paraplegia, there was no documentation in the EMR indicating assistance with formulating an advance directive. During an interview, Corporate Nurse #1 confirmed that an audit of the charts revealed the absence of an advanced directive acknowledgment for this resident.
Failure to Document Alleged Abuse Incident
Penalty
Summary
The facility failed to document an alleged abuse incident involving a resident diagnosed with Hypertensive Chronic Kidney Disease and Anxiety Disorder. The facility's policy, dated 06/23/17, requires that all incidents of alleged abuse or neglect be documented on incident reports and forwarded to the Abuse Counselor. However, on 09/20/24, it was found that there was no record of an initial report for the alleged abuse reported by the resident. An LPN reported that a CMA had received the allegation from the resident on 09/06/24 during a shift change but failed to document it. The Director of Nursing confirmed that the company policy mandates the person receiving the allegation to complete an incident report, which was not done in this case.
Failure to Complete Timely Quarterly Assessments
Penalty
Summary
The facility failed to ensure that quarterly assessments for residents were completed within the required 92-day timeframe. Specifically, two residents, identified as Resident #1 and Resident #25, did not have their Minimum Data Set (MDS) assessments completed within the stipulated period. Resident #1, who was admitted with diagnoses including morbid obesity and hypotension, had a quarterly assessment with an Assessment Reference Date (ARD) of 04/25/24, but no subsequent assessment was completed by 07/25/24. Similarly, Resident #25, admitted with conditions such as epilepsy and major depressive disorder, had an ARD of 04/06/24, but no assessment was completed by 07/05/24. Corporate Nurse #1 confirmed the absence of these assessments upon review, acknowledging the oversight.
Inaccurate MDS Discharge Documentation
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) records accurately reflected the resident's discharge status. Specifically, the MDS assessment records incorrectly documented that the resident was discharged to the hospital, while nursing notes and physician orders indicated that the resident was discharged home. This discrepancy was identified during a review of the resident's records, which included a phone call arrangement for the resident to be discharged home and physician orders confirming the discharge home. The MDS Coordinator acknowledged the error in coding the resident's discharge status. Additionally, the facility's Administrator reported that there was no existing policy for addressing inaccurate MDS documentation.
Failure to Maintain Safe Environment Leads to Resident Fall
Penalty
Summary
The facility failed to maintain a safe environment for its residents, resulting in a fall incident involving a resident with Parkinson's disease, dementia, and bipolar disorder. The resident, who was cognitively intact and used a walker for ambulation, fell due to uneven flooring and not using their walker. The incident report noted a skin tear and pain in the resident's left arm as a result of the fall. Despite the facility's Fall Management policy, which requires immediate investigation and intervention to prevent future falls, the intervention plan only included educating the resident to use their walker and did not address the torn and frayed carpet that contributed to the fall. Observations and interviews revealed that the carpet in the resident's room was torn and frayed, with strings and raised areas, and the bathroom tiles were missing or damaged. The housekeeping supervisor confirmed the carpet had been in disrepair for at least a year, and maintenance was aware of the issue. However, the Director of Plant Operations was unaware of the damaged carpet and acknowledged that the work order for repairs was not completed. The failure to repair the carpet and ensure a safe environment directly contributed to the resident's fall.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure allegations of abuse were reported to the Oklahoma State Department of Health (OSDH) for seven residents. The facility's policy required timely investigation and reporting of abuse allegations to state and local agencies, but this was not adhered to. For instance, Resident #1 had multiple incidents where abuse was alleged, including being held down against their will and having their mouth covered by a staff member. These incidents were not reported within the required time frames, and some were not reported at all. Additionally, Resident #1's claims of being mistreated by staff were not followed up with proper investigations or timely reports to the OSDH. Resident #10 reported that a therapy staff member was not being nice, which was not reported to the OSDH. Similarly, Resident #11 mentioned that staff sometimes took a long time to answer call lights, especially in the evening and night, but this was also not reported. Resident #4 had multiple incidents, including making threats to another resident, leaving the facility without notifying anyone, and displaying inappropriate behavior in the dining room. These incidents were not reported to the OSDH as required. Other residents, including Resident #7, Resident #3, and Resident #9, also reported concerns about staff treatment and interactions with other residents. These allegations were not documented or reported to the OSDH. The Director of Nursing (DON) and Corporate RN acknowledged that these incidents should have been reported but were not. The facility's failure to report these allegations of abuse, neglect, and resident-to-resident altercations within the required time frames constitutes a significant deficiency in compliance with federal and state regulations.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to fully investigate allegations of abuse for nine of eleven sampled residents. The facility's policy on Abuse, Neglect, and Exploitation requires timely investigations upon receiving an allegation, but this was not adhered to in multiple instances. For example, Resident #1's complaints of being held down and having their mouth covered by a CNA were not investigated, and there was no documentation of an investigation into the resident's disruptive behavior to ensure other residents were not fearful. Similarly, Resident #10's and Resident #11's complaints about staff treatment were not investigated, despite being documented in incident reports. Resident #2, who had severe cognitive impairment, reported through a hospital liaison that a nurse had slapped them twice, but the facility only interviewed the resident's family and did not conduct a thorough investigation involving other residents or staff. Resident #4, who had moderate cognitive impairment, made threats to another resident and left the facility without notifying anyone, but these incidents were not investigated. Additionally, Resident #4's altercations with other residents in the dining room were not investigated. Other residents, including Resident #7, Resident #3, and Resident #9, also reported concerns about staff treatment and interactions with other residents, but these allegations were not investigated. The Director of Nursing (DON) and Corporate RN acknowledged that these incidents should have been investigated but were not. The lack of thorough investigations into these allegations of abuse and neglect indicates a significant deficiency in the facility's adherence to its own policies and regulatory requirements.
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 213 citations issued within 25 miles in the last 12 months — including the 8 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 Yukon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gran Gran's Place | 1 mi | ★★★★★ | 6 | 0 |
| Spanish Cove Housing Authority | 1.1 mi | ★★★★★ | 0 | 0 |
| Heritage Park | 5.1 mi | ★★★★★ | 0 | 0 |
| The Grand At Bethany Skilled Nursing And Therapy | 5.1 mi | ★★★★★ | 9 | 0 |
| The Health Center At Concordia | 6.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.