Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Golden Rule Home during CMS and state inspections, most recent first.
The facility did not ensure that two residents were offered the right to formulate an advance directive, as required by their policy. The medical records lacked the necessary documentation, and the DON and SSD confirmed the absence of these forms.
The facility failed to update care plans quarterly for three residents, as required by their policy. Despite having significant medical diagnoses, the care plans lacked quarterly updates. The DON admitted that care plans were updated with new orders but not quarterly, relying on personal knowledge for evaluating interventions.
A resident with multiple diagnoses, including metabolic encephalopathy, was not given thorough weekly skin assessments as required. Despite physician orders, assessments were incomplete, with dressings on the resident's heels not being removed for proper evaluation. The facility failed to adhere to its protocol for skin assessments.
The facility failed to ensure dietary staff properly used hair nets, as observed with a cook who had hair outside the hairnet and a ponytail not secured. The Dietary Manager confirmed the policy required all hair to be secured, which was not followed in this instance.
The facility failed to provide adequate pressure ulcer care, as a resident was not consistently repositioned, and timely wound care orders were delayed. Another resident did not receive consistent weekly wound assessments, with missing documentation for June and July.
A facility failed to provide adequate hydration to a resident with hypotension and acute kidney failure. Records showed missed hydration opportunities over several months, and the ADON could not explain the missing entries despite hydration being scheduled three times daily.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to ensure that residents were offered the right to formulate an advance directive, as required by their policy. This deficiency was identified for two of the three sampled residents reviewed for advance directives. The facility's policy, dated April 2008, mandates that upon admission, the Social Services Director or designee should provide written information to residents about their right to make medical decisions and formulate advance directives. However, the medical records for two residents did not contain an advance directive or an acknowledgement form. During an interview, the Director of Nursing (DON) was unable to locate these documents in the residents' charts, and the Social Services Director (SSD) confirmed that the forms were not present for the two residents.
Failure to Update Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans were updated quarterly for three residents, as required by their Care Plans policy. The policy, dated October 2010, mandates that care plans include measurable objectives and timetables to meet residents' needs and be reviewed and updated at least quarterly by the Care Planning/Interdisciplinary Team. However, the care plans for three residents, each with significant medical diagnoses, lacked these quarterly updates. Resident #14, diagnosed with depression and anxiety, had a care plan dated December 11, 2023, but no quarterly updates were recorded. Similarly, Resident #26, with acute kidney failure, cerebral infarction, bipolar disorder, COPD, and hypertension, had a care plan dated November 20, 2023, without quarterly updates, despite having comprehensive assessments in May and August 2024. Resident #27, diagnosed with neuralgia, ALS, and major depressive disorder, had a care plan dated March 6, 2024, but no quarterly updates, even though comprehensive assessments were conducted in June and September 2024. During an interview on October 2, 2024, the Director of Nursing (DON) acknowledged that care plans were updated with each new order but admitted that quarterly updates were not conducted. The DON stated that quarterly MDS assessments were performed, but care plan updates were only done annually. When asked about evaluating the effectiveness of interventions, the DON responded that they relied on personal knowledge rather than formal evaluations. This lack of adherence to the facility's policy resulted in the failure to conduct quarterly updates for the care plans of the three residents, as required.
Failure to Conduct Comprehensive Weekly Skin Assessments
Penalty
Summary
The facility failed to conduct thorough weekly skin assessments for a resident with non-pressure related skin conditions. The resident, who was admitted with diagnoses including metabolic encephalopathy, neuropathy, and gout, had a physician order for weekly skin assessments on Mondays. However, documentation showed that the resident refused a skin assessment on two occasions, and the assessments that were conducted did not include the removal of dressings to properly assess the skin underneath. On one occasion, the LPN documented a head-to-toe skin assessment but failed to note the presence of dressings on the resident's heels. Observations revealed that the resident had adhesive foam dressings on their heels, which had been placed by the hospital prior to their arrival at the facility. The dressings were dated several weeks prior, and the facility had not addressed them. The ADON stated that skin assessments should include the removal of dressings to assess the skin beneath, which was not done in this case. The deficiency was identified as a failure to perform comprehensive skin assessments as per the facility's protocol and physician orders.
Improper Use of Hair Nets by Dietary Staff
Penalty
Summary
The facility failed to ensure proper use of hair nets by dietary staff, specifically Cook #1, during kitchen sanitation. On the morning of September 30, 2024, Cook #1 was observed preparing the noon meal with hair outside of their hairnet around the ears and a ponytail not secured within the hairnet. When questioned, the Dietary Manager (DM) confirmed that the policy required all hair to be secured in a hairnet and acknowledged that Cook #1's hair was not fully contained as per the policy. This observation was made in a facility housing 34 residents.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for residents, as evidenced by several deficiencies. A resident admitted with multiple wounds was not consistently repositioned according to the facility's policy, which requires repositioning at least every two hours. Documentation of repositioning was missing for several periods, and the resident was not repositioned for extended hours on multiple occasions. Additionally, the facility did not obtain timely orders for wound care upon the resident's admission, with a delay in consulting a wound care specialist. Another resident with a stage four pressure ulcer did not receive consistent weekly wound assessments as required by the facility's policy. The documentation for June and July was incomplete, with missing measurements and observations of the pressure ulcer. The Director of Nursing acknowledged that the required skin assessments were not completed during these months.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to provide adequate hydration to a resident, identified as Res #2, who was admitted with diagnoses including hypotension and acute kidney failure. A review of meal percentage records and intake and output records revealed that the resident did not receive hydration on 13 out of 69 opportunities in May 2024, 2 out of 90 opportunities in June 2024, and 7 out of 51 opportunities in July 2024. The Assistant Director of Nursing (ADON) confirmed that hydration and ice are supposed to be provided to residents three times per day, once on each shift, but was unable to explain the missing entries on the resident's hydration records.
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 17 citations issued within 25 miles in the last 12 months — 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 Shawnee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Skilled Nursing And Therapy | 3.5 mi | ★★★★★ | 0 | 0 |
| Shawnee Colonial Estates Nursing Home | 4.1 mi | ★★★★★ | 0 | 0 |
| Shawnee Care Center | 4.5 mi | ★★★★★ | 1 | 0 |
| The Regency Skilled Nursing And Therapy | 5.2 mi | ★★★★★ | 0 | 0 |
| Mcloud Nursing Center | 11 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.