Below 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 Lodge At Brookline during CMS and state inspections, most recent first.
A deficiency occurred when staff failed to immediately initiate CPR for a resident with a full code status who was found unresponsive and without vital signs. Instead of starting CPR, staff moved the resident, cleaned them, and delayed resuscitative efforts while checking code status and waiting for supervisory direction. This delay resulted in the resident not receiving timely basic life support as required by physician orders and facility policy.
Surveyors found that appropriate care was not consistently provided for residents with bowel or bladder continence or incontinence, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
Two residents with PEG tubes did not have physician orders for tube care transcribed or completed. One resident's PEG site was observed without gauze, with dark residue and red droplets, while another had old gauze left in place and dark residue at the site. Both residents were dependent on staff and had moderately impaired cognition, and staff confirmed that proper daily care was not consistently provided.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with multiple severe pressure ulcers and significant mobility limitations did not consistently receive or have documented turning and repositioning every two hours as required by facility policy and care plan. Staff reported the resident was often resistive to turning due to discomfort, and documentation of these interventions was frequently incomplete, making it impossible to verify that pressure ulcer prevention measures were consistently implemented.
A resident with a newly placed PICC line did not have documented site assessments or dressing changes as required by facility policy, and nursing staff were unclear about documentation procedures. Only heparin flushes were recorded, and neither the DON nor the administrator could find evidence of proper PICC line care during the time the line was in place.
A resident did not receive their prescribed oxycodone for several days due to delays in medication reordering and communication issues between staff and the physician. During this period, the resident was given tramadol, which they reported was ineffective for their pain. Staff interviews indicated confusion about the timing and process for medication refills, and the DON acknowledged a breakdown in communication that led to the lapse in pain management.
The facility did not have grievance forms available in the designated location as per policy. Grievance information indicated forms should be in a binder on the front lobby table, but none were found. A CNA was unaware of their location, and the social services director confirmed they were incorrectly kept in their office.
A resident with amyotrophic lateral sclerosis was admitted with a noninvasive ventilator, but the MDS assessment failed to reflect this. The DON, responsible for MDS completion, acknowledged the oversight despite the resident confirming the ventilator's presence since admission.
A facility failed to include the use of a noninvasive ventilator in a resident's care plan, despite the resident having a diagnosis of amyotrophic lateral sclerosis and being admitted with the device. The ventilator was observed at the bedside, and the resident confirmed its use at bedtime. The DON acknowledged the oversight, stating the ventilator had been in use since admission but was not documented in the care plan.
A facility failed to obtain a physician order for a noninvasive ventilator for a resident with amyotrophic lateral sclerosis. The resident used the device at bedtime, but no order was documented until after surveyor observation. The DON confirmed the absence of a prior order.
A facility failed to provide an accessible emergency call cord in a resident's bathroom. The resident, who relies on a wheelchair, reported falling and being unable to reach the emergency call system. The bathroom had a red emergency switch by the toilet, but it lacked a string, making it inaccessible to someone on the floor. A CNA confirmed the absence of the string, and the administrator acknowledged the pull string should be positioned near the toilet.
The facility failed to secure medication carts on hall 400, as observed on three occasions. Despite a policy requiring locked storage, carts containing medications, insulin, and needles were found unlocked and unattended. An LPN admitted to leaving the cart unlocked and was unsure of the policy.
The facility failed to maintain appropriate dishwasher temperature and sanitization levels, with observed wash temperatures below the required 165 degrees and no sanitizer reaction. The CDM acknowledged the issue and called maintenance, who advised contacting the company for repairs. The facility used a three-compartment sink to ensure proper sanitization until repairs were made.
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices and open wounds, as there was no signage or PPE available. Staff were unaware of the new policy, and infection control practices were not followed, as observed in multiple instances, including improper handling of a glucometer and unbagged linen.
A facility failed to ensure a resident with malignant neoplasm of the lungs and end-stage renal disease was offered the choice to formulate an advance directive. The Executive Director could not locate the acknowledgment despite multiple requests, and no policy was provided by the time of the survey exit.
The facility failed to maintain privacy and confidentiality of residents' medical records. An LPN left a cart unlocked with a laptop open, exposing a resident's information, and admitted to not following policy. Another LPN left a laptop open displaying a resident's treatment record. Additionally, a new LPN applied cream to a resident's legs in the hallway, failing to ensure privacy. The Executive Director was informed of these findings.
The facility failed to accurately code Resident Assessments for two residents. One resident was incorrectly documented as taking anticoagulants without physician orders, while another was inaccurately recorded as receiving insulin injections. An LPN confirmed the inaccuracies, and the Executive Director stated that the policy required accurate MDS coding.
A facility failed to complete a baseline care plan within 48 hours for a resident admitted with hemiplegia, malnutrition, gastrostomy, and chronic pain. The comprehensive care plan was delayed, being created only after the required timeframe. Interviews with an LPN and the Executive Director confirmed the oversight, which was against the facility's policy.
A resident with epilepsy, end-stage renal disease, and cirrhosis fell while attempting to move from a chair to bed without assistance. Although a nurse's note indicated that neurological checks were initiated, no documentation was found. The interim DON and an LPN could not locate the records, and the LPN admitted that checks should have been completed, revealing a failure to follow best practices.
The facility did not update and post the required daily staffing information, missing details such as the facility name, resident census, and hours worked by RNs, LPNs, CMAs, and CNAs. Observations on two occasions revealed these omissions, and the ED confirmed the absence of necessary information.
A facility failed to administer medication as ordered for a resident with systemic lupus erythematosus, hypertension, and diabetes mellitus. A physician's order required Aquaphor application twice daily for ten days, but the treatment was not documented on the TAR for the specified period. An LPN confirmed the lack of documentation and was unaware of the resident's foot issues until observing redness and dryness.
A facility failed to ensure a call light was within reach for a dependent resident, who was observed in pain and unable to call for assistance. The call light was found hanging between the bed and the wall, out of reach. A CNA acknowledged the issue, stating it might have been moved during wound care. The facility's policy requires call lights to be accessible, which was confirmed by the Executive Director.
The facility failed to prevent cross-contamination during finger stick blood sugar tests. An LPN did not wash hands or sanitize the glucometer before or after use on multiple residents. Another LPN cleaned the glucometer but did not wash hands. Both LPNs were unaware of infection control protocols, leading to potential cross-contamination risks.
A facility failed to address and document grievances regarding missing clothing and medical equipment for a resident with severe protein-calorie malnutrition and end-stage renal disease. The resident's family complained about a missing wheelchair, purse, and clothes, but there was no documentation in the clinical record about the resolution of these grievances. Both the administrator and social service director acknowledged the complaints but admitted there was no documentation on how they were handled.
A facility failed to complete a discharge summary with a recapitulation of stay for a resident discharged with diagnoses including protein calorie malnutrition, diabetes mellitus, and cachexia. The discharge instruction form only noted that the resident went home with their daughter and medications were provided, lacking a complete summary of the resident's stay. The administrator confirmed that the discharge instructions form was the only document used as a discharge summary, which did not include a full recapitulation of the resident's stay.
Failure to Timely Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to initiate cardiopulmonary resuscitation (CPR) immediately for a resident with a full code status who was found unresponsive and without vital signs. The resident had a physician's order indicating full code status and had been admitted with diagnoses including bladder cancer, stage 3 kidney disease, and absence of a kidney. On the day of the incident, the resident was last observed sitting up in bed and later was found by a family member to be unresponsive, not breathing, and with open mouth and eyes. The family member alerted staff, who responded to the room. Upon entering the room, staff, including CNAs and LPNs, checked for vital signs and found none. Instead of immediately initiating CPR, staff moved the resident onto the bed, cleaned the resident, and put on a gown and brief. Multiple staff members, including nurses and CNAs, were present, but CPR was not started right away. There was confusion among staff regarding the resident's code status and who was responsible for initiating CPR. Some staff waited for direction from a supervisor, and others were occupied with checking for code status in binders or the electronic health record. According to interviews, there was a delay of several minutes before CPR was initiated, and 911 was called only after this delay. Staff interviews revealed inconsistent understanding of the process for identifying code status and when to begin CPR. Some staff believed only nurses should initiate CPR, while others were unsure of their roles during a code. The delay in starting CPR was attributed to waiting for confirmation of code status and for instructions from supervisory staff. The resident ultimately did not receive timely CPR as required by facility policy and physician orders, and was later pronounced deceased by emergency medical services.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the cited deficiency.
Failure to Transcribe and Complete Physician Orders for PEG Tube Care
Penalty
Summary
The facility failed to ensure that physician orders for PEG tube care were transcribed and completed for two residents with PEG tubes. For one resident, observation revealed that the PEG site had no gauze, dark residue around the insertion site, and red droplets on the clamp. There were no physician orders in place for PEG tube care for this resident, who was blind, had moderately impaired cognition, and was dependent on staff for all activities of daily living. The Director of Nursing (DON) confirmed that the site was not clean and that daily care should have been provided, especially in the presence of drainage. For another resident, the PEG tube site was observed with old gauze labeled with a previous date and shift, and dark residue was present under the gauze at the site entrance. Similarly, there were no physician orders for PEG tube care for this resident, who also had moderately impaired cognition, chronic kidney disease stage 5, and was dependent on staff for all activities of daily living. An LPN confirmed that care was documented as completed, but new gauze was not available, so the old gauze was left in place.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Consistently Document and Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions to promote pressure ulcer healing were consistently implemented for a resident with multiple pressure ulcers. Facility policies required turning and repositioning of residents at risk for pressure ulcers at least every two to three hours, with documentation of these interventions. Wound care provider notes specified that the resident should be turned every two hours using a foam wedge. However, review of the resident's ADL records over several months revealed numerous undocumented opportunities for turning and repositioning, with significant numbers of blanks in the records for this task. The resident's care plan also indicated the need for staff assistance with transfers and repositioning due to severe mobility limitations. Interviews with staff confirmed that the resident was immobile, contracted, and unable to turn independently, requiring substantial assistance. Staff reported that the resident was sometimes resistive to turning due to discomfort, and repositioning was attempted as much as the resident would allow. Despite these efforts, the Director of Nursing acknowledged that, due to the incomplete documentation, there was no way to verify that the resident was turned every two hours as required. The resident had multiple stage three and four pressure ulcers and deep tissue injuries, all present upon admission, and required ongoing wound care interventions.
Failure to Document and Provide PICC Line Care
Penalty
Summary
The facility failed to provide proper care and documentation for a resident with a peripherally inserted central catheter (PICC) line. According to the facility's policy, central line sites should be assessed with each infusion and at least daily, and dressings should be changed at least every seven days or sooner if compromised. The resident was discharged from the hospital with a newly placed tunneled PICC line and required intravenous antibiotics. However, there was no physician's order for central line care, and the medication administration records (MAR/TAR) for October and December did not document any central line care or dressing changes. Progress notes also lacked documentation of daily site assessments or dressing changes from the time of readmission until the line was discontinued. Interviews with nursing staff revealed uncertainty about documentation practices for PICC line care, with one LPN stating they were unfamiliar with the charting system and did not know where or if dressing changes were documented. The DON confirmed that dressing changes should be recorded on the nurse's treatment sheet, but only heparin flushes were documented. Neither the DON nor the administrator could locate any records of site assessments or dressing changes while the central line was in place, despite facility policy and staff statements that such care should occur regularly.
Failure to Provide Timely Pain Medication Due to Reordering and Communication Lapses
Penalty
Summary
The facility failed to ensure that a resident received their prescribed pain medication, oxycodone, as ordered by the physician. According to the facility's policy, medications are to be administered in a safe and timely manner, with reordering procedures in place to prevent interruptions. Documentation showed that the resident's supply of oxycodone ran out, and there was a gap of several days before the medication was available again. During this period, the resident was given tramadol instead, which they reported was ineffective for their pain. The resident stated they had to wait three to four days without their prescribed oxycodone. Staff interviews revealed that medication reordering was supposed to occur when a four to five day supply remained, but there was confusion and lack of documentation regarding when the refill was requested. The LPN involved was unsure of the exact timing of the request and noted difficulty obtaining the necessary prescription due to the physician being out of the office for a holiday. The DON confirmed that the request was not made until the medication had already run out and acknowledged that there was a breakdown in communication between the facility and the physician, resulting in the resident not having access to their prescribed narcotic.
Grievance Forms Not Available in Designated Location
Penalty
Summary
The facility failed to ensure grievance forms were available in the designated location as per their policy. During a tour of the facility, it was observed that grievance information was posted at the entrance, indicating that grievance forms could be found in a binder on the table in the front lobby. However, upon inspection, no grievance forms or binder were present on the table. A CNA was unaware of the location of the grievance forms, and the social services director confirmed that the forms were supposed to be on the table in the front lobby, as per the grievance policy, but were instead located in their office.
Inaccurate MDS Coding for Resident with Ventilator
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one of the six sampled residents. The resident in question had a diagnosis of amyotrophic lateral sclerosis and was admitted to the facility with a noninvasive ventilator. However, the significant change in status MDS assessment dated 09/26/24 did not reflect that the resident received noninvasive ventilator services. On 11/26/24, a noninvasive ventilator was observed on the resident's bedside table, although it was turned off. The resident confirmed on 11/27/24 that they were admitted with the ventilator. The Director of Nursing (DON), who was responsible for completing care plans and MDS assessments, acknowledged that the ventilator was not coded in the MDS assessment despite the resident having it since admission.
Care Plan Lacks Documentation for Noninvasive Ventilator Use
Penalty
Summary
The facility failed to ensure that a resident's care plan included the use of a noninvasive ventilator, which was necessary for one of the two sampled residents reviewed for respiratory services. The resident, who had a diagnosis of amyotrophic lateral sclerosis, was admitted to the facility with a noninvasive ventilator. However, the care plan dated 10/02/24 did not document the use of this device. On 11/26/24, the ventilator was observed on the resident's bedside table, turned off, and the resident confirmed its use at bedtime. The Director of Nursing (DON) acknowledged that the resident had the ventilator since admission and admitted that there was no care plan for its use, although it should have been included.
Lack of Physician Order for Noninvasive Ventilator Use
Penalty
Summary
The facility failed to ensure a resident had a physician order for the use of a noninvasive ventilator. The facility's policy required obtaining an order for devices such as CPAP, BiPAP, or AVAPS. A resident with amyotrophic lateral sclerosis was observed with a noninvasive ventilator at their bedside, which they used at bedtime. The resident stated they were admitted with the device. However, there was no physician order for its use and monitoring until after the surveyor's observation. The Director of Nursing confirmed the absence of a prior order upon reviewing the resident's hospice and electronic health records.
Inaccessible Emergency Call System in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that an emergency call cord was available in a resident's bathroom, specifically for one of the three sampled residents. The facility's policy on call lights, revised in October 2024, mandates that the call system must be accessible to residents at each toilet and bath or shower facility, and should be reachable by a resident lying on the floor. Resident #2, who has mobility issues and relies on a wheelchair, reported falling in the bathroom and being unable to reach the emergency call system. Upon inspection, it was observed that the bathroom had a red emergency switch by the side of the toilet, but it lacked a string, making it inaccessible to a resident lying on the floor. A CNA confirmed that the call switch did not have a string, and the administrator acknowledged that the pull string should be positioned on either side or in front of the toilet.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that medication carts were secured when not in use, as observed during three separate instances on hall 400. The Medication Storage policy, dated July 2024, mandates that all drugs and biologicals be stored in locked compartments. However, on September 3, 2024, at 12:42 p.m., a nurse cart was found unlocked and unattended, containing medications, insulin, and needles. An LPN acknowledged the cart was not locked, contrary to the policy. On September 4, 2024, at 7:59 a.m., the same LPN was seen leaving the medication cart unlocked while carrying medication cups. Upon returning, the LPN admitted to not locking the cart again. On September 6, 2024, at 9:39 a.m., another cart was observed unattended and unlocked, with similar contents. An LPN returned and admitted awareness of the unlocked cart but was unsure of the exact policy.
Dishwasher Temperature and Sanitization Deficiency
Penalty
Summary
The facility failed to ensure the appropriate dishwasher temperature and sanitization concentration levels were reached on a high temperature dishwasher. During a follow-up tour of the kitchen, it was observed that the dishwasher's wash temperature was 162 degrees, which is below the required 165 degrees for stationary rack, single temperature machines. Further testing showed wash and rinse temperatures of 167 and 159 degrees, respectively, and no reaction on the sanitizer strip, indicating improper sanitization. The Certified Dietary Manager (CDM) acknowledged the issue and attempted to address it by calling maintenance. Maintenance personnel noted that the pump did not switch on and advised contacting the company for repairs. The CDM confirmed they would use the three-compartment sink until the dishwasher was repaired, ensuring appropriate temperature and sanitization levels were maintained in the interim.
Failure to Implement Enhanced Barrier Precautions and Adhere to Infection Control Practices
Penalty
Summary
The facility failed to implement enhanced barrier precautions for residents with indwelling devices and open wounds, as observed in two residents. One resident had a gastric tube, indwelling catheter, and multiple pressure ulcers, yet there was no signage indicating the need for enhanced barrier precautions, and no personal protective equipment (PPE) was available. A registered nurse acknowledged the absence of necessary precautions and PPE. Another resident, who was bedridden with a gastric tube, indwelling catheter, and pressure ulcers, also lacked enhanced barrier precautions signage. A licensed practical nurse admitted to not being aware of the enhanced barrier precautions policy and noted that gowns were stored on a different hall. Additionally, the facility's staff did not adhere to infection control practices after providing resident care. An LPN was observed performing wound care without wearing a gown, and another LPN was seen handling a glucometer and walking through the facility with gloves on, acknowledging the risk of cross-contamination. Furthermore, an LPN was observed carrying unbagged linen through the facility, contrary to the infection prevention policy. These observations indicate a lack of compliance with established infection control protocols and inadequate staff training on new policies.
Failure to Offer Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that a resident was offered the choice to formulate an advance directive. This deficiency was identified during a review of records and interviews, where it was found that one of the twelve sampled residents, who had diagnoses including malignant neoplasm of the lungs and end-stage renal disease, did not have an advance directive acknowledgment on file. The Executive Director was unable to locate the acknowledgment despite being asked on two separate occasions. Additionally, no policy regarding advance directives was provided by the time of the survey exit.
Privacy and Confidentiality Breach in Resident Care
Penalty
Summary
The facility failed to maintain privacy and confidentiality of residents' personal and medical records, as observed during a tour. Two residents, including Resident #25 and an unidentified resident, had their privacy compromised during care provision. Additionally, protected health information for two residents, Resident #21 and Resident #40, was not secured. On one occasion, a cart on hall 500 was found unlocked with a laptop open, exposing Resident #21's information, while no nurse was present. LPN #4 admitted to not following the policy by performing a fingerstick blood sugar (FSBS) test in the lobby and acknowledged the need to lock the computer screen, which they subsequently did. Further observations revealed a laptop on the hall 400 treatment cart left open, displaying the treatment administration record (TAR) for Resident #40, with no staff nearby. LPN #3 admitted to leaving the laptop open and was unaware of the exact policy. Additionally, LPN #1 was observed applying cream to a resident's legs in the hallway, failing to ensure dignity and privacy. LPN #1, who was new to the facility, was unable to articulate the policy for maintaining privacy during point-of-care treatments. The Executive Director was informed of these findings.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to ensure accurate coding of Resident Assessments for two residents. Resident #21, who had diagnoses including gastrostomy, stage 4 pressure ulcers, osteomyelitis, and hepatitis C, was inaccurately documented as taking anticoagulants in the last 7 days on an Annual Resident Assessment. However, there were no physician orders for anticoagulant use, and the medication administration record for August confirmed that the resident was not taking anticoagulants. LPN #1 acknowledged the inaccuracy in the MDS coding. Similarly, Resident #34, with diagnoses of heart disease, end-stage renal disease, and COPD, was inaccurately documented as receiving insulin injections for 7 of the past 7 days on a Quarterly Resident Assessment. There was no physician order for insulin, and the medication administration record for June showed that the resident did not receive insulin. LPN #1 confirmed the MDS was coded inaccurately. The Executive Director stated that the policy required accurate MDS coding.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed in a timely manner for a resident, identified as #38, who was part of a sample of 13 residents reviewed for baseline care plans. The facility's policy required that a baseline care plan be developed within 48 hours of a resident's admission. Resident #38 was admitted with diagnoses including hemiplegia, malnutrition, gastrostomy, and chronic pain. However, a baseline care plan was not put into place within the required 48-hour timeframe. Instead, the comprehensive care plan was only created on June 26, 2024, well beyond the stipulated period. Interviews with LPN #1 and the Executive Director confirmed that the baseline care plan was not completed within the 48 hours as required by the facility's policy.
Failure to Conduct Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to conduct and monitor neurological checks after an unwitnessed fall involving a resident with diagnoses including epilepsy, end-stage renal disease, and cirrhosis of the liver. The incident occurred when the resident attempted to move from a chair to their bed without assistance, resulting in a fall. A nurse's note documented that a head-to-toe evaluation was performed, and no injuries were noted. The resident reported not hitting their head, and initial vital signs were recorded. Despite the nurse's note indicating that neurological checks were initiated, no documentation of these checks was found. Upon inquiry, the interim DON and LPN were unable to locate the neurological check records. The LPN initially stated that neurological checks were not initiated because the resident did not hit their head. However, the nursing note contradicted this by stating that checks were initiated. The LPN later acknowledged that the facility's policy did not specifically require neurological checks for unwitnessed falls unless there was a variance from the initial assessment. The LPN admitted that neurological assessments should have been completed, indicating a failure to adhere to best practices in monitoring the resident's condition post-fall.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the daily staffing information was properly updated and posted as required. During observations on two separate occasions, the staffing sheet displayed next to the nurses' station window lacked essential information, including the facility name, resident census, and the actual hours worked by RNs, LPNs, CMAs, and CNAs. On September 4th and September 6th, the posted staffing sheets were missing these critical details. When questioned, the Executive Director (ED) acknowledged that the staffing sheet did not contain the necessary information, which should have included each discipline for direct care, the shift, the date, and the resident census.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medication according to physician orders for a resident diagnosed with systemic lupus erythematosus, hypertension, and diabetes mellitus. A physician's order dated August 31, 2024, required the application of Aquaphor to the resident's body twice a day for ten days. However, the September Treatment Administration Record (TAR) lacked documentation of Aquaphor administration from September 1 to September 10, 2024, and indicated cessation of treatment from September 11 to September 30, 2024. On September 6, 2024, the resident's left foot was observed to be red, inflamed, and dry, with the resident reporting pain and mentioning a cream for the condition. An LPN confirmed the absence of documentation on the TAR, indicating the treatment was likely not administered. The LPN was unaware of any foot issues for the resident until observing the dryness and redness on the resident's foot, acknowledging a problem.
Inaccessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to ensure that emergency call cords were within reach for a dependent resident, leading to a deficiency. During an observation, it was noted that the call light for a resident who was dependent on staff for all activities of daily living (ADLs) was hanging between the head of the bed and the wall, making it inaccessible to the resident. The resident was observed moaning in pain and stated that they had to scream to get the staff's attention. A Certified Nursing Assistant (CNA) acknowledged that the call button was out of reach and mentioned that it might have been moved during wound care. The facility's policy requires that call lights be within reach of residents, and the Executive Director confirmed that call lights should be accessible to residents.
Inadequate Infection Control During Blood Sugar Monitoring
Penalty
Summary
The facility failed to prevent cross-contamination during the process of obtaining finger stick blood sugars for residents. Observations revealed that LPN #1 did not wash hands or use hand sanitizer before or after performing finger stick blood sugar tests and administering insulin to Resident #2. Additionally, the glucometer was not cleaned or disinfected before or after use, and it was used on multiple residents without proper sanitation. LPN #1 was unaware of the facility's policy regarding the cleaning of medical equipment and hand hygiene. Further observations showed that LPN #3, while cleaning and sanitizing the glucometer before use, did not wash hands or use hand sanitizer before obtaining a finger stick blood sugar reading from Resident #4. Interviews with the LPNs confirmed a lack of adherence to infection control protocols, as they admitted to not washing hands or sanitizing the glucometer as required. The facility's failure to implement proper infection prevention and control measures during these procedures was evident, potentially exposing residents to cross-contamination risks.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to address and document grievances related to missing clothing and medical equipment for one of the four sampled residents. The resident, who was admitted with severe protein-calorie malnutrition and end-stage renal disease, had family members who complained about a missing wheelchair, purse, and clothes. A handwritten social service note dated 04/23/24 documented these complaints, but there was no additional documentation in the resident's clinical record regarding the resolution of these grievances. The administrator and social service director both acknowledged receiving the complaints but admitted there was no documentation on how the grievances were handled.
Failure to Complete Discharge Summary with Recapitulation of Stay
Penalty
Summary
The facility failed to complete a discharge summary with a recapitulation of stay for a resident who was discharged. The resident was admitted with diagnoses including protein calorie malnutrition, diabetes mellitus, and cachexia. Upon review, it was found that the resident was discharged and went home with their daughter, as documented in the progress notes. However, the discharge instruction form only noted that the resident went home with their daughter and that medications were provided, lacking a complete summary of the resident's stay. The clinical record did not contain a discharge summary with a recapitulation of the resident's stay. When asked, the administrator confirmed that the discharge instructions form was the only document used as a discharge summary, which did not include a full recapitulation of the resident's stay.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Northwest Nursing Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Okc, Llc | 1.2 mi | ★★★★★ | 9 | 0 |
| Bellevue Health & Rehabilitation Center | 1.3 mi | ★★★★★ | 8 | 0 |
| North Winds Living Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Heritage Manor | 2.4 mi | ★★★★★ | 15 | 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.