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 Tuscany Village Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and diagnoses including obstructive uropathy and non-Alzheimer dementia had physician orders for weekly weights, a milk/soy protein supplement, and sodium bicarbonate. Over multiple occasions, the resident refused the ordered protein supplement, a scheduled weight, and sodium bicarbonate, with these refusals documented in nurses' notes. However, there was no documentation that the resident's family or physician were notified of these refusals, despite facility policy and staff statements indicating that such refusals should be communicated and recorded. The DON confirmed that the record lacked evidence of required notifications.
Two residents with urinary catheters did not receive appropriate assessment, orders, and monitoring. One resident with a suprapubic catheter had no admission documentation of the catheter, no physician order specifying catheter type or diagnosis, and no catheter-related focus or interventions in the care plan, even though staff and a representative confirmed the catheter was present on admission and throughout the stay. Another resident with an indwelling catheter was observed with thick off-white material filling the catheter tubing into the drainage bag; staff described this as sometimes normal, and the DON noted the tubing was very cloudy with sediment and not secured to the leg, despite acknowledging it should be secured.
A resident with a tracheostomy, severe cognitive impairment, COPD, and documented need for suctioning received regular tracheostomy suctioning without a corresponding physician order, contrary to facility policy requiring care in accordance with standard practice guidelines. The baseline care plan and admission assessment both indicated the need for suctioning and tracheostomy care, but a review of physician orders showed no order for tracheostomy suctioning. The DON confirmed that an order should have been in place, and an LPN reported suctioning the resident’s tracheostomy after the family requested suctioning and stated that the resident was suctioned regularly.
A resident with obstructive uropathy and severe cognitive impairment was admitted with an indwelling catheter and received a regular diet, but the physician orders and treatment records documented suprapubic catheter care and enteral tube feeding. An LPN and the DON confirmed there was no physician order for the actual catheter type in use and that the enteral feeding order was erroneous, resulting in medical records and orders that did not accurately reflect the resident’s catheter type or nutritional status.
A resident with severe cognitive impairment, obstructive uropathy, and a suprapubic catheter was admitted with physician orders for catheter changes as needed, output monitoring each shift, and catheter care every shift, and treatment records showed catheter care was being provided. However, the comprehensive care plan created after admission addressed only activities and did not include any focus, goals, or interventions for catheter care or ADLs, despite the resident’s dependence for transfers and need for assistance with self-care. A resident representative confirmed the catheter was present throughout the stay, a CNA reported there was no documentation directing catheter care, and both the DON and MDS coordinator later acknowledged that the comprehensive care plan was incomplete and had been missed.
Two residents who required assistance with ADLs did not consistently receive scheduled baths, and refusals or completed baths were not properly documented. One cognitively impaired resident, scheduled for twice‑weekly showers, only received showers on two occasions during a two‑week period, with no refusals recorded and family reporting showers occurred only after complaints. Another resident with intact cognition but significant physical impairments and physician‑ordered twice‑weekly baths did not receive a bath on a scheduled day, despite an LPN initialing the MAR as if the bath occurred, while the TAR and nurses’ notes showed no bath or refusal. Staff interviews revealed that showers were not completed for all residents, that aides cited insufficient staffing, and that required documentation and notification procedures for bath refusals were not followed.
A resident with severe cognitive impairment, septicemia, renal failure, and IV access had a physician order for weekly IV midline dressing changes on day shift, or sooner if the dressing became compromised. Review of the MAR showed a scheduled dressing change was missed without a documented reason, and a family grievance later reported the IV dressing had not been changed since admission and was dated nearly two weeks earlier. Nursing staff told the family the dressing change was missed because the resident was at dialysis when it was scheduled, and documentation and interviews with the DON and regional nurse consultant confirmed there was no record of the ordered IV dressing change being completed as required.
A resident with multiple medical conditions experienced a significant change in condition and received a new medication order. In both cases, documentation showed that the spouse and hospice company were notified, but there was no evidence that the designated HealthCare contact, the resident's daughter, was informed as required by policy. Staff interviews confirmed the omission.
A resident with multiple diagnoses, including hemiplegia and muscle weakness, was admitted to hospice care as documented by certification and physician's order. However, the significant change MDS assessment did not indicate the resident's hospice status, and the MDS coordinator confirmed the assessment was not accurately coded to reflect this change.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident with multiple medical conditions, including hemiplegia and muscle weakness, did not have required documentation of intake, output, or meal percentages for a week prior to a hospital stay. Facility policy required documentation of meal consumption in the EHR, but records for this period were missing, and the regional nurse consultant confirmed the absence of both the documentation and a specific policy for eating or intake and output.
An LPN in a facility used disinfectant wipes, not intended for skin use, to clean two residents' skin before blood sugar testing and insulin administration, contrary to the facility's policy requiring alcohol swabs. The LPN acknowledged the correct procedure, highlighting a deviation from established protocols.
The facility failed to ensure staff competency with the new EMR system, affecting three staff members. A medication was not administered to a resident because the CMA was unaware of how to verify orders using the new system. Both the CMA and an LPN reported not receiving training on the EMR. The corporate nurse confirmed that in-service sheets did not show attendance for these staff members, and the AD also demonstrated a lack of knowledge about the system.
The facility failed to administer medications as ordered for five residents. Observations showed that a CMA and an LPN did not administer medications according to physician orders, with issues such as missing medications, incorrect dosages, and unauthorized administration. Staff interviews revealed problems with medication availability and adherence to procedures, contributing to these deficiencies.
The facility experienced a medication error rate of 23.68%, significantly above the acceptable threshold. Errors included missed doses of hydrocodone/acetaminophen, lisinopril, amlodipine, and clindamycin, as well as incorrect administration of Vitamin B12 and gabapentin. Staff interviews revealed issues with medication availability and adherence to the MAR.
The facility failed to maintain infection control practices during the handling of soiled linen and hand hygiene. An LPN transported a soiled incontinent pad without bagging it, and a CNA did not change gloves or perform hand hygiene during incontinent care, placing soiled items on the floor instead of in a bag.
The facility failed to provide adequate treatment and services for a resident with a stage 3 pressure ulcer, resulting in the worsening of the wound. Despite physician orders for bi-weekly treatments and a care plan requiring frequent repositioning, the resident received only one wound care treatment over a two-week period, and staff did not document turning or repositioning efforts.
The facility failed to ensure that two residents experiencing pain received appropriate treatment. One resident, who had a hip fracture, was not properly assessed for pain during care, and another resident experienced delays in receiving prescribed pain medication. The staff did not follow the facility's pain management policy, resulting in prolonged pain and discomfort for the residents.
The facility failed to hold a care plan meeting and include a resident's representative for a resident with chronic kidney disease and chronic pain. The meeting was missed due to the responsible LPN not working and no one covering for them.
The facility failed to ensure accurate resident records, as one resident's clinical record contained hospital records belonging to four other residents. The Records Management policy requires consistent and logical maintenance of records, but the process failed, leading to incorrect documents being included in the resident's record.
The facility failed to ensure dishware was clean, as 32 blue-handled coffee cups were found with white residue and contaminants. Both a cook and the Corporate Dietary Manager confirmed the presence of debris inside the cups. The Administrator identified that 114 residents received nutrition from the kitchen.
The facility failed to maintain proper infection control during incontinent care for two residents and did not ensure staff wore required PPE before entering a COVID-19 positive room. CNAs did not change gloves as required, and a CMA entered a COVID-19 positive room without appropriate PPE.
A CNA failed to provide thorough incontinent care for a resident with hemiplegia and hemiparesis by not cleaning the labia, contrary to the facility's perineal care policy. The CNA acknowledged the omission, stating they did not wipe the labia because the resident had just voided.
Failure to Notify Family and Physician of Resident's Repeated Refusals of Care
Penalty
Summary
The facility failed to notify a resident's family and physician of repeated refusals of ordered care and treatment. Facility policy on Refusal of Care and Treatment, dated 02/16/23, required staff to notify the physician when a resident refused ordered treatment or procedures and to notify the resident's responsible party unless the resident chose otherwise. Resident #8 had physician orders dated 10/08/25 for weekly weights for four weeks, a milk/soy protein supplement of 60 milliliters twice daily, and sodium bicarbonate 650 milligrams twice daily. An admission assessment dated 10/14/25 documented that the resident had severely impaired cognition with a BIMS score of 3 and diagnoses of obstructive uropathy and non-Alzheimer dementia, and that the resident did not reject care during the seven-day look-back period. Subsequent nurses' notes from 10/2025 through 11/2025 showed multiple refusals of ordered care by Resident #8, including repeated refusals of the protein supplement health shake on several dates, refusal to be weighed on one date, and refusals of both the protein supplement and sodium bicarbonate on multiple dates. The resident representative stated they were not notified of these refusals. CNA #4 and LPN #6 each stated that when a resident refused care, the nurse should document the refusal and notify both the family and the physician. When shown the nurses' notes, the DON acknowledged there was no documentation that the family or physician had been notified of Resident #8's refusals of care and confirmed that such notification should have occurred and been documented in the nurses' notes.
Failure to Maintain Appropriate Catheter Orders, Assessment, and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate assessment, orders, and care for residents with urinary catheters. For one resident with a suprapubic catheter, the admission assessment did not document the presence of a catheter, and physician orders lacked a specific order for the catheter type and supporting diagnosis, despite orders for suprapubic catheter care, catheter changes as needed, and monitoring of output each shift. The treatment administration record showed ongoing suprapubic catheter care, but the comprehensive care plan contained no focus or interventions for catheter care, and the catheter was not included on the baseline or comprehensive care plan. The resident had severe cognitive impairment, obstructive uropathy, and non-Alzheimer dementia, and was known by staff and the resident representative to have a catheter upon admission and throughout the stay. Staff, including an LPN and the DON, acknowledged that there was no physician order specifying the catheter type, even though they stated such an order was required to guide care. For another resident with an indwelling catheter, surveyors observed the catheter tubing filled with a thick off-white substance extending from the resident’s body into the drainage bag. The physician order directed that the catheter be changed as needed or when clinically indicated. The resident had severe cognitive impairment with a BIMS score of 0, diagnoses of cerebral palsy and traumatic brain injury, and was dependent on staff for all needs. An LPN stated that catheters should be changed if there were signs of infection, but noted the resident did not have a fever and described the thick off-white substance as sometimes normal. The DON described the catheter tubing as stained and very cloudy with sediment and was unsure if this appearance was normal for the resident, and also noted the catheter tubing was not secured to the resident’s leg, despite acknowledging it was advised to secure the catheter to prevent pulling against the bladder wall.
Failure to Obtain Physician Order for Tracheostomy Suctioning
Penalty
Summary
The facility failed to obtain a physician’s order for tracheostomy suctioning for one resident who required this care. The facility’s Tracheostomy Care policy dated 03/02/23 stated that staff would provide care and suctioning for residents with a tracheostomy in accordance with standard practice guidelines. A baseline care plan for Resident #1 dated 01/14/26 documented that the resident had a tracheostomy and required suctioning, and an admission assessment dated 01/21/26 showed the resident had severely impaired cognition with a BIMS score of 07, required suctioning and tracheostomy care, and had a diagnosis of chronic obstructive pulmonary disease. However, a review of physician orders from 01/14/26 through 01/27/26 showed no order for tracheostomy suctioning. The DON confirmed that Resident #1 should have had a physician order for tracheostomy suctioning and that no such order was present. An LPN reported that on 01/26/26 the resident’s family stated the resident needed to be suctioned; the resident was not in distress and was suctioned via the tracheostomy after eating and after the family left, and the LPN stated the resident’s tracheostomy was suctioned regularly despite the absence of a physician order. This deficiency centers on the provision of tracheostomy suctioning without a corresponding physician order, despite documented care needs and facility policy requiring care in accordance with standard practice guidelines.
Inaccurate Physician Orders for Catheter Type and Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate physician orders and medical records for a resident with an indwelling catheter and no enteral feeding. Facility policy on care and removal of indwelling catheters required staff to evaluate the need for catheter removal by validating the record and physician’s order. For this resident, physician orders dated 10/08/25 included directions to change a suprapubic catheter as needed, monitor output every shift, provide suprapubic catheter care every shift, and administer enteral tube feeding twice a day. The treatment administration record for the same period showed the resident received care for a suprapubic catheter. However, the resident’s annual assessment dated 10/14/25 documented that the resident had a catheter in place, not a suprapubic catheter, and that the resident did not have a tube feeding device and instead ate with supervision or touching assistance. The resident had diagnoses of obstructive uropathy and non-Alzheimer dementia, with severely impaired cognition (BIMS score of 3), and was later discharged for a short-term hospital stay. During interviews, the resident’s representative stated the resident had a catheter upon admission and throughout the stay and was not receiving enteral tube feeding. An LPN confirmed that residents admitted with catheters should have orders specifying the catheter type and size, acknowledged that this resident had a catheter upon admission, and identified that there was no physician order for a catheter, only for suprapubic catheter care, and that the resident was on a regular diet rather than enteral tube feeding. The DON similarly confirmed the resident had a catheter upon admission, that the orders incorrectly specified suprapubic catheter care and lacked an order for the actual catheter, and that the resident was on a regular diet and not nothing by mouth, identifying the enteral tube feeding order as an error. These findings show the resident’s physician orders were inaccurate and inconsistent with the resident’s actual catheter type and nutritional status.
Failure to Develop Comprehensive Care Plan for Resident With Suprapubic Catheter
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for one resident with a suprapubic catheter. Facility policy required a comprehensive care plan with measurable objectives and timeframes to be developed within seven days after completion of the comprehensive MDS, considering all triggered Care Area Assessments and other identified needs. For this resident, physician orders dated at admission directed suprapubic catheter changes as needed, monitoring of catheter output every shift, and catheter care every shift, and the treatment administration record showed ongoing suprapubic catheter care throughout the month. However, the comprehensive care plan initiated shortly after admission contained only an activities focus and did not include any focus, goals, or interventions related to catheter care or other ADLs. The resident’s admission assessment documented severe cognitive impairment with a BIMS score of 3, diagnoses of obstructive uropathy and non-Alzheimer dementia, and the presence of a catheter, with urinary continence not rated due to catheter use. The assessment also showed the resident required varying levels of assistance for eating, bathing, dressing, and was dependent for bed transfers, but these needs were not reflected in the comprehensive care plan. A resident representative confirmed the resident had a catheter upon admission and throughout the stay. A CNA reported there was no documentation directing catheter care, although they stated they checked and provided care for all catheters every two hours. The DON and the MDS coordinator both acknowledged on review that the comprehensive care plan for this resident was incomplete, containing only an activities focus and omitting catheter care and ADLs, and that the comprehensive care plan had been missed.
Failure to Provide and Accurately Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing and to document refusals or completed baths for two residents who required assistance with activities of daily living. Facility policy required staff to provide bathing services per standard practice and to document refusals in the record. For one resident with severely impaired cognition, a BIMS score of 7, and no history of rejecting care, CNA flow sheets showed showers only on two Sundays within a two‑week period, despite the resident being scheduled for showers on Tuesdays and Fridays. Interdisciplinary progress notes contained no documentation of shower refusals, and the resident’s family member reported the resident only received showers after they complained to staff. For a second resident with intact cognition (BIMS 14), polyneuropathy, anxiety disorder, depression, and bilateral upper and lower extremity impairments, assessments showed the resident required substantial to maximum assistance with showers/baths and personal hygiene and was dependent for tub/shower transfers and non‑ambulatory. Physician orders specified bath days twice weekly on first shift. The TAR for a specific month showed the resident did not receive a bath on one scheduled bath day, while the MAR for the same date was initialed by an LPN as if a bath had been given. Nurses’ notes for that date contained no documentation of a bath being provided or refused. Multiple staff interviews confirmed that scheduled showers were not consistently completed for all residents and that there were no bath sheets for the second resident over several days at the end of the month. A CNA reported the second resident stated they had not had a shower for two weeks and that aides told the resident there was not enough staff to bathe all residents. Nursing staff, including CNAs, LPNs, the ADON, and the DON, described a process in which CNAs should notify nurses of refusals, and nurses should document refusals and notify family and physicians, but review of the electronic health record and bath documentation showed no evidence that this process was followed for the missed bath date. The second resident stated they did not receive a bath over several consecutive days and reported being told by aides that staffing shortages prevented all residents from being bathed.
Failure to Perform Ordered IV Midline Dressing Change
Penalty
Summary
The facility failed to provide a physician-ordered IV midline dressing change for one resident receiving IV therapy. A physician’s order dated 07/09/25 directed that the resident’s IV midline dressing be changed on the day shift weekly on Friday, or sooner if the dressing became damp, loose, soiled, or if problems at the site required further inspection. The MAR for 07/11/25 showed the IV midline dressing change was missed, with no documented reason. The resident’s admission assessment dated 07/12/25 documented severe cognitive impairment with a BIMS score of 07, dependence in ADLs, and active IV access, with diagnoses including septicemia and renal failure. The resident’s care plan dated 07/28/25 indicated the resident was on IV therapy for infection and that medications and treatments were to be administered as ordered. A grievance form dated 07/16/25 documented that the resident’s family reported the IV dressing had not been changed since admission, and that the dressing present at that time was dated 07/03/25. Family reported being told by nursing staff that the dressing change had been missed because the resident was at dialysis when it was scheduled, and that it would be changed that day. A nurse progress note dated 07/18/25 stated the IV dressing change was not performed because it had been changed on 07/16/25. During interviews, the DON stated the resident had been out of the facility for an appointment and that the dressing change should have been done upon return, and the regional nurse consultant confirmed there was no documentation that the IV dressing change was performed before 07/16/25.
Failure to Notify Responsible Party of Change in Condition and New Medication Order
Penalty
Summary
The facility failed to ensure that responsible parties were notified in two separate instances for one resident. In the first instance, a resident with a history of hemiplegia, hemiparesis, cerebral infarction, muscle weakness, and bipolar disorder experienced a significant change in condition, including vomiting, inability to keep food, water, and medication down, increased confusion, and hallucinations. The physician ordered the resident to be sent to the emergency room, and documentation showed that the resident's spouse, who was also the roommate, was notified. However, there was no documentation that the designated HealthCare contact, the resident's daughter, was notified as required by facility policy. In the second instance, a new physician's order for alprazolam was issued for the same resident to address anxiety. Documentation indicated that the resident and the hospice company were notified of the new medication order, but again, there was no documentation that the HealthCare contact was informed. Interviews with staff confirmed that the daughter was listed as the HealthCare contact and should have been notified in both cases, but there were no notes indicating that this notification occurred.
Inaccurate Coding of Significant Change MDS Assessment
Penalty
Summary
The facility failed to accurately code a significant change Minimum Data Set (MDS) assessment for one resident. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and bipolar disorder. Documentation showed the resident was admitted to hospice care, with a hospice certification and physician's order confirming the start of hospice services. However, the significant change MDS assessment did not reflect the resident's hospice status, as the section for hospice care was not marked. The MDS coordinator confirmed that the assessment was related to the resident's transition to hospice but acknowledged that hospice was not coded on the MDS, resulting in an inaccurate assessment.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency were not provided in the report.
Failure to Document ADL Intake and Output for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure that activities of daily living (ADL) documentation was completed for one of three sampled residents reviewed for ADLs. Specifically, for a resident with diagnoses including hemiplegia, hemiparesis, muscle weakness, cerebral infarction, and bipolar disorder, there was no documentation of intake and output or meal percentages for a seven-day period leading up to a hospital stay. The resident was assessed as cognitively intact with a BIMS score of 15. Review of facility policy indicated that staff were required to document percentage consumed in the electronic health record (EHR), but no such documentation was found for the specified period. The regional nurse consultant confirmed that all available ADL documentation had been provided and acknowledged the absence of a generalized ADL policy, as well as the lack of a specific policy for documenting eating or intake and output.
Improper Use of Disinfectant Wipes for Blood Sugar Testing and Insulin Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed during blood sugar testing and insulin administration for two residents. On April 1, 2025, an LPN was observed using disinfectant wipes, which were not intended for use on skin, to clean the fingers of two residents before obtaining blood sugar levels. Additionally, the LPN used the same type of disinfectant wipe to clean the skin on a resident's abdomen before administering insulin. The disinfectant wipes' container and Safety Data Sheet explicitly stated they were not safe for skin contact. The facility's policy required the use of alcohol swabs for these procedures. The LPN acknowledged the correct procedure involved using alcohol swabs, indicating a deviation from established protocols.
Staff Competency with New EMR System Lacking
Penalty
Summary
The facility failed to ensure that staff were competent with the new Electronic Medical Records (EMR) system, affecting three staff members observed for competency. During a medication pass observation, a medication for a resident was not administered because the Certified Medication Aide (CMA) was unaware of how to verify if the medication had been ordered using the new EMR system. The CMA stated they had not received training on the new EMR and were unaware of how to check medication orders. Similarly, an LPN also reported not knowing how to order medication on the new EMR system. The corporate nurse indicated that a two-day training was conducted with key staff and nursing administration, who were then responsible for training the rest of the staff. However, in-service sheets did not show that the CMA, LPN, or the Activities Director (AD) attended the training sessions. During an interview, the AD asked the corporate nurse how to access care plans in the new system, further indicating a lack of training. The corporate nurse was unable to find additional in-service sheets to confirm that all staff had been trained, highlighting a gap in ensuring staff competency with the new EMR system.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered for five residents. Observations revealed that a CMA did not administer hydrocodone/acetaminophen to one resident and incorrectly administered Vitamin B12 without an order to another resident, while failing to administer thiamine and ferrous sulfate as prescribed. Another resident did not receive their prescribed lisinopril, and yet another resident did not receive their prescribed amlodipine and clindamycin. Additionally, an LPN administered only one capsule of gabapentin instead of two and failed to administer a potassium tablet due to an empty medication card. Interviews with staff revealed issues with medication availability and administration. A CMA stated that clindamycin was not in the facility and was unsure of the pharmacy's delivery timeline. An LPN acknowledged administering an incorrect dosage of gabapentin and not administering potassium due to an empty medication card. The corporate nurse explained the process for ensuring medications are administered per physician orders, including interfacing with the pharmacy through the EMR and faxing orders if necessary. However, the observations indicated lapses in following these procedures, leading to the deficiencies noted.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 23.68 percent. This deficiency was observed in the administration of medications to five residents. For instance, a Certified Medication Aide (CMA) did not administer hydrocodone/acetaminophen to one resident as ordered. Another resident was given Vitamin B12 without an order, while their prescribed thiamine and ferrous sulfate were not administered. Additionally, a resident did not receive their prescribed lisinopril, and another resident did not receive their ordered amlodipine and clindamycin. Further observations revealed that a Licensed Practical Nurse (LPN) administered only one capsule of gabapentin instead of the prescribed two and failed to administer a potassium tablet to a resident. The facility's Medication Administration policy requires medications to be administered according to prescriber orders, but this was not adhered to in these cases. Interviews with staff indicated issues such as medication unavailability and failure to follow the Medication Administration Record (MAR), contributing to the high error rate.
Infection Control Deficiency in Handling Soiled Linen and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices during the handling of soiled linen and hand hygiene during incontinent care for one of the sampled residents. On two separate occasions, staff members were observed not following the facility's infection control policies. An LPN was seen exiting a resident's room with a soiled incontinent pad without placing it in a bag before transporting it to the soiled utility room. This action was contrary to the facility's policy, which requires contaminated laundry to be bagged or contained at the point of collection. Additionally, a CNA was observed providing incontinent care to a resident without changing gloves after cleaning the resident. The CNA used the same soiled gloves to handle clean items, including a clean brief, incontinent pad, and draw sheet. Furthermore, the CNA placed soiled linen and wipes on the floor instead of in a plastic bag, and did not perform hand hygiene during the process. These actions were in violation of the facility's hand hygiene policy, which mandates handwashing after contact with soiled or contaminated articles.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate treatment and services to promote the healing of a pressure ulcer for a resident with multiple diagnoses, including Parkinson's disease and cognitive impairment. The resident's care plan required frequent turning and repositioning, as well as weekly skin inspections. Despite these requirements, the resident developed a stage 3 pressure ulcer on the sacrum, which worsened over time. Documentation revealed that the resident received only one wound care treatment between late April and early May, despite physician orders for bi-weekly treatments. Additionally, the facility staff did not document turning or repositioning efforts, relying instead on an informal understanding to make rounds every two hours. The DON confirmed that wound measurements were performed by hospice services, not facility staff. The deficiency was identified through observation, record review, and interviews. The resident's wound care was observed, and it was noted that the wound had increased in size. The DON acknowledged the lack of documentation for turning and repositioning and the missed wound care treatments. The facility's failure to adhere to the care plan and physician orders, as well as the lack of proper documentation and consistent wound care, contributed to the worsening of the resident's pressure ulcer.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure that two residents experiencing pain received appropriate treatment. Resident #15, who had diagnoses including Parkinson's disease and cognitive communication deficit, fell and sustained a hip fracture. Despite the resident's cries of pain during incontinent care, CNA #1 did not notify the nurse and continued with the care. The DON later confirmed that CNA #1 was aware of the fall but did not stop to get the nurse when the resident expressed pain. Video surveillance showed the resident screaming in pain multiple times during care, but CNA #1 did not take appropriate action to address the pain. Resident #1, who had diagnoses including metabolic encephalopathy and anxiety disorder, experienced delays in receiving prescribed pain medication. The resident reported that it took 1.5 weeks to get their pain pills at the facility, and during this period, they were only offered Tylenol despite having a prescription for oxycodone. The DON confirmed that the resident's pain levels were documented as high as five on multiple occasions, but the resident only received Tylenol and not the prescribed oxycodone until the order was received on 02/29/24. The facility's failure to provide timely and appropriate pain management for both residents resulted in prolonged pain and discomfort. The staff did not follow the facility's Pain Management and Basic Comfort Measures policy, which required evaluating pain and providing appropriate interventions. The lack of communication and proper assessment by the staff contributed to the deficiencies in pain management for these residents.
Missed Care Plan Meeting for Resident
Penalty
Summary
The facility failed to ensure a care plan meeting was held and a resident's representative was included for one of three sampled residents reviewed for representative inclusion in the plan of care. Resident #4, who had diagnoses including chronic kidney disease and chronic pain, had a Care Plan Conference on 07/31/23 and an Annual Resident Assessment completed on 10/10/23. A Nurse's Note dated 10/17/24 documented an email was sent to Resident #4's representative regarding setting up a care plan meeting. However, the next documented Care Plan Conference for Resident #4 was on 02/09/24, indicating a missed care plan meeting. LPN #1, responsible for care plan meetings, stated that the meetings were supposed to be every three months and acknowledged that a meeting was missed because it was scheduled when they were not working, and no one covered for them.
Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure resident records were accurate for one of three sampled residents reviewed for accurate records. The Records Management policy, revised on 06/01/17, mandates that records be maintained in a consistent and logical manner, meeting legal standards for protection, storage, and retrieval, and protecting the privacy of healthcare facility residents and patients. However, Resident #3's clinical record contained hospital records belonging to four other residents. Specifically, hospital records for Residents #14, #13, #11, and #12 were found in Resident #3's clinical record. Medical Records staff stated that they received resident information in a basket by the scanner, which the ADON reviewed to ensure orders were correctly entered before scanning. Despite this process, incorrect documents were included in Resident #3's record, indicating a failure in the record management system.
Unclean Dishware in Kitchen
Penalty
Summary
The facility failed to ensure dishware was clean during a kitchen observation. The Cleaning Dishes in Dish Machine policy, dated 08/01/18, required dishes to be inspected and put away if clean and dry, and to repeat the cleaning steps if dishes were not clean. On 01/26/24 at 2:54 p.m., 32 blue-handled coffee cups were observed in the clean dish area with white residue, small particles, and visible contaminants inside. Cook #1 acknowledged the presence of the white substance and stated it did not look clean. The Corporate Dietary Manager also confirmed the debris and residue inside the cups when shown the cups at 3:05 p.m. The Administrator identified that 114 residents received nutrition from the kitchen.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control during the provision of incontinent care for two residents and did not ensure staff donned appropriate PPE before entering a COVID-19 positive room. For Resident #8, a CNA did not change gloves during the entire process of providing incontinent care, including when handling clean and dirty items. The CNA also placed a dirty pad on the floor instead of disposing of it immediately. Similarly, for Resident #10, another CNA did not change gloves during the provision of incontinent care, resulting in the resident being left with a smear of fecal matter on their anal area. The CNA also failed to take the trash out of the room promptly. Both CNAs acknowledged their failure to change gloves as required by the facility's policy during their respective tasks. Additionally, the facility did not ensure that staff wore the required PPE when entering a COVID-19 positive room. A CMA entered Resident #11's room without wearing an N95 mask, gown, face shield, and gloves, despite the posted precautions indicating these were necessary. The CMA stated they believed the precautions only applied to direct care involving body contact. The DON confirmed that staff were required to wear full PPE in COVID-19 isolation rooms, indicating a lapse in adherence to the facility's infection control policies.
Failure to Provide Thorough Incontinent Care
Penalty
Summary
The facility failed to ensure thorough incontinent care for a resident diagnosed with hemiplegia and hemiparesis. The resident's care plan required perineal care with incontinent changes. During an observation, a CNA performed incontinent care but did not clean the resident's labia, only wiping the groin and buttocks. The CNA acknowledged the omission, stating they did not wipe the labia because the resident had just voided. This action was contrary to the facility's perineal care policy, which mandates cleaning the labia majora and washing downward from the pubic area toward the rectum in one smooth stroke.
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 216 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Epworth Villa Health Services | 2.3 mi | ★★★★★ | 0 | 0 |
| Northwest Nursing Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Bellevue Health & Rehabilitation Center | 2.9 mi | ★★★★★ | 8 | 0 |
| Ignite Medical Resort Okc, Llc | 3.1 mi | ★★★★★ | 9 | 0 |
| The Lakes | 3.4 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.