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 York Manor Nursing Home during CMS and state inspections, most recent first.
A resident with Parkinson's disease and schizophrenia reported a missing flip phone and said the administrator had been told and staff had looked for it, but no follow-up had been provided. The facility had a grievance policy requiring prompt resolution and written decisions, yet the DON/administrator stated there was no grievance log to track grievances.
Kitchen sanitation and cross-contamination failures were observed when wet trays and utensils were stored before drying, the ice machine contained black substance and black/red growth identified as mold, and staff handled trays, silverware, tortillas, and other items while wearing gloves without washing hands or changing gloves between surface contact and food handling. The DON stated 41 residents ate meals from the kitchen.
Failure to implement an antibiotic stewardship program. The facility’s policy called for protocols to optimize infection treatment, a facility-wide system to monitor antibiotic use, leadership accountability, and tracking of antibiotic use and resistance. The DON stated the facility could not locate trending of infections, used nurses’ progress notes to monitor antibiotic side effects, had not found the expected color-coded infection map, and was supposed to use McGreer’s criteria but had not been doing so.
The facility failed to designate an infection preventionist for the infection prevention and control program. An undated staff list did not identify anyone in that role, and the administrator stated the facility did not currently have an infection preventionist. The DON said they were trying to determine who would complete training for the position and noted the former DON had been the previous infection preventionist.
Daily nurse staffing information was not fully posted. A dry erase board showed staff names, shift, date, and census, but did not include actual hours worked, and Daily Nursing Sign-In Sheets for multiple shifts over 7 reviewed days did not identify the discipline for many staff members. The facility policy required daily posting of the total number and actual hours worked by RN, LPN/LVN, and CNA staff.
Failure to provide appropriate nephrostomy care occurred for a resident with spina bifida and cerebral palsy who also had a suprapubic catheter and colostomy. The resident’s orders did not include nephrostomy care, the care plan did not address it, and the TARs only documented care for the suprapubic catheter area. CNA staff said the nephrostomy was emptied daily, while the DON stated staff monitored and cleaned it and placed a dressing around it, but the order was never entered into the system and the care plan was not updated.
Ordered meds were not available for two residents. One resident with COPD had Daliresp ordered daily, but the MAR showed no administration over multiple months and the CMA said the drug was still awaiting pharmacy delivery due to prior auth issues. Another resident with bipolar disorder had Abilify Maintena ordered monthly, but the September dose was not given because the med was not in the building, despite staff initially indicating it had been administered.
The facility failed to document clinical rationales when physicians declined pharmacist-recommended GDRs for several residents receiving psychotropic medications. Residents had varying cognitive status and diagnoses including anxiety, depression, schizophrenia, dementia, and schizoaffective disorder, and the records showed physician disagreement with GDR recommendations for meds such as clonazepam, lorazepam, citalopram, trazodone, and buspirone without supporting rationale.
Failure to notify a resident’s guardian of changes in condition and treatment. The record showed a resident with a guardian was sent to the ER twice and had multiple medication changes, including stopping clonidine and starting prazosin, Aldactone, and propranolol adjustments, but the chart did not show the guardian was notified. The guardian stated notifications were not consistent, and the DON confirmed the record lacked documentation of notification.
Discharge Summary and Medication Instructions Not Documented: A resident who was cognitively intact and planned to return home was discharged with personal belongings and medications, but the discharge paperwork did not include a recapitulation of the stay or documentation that medication instructions and the current reconciled med list were provided. The discharge forms and summary also lacked complete med directions, including frequency and instructions for use.
Failure to encode and transmit required assessments for two residents. One resident with severe cognitive impairment was sent to the hospital and no discharge assessment was completed, while another resident with a BIMS of 15 was readmitted but the record did not show an entry assessment after return. The MDS coordinator stated the required assessments should have been completed.
A resident’s quarterly assessment was inaccurate because nurse notes documented delusions, yet the MDS assessment stated the resident did not have delusions during the look-back period and was cognitively intact for daily decision making. The DON later confirmed the resident experienced delusions, and the MDS coordinator said they reviewed nurse progress notes but were unsure whether the assessment was correct.
Incomplete care plans for two residents were identified when one resident with edentulous status had loose upper dentures and a dental concern triggered on assessment, but the care plan did not address dental needs or documented dental follow-up. Another resident with a colostomy, suprapubic catheter, and nephrostomy had a care plan that addressed only the colostomy and suprapubic catheter, while the nephrostomy and related care were not included in the care plan, order summary, or MAR.
A facility failed to revise and accurately update care plans for two residents. One resident with severe cognitive impairment, schizophrenia, anxiety, depression, and other diagnoses had an elopement attempt requiring police, EMS, and ED evaluation, but the care plan did not reflect that event. Another resident with spina bifida, cerebral palsy, and a pressure ulcer had conflicting wound staging in the record, yet the care plan listed a stage four ulcer even though the wound doctor documented a stage three pressure injury.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found 2 medication errors in 31 opportunities, resulting in a 6.25% error rate. An inhaled corticosteroid was given to a resident without the required mouth-rinse instruction, and a prescribed COPD medication was not available for administration. The resident was cognitively intact, and the DON stated the medication should have been provided as ordered and the resident should have been encouraged to rinse after inhaler use.
An LPN left treatment cart #1 unlocked and unattended after entering a resident room, then returned a few minutes later to lock it. The LPN stated medications were normally secured by locking treatment carts when unattended but had not been paying attention. The DON stated treatment carts were to be kept locked when unattended to secure medications.
A facility failed to follow the noon menu for one observed meal served to residents eating from the kitchen. Soft beef tacos were served without the listed capri blend vegetables, and an LPN used tongs to portion lettuce, tomatoes, and cheese in an amount less than the stated serving size. The DM said the vegetables were not served because none were available and that residents would not eat all of the lettuce and cheese.
Uncovered Kitchen Trash Can: The facility failed to keep the trashcan by the handwashing sink covered in the kitchen. Two trash cans were identified in the kitchen, and the DON stated that 41 residents received nourishment from the kitchen. Surveyors observed the trashcan next to the handwashing sink uncovered and without a lid on two separate observations, and the DM stated there had never been a lid for that trashcan. The facility policy stated that all containers must have tight-fitting lids or covers when stored or not in continuous use.
The facility failed to provide written notices of transfer for residents transferred to acute care hospitals. This deficiency was identified for three residents with various medical conditions, including Parkinson's disease, dementia, diabetes, heart failure, and paranoid schizophrenia. The facility's policy lacked procedures for written notification, and the DON was unaware of this requirement.
The facility did not post nurse staffing information in a prominent place accessible to residents and visitors. During a facility tour, it was observed that the staffing information was missing on two occasions. The DON was unaware of the requirement to post this information. The facility had 42 residents at the time.
The facility failed to clean the deep fryer after use and did not label or date refrigerated items, including boiled eggs and chocolate-covered cherries. The dietary manager confirmed the fryer had been used three days prior without cleaning, and the facility's policy on food storage and labeling was not followed.
The facility failed to ensure the medical director's participation in the QAPI program, as required. Despite the QAPI Plan's requirement for input from all disciplines, including the medical director, a review of meeting documents revealed the medical director did not attend any meetings throughout the year. The facility administrator confirmed the medical director's absence from the meetings, acknowledging the requirement for quarterly participation.
A facility failed to provide a NOMNC form to a resident within the required time frame, resulting in a deficiency. The form was signed by staff on the day before services ended, rather than two days prior as required. The ADON acknowledged the delay, and the DON noted the absence of a specific policy, relying instead on CMS guidelines.
An LPN failed to follow infection control practices during wound care for a resident with a stage four pressure ulcer. The LPN did not wash hands before or after glove use, did not change gloves between clean and unclean tasks, and placed supplies on an unclean surface without cleaning them before returning to the treatment cart.
Failure to Maintain Grievance Records and Resolutions
Penalty
Summary
The facility failed to maintain evidence of grievances with resolutions for 1 of 1 sampled resident reviewed for grievances. The facility had an undated grievance policy stating residents have the right to voice complaints and grievances, that grievances may be communicated orally or in writing, that the facility will promptly work to resolve grievances, and that the resident will receive the resolution decision in writing. Resident #8 had a quarterly assessment dated 08/14/25 showing a BIMS of 14, indicating the resident was cognitively intact for daily decision making, and diagnoses including Parkinson's disease and schizophrenia. On 09/09/25, Resident #8 stated their flip phone had been missing for about a month, that they had informed the administrator, that staff had looked for it, and that they had not received any follow-up. On 09/12/25, the administrator stated the facility did not have a grievance log to track resident grievances.
Kitchen sanitation and cross-contamination failures
Penalty
Summary
The facility failed to ensure kitchen equipment was properly dried before storage, the ice machine was free of debris and build-up, and cross contamination was prevented during meal service. On 09/08/25, cook #1 was observed stacking wet trays by the steam table and placing wet cooking utensils in drawers. Later that day, the maintenance supervisor removed the front cover of the ice machine and observed a black substance on the back of the cover, along with black and red growth in the corners and underneath where the pump was held. The maintenance supervisor stated the substance was mold and that the ice machine was being shut down to clean it; there was no documentation of when the facility had cleaned the ice machine. The DON identified that 41 residents ate meals from the kitchen. During meal service observations on 09/09/25, DA #1 was observed wearing gloves while placing a spoon and fork on a napkin on a tray, then touching their shirt and left hip in a rubbing motion, and continuing to place silverware on trays without washing hands or changing gloves. The DM was also observed wearing gloves while touching the counter, meal cards, thermometer, and plates, then pulling tortillas from a bag and rolling them from side to side to separate them, without changing gloves or washing hands between touching surface items and food. On 09/15/25, the DM stated kitchen staff wore gloves to stop cross contamination and changed gloves and washed hands when they left the kitchen, and stated trays and dishes were allowed to air dry before being put away.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program. The undated Antibiotic Stewardship policy stated that the facility would develop and implement protocols to optimize infection treatment, ensure residents who require an antibiotic are prescribed the appropriate antibiotic, develop and implement a facility-wide system to monitor antibiotic use, assign leadership accountability for safe and appropriate antibiotic use, implement policies or practices to improve antibiotic use, and track measures of antibiotic use and resistance for relevant staff. During interview on 09/10/25 at 12:25 p.m., the DON stated the facility had not been able to locate trending of infections. The DON said nurses documented and monitored for side effects of antibiotics in progress notes and that they monitored the nurses' notes, but the facility had not found the expected facility map with color coding for different infections to trend infections. The DON also stated the facility was supposed to use McGreer’s criteria but had not been doing so.
No Designated Infection Preventionist
Penalty
Summary
The facility failed to ensure an individual was designated as the infection preventionist for the infection prevention and control program. Record review showed an undated staff list did not identify any staff member assigned to that role. The DON identified 41 residents in the facility, and on 09/08/25 the administrator stated the facility did not currently have an infection preventionist. On 09/15/25, the DON stated they were trying to determine who would complete training to become the infection preventionist and said the former DON had been the previous infection preventionist.
Daily Nurse Staffing Information Not Fully Posted
Penalty
Summary
The facility failed to include the actual and working hours of licensed and unlicensed nursing staff on the daily posted staffing information and failed to include staff disciplines on the nurse staffing data for 7 of 7 days reviewed from 09/08/25 through 09/14/25. The DON identified that 41 residents resided in the facility. On 09/15/25 at 3:18 p.m., a dry erase board was observed with staff names, shift, date, and census, but it did not show the number of hours worked. The facility’s undated policy titled Nurse Staffing Information stated that the facility must post daily staffing information, including the total number and actual hours worked by RN, LPN/LVN, and CNA staff directly responsible for resident care per shift. Review of the Daily Nursing Sign-In Sheets showed multiple shifts each day with staff listed, but the discipline was missing for many employees across all reviewed dates. On 09/15/25 at 3:20 p.m., the administrator stated that the daily staffing information was posted on the dry erase board and that the information was maintained on the Daily Nursing Sign-In Sheets.
Failure to Document and Plan Nephrostomy Care
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not met for one resident with a nephrostomy. Resident #4 had diagnoses including spina bifida and cerebral palsy and was assessed as cognitively intact for daily decision making with a BIMS of 13. The resident’s physician orders from 05/20/24 through current did not include active orders for nephrostomy care, the care plan revised 08/27/25 addressed a suprapubic catheter and colostomy but did not address the nephrostomy, and the July, August, and September 2025 treatment records documented cleaning of the suprapubic catheter area but did not address nephrostomy care. CNA #3 stated the resident had a nephrostomy that was emptied daily, and the DON stated the resident had a colostomy, nephrostomy, and suprapubic catheter, that staff monitored and cleaned the nephrostomy and placed a dressing around it, and that an order had not been entered into the system so it did not populate on the TAR. The DON also stated the care plan was not updated to reflect nephrostomy care and staff appeared to assume the nephrostomy was included when cleaning the colostomy and suprapubic catheter.
Ordered medications were not available for administration
Penalty
Summary
The facility failed to ensure ordered medications were available for two residents. For one resident with a BIMS score of 15 and a diagnosis of chronic obstructive pulmonary disease, a physician order dated 07/02/25 showed Daliresp 250 mcg by mouth once daily, but the medication administration record did not show the medication had been administered in July, August, or through 09/10/25. During medication administration observation on 09/10/25, the CMA was not observed administering the Daliresp and stated the medication was still waiting to be delivered from the pharmacy because it required prior authorization. The CMA also stated the DON had been notified the medication was not available, and the DON later stated the medication had not been available because the physician had not signed the prior authorization. For another resident with a BIMS score of 13 and a diagnosis of bipolar disorder, a physician order showed Abilify Maintena 400 mg IM was to be given on the 8th of each month. The September 2025 treatment administration record showed the dose was ordered for 09/08/25, but the record also showed an entry stating the medication was not administered because it was not in the building and had been reordered. The DON stated the nurse had told the oncoming shift the injection had been administered, but later acknowledged the medication had been unavailable on 09/08/25. The resident stated they were supposed to receive a monthly injection for auditory hallucinations and had not yet received the September injection.
Missing Clinical Rationales for Declined GDR Recommendations
Penalty
Summary
The facility failed to provide documented clinical rationales for declining pharmacist-recommended gradual dose reductions for multiple residents receiving psychotropic medications. For Resident #9, a quarterly assessment showed severe cognitive impairment with a BIMS score of 6, and the pharmacist recommended gradual dose reductions for clonazepam and lorazepam; the physician disagreed, but the record did not show a clinical rationale. The DON stated the physician should have documented a clinical rationale for declining the recommendation. For Resident #11, a quarterly assessment showed a BIMS score of 13, indicating cognitive intactness, and the pharmacist recommended gradual dose reductions for citalopram and trazodone; the physician again disagreed without documenting a clinical rationale, and the DON stated one should have been documented. For Resident #8, the record showed diagnoses including borderline personality disorder, dementia, anxiety, depression, schizoaffective disorder, and Parkinson's disease, and a pharmacist-recommended gradual dose reduction for buspirone was marked disagree without rationale. For Resident #45, assessments showed BIMS scores of 15 and diagnoses of anxiety, depression, and schizophrenia; a gradual dose reduction for buspirone was denied without rationale, and the DON stated the pharmacist sends recommendations to the doctor but did not know who followed up, with no answer provided by the end of the survey.
Failure to Notify Resident Representative of Changes in Condition and Treatment
Penalty
Summary
The facility failed to ensure the resident representative was notified of changes in condition for one resident with a guardian. The facility’s policy required immediate notification of the resident, the physician, and the resident representative when there was a significant change in treatment or a decision to transfer or discharge the resident. Record review showed Resident #9 had guardianship paperwork dated 02/13/25, but the clinical record did not show the guardian was notified when the resident was sent to the emergency room on 08/05/25 and again on 08/12/25. The record also did not show guardian notification when the physician discontinued clonidine and started prazosin and Aldactone on 08/12/25, when propranolol was ordered on 08/25/25, when propranolol was increased on 08/27/25, or when it was decreased on 08/28/25. On 09/09/25, the guardian stated they were not consistently notified of changes in the resident’s treatment, medication, and hospitalization. The DON later reviewed the electronic record and confirmed it did not show the guardian had been notified of those changes.
Discharge Summary and Medication Instructions Not Documented
Penalty
Summary
The facility failed to ensure that a recapitulation of Resident #44’s stay was completed and that discharge medication information was provided at discharge. Resident #44’s annual assessment showed a BIMS score of 15, indicating the resident was cognitively intact for daily decision making and independent with most activities of daily living. The care plan noted the resident wanted to be discharged to their own apartment, and a nurse note documented that the resident was discharged from the facility with personal belongings and medications. The discharge return not anticipated assessment showed a planned discharge to home/community, but it did not document that the resident or resident representative received the resident’s current reconciled medication list. The interdisciplinary discharge summary showed discharge to a private residence, but it did not include a recapitulation of the resident’s stay or documentation that medication instructions had been provided. The check out medication list included the medication name, dosage, and number of pills provided, but did not include frequency or instructions for use. The Resident Transfer/Discharge Form also did not show a recapitulation of the resident’s stay or documentation that medication instructions had been provided. The administrator, MDS coordinator, and DON each stated the discharge summary should have included the recapitulation and medication instruction documentation, and the DON stated there was no documentation that the information had been provided to Resident #44.
Failure to Encode and Transmit Required Assessments
Penalty
Summary
The facility failed to ensure assessments were encoded and transmitted to the State within 7 days of assessment for 2 residents. Resident #9 had a quarterly assessment on 06/11/25 showing a BIMS score of 6, indicating severe cognitive impairment for daily decision making. The resident was readmitted on 07/21/25, then sent to the hospital on 07/28/25, but review of the electronic clinical record did not show a discharge assessment had been completed. An entry assessment dated 08/04/25 showed the resident had been readmitted again. On 09/11/25, the MDS coordinator reviewed the record and stated a discharge return anticipated assessment should have been completed on 07/28/25. Resident #45 had a quarterly assessment on 06/23/25 showing a BIMS score of 15, indicating cognitive intactness. The record showed a discharge return anticipated assessment dated 07/26/25, but did not show the resident had been readmitted to the facility. A nurse note dated 07/30/25 documented the resident had been readmitted, and on 09/09/25 the MDS coordinator stated the resident had discharged on 07/26/25 and an entry assessment should have been completed upon return on 07/30/25.
Inaccurate assessment of resident with documented delusions
Penalty
Summary
The facility failed to ensure an accurate assessment for Resident #16. Record review showed nurse notes dated 06/18/25 and 06/20/25 documented delusions for the resident. However, the quarterly assessment dated 06/23/25 recorded a BIMS score of 13, indicating the resident was cognitively intact for daily decision making, listed a diagnosis of schizophrenia, and stated the resident did not experience delusions during the seven-day look-back period. During interview on 09/11/25, the DON stated Resident #16 experienced delusions, and the MDS coordinator stated they reviewed nurse progress notes when completing assessments but were unsure whether the assessment was correct related to delusions for Resident #16.
Incomplete Care Plans for Dental Needs and Nephrostomy Care
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for 2 of 12 sampled residents. For Resident #16, an admission assessment dated 09/23/24 identified dental concerns because the resident was edentulous, and a significant change assessment dated 07/08/25 showed a BIMS of 13, indicating cognitive intactness for daily decision making. During observation and interview, Resident #16’s upper dentures did not stay in place while talking, and the resident repeatedly pushed the denture back into place. The resident stated the dentures did not fit correctly and had not told staff. Facility staff, including CNA #1, the social services director, the DON, and the MDS coordinator, stated the resident had loose dentures, had not been seen by a dentist to their knowledge, and that the care plan did not address dental concerns even though the care area assessment triggered dental concerns. For Resident #4, an annual assessment dated 08/09/25 showed a BIMS of 13 and diagnoses including colostomy, spina bifida, and cerebral palsy. The care plan revised 08/27/25 addressed the suprapubic catheter and colostomy, but did not address the nephrostomy or nephrostomy care. The order summary report for September 2025 did not show an order for nephrostomy care, and the July, August, and September 2025 MARs did not address nephrostomy care. CNA #3 stated the resident had a nephrostomy and CNAs emptied the collection bag. The DON stated the resident had a colostomy, nephrostomy, and suprapubic catheter, that the facility did not change the nephrostomy but monitored, cleaned, and dressed it, and that an order was not entered. The DON stated the nephrostomy must have been missed on the care plan.
Care plans were not revised to match resident events and wound status
Penalty
Summary
The facility failed to revise and accurately revise care plans for 2 residents reviewed for care plans. One resident had a quarterly assessment showing severe cognitive impairment, diagnoses including schizophrenia, heart failure, anxiety, and depression, and medications including antipsychotic, antianxiety, antidepressant, and anticonvulsant drugs. A progress note documented that the resident ran toward the front door, hit it until it opened, exited the building before staff could reach them, and was stopped approximately five feet outside the facility. Police and emergency medical services responded, and the resident was taken to the emergency department for evaluation due to increased anxiety. After returning to the facility, the resident continued pacing and was placed on one-on-one observation, but the care plan revised later did not include the elopement attempt on 06/05/25. The second resident had an annual assessment showing cognitive ability for daily decision making, diagnoses including spina bifida, cerebral palsy, and a stage four pressure ulcer, and was identified as at risk for pressure ulcers with a current pressure ulcer stage three present on admission. A physician wound note later described the wound as a stage three pressure injury, but the care plan revised the same day documented the resident as having a stage four pressure ulcer. During interview, the resident stated they had a wound on their bottom and staff told them it was getting better, while the MDS coordinator stated the face sheet showed a stage four wound but the wound doctor staged it as stage three to the right ischium and that the care plan should have followed the wound doctor orders and assessment.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of 5% or less. Surveyors observed 2 medication errors out of 31 opportunities, resulting in a 6.25% medication error rate. The DON identified that 41 residents received medications in the facility. On 09/10/25 at 8:19 a.m., CMA #2 administered Budesonide-Formoterol Fumarate inhalation aerosol 80-4.5 mcg/act, 2 puffs, to Resident #45 but was not observed encouraging or instructing the resident to rinse their mouth after using the corticosteroid inhaler. Resident #45 was also not observed to receive Daliresp 250 mcg by mouth. The resident had a physician order dated 11/21/24 for Budesonide-Formoterol Fumarate inhalation aerosol 80-4.5 mcg/act, two puffs twice daily, with instructions to rinse the mouth with water after each dose, and a physician order dated 07/02/25 for Daliresp 250 mcg, one tablet by mouth once daily. Resident #45’s quarterly assessment dated 06/23/25 showed a BIMS score of 15, indicating the resident was cognitively intact for daily decision making. CMA #2 stated the Daliresp tablet was not available for administration and stated they did not encourage the resident to rinse their mouth after inhaler use because the resident would become argumentative. The DON stated the charge nurses were to monitor the CMAs to ensure medications were provided as ordered and stated they were unaware the Daliresp was unavailable; the DON also stated Resident #45 should have been encouraged to rinse their mouth after inhaler use.
Unattended treatment cart left unlocked
Penalty
Summary
Medications were not secured when treatment cart #1 was left unlocked and unattended. Based on observation and interview, an LPN entered a room and then left treatment cart #1 unlocked and unattended before returning a few minutes later to lock it. During interview, the LPN stated medications were kept secured by locking treatment carts when unattended and acknowledged not paying attention when leaving treatment cart #1 unlocked. The DON stated that treatment carts were to be kept locked when unattended to secure medications.
Menu Not Followed for Lunch Service
Penalty
Summary
The facility failed to ensure menus were followed for 1 observed meal for residents who ate meals from the kitchen. On 09/09/25 at 12:00 p.m., soft beef tacos were observed served for lunch, but no vegetable was served other than lettuce and tomatoes. At 12:01 p.m., cook #1 used tongs to place lettuce, tomatoes, and cheese on each plate, and the amount served was less than three ounces. The facility's Production Guides menu for the noon meal listed soft beef taco with sauce, Spanish rice, capri blend vegetables, shredded lettuce/tomato, and a summer fruit cup, and directed use of a #8 scoop for the shredded lettuce and tomato. The DON identified that 41 residents ate meals from the kitchen. On 09/15/25 at 2:03 p.m., the DM stated the serving size for lettuce, tomato, and cheese was four ounces, that tongs were used because residents would not eat all that lettuce, and that the capri vegetables were not served because they did not have any.
Uncovered Kitchen Trash Can
Penalty
Summary
The facility failed to ensure trash cans were covered in the kitchen, including the trash can by the handwashing sink, which was one of 2 trash cans observed in the kitchen. The human resources employee identified 2 trash cans in the kitchen, and the DON stated that 41 residents received nourishment from the kitchen. On 09/08/25 at 12:05 p.m. and again on 09/09/25 at 11:18 a.m., the trashcan next to the handwashing sink was observed uncovered and without a lid. An undated facility policy titled, Disposal of Garbage/Rubbish, stated that all containers will have tight-fitting lids or covers and will be kept covered when stored or not in continuous use. On 09/15/25 at 2:03 p.m., the DM stated they had never had a lid for the trashcan by the handwashing sink.
Failure to Provide Written Notices of Transfer
Penalty
Summary
The facility failed to provide written notices of transfer for residents who were transferred to acute care hospitals. This deficiency was identified for three residents who were reviewed for discharges and hospitalizations. The facility's Transfer and Discharge policy did not include procedures for providing written notification prior to transfer, which is essential for ensuring safe and orderly transitions. The Assistant Director of Nursing (ADON) confirmed that nine residents had been transferred to acute care hospitals in the previous three months, but no written notices were provided. Resident #17, diagnosed with Parkinson's disease and dementia, was transferred to an acute care hospital twice, once following a fall and another time for altered mental status. Resident #27, with diagnoses of diabetes and heart failure, was transferred for confusion. Resident #45, diagnosed with paranoid schizophrenia, was transferred due to verbal and physical aggression. The Director of Nursing (DON) acknowledged that the facility had not been providing written notices of transfers and was unaware of the requirement until the day of the survey.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in a prominent place accessible to residents and visitors. During a tour of the facility, it was observed that the nurse staffing information was not posted on two separate occasions. The Director of Nursing (DON) stated they were not aware that the nurse staffing information was not posted or that it needed to be posted. The facility had 42 residents at the time of the observation.
Failure to Maintain Kitchen Cleanliness and Food Labeling Standards
Penalty
Summary
The facility failed to maintain proper cleanliness and labeling standards in the kitchen, affecting the quality of food service for residents. During a kitchen tour, it was observed that the deep fryer had not been cleaned after use, with dark grease and food particles present around its edges. Additionally, refrigerated items, including a sandwich bag containing six boiled eggs and an open box of chocolate-covered cherries, were found without proper labeling or dating. The dietary manager confirmed that the deep fryer had been used three days prior and was not cleaned afterward. Furthermore, the facility's policy required that food returned to storage after cooking be covered, labeled, and dated, with previously cooked foods not stored for more than 48 hours, which was not adhered to in this instance.
Medical Director's Non-Participation in QAPI Program
Penalty
Summary
The facility failed to ensure the participation of the medical director in the Quality Assessment and Performance Improvement (QAPI) program, as required. The QAPI Plan for the facility, dated 09/30/24, outlined the necessity for input from all disciplines, including the medical director, in performance improvement efforts. However, a review of thirteen QAPI Meeting & Agenda documents from 01/25/24 to 12/30/24 revealed that the medical director did not attend any of the meetings, as indicated by the blank signature line next to the pre-printed title 'Medical Director.' The facility administrator confirmed that the quality assurance committee met monthly and acknowledged the requirement for the medical director to participate in at least quarterly meetings, although the medical director was available for resident clinical issues throughout the year. This lack of participation by the medical director in the QAPI program constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Timely Provide NOMNC Form
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) form to a resident within the required time frame, resulting in a deficiency. Specifically, the NOMNC form for a resident was signed by two staff members on 09/19/24, indicating the resident's unwillingness to sign, but the services were set to end on 09/20/24, making the notice late. The Assistant Director of Nursing (ADON) acknowledged that the NOMNC forms should be given at least two days prior to the end of services, but in this case, it was not done timely. Additionally, the Director of Nursing (DON) stated that the facility did not have a specific policy and procedure regarding beneficiary notices and instead relied on CMS guidelines.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection control practices during wound care for a resident with cerebral palsy, spina bifida, and a stage four pressure ulcer on the buttock. The LPN/charge nurse did not follow proper hand hygiene protocols as outlined in the facility's policy. Specifically, the LPN did not wash their hands before donning gloves or after removing them. Additionally, the LPN did not change gloves between handling unclean and clean areas during the wound care procedure. The LPN also failed to clean the bedside table or provide a barrier for the supplies, which were placed on an unclean surface. After completing the wound care, the LPN returned the supplies to the treatment cart without cleaning them. These actions were contrary to the facility's hand hygiene policy, which requires handwashing before and after glove use and cleaning of supplies before returning them to the treatment cart.
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 37 citations issued within 25 miles in the last 12 months — including the 1 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 Muskogee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadway Care & Rehab Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Pleasant Valley Health Care Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Muskogee Nursing Center | 1 mi | ★★★★★ | 1 | 1 |
| Eastgate Village Care & Rehab Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Brentwood Extended Care & Rehab | 4.2 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.