Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Premier Health Care Center during CMS and state inspections, most recent first.
Care plans for four residents lacked measurable goals and time frames. Residents with diagnoses including schizophrenia, anxiety, heart failure, Alzheimer's disease, dementia, and other conditions had care plan goals such as maintaining health, feeling better about meals, having less constipation, feeling comfortable with hospice, and hollering out less, but the objectives were not measurable. The DON stated goals should be measurable so staff and other disciplines could track progress and evaluate interventions.
Indwelling catheters were used for three residents without valid physician orders for the catheter, monitoring, or catheter care. Each resident had diagnoses such as neurogenic bladder or urinary retention, and care plans included catheter maintenance and UTI monitoring, but the records showed no corresponding orders or evidence of catheter care documentation. Observations found the residents with catheters draining clear yellow urine, including one resident in bed and another in a wheelchair with a catheter bag lacking a privacy bag.
Respiratory Equipment Not Properly Stored or Maintained: Three residents with oxygen and nebulizer orders were observed with nebulizer masks/tubing left on bedside tables or nightstands, not bagged, and one resident had no oxygen sign posted. One resident’s oxygen tubing was undated, and another resident’s nebulizer tubing was dated but not stored per the care plan/order. The DON and ADON stated nebulizers should be cleaned after use, bagged when not in use, and changed weekly; staff also stated improper storage could lead to infection.
Medication Administration Error Rate Exceeded 5 Percent: Two residents had medication administration errors that contributed to a 10.34% error rate. An LVN left nebulizer meds in a resident’s room and documented them as given without staying to verify completion, and another resident’s Eliquis was not available in the med cart and was not administered as ordered. The DON and LVN stated meds should be given as ordered and nebulizer treatments should be observed until completed.
An infection control deficiency occurred when an LPN used a shared glucometer and blood pressure cuff without proper sanitizing and did not perform hand hygiene before or after resident contact. The issue involved residents with asthma/COPD, insulin dependent diabetes, and chronic atrial fibrillation with an acute URI, and the DON stated staff were expected to use hand hygiene and the facility’s purple top disinfectant wipe.
Ripped and Stained Hallway Carpet: A survey found the carpet in a back hallway was ripped and visibly stained, with the tear described by the maintenance director as longstanding. The DON said intact, clean carpets were expected and noted the torn carpet could be an accident hazard, while the Administrator stated it could be a fall hazard; the facility policy required a clean, safe environment free from trip and fall hazards.
Inaccurate MDS Skin Assessment Documentation: A resident with dementia, a femur fracture, anxiety, major depressive disorder, and rheumatoid arthritis had an MDS that incorrectly documented unhealed pressure ulcers/injuries in Section M. The chart instead showed skin tears/abrasions orders, skin assessments noting redness and resolving skin issues, and no care plan addressing current skin issues or skin risk; the DON stated the wound on the MDS was most likely entered in error.
A resident with schizoaffective disorder bipolar type and orders for sertraline was not correctly identified on the PASRR Level I screening, which remained negative for mental illness and was not updated. The DON said she was not familiar with the PASRR process, and the MDS Coordinator stated a new Level I reflecting mental illness should have been completed for the resident.
A resident admitted with UTI, neurogenic bladder, and BPH had a suprapubic catheter in place on admission, but the DON did not initiate a baseline care plan within 48 hours to address the catheter. The catheter was not added to the care plan until later, and the DON stated she was unaware of the 48-hour requirement; the administrator stated baseline care plans were expected to include all immediate care needs.
Care Plan Not Reviewed and Revised by Interdisciplinary Team: A resident with anxiety, Alzheimer's disease, HTN, neurogenic bladder dysfunction, and chronic pain had a care plan that added a Foley catheter intervention before the physician's order for catheter placement was entered. The quarterly MDS showed severe cognitive impairment, and the bladder/bowel section indicated no appliance was present. The DON stated care plans should be reviewed frequently and revised with changes in status, but also said she had not received formal care plan training when hired.
A resident with moderate cognitive impairment and no documented anxiety diagnosis received Clonazepam orders and a Diazepam order entered with prophylaxis as the indication, including one Clonazepam order tied to cognitive communication deficit. The chart lacked side-effect monitoring orders for either medication, and the MAR showed repeated Clonazepam administration. The DON and ADON acknowledged the diagnosis/indication issues and the absence of monitoring orders.
A resident with limited mobility and moderate cognitive impairment was transported by a CNA in a facility van while seated in a wheelchair that was required to be secured with a 5‑belt restraint system. The CNA reported locking the wheelchair wheels and fastening all belts, but during the trip the van overheated, the CNA slowed in a construction zone, and the wheelchair flipped backward, leaving the resident on the floor. Hospital records documented an acute subdural hematoma and cervical fracture from a fall from the wheelchair during van transport. Subsequent testing of the van’s restraint system showed the wheelchair could only flip if both front floor straps were not fastened, and the Administrator concluded the front belts must not have been secured. Interviews and record reviews revealed no documented training or competency validation in transportation safety or wheelchair securement for the aides involved, despite a written policy requiring such training, and the Administrator acknowledged there were no maintenance logs or routine safety inspections for the van.
The facility did not ensure that multiple full-time nurse aides obtained CNA certification or completed a state-approved training and competency evaluation program within four months of hire, as required by regulation and the facility’s own job description. Record reviews showed that several aides had been employed beyond four months with employability checks indicating no CNA certification, and interviews with the Office Manager and Administrator confirmed they were aware many aides were past the certification deadline. Leadership cited difficulty obtaining certification and recruiting CNAs in a rural area and noted they were awaiting or had just obtained approval to conduct a CNA class, while acknowledging ongoing noncompliance that could affect the appropriateness of care provided.
The facility failed to maintain its transport van in safe operating condition, as there were no maintenance logs, routine inspections, or documented safety checks. An administrator acknowledged that the van was not routinely inspected. A CNA reported that while transporting a resident, the van began to overheat in a construction zone with no place to exit, prompting her to call maintenance and slow down after seeing a yellow warning light. This deficiency was cited for failure to keep essential equipment working safely.
The facility failed to properly store and label food items in the kitchen's dry storage, with several items found unsealed and without necessary dates. This was attributed to the absence of the Dietary Manager, who was responsible for labeling, leading to a risk of foodborne illnesses.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairment, resulting in outdated hospice care orders. The resident was discharged from one hospice and admitted to another, but the facility's records did not reflect this change. The DON acknowledged the oversight and its potential impact on care, attributing the error to staff oversight.
The facility failed to maintain an effective infection prevention and control program, lacking Enhanced Barrier Precautions (EBP) signage and Personal Protective Equipment (PPE) for residents with indwelling medical devices and those in COVID-19 isolation. Observations showed missing PPE and inadequate signage, with staff untrained on EBP requirements. The Director of Nursing and Administrator acknowledged the deficiencies, citing delays and lack of attention to infection control measures.
A facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including Diabetes Mellitus and Gout. The care plan lacked interventions and goals for several diagnoses, despite the resident receiving various medications. The DON confirmed that care plans should address all diagnoses and be updated with significant changes, but this was not done, potentially risking the resident's care.
A resident's care plan was not updated following a fall that resulted in a clavicle fracture and a physician's order for a figure eight binder. Despite the resident's complex medical history, the care plan remained unchanged, which was acknowledged by the DON as a failure to meet the facility's policy for timely updates after significant changes in condition.
A resident with an indwelling urinary catheter was at risk for infection due to the facility's failure to secure the urine collection bag off the floor, contrary to policy. Despite the resident's awareness of catheter care, staff interviews revealed non-compliance with infection control training, as the bag was observed lying on the floor. The DON and ADON, responsible for training, could not explain the oversight.
The facility failed to post 'Oxygen in Use' signs for three residents using oxygen, as required by policy. Observations revealed that these residents, who had varying levels of cognitive impairment, were using oxygen without the necessary signage on their doors. The ADON and DON acknowledged the oversight and the importance of such signage in meeting care needs.
Care Plans Lacked Measurable Goals and Time Frames
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and time frames for 4 of 16 residents reviewed. For Resident #3, who had diagnoses including paranoid schizophrenia, schizoaffective disorder, high blood pressure, repeated falls, and pain, the care plan dated 12/27/2025 included the focus "Victim of emotional abuse by intimate partner" with the goal "No known psychological abuse," but the goal was not measurable. Resident #4, who had anxiety, heart failure, high blood pressure, obesity, and a BIMS score of 11 indicating moderate cognitive impairment, had a care plan dated 05/09/2026 with the focus "Resident will maintain current weight and feel better about diet and meals provided" and the goal "Residents health will be maintained," which was also not measurable. Resident #6 had diagnoses including anxiety, Alzheimer's disease, chronic pain, and high blood pressure, and a BIMS score of 3 indicating severe cognitive impairment. Her care plan dated 04/13/2026 included goals such as "Resident will have less constipation," "Resident will feel comfortable with Hospice," "Resident will be able to eat more food easier," and "Medication will be administered for agitation and dementia outbreaks," none of which were measurable. Resident #43, who had anxiety, depression, dementia, and a BIMS score of 3 indicating severe cognitive impairment, had a care plan dated 03/22/2026 with the focus "Psychiatric evaluation for hollering out every 2-3min" and the goal "Resident will have less hollering out throughout the review period," along with interventions stating the resident would have less outbursts and would push the call light instead of screaming or hollering; these goals and interventions were not measurable. During interview, the DON stated goals should be measurable and that measuring goals allowed staff and other disciplines to see progress and evaluate the effectiveness of interventions.
Indwelling Catheters Lacked Physician Orders and Documented Monitoring
Penalty
Summary
The facility failed to ensure that indwelling catheters were used only with valid physician orders and that catheter monitoring and maintenance were documented for three residents. Resident #25 was admitted with diagnoses including upper respiratory infection, femur fracture, and neuromuscular dysfunction of the bladder. Her MDS showed moderate cognitive impairment and identified an indwelling catheter, and her care plan included monthly catheter changes, intake and output monitoring, and monitoring for signs and symptoms of UTI. However, the electronic record contained no physician order for the catheter, no order for monitoring output or UTI symptoms, and no evidence of catheter care or monitoring documentation. During observation, she was in bed with the catheter bag hanging and urine draining clear yellow. Resident #12 was admitted with diagnoses including neuromuscular dysfunction of the bladder and prostatic hyperplasia. His MDS showed moderate cognitive impairment and identified an indwelling catheter. His care plan described a suprapubic catheter and included monthly changes, bedside drainage, positioning of the bag and tubing below bladder level, intake and output monitoring, and monitoring for UTI signs and symptoms. The electronic physician orders did not include an order for an indwelling catheter, monitoring output, monitoring for UTI symptoms, or catheter care, and the record contained no evidence of catheter care or monitoring. During observation, he was in an electric wheelchair with a catheter bag full of clear yellow urine and no privacy bag. Resident #49 was admitted with diagnoses including urinary retention, COPD, and neuromuscular dysfunction of the bladder. His MDS showed moderate cognitive impairment and identified an indwelling catheter. His care plan stated he had a 16g indwelling Foley catheter attached to bedside drainage and also referenced a suprapubic catheter, with instructions to position the bag and tubing below bladder level and away from the room door. The only physician order found was to change the catheter once a month, with no order for a Foley catheter, monitoring, or catheter care. The record contained no evidence of Foley catheter care or monitoring, and during observation he was resting in bed with the Foley hanging, tubing unkinked, and clear yellow urine draining.
Respiratory Equipment Not Properly Stored or Maintained
Penalty
Summary
The facility failed to ensure that respiratory care was provided consistent with professional standards of practice, the comprehensive care plan, and resident preferences for 3 residents reviewed for respiratory care. Resident #25 had diagnoses including an upper respiratory infection and femur fracture, a BIMS score of 12 indicating moderate cognitive impairment, and documentation showing oxygen use and an order for Ipratropium bromide/Albuterol sulfate inhalation four times daily plus oxygen at 2-4 LPM via nasal cannula as needed for shortness of breath. During observation, the resident was resting in bed with oxygen at 3 LPM via nasal cannula, the tubing had no date, the nebulizer was on the nightstand with no date and not in a bag, and there was no oxygen sign outside the door. The resident stated she had worn oxygen for years and usually removed the nebulizer mask when treatment finished and laid it on the table. Resident #5 had diagnoses including wheezing, upper respiratory infection, and shortness of breath, with a BIMS score of 05 indicating severe cognitive impairment. The care plan directed staff to change O2 tubing weekly and as needed if it fell on the floor, keep O2 or HHN equipment in a plastic bag when not in use, and administer medications as ordered. The physician order stated the nebulizer tubing should be checked and dated within 1 week and bagged when not in use. During observation, the resident’s nebulizer was on the bedside table, dated 04/24/2026, and not bagged. Resident #49 had diagnoses including COPD, urinary retention, and neuromuscular dysfunction of the bladder, with a BIMS score of 09 indicating moderate cognitive impairment and documentation showing oxygen use. The care plan included albuterol nebulizer treatment and monitoring for abnormal breathing patterns. During observation, the resident was resting in bed with oxygen in place, the nasal cannula had no date, and the nebulizer mask was on the nightstand with no date and not in a bag. During interview, an LVN stated nebulizers were to be changed weekly and kept in a plastic bag when not in use, and that failing to keep the nebulizer and tubing clean, covered, and changed out could result in infection. The DON stated her expectation was to keep nebulizers covered when not in use and clean them after each treatment, and said she was unaware the LVNs were not doing that. The ADON stated all nebulizers should be cleaned after use and placed in a plastic bag, changed weekly and dated, and that not bagging them could lead to infection. Facility policies stated nebulizers are to be cleaned after each treatment and placed in a storage compartment, and that oxygen in use signage shall be posted and respiratory equipment cleaned and disinfected per manufacturer recommendations and facility infection control policies.
Medication Administration Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, with a documented rate of 10.34 percent for 2 of 4 residents reviewed for medication administration. The deficiency involved Resident #34 and Resident #49, and the report states that this failure placed residents at risk of incorrect doses of medications and optimal therapeutic response. Resident #34 had diagnoses of asthma and chronic obstructive pulmonary disease. Physician orders included Brovana inhalation nebulization solution 15 mcg/2 mL and Budesonide inhalation suspension 0.5 mg/2 mL, both ordered twice daily via nebulizer in the room. During observation, Resident #34 was seen receiving a nebulizer treatment in her room, and she stated that nurses left her nebulizer medication in the room for her to finish and that she turned the machine off when done. On a later observation, an LVN administered the Brovana and Budesonide treatments, left one vial of medication in the room for the resident to administer later, did not remain in the room to verify completion, and documented both medications as given on the eMAR. Resident #49 had diagnoses of chronic atrial fibrillation and acute upper respiratory infection. The physician order for Eliquis 5 mg daily was present on the MAR, but the medication was not in the cart and was not given as ordered. The LVN stated she thought the medication had been discontinued while the resident was in the hospital. During the same observation, the LVN also administered ipratropium bromide/albuterol sulfate via nebulizer, returned to the cart, documented the medication as completed, and left the medication in the room without waiting to see that it was taken. The DON and LVN both stated that medications should be given as ordered and that nurses should remain with residents until nebulizer treatments are completed; the facility policy also stated that medications are administered according to physician orders and that the medication is initialed by the nurse after it is taken.
Infection Control Lapses During Shared Equipment Use and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent communicable diseases and infections for 3 residents reviewed for infection control. During an observation on 05/20/2026 at 9:09 AM, LVN B obtained a blood pressure reading with a wrist cuff and administered a nebulizer treatment to Resident #34 without sanitizing the blood pressure cuff prior to use and without performing hand hygiene before or after touching the resident. Resident #34 was a female with diagnoses of asthma and chronic obstructive pulmonary disease, and her quarterly MDS documented a BIMS score of 10, indicating moderate cognitive impairment. Resident #37 was a female with insulin dependent diabetes. During an observation and interview on 05/19/2026, LVN B performed a fingerstick blood sugar using a shared glucometer and cleaned the device before and after use with an alcohol wipe. He stated he used alcohol wipes and another disinfectant wipe with a purple top, but said the facility was low on disinfectant wipes and there were none on his cart, so he used the alcohol pad to clean the glucometer before and after obtaining the FSBS. Resident #49 was a female with diagnoses of chronic atrial fibrillation and acute upper respiratory infection. During an observation on 05/20/2026 at 8:00 a.m., LVN B obtained a blood pressure reading with a wrist cuff and administered a nebulizer treatment to Resident #49 without sanitizing the blood pressure cuff prior to use and without performing hand hygiene before or after touching the resident. In interview, LVN B stated he should have sanitized the blood pressure cuff before each use and should have performed hand hygiene after touching residents, and the DON stated it was her expectation that staff perform hand hygiene and use the purple top disinfectant wipe provided by the facility.
Ripped and Stained Hallway Carpet
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 of 4 hallways reviewed. During an observation on 05/20/2026 at 11:00 AM, the carpet in the back hallway was observed to be ripped and soiled with visible stains. The deficiency was cited under F921/N4888 for the physical environment. During interview, the maintenance director stated on 05/20/2026 that the tear had been in the carpet for a long time and that the carpet stains remained even after they were cleaned. The DON stated on 05/20/2026 at 11:40 AM that it was her expectation for carpets to be intact and clean, and she stated the torn carpet could be an accident hazard for residents, staff, and visitors. The Administrator stated on 05/21/2026 at 9:15 AM that potential negative outcomes of the ripped carpet could be a fall hazard and that the carpet needed to be repaired or replaced. The facility policy titled Clean and Safe Environment Policy and Procedure stated that hazards shall be identified and corrected immediately and that the environment shall remain free from trip and fall hazards.
Inaccurate MDS Skin Assessment Documentation
Penalty
Summary
Resident #43’s quarterly MDS assessment did not accurately reflect her skin status. The resident was a female admitted to the facility with diagnoses including a closed fracture of the left femur, dementia, anxiety, major depressive disorder, and rheumatoid arthritis. Her Medicare 5-day MDS documented severe cognitive impairment with a BIMS score of 4 out of 15, and Section M indicated that she had one or more unhealed pressure ulcers/injuries, including one unstageable injury due to a non-removable dressing/device and one unstageable injury due to slough and/or eschar. Record review did not show a physician order or diagnosis for a pressure ulcer. The physician orders dated 03/12/2026 addressed skin tears/abrasions only. Skin assessments documented redness from sutures and pressure from lying on her side due to right hip surgery, then noted skin issues to the bottom that were resolving, and later noted no new areas after an unwitnessed fall. The comprehensive care plan did not address current skin issues or risk for skin issues. During interviews, the DON stated the wound claimed on the MDS was most likely selected in error, and the MDS Coordinator stated the DON was responsible for entering Section M data and monitoring MDS accuracy.
PASRR screening not updated for resident with mental illness
Penalty
Summary
The facility failed to ensure that all PASARR Level I screening residents diagnosed with mental illness were provided a PASARR Level II screening for 1 of 1 residents reviewed for PASARR Level I screenings. Resident #16’s PASRR Level One Screening Form, dated 02/19/2026, stated she did not have a primary diagnosis of dementia and was negative for mental illness, intellectual disability, or developmental disability, and the form had not been updated. Her care plan, dated 03/12/2026, showed she received antidepressant medication, and her face sheet, dated 05/21/2026, identified her as a [AGE]-year-old female admitted to the facility on [DATE]. Resident #16’s physician orders, dated 05/21/2026, included Zoloft 75 mg by mouth daily related to Major Depressive Disorder, single episode. The DON stated she was not familiar with the PASRR process and said the ADON had been completing PASRRs in February 2026 when Resident #16 was admitted from another facility. The MDS Coordinator stated that, given Resident #16’s diagnosis of schizoaffective disorder bipolar type, a new Level I reflecting mental illness should have been completed, and said she did not complete the form herself. The facility policy stated that residents requiring PASRR screening must have the appropriate documentation completed prior to admission and that PASRR positive residents must have a Level II evaluation when required.
Baseline Care Plan Not Completed for Catheter Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #13, who was admitted with diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, and benign prostatic hypertrophy. Record review showed the resident had a suprapubic catheter present at the time of admission, but there was no baseline care plan initiated within the required 48-hour time frame to address that catheter. The catheter was not added to the resident’s care plan until 03/21/2026. During interview, the DON stated she was responsible for completing baseline care plans and said she was not aware of the 48-hour requirement, while the administrator stated the DON was responsible for completing baseline care plans and that they were expected to be completed within 48 hours of admission and include all immediate care needs. The facility policy stated that a person-centered baseline care plan would be developed within 48 hours of admission and include instructions needed to provide effective and person-centered care that meets the resident’s immediate needs and preferences.
Care Plan Not Reviewed and Revised by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for one resident. Resident #43, an elderly female admitted to the facility with diagnoses including anxiety, Alzheimer's disease, high blood pressure, neurogenic bladder dysfunction, and chronic pain, had a comprehensive care plan dated 03/18/2026 that included a focus on risk for impaired urinary elimination related to cognitive inability to urinate and placement of a catheter. The care plan intervention stated to insert a 16fr Foley catheter per physician orders and keep it in place. The resident's quarterly MDS showed severe cognitive impairment with a BIMS score of 3 out of 15, and the bladder and bowel section indicated no appliance was present. Physician orders dated 03/21/2026 directed placement of a 16fr Foley catheter for abdominal distention, collection of urine, and leaving the catheter in place if more than 600 ml was drained; 1500 ml was drained and the catheter was to remain until the doctor stated otherwise. During interview, the DON stated care plans should be reviewed frequently and revised with changes in resident status, and that multiple disciplines were involved in care planning, but she also stated she had not had formal care plan training when hired and learned by reviewing other care plans.
Unnecessary Antianxiety Medications Without Proper Diagnosis or Monitoring
Penalty
Summary
The facility failed to ensure Resident #25’s drug regimen was free from unnecessary medications and lacked adequate monitoring for antianxiety drugs. Resident #25 was a female admitted with diagnoses including an upper respiratory infection and femur fracture, and her record showed no diagnosis related to anxiety. Her Significant Change MDS dated 05/13/2026 documented a BIMS score of 12, indicating moderate cognitive impairment, and also noted the use of antianxiety medications. However, her care plan revised on 05/19/2026 contained no evidence of anxiety or antianxiety medications. Record review showed orders for Diazepam 10 mg/ml gel, to be applied to the inner wrist every 4 hours as needed for prophylaxis, with no diagnosis entered, and Clonazepam 0.25 mg ODT at bedtime for prophylaxis related to cognitive communication deficit, as well as Clonazepam 0.25 mg ODT every 8 hours as needed for prophylaxis with no diagnosis entered. There were no orders to monitor for side effects related to Clonazepam or Diazepam. The MAR showed Clonazepam was administered multiple times between 05/14/2026 and 05/22/2026, while Diazepam was not administered. During interviews, the DON stated psychotropic medications should have proper diagnosis and indications and that side-effect monitoring orders should have been in place, and the ADON stated prophylaxis was not an appropriate diagnosis or indication for an antianxiety medication.
Improper Wheelchair Securement During Van Transport Leads to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents during van transportation. A female resident with a history of left femur fracture, anxiety, and depression, and with moderate cognitive impairment (BIMS score of 10), required substantial/maximal assistance for sit-to-stand and car transfers, and walking was not attempted due to her medical condition. Her care plan identified limited physical mobility related to a fractured hip and indicated she required assistance by one staff to walk. Despite these needs, she was transported in the facility van in a wheelchair and was not properly secured using the required 5‑seatbelt restraint system. On the day of the incident, the CNA assigned to transport the resident took her to what turned out to be the wrong orthopedic office and then returned her to the van to go to the correct location. The CNA reported pushing the resident up the wheelchair ramp, locking the wheelchair wheels, and fastening the two rear seatbelts that secured the wheelchair to the floor. She then moved to the front of the van and stated she fastened the remaining three belts, which included two front straps securing the wheelchair to the floor and a lap belt over the resident’s lap. While driving, the van began to overheat in a construction zone, and as the CNA slowed down after seeing a yellow light, she heard a noise and saw that the resident’s wheelchair had flipped backwards, with the resident on the floor at the back of the van. The CNA reported that the resident’s front safety belt was unclamped and that she had to unbuckle the lap belt to move the wheelchair to reach the resident. The resident was transported by EMS to the hospital, where records documented an acute subdural hematoma and a cervical fracture following a fall from a wheelchair while being transported in a van. When interviewed in the hospital, the resident, who was wearing a cervical collar, recalled that the CNA hit the brakes and the wheelchair flipped; she stated she did not know if all straps were fastened and that she had not unfastened any safety belts herself. Facility staff later tested the van’s 5‑belt restraint system with an empty wheelchair and found that when all four floor straps and the lap belt were secured, the wheelchair could not be flipped, and even with the lap belt removed or one front strap unfastened, the chair still would not budge. The wheelchair only flipped backwards when both front straps were unfastened, leading the Administrator to state that the only way the chair could have flipped was if the two front safety belts were not fastened. Further review revealed systemic failures related to transportation safety. The Office Manager initially stated that transportation aides were trained and had demonstrated competency in wheelchair securement and safety belt placement before transporting residents, but later acknowledged there was no evidence of such training or competencies for the CNA involved or for the current transportation aide. Personnel file reviews for both aides showed no documentation of training related to transportation safety or wheelchair securement, despite a facility policy requiring that staff responsible for transportation be trained and demonstrate competency in wheelchair securement procedures, with competency documented prior to independent transport duties. Additionally, the Administrator reported that the van had no maintenance logs, no records of routine safety checks, and was not inspected routinely, even though the van had recently overheated during the incident. These inactions and lack of documented training, competency validation, and vehicle safety oversight contributed to the improper securement of the resident’s wheelchair and the resulting accident and injuries.
Removal Plan
- Ceased all resident transportation via van and wheelchair transfers requiring safety restraint usage; ceased all other facility transports unless staff were trained by nursing staff trained in safe transport and proper safety restraints.
- Required verification that safety restraints are applied correctly and staff supervision is present prior to movement; implemented and used a transport check sheet/checklist located at the nurses station; trained all transport staff on proper use of the transport checklist.
- Required that no resident is transported or transferred using the facility van until safety checks are completed and documented; completed staff in-service/sign-off for training and notification of safety checks.
- Required licensed nursing staff trained in van safety transportation to provide supervisory oversight for all transfers involving wheelchairs.
- Completed a 100% audit of all residents transported outside the facility and identified residents likely to be affected; updated care plans and implemented additional supervision for any resident identified as high risk.
- Established a standardized transportation and wheelchair restraint checklist process; implemented a Skilled Nursing Facility Transportation Safety Checklist and Wheelchair Van Restraint Safety Checklist for all nursing staff.
- Provided staff education and competency validation (return demonstration) for all staff involved in resident transfers/transportation (nurses, CNAs, drivers) on wheelchair brake locking, proper restraint use, and supervision requirements; prohibited staff from transport duties until competency is demonstrated.
- Trained all nurses on proper procedure for transports with a wheelchair upon hire and annually.
- Updated care plans to clearly identify supervision and transport requirements.
- Created/revised transportation and accident prevention policy to include training requirements, safety checklist, transportation safety, and restraint checklist.
- Adopted a zero tolerance policy for noncompliance with transportation safety procedures; made in-service mandatory for current staff and before starting first shift for new staff.
- Implemented supervisory sign-off requirement for all external transports.
- Implemented weekly preventive maintenance checks for wheelchairs and van restraints.
- Implemented monitoring/oversight: DON/designee conducts daily audits of transportation documentation, then weekly; reviews findings during QAPI meetings; initiates immediate corrective action for any noncompliance.
- Incorporated transportation safety training into new hire orientation and required annual competency validation for all applicable staff; continued ongoing QAPI monitoring to ensure sustained compliance.
- Established a standardized maintenance checklist to be reported monthly in QAPI meetings with the IDT.
Failure to Ensure Nurse Aide Certification and Competency Within Required Timeframe
Penalty
Summary
The facility failed to ensure that nurse aides working more than four months on a full-time basis were trained, competent, and had completed a state-approved training and competency evaluation program, as required. Record review showed that multiple nurse aides (NA-F, NA-I, NA-K, and NA-L) had been hired and working full time without obtaining CNA certification within four months of hire. Employability status checks for these aides, conducted months after their hire dates, documented that they had no CNA certification. The facility’s own job description for nurse aides required that they either have completed a state-approved training and competency evaluation program and hold a current state certificate, or be enrolled in an approved competency training program and perform only services for which they had demonstrated competence. During interviews, the Office Manager acknowledged that nurse aides were required to be certified within four months of hire and stated she was aware that many aides were past that deadline. She reported the facility was waiting for approval to conduct a nurse aide class. The Administrator also acknowledged awareness that many nurse aides were beyond the four-month deadline for certification, explaining that it was very hard to get people certified and difficult to find CNAs in a rural area. She stated the facility had just become certified to offer a CNA class but was uncertain whether the class could be held due to an Immediate Jeopardy that had been called and expressed uncertainty about how to proceed. The report notes that this failure could place residents at risk for receiving inappropriate care from individuals whose skill level was not known.
Failure to Maintain and Routinely Inspect Facility Van
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition by not ensuring the facility van was properly maintained. During an interview, the Administrator reported there were no maintenance logs or routine safety or maintenance checks for the van, and confirmed the van was not inspected routinely. In a separate interview, a CNA stated that while transporting a resident, the van began to overheat while she was in a construction zone with no available exit. She reported calling the maintenance staff by phone and then noticing a yellow light on the dashboard as she began to slow down. The report states that this failure could place residents at risk of injury due to not being supervised and at risk of serious bodily harm, physical impairment, hospitalization, or death.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage and labeling of food items in the kitchen's dry storage area. During an observation, it was noted that several food items, including a bag of toasted oats, cornbread mix, and various plastic containers of cereals and dry goods, were not properly sealed or labeled with necessary information such as open dates, expiration dates, or use-by dates. This lack of proper labeling and sealing could potentially expose residents to foodborne illnesses. Interviews with dietary staff revealed that there was an expectation for all food items to be labeled with the date they arrived, the date they were opened, and the expiration date. However, the dietary cook was unaware of why the labeling was not done, and the Dietary Manager (DM) admitted that the failure occurred due to her absence from work due to illness, as she was responsible for labeling and dating the products. The Assistant Dietary Manager (ADM) also confirmed that the failure was due to the DM's absence and acknowledged that the kitchen staff did not follow the facility's policy on food storage and labeling, which could lead to foodborne illnesses if not addressed.
Inaccurate Hospice Orders for Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding the resident's hospice care orders. The resident, who had severe cognitive impairment and was receiving hospice care, was discharged from one hospice provider and admitted to another. However, the facility's records did not reflect this change, as there was no order to discharge from the initial hospice or to admit to the new hospice. This oversight was identified during a review of the resident's physician orders, which inaccurately indicated the resident was still under the care of the initial hospice provider. During interviews, the Director of Nursing (DON) acknowledged that the resident's orders should have been updated to reflect the current hospice care provider. The DON explained that the responsibility for entering and monitoring orders fell to the charge nurse, herself, and the Assistant Director of Nursing (ADON). The failure to update the orders was attributed to staff oversight, which could have led to potential delays in care due to contacting the wrong hospice provider. The facility was unable to provide requested policies on maintaining accurate records at the time of the exit conference.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) signage and Personal Protective Equipment (PPE) availability for several residents. Specifically, residents with indwelling medical devices such as urinary catheters and those with open wounds did not have the necessary EBP signage or PPE available for staff providing care. This deficiency was observed in residents with conditions requiring additional precautions, such as suprapubic urinary catheters and open wounds, yet there were no orders for EBP or appropriate signage to guide staff in infection control measures. Additionally, the facility did not ensure that PPE was readily available for residents placed in isolation due to positive COVID-19 tests. Observations revealed that isolation rooms lacked PPE outside the doors, and signage did not provide adequate instructions for staff or visitors. The Director of Nursing (DON) acknowledged the absence of PPE and signage, attributing it to delays in implementation. Staff interviews further revealed a lack of training on EBP, with some staff unaware of the requirements and procedures for infection control. The facility's policies on COVID-19 and EBP were not effectively implemented, as evidenced by the lack of PPE availability and inadequate staff training. The Administrator admitted to being aware of the EBP requirement but cited being too busy to address it. The DON and Assistant Director of Nursing (ADON) were responsible for infection control training, yet there was a clear gap in compliance and understanding among staff. This failure to implement an effective infection prevention and control program could lead to cross-contamination and increased risk of infection among residents.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive and person-centered care plan for a resident with multiple medical conditions, including Type 1 Diabetes Mellitus and Gout. The care plan did not include problems, interventions, or goals for several diagnoses such as Paroxysmal Atrial Fibrillation, Obesity, and Osteoarthritis, among others. This oversight was identified during a review of the resident's comprehensive care plan and was confirmed by the Director of Nursing (DON), who acknowledged that care plans should address all diagnoses and be updated with any significant changes. The resident, a cognitively intact female, was admitted with a range of diagnoses including Hypothyroidism, Hypertension, and Shortness of Breath, and was receiving medications such as Metoprolol Tartrate, Losartan, and Metformin HCL. Despite these conditions and treatments, the care plan lacked measurable objectives and timeframes to address the resident's needs. The facility's policy mandates that a comprehensive care plan be completed within seven days after the initial MDS assessment, but this requirement was not met, potentially placing the resident at risk of not receiving necessary care.
Failure to Update Care Plan After Resident's Fall and Injury
Penalty
Summary
The facility failed to revise the care plan for a resident following a significant change in their medical condition. Specifically, the care plan was not updated to include a recent fall resulting in a left distal clavicle fracture and the subsequent physician's order for a figure eight binder (clavicle support brace). This oversight was identified during a review of the resident's care plan, which had not been updated since its initiation, despite the resident's injury and new medical orders. The resident in question is an elderly male with a history of multiple medical conditions, including nonrheumatic aortic valve stenosis, congestive heart failure, nicotine dependence, epilepsy, hypertension, and chronic obstructive pulmonary disease. The Director of Nursing (DON) acknowledged that care plans should be updated with any significant change in a resident's condition and at least quarterly. However, the DON was unaware of the reason for the failure to update the care plan, which could potentially impact the resident's care.
Failure to Secure Urinary Catheter Collection Bag
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with an indwelling urinary catheter, specifically in preventing urinary tract infections. The deficiency was identified when the resident's urine collection bag was observed lying on the floor, which is against the facility's policy that mandates catheter tubing and drainage bags be kept off the floor. This oversight was noted during an observation and confirmed through interviews with staff, who acknowledged that the collection bag should be hung from the bed frame to minimize infection risk. The resident involved was a female with multiple medical diagnoses, including anxiety, obesity, high blood pressure, heart disease, and a history of cervical cancer, among others. Despite the resident's moderate cognitive impairment, she was aware of the catheter care routine and reported no issues with the catheter. However, staff interviews revealed a lack of compliance with infection control training, as the urine collection bag was not properly secured. The Director of Nursing and Assistant Director of Nursing were responsible for training, yet they could not provide a satisfactory explanation for the failure to adhere to the facility's catheter care policy.
Failure to Post Oxygen Use Signage for Residents
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care were provided with appropriate signage indicating oxygen use, as per professional standards and facility policy. Specifically, three residents who were observed using oxygen did not have 'Oxygen in Use' signs posted on their doors. This oversight was noted during observations and interviews, where it was found that the absence of signage could lead to staff and visitors being unaware of the residents' oxygen use. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged the expectation for such signage and admitted that the failure to post signs was due to staff oversight. Resident #4, a male with severe cognitive impairment, was observed using oxygen without the required signage. Similarly, Resident #13, a female with moderate cognitive impairment, and Resident #17, also with moderate cognitive impairment, were both observed using oxygen without the necessary door signage. The facility's policy, dated February 2024, mandates that 'Oxygen in Use' signs must be placed in resident rooms as needed, highlighting a clear deviation from established protocols. The ADON and DON both recognized the importance of these signs in ensuring that care needs are met and acknowledged their responsibility in monitoring and ensuring compliance with this policy.
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 9 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ranger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Woodlands | 10.8 mi | ★★★★★ | 0 | 0 |
| Avir At Cisco | 19.1 mi | ★★★★★ | 1 | 0 |
| Villa Haven Health And Rehabilitation Center | 22.6 mi | ★★★★★ | 8 | 0 |
| De Leon Nursing And Rehabilitation | 26.3 mi | ★★★★★ | 5 | 0 |
| Rising Star Nursing Center | 31 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Premier Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.