Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vista Grande Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff failed to follow hand hygiene practices during meal service in the kitchen and dining room. A cook and a dietary aide handled refrigerators, cabinets, food, and equipment while changing gloves or continuing with the same gloves without washing hands, and a resident assistant and CNA assisted two residents at one table and two more at other tables while touching wheelchairs, utensils, and beverage cups without hand hygiene. Interviews confirmed staff knew hand hygiene was required before food handling, after glove removal, and after touching potentially contaminated items.
Failure to document rationale for pharmacist MRR disagreements: A physician repeatedly disagreed with pharmacist recommendations for several residents, including renal dose reductions, Benadryl dosing clarification, antidepressant and antihypertensive dose changes, and insulin titration, but did not document the clinical rationale in the chart or on the review forms. The residents had significant diagnoses such as dementia, CKD, diabetes, HF, AFib, PTSD, depression, and recent falls, and interviews confirmed the physician was expected to explain why the recommendations were not accepted.
The facility failed to maintain infection control practices when staff used the same sit-to-stand lift for multiple residents without disinfecting it between uses and did not perform hand hygiene after resident contact. CNAs also returned blood pressure cuffs to medication carts without cleaning them after use on residents. In addition, a housekeeper repeatedly donned and doffed gloves while cleaning resident rooms without hand hygiene, including when moving between rooms and handling cleaning tasks.
Failure to Protect a Resident from Sexual Abuse: A resident with intact cognition and multiple chronic conditions was sexually abused by another resident in the dining room when he touched her breast over her clothing after summoning her to his table. The event was substantiated by video and witness statements, but the victim’s record showed no added care plan interventions, no progress notes, and no documented monitoring for changes from baseline. The other resident had dementia and a known history of inappropriate touching, with existing interventions that were not effective in preventing the incident.
Failure to Report Abuse Allegations to Required Authorities: The facility did not report two allegations of sexual abuse to required authorities. One incident involved two residents, including a resident with dementia and severe cognitive impairment, and another involved a resident who was verbally sexually abusive to a CNA and then to another resident. Records showed no documentation that the ombudsman was notified for one incident, and no documentation that the State Agency or ombudsman were notified for the other; the NHA stated she did not know allegations had to be reported to the ombudsman.
Failure to investigate allegation of sexual abuse: Staff documented that a resident with a history of inappropriate sexual comments made sexually abusive remarks to a female CNA and another resident, but the facility could not provide evidence of a timely investigation. The resident involved had dementia and a behavior care plan addressing inappropriate touching and lewd comments, while the other resident had dementia and other significant medical conditions. Leadership later stated the incident was not investigated until well after staff were aware of the allegation.
Improper lien placed on resident property for unpaid charges: The facility placed a deed of trust/lien on a resident’s shared property for about $28,000 in unpaid care costs while Medicaid processing was delayed. The resident had severe cognitive impairment, and the POA signed the note that also included interest, late fees, and collection costs. Staff said the lien was used to cover back pay, but federal law prohibits conditioning admission or continued stay on a third-party guarantee or similar financial liability.
A resident with dementia, osteoporosis, and a history of falls sustained a fall and later was found to have a displaced left femoral neck fracture. An LPN completed the immediate post-fall assessment, but there was no documentation that an RN performed the required head-to-toe assessment before the resident was placed in a recliner for observation. The DON, who was an RN, did not visually assess the resident until hours later, and staff later noted pain, prompting EMS transfer to the hospital.
Failure to Assist Resident With Hearing Aids: A resident with dementia, severe cognitive impairment, and dependence for ADLs was repeatedly observed without hearing aids in place in multiple settings, including the common area, room, dining room, and bed. The resident’s representative said she had to insert the hearing aids during visits, while CNA/CNA-Med staff and the DON stated staff were expected to assist with hearing aids daily.
The facility failed to provide consistent behavioral monitoring and effective psychosocial interventions for two residents with mental health and behavior concerns. One resident with PTSD, depression, and dementia had elevated PHQ-9 findings and behavior-monitoring orders, but the record lacked documentation of follow-up or whether interventions such as reassurance, active listening, and a calm environment were effective. Another resident with dementia and agitation continued to display inappropriate touching and lewd sexual comments toward staff, visitors, and other residents despite care plan interventions, behavioral orders, and a behavioral contract, with documentation showing the interventions were not consistently offered or shown to be effective.
Hospice documentation, care coordination, and care planning were incomplete for two residents. Hospice notes were not available in the EMR, the care plans did not clearly divide responsibilities between facility staff and the hospice team, and the DON and NHA stated there was no designated hospice coordinator. One resident had hospice-managed wound care with no hospice orders in the chart and no hospice interventions in the care plan, while another resident’s hospice plan lacked facility-hospice role delineation.
A resident with multiple risk factors for pressure injuries did not consistently receive ordered interventions such as a pressure redistribution mattress and heel protectors, leading to the development of a new heel wound. Documentation and assessment of the wound were incomplete, and staff interviews confirmed lapses in both the implementation of preventive measures and ongoing evaluation of the resident's condition.
A resident with severe cognitive impairments and a history of falls experienced multiple incidents due to inadequate supervision and delayed interventions. Despite known risk factors, the facility failed to update care plans promptly and did not secure the environment, leading to a serious injury when the resident self-transferred in an unsecured shower room.
A resident with severe cognitive impairments was admitted to the hospital with bilateral hip fractures and a hematoma, but the LTC facility failed to report the injury of unknown origin to the State Agency within the required timeframe. The incident occurred, but the facility did not report it until 24 days later, contrary to their policy. The NHA did not save investigation notes, and the DON acknowledged the reporting failure.
A resident with severe cognitive impairments sustained bilateral hip fractures and a hematoma, but the facility failed to conduct a thorough investigation as required by their policy. The investigation lacked staff and resident interviews, and inconsistencies were found in staff accounts. The facility did not document or investigate a bruise of unknown origin reported by the hospital, leading to a deficiency in addressing the resident's injuries.
The facility failed to ensure a safe environment for two residents, leading to multiple falls for one resident due to inconsistent implementation and follow-up of fall interventions. Despite having a care plan, the facility did not consistently follow it, resulting in repeated falls and a major injury requiring hospitalization.
The facility failed to ensure that three residents had the right to formulate an advance directive. Specifically, the facility did not provide written advance directive forms or discussions to the residents, did not re-evaluate their decision-making capacity periodically, and did not re-evaluate if their advance directives were still in line with their wishes.
The facility failed to test residents with upper respiratory infections for COVID-19 and did not vaccinate residents who had consented to receive the COVID-19 vaccine. This lapse in infection control practices was acknowledged by the DON and the CC during interviews.
The facility failed to ensure CNAs received at least 12 hours of annual in-service training, including dementia management and abuse prevention. A review of training records showed that none of the five randomly selected CNAs met the required training hours. Interviews revealed a lack of awareness and proper tracking of training hours among the staff.
The facility failed to ensure care for residents was provided in a manner that maintained or enhanced their dignity and respect. Staff did not acknowledge or respond to a resident when she spoke, failed to treat another resident with respect during meals, and yelled at or moved a third resident hastily. Multiple residents reported being yelled at during meals, and observations confirmed these actions, which were not in line with the facility's dignity policy.
The facility failed to obtain informed consents for the use of psychotropic medications for two residents. One resident was prescribed Trazodone without documented consent, and another was prescribed Seroquel without documented consent until it was obtained during the survey. The facility's policy requires consents prior to administration, but documentation was incomplete.
The facility failed to ensure proper management of personal funds accounts for four residents. Specifically, there were no signed written authorizations for one resident, and personal funds withdrawal sheets lacked signatures for four residents. The facility's policy required written authorization and signatures on receipts, but these were not obtained, leading to unauthorized management and withdrawals of residents' funds.
The facility failed to notify two Medicaid-funded residents or their legal representatives when their personal funds accounts approached the Medicaid eligibility resource limit. One resident's account exceeded the limit, and another's was close to it, with no documentation of required notifications.
The facility failed to protect a resident from potential sexual abuse by another resident. The incident, captured on video, lasted over ten minutes before staff intervened. The resident with a history of inappropriate behaviors was placed on 15-minute checks, but the facility did not implement sufficient preventive measures or document staff training and interviews.
The facility failed to ensure that residents were free from physical restraints unless needed for medical treatment. Specifically, the facility did not evaluate a resident for the use of a restraint, obtain a signed consent, or secure a physician's order for the restraint. Additionally, the facility did not complete quarterly safety risk assessments, document less restrictive measures attempted, or conduct trial periods without the restraints for two residents.
The facility failed to provide adequate restorative and occupational therapy services to two residents with limited range of motion, leading to deficiencies in their care. Both residents did not receive the required therapy sessions as per their care plans, and staff interviews confirmed inconsistencies and challenges in service delivery.
A resident with severe cognitive impairment and multiple diagnoses, including COPD and hypoxemia, was frequently observed without his oxygen cannula in place. Staff did not consistently remind or assist the resident to wear his oxygen, and the care plan lacked clear directives on oxygen use. The DON and NHA acknowledged that the resident's oxygen needs and refusals had not been adequately addressed.
The facility failed to ensure proper storage and monitoring of medications, including expired medications in storage carts and incomplete temperature logs for refrigerated medications. Staff interviews confirmed these deficiencies and highlighted a recent process change that contributed to missed documentation.
Hand Hygiene Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served under sanitary conditions in the main kitchen because staff did not follow appropriate hand hygiene practices during meal service. During a continuous observation of lunch meal service in the kitchen, a cook removed gloves, placed a container in the refrigerator, donned new gloves, and then plated resident meals without washing hands after touching the refrigerator door handle. A dietary aide also used gloved hands to open a cabinet, removed a hamburger patty from a bag and placed it directly on the grill without changing gloves or performing hand hygiene after touching the cabinet handle. Additional kitchen observations showed the dietary aide opening the refrigerator, retrieving hot dogs, and putting on new gloves without performing hand hygiene first. The aide then touched a microwave handle with gloved hands, returned remaining hot dogs to the refrigerator, and continued using the same gloved hands to touch lettuce, sliced onion, and tomato while plating food. The aide later used gloved hands to open and close the refrigerator and placed a hamburger patty in a bun on a plate, touching the bun with gloved hands. During assisted dining in the dining room, a resident assistant and an unidentified CNA moved from table to table assisting four residents by positioning them, touching wheelchairs, and handling each resident's utensils and beverage cups without performing hand hygiene. Staff interviews confirmed that hand hygiene should be performed before and after glove use and after touching potentially contaminated items. The DON stated she did not educate kitchen staff or spot check them in the kitchen for infection control practices, and the NHA stated the facility mainly focused on resident hand hygiene.
Failure to Document Rationale for Disagreeing With Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to document a rationale when the physician disagreed with pharmacist medication regimen review recommendations for three residents. The facility policy stated that when the pharmacist submits a medication recommendation report, the physician reviews it and documents in the resident’s medical record what actions were taken, and if the physician disagrees, a clinical rationale is to be documented on the form. Record review and interviews showed that this documentation was not completed for multiple pharmacist recommendations across several residents. For one resident with diagnoses including Lewy body dementia, epilepsy, chronic kidney disease stage 3, atrial fibrillation, diabetes, PTSD, major depressive disorder, insomnia, and hallucinations, the pharmacist made multiple recommendations related to renal dose adjustments, Benadryl dosing instructions, antidepressant dosing, and diabetes management. The physician marked disagreement on the forms, but the record did not include a clinical rationale for not reducing cetirizine, sitagliptin, duloxetine, famotidine, or for not adding dosing frequency or maximum-dose warnings to the PRN Benadryl order. The record also did not show documentation that the pharmacist’s recommendation to increase basal insulin was reviewed with the resident. For another resident with non-Alzheimer’s dementia, anxiety, depression, and diabetes, the pharmacist recommended review of mirtazapine due to a recent fall. The physician responded that the fall was unrelated to the medication and that the medication was warranted, but no clinical rationale was documented for not decreasing mirtazapine. For a third resident with heart failure, atrial fibrillation, dementia with behavioral disturbance, delusional disorder, and chronic kidney disease stage 3, the pharmacist twice recommended decreasing metoprolol because blood pressures were consistently low and the medication had been frequently held. In both instances, the physician marked disagreement without documenting a rationale, and the medical record did not show why the pharmacist’s recommendations were not addressed. Interviews with the MD, DON, and pharmacist confirmed that the physician was expected to document the rationale when disagreeing with pharmacist recommendations, but this was not consistently done.
Infection Control Failures With Shared Equipment and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring staff disinfected shared resident-care equipment and performed hand hygiene between resident contacts. During an observation, two CNAs and the NHA transferred four residents one after another using the same sit-to-stand mechanical lift in a common area. The staff touched the residents’ clothing and assisted them with placing their hands on the lift bar, but the lift was not disinfected between residents and the staff did not perform hand hygiene after touching each resident. The facility also failed to ensure blood pressure cuffs were disinfected between residents. A CNA with medication authority used a blood pressure cuff from a medication cart to obtain one resident’s blood pressure and returned the cuff to the cart without disinfecting it. Another CNA with medication authority did the same with a different resident, placing the cuff back into the medication cart without cleaning it after use. The DON stated the night shift cleaned and disinfected wheelchairs and medical equipment such as mechanical lifts and blood pressure tower machines, and said the blood pressure cuffs were not cleaned between residents because they generally touched clothing and not the skin. Housekeeping staff also did not perform appropriate hand hygiene while cleaning resident rooms. A housekeeper cleaned a double-occupancy resident room while repeatedly donning and doffing gloves without hand hygiene, including after handling trash, sweeping, wiping surfaces, and moving between rooms to obtain gloves. She entered another resident room to get a box of gloves without performing hand hygiene and then continued cleaning the first room and began cleaning the second room without hand hygiene. The environmental director stated hand hygiene should be performed after disinfecting resident rooms and between putting on and taking off each pair of gloves.
Failure to Protect a Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was kept free from abuse when Resident #73 sexually abused Resident #2 in the dining room. The investigation found that Resident #73 summoned Resident #2 over, held her hands, stroked her sweater, and touched her breast over her clothing. Resident #2 reported the incident to nursing staff after breakfast. Two staff members were present in the dining room, but neither reported seeing the breast touching. The facility substantiated the allegation based on video surveillance and witness statements. Resident #2 was cognitively intact with a BIMS score of 14 out of 15 and had diagnoses including neurocognitive disorder with Lewy bodies, epilepsy, chronic kidney disease stage 3, TIA, cerebral infarction, atherosclerotic heart disease, atrial fibrillation, hypertension, type 2 diabetes mellitus, PTSD, major depressive disorder, insomnia, and hallucinations. She used a walker and wheelchair and required assistance with eating, oral hygiene, showering, personal hygiene, and toileting. Her record showed no care plan focus or interventions were added to protect her from further incidents with Resident #73 after the event, and there was no documentation that she was monitored for changes from baseline or that progress notes were entered related to the incident. Resident #73 had diagnoses including unspecified dementia, behavior disturbance, sexual dysfunction, cerebrovascular disease, atrial fibrillation, ischemic cardiomyopathy, peripheral vascular disease, hypertension, insomnia, and TIA. His care plan already identified inappropriate touching of others and included interventions such as reminding him to keep his hands to himself, redirection, activities, non-judgmental support, and monitoring/documenting inappropriate behaviors. The investigation documented that the facility knew Resident #73 had sexual behavior before the incident, but the interventions in place were not effective in preventing the abuse of Resident #2.
Failure to Report Abuse Allegations to Required Authorities
Penalty
Summary
The facility failed to report allegations of abuse in accordance with state law for two separate incidents of sexual abuse. The facility investigation for an incident involving Resident #73 and Resident #2 documented that the sexual abuse occurred on 12/11/25 at 7:23 a.m., but there was no documentation that the ombudsman was notified. Facility policy stated that when abuse is identified, the facility will report the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations. A second allegation involved Resident #18 and Resident #48. Resident #48 had diagnoses including TIA, cerebral infarction, dementia, anxiety, depression, and chronic respiratory failure with hypoxia, and was severely cognitively impaired with a BIMS score of 5, used a wheelchair, and required assistance with several activities of daily living. Resident #18 had diagnoses including COPD, hypertension, intracranial injury with loss of consciousness, osteoarthritis, and dementia with agitation, and had a BIMS score of 14. A nurse behavior note stated Resident #18 became verbally sexually abusive to a female CNA and then to Resident #48, but there was no further documentation of the incident and no documentation that the allegation was reported to the State Agency or the ombudsman. During interview, the NHA stated she reported abuse to the State Agency but did not report abuse to the ombudsman and did not know allegations of abuse needed to be reported to the ombudsman.
Failure to investigate allegation of sexual abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving one resident and another resident after staff became aware that sexually inappropriate comments had been made. The facility had a policy requiring immediate remediation, a thorough investigation of alleged abuse, and appropriate corrective actions, but it was unable to provide documentation showing that an investigation had been completed when requested by surveyors. Resident #18 had diagnoses including COPD, HTN, intracranial injury with loss of consciousness, osteoarthritis, and dementia with agitation. His behavior care plan documented a history of inappropriate touching of other residents and unwanted lewd and sexual comments to staff and others. A nurse behavior note stated that he was taken to smoke and became verbally sexually abusive to a female CNA and to another female resident, Resident #48, and that the nurse spoke to him and he laughed. Resident #48 had diagnoses including TIA, cerebral infarction, dementia, anxiety, depression, and chronic respiratory failure with hypoxia, and her MDS showed cognitive impairment with a BIMS score of 5. Facility leadership later stated the incident was not investigated until 18 days after staff were aware of the allegation, and the NHA said the facility was aware that Resident #18 had a history of making sexual comments toward residents.
Improper lien placed on resident property for unpaid charges
Penalty
Summary
The facility failed to ensure it did not condition payment for care on a third party guarantee or place a lien on a resident’s property for unpaid charges. The deficiency involved Resident #3, who was admitted with diagnoses including non-Alzheimer’s dementia, anxiety, depression, and diabetes, and whose MDS showed severe cognitive impairment with a BIMS score of 5 out of 15 and need for partial assistance with ADLs. The record showed a promissory note secured by deed of trust dated 2/3/26 that was signed by the power of attorney for Resident #3. The note stated that the family representative and Resident #3 promised to pay the facility $28,201 plus interest, late penalties, collection costs, and attorney’s fees, and it granted rights in Resident #3’s undivided one-third interest in the property. The note also stated that the indebtedness was secured by a deed of trust and that the entire principal and accrued interest would become due upon sale of the property. The resident’s representative said the facility placed a lien on the shared property for back payment that Medicaid did not pay, and that the facility approached her with the lien information. She said she had been paying privately before applying for Medicaid, that the Medicaid application was delayed by repeated requests for additional information, and that the lien was completed after Medicaid reimbursed the facility but did not cover all of the stay while the application was pending. Staff interviews confirmed that the social services director and corporate business office manager assisted with the Medicaid process, that the lien was completed because of alleged Medicaid denial or delay, and that the facility had multiple residents with liens on their properties. The report states that federal law prohibited the facility from placing a lien on a resident’s home when the resident received Medicaid benefits.
Failure to complete RN assessment after resident fall with hip fracture
Penalty
Summary
The facility failed to ensure a registered nurse completed a head-to-toe assessment after a resident fell and later was found to have a left hip fracture. Resident #7 had diagnoses including respiratory failure, dementia, osteoporosis, and a history of falls with fractures, and was severely cognitively impaired and dependent on staff for activities of daily living. After the fall, an LPN documented that the resident was found lying on her left side, was alert to self, could not describe the fall, and initially showed no signs or symptoms of injury. The resident was then placed in a recliner at the nurses’ station for observation. The record showed the LPN completed the immediate post-fall assessment, but there was no documentation that an RN completed a head-to-toe assessment before the resident was moved to the recliner. The DON, who was an RN, did not provide a visual assessment until almost four hours after the resident initially fell and was transferred from the floor to the recliner. Later that evening, the resident became painful when staff attempted to get her up, moaned, grimaced, and stated that it hurt. The nurse notified the DON and physician, reviewed camera footage with the DON, and EMS was called for hospital transfer. Hospital records showed the resident sustained a displaced fracture of the left femoral neck. The facility’s IDT note documented video surveillance showing the resident scooting herself in the wheelchair, sliding due to silk pajamas, attempting to reposition by grabbing the nurses’ station and partially standing, and then falling to the floor onto her left side. Interviews with CNA staff and the DON confirmed that a nurse was expected to complete the assessment after a fall, but the DON stated the LPN completed the assessment and that the RN did not have to go in for the assessment.
Failure to Assist Resident With Hearing Aids
Penalty
Summary
The facility failed to provide assistance with activities of daily living to ensure the highest practicable quality of life and care for one resident with hearing problems. Resident #7, who was over age 65, had diagnoses including respiratory failure, dementia, osteoporosis, and a history of falls with fractures. The 3/26/26 MDS showed the resident was severely cognitively impaired, dependent on staff for ADLs, and wore a hearing device daily. The resident’s impaired communication care plan directed staff to apply the resident’s hearing aids in the morning and remove them at bedtime. Observations showed Resident #7 repeatedly without hearing aids in place while sitting in the common area, in her room, in the dining room, and while lying in bed. During one observation, an attempt was made to interview the resident, but she did not respond when spoken to. The resident’s representative stated she had to put the hearing aids in every time she visited and had asked the facility to make sure the resident wore them daily. Staff interviews indicated CNAs and CNA-Meds were expected to assist residents with hearing aids in the morning and at bedtime, and the DON stated Resident #7 should be assisted to put them in daily.
Inconsistent behavioral monitoring and ineffective interventions for residents with mental health and sexual behavior issues
Penalty
Summary
The facility failed to ensure that residents diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment to attain their highest practicable mental and psychosocial well-being. For one resident with neurocognitive disorder with Lewy bodies, PTSD, major depressive disorder, insomnia, hallucinations, and a PHQ-9 score indicating moderate depression, the record showed care plans for psychosocial well-being, impaired mood, and psychotropic medication use, but there was no documentation addressing the resident’s PHQ-9 scores or what follow-up, interventions, or services were offered in response to the scores. The same resident had physician orders for aripiprazole, donepezil, duloxetine, and trazodone, along with behavior monitoring orders for hallucinations, attention seeking, and inability to sleep, and non-pharmacological interventions such as positive reassurance, active listening, a calm environment, and a recliner in the room. However, review of the MAR and TAR from the cited period showed the resident exhibited behaviors and interventions that were not consistently offered, and there was no documentation showing whether the interventions that were offered were effective. For another resident with dementia with agitation, the record and interviews showed ongoing inappropriate touching, agitation toward staff, accusations toward staff, and unwanted lewd and sexual comments to staff and others. The care plan and behavioral contract addressed these behaviors, and physician orders included behavior monitoring and non-pharmacological interventions such as redirection and reminders about appropriate communication. Despite this, the resident continued to make inappropriate remarks to female residents, visitors, and staff, including sexually abusive comments and other sexually inappropriate statements, and the record showed that interventions were not consistently offered and/or documented as effective.
Hospice documentation, care coordination, and care planning were incomplete
Penalty
Summary
The facility failed to meet hospice care requirements for two residents receiving hospice services. Surveyors found that hospice notes were not readily available in the facility EMR for either resident, the comprehensive care plans did not delineate responsibilities between facility staff and the hospice team, and the facility did not have a designated hospice care services coordinator. The facility policy stated that someone should be designated to coordinate care between facility staff and hospice staff and obtain hospice contact information, but staff interviews showed this was not in place. One resident was admitted for a respite stay with hospice involvement and had diagnoses including COPD, adult failure to thrive, severe protein malnutrition, and a pressure ulcer. The resident reported that hospice nurses changed the wound dressings and that facility staff did not look at the wound or help with dressing changes. The hospice RN said the hospice team managed the wound using standing orders, that the wound had tunneled and developed an odor, and that she hoped the facility medical director would help guide wound care. The RN also stated she completed progress notes for each visit but did not leave copies with the facility, and she did not coordinate with anyone specific at the facility regarding the resident's care. Record review for that resident showed physician orders for wound monitoring and wound care, but no orders indicating hospice was responsible for wound care and no physician orders for hospice care services. The care plan contained no hospice focus or hospice interventions. For the other resident, the hospice care plan showed hospice services were being provided for end-of-life diagnoses including CHF, COPD, and vascular dementia, but the facility EMR did not contain hospice notes. The hospice care plan also did not include a delineation of care services between the facility and hospice team. Staff interviews showed inconsistent knowledge about hospice schedules and documentation, and the DON and NHA stated the facility did not have a hospice care services coordinator and did not know one was required.
Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident at risk for pressure injuries received the necessary treatment and services to prevent the development of a new pressure ulcer. Despite having physician orders in place for a pressure redistribution mattress and heel protectors, these interventions were not consistently implemented or documented. The resident, who had multiple risk factors including dementia, diabetes, muscle wasting, and was dependent on staff for activities of daily living, was identified as being at risk for pressure ulcers and had a history of unhealed pressure injuries. Documentation revealed that the resident did not have a pressure redistribution mattress in use as ordered, and heel protectors were not implemented until after a new right heel wound was identified. There was a gap in documentation and implementation of these interventions, as the medication and treatment administration records did not show use of the mattress or heel protectors prior to the development of the wound. The wound was first noted as a non-blanchable area on the right heel, and subsequent wound evaluations did not consistently involve assessment by a physician, nurse practitioner, or wound care specialist, nor did they identify the source of pressure or factors contributing to improvement. Staff interviews confirmed that the resident's risk for pressure injuries increased as her condition declined, yet interventions were not adjusted accordingly. The facility's wound nurse acknowledged that the root cause of the pressure injury was not adequately identified and that the resident's shoes and leg rests may have contributed to the development of the heel wound. The facility also failed to ensure ongoing and thorough assessment of the wound, as the condition of the right heel was not evaluated after a certain point, and the nurse practitioner did not assess the wound until after the resident returned from a hospital stay.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure adequate supervision and timely interventions to prevent accidents for a resident with a history of falls. The resident, who was admitted with severe cognitive impairments and required substantial assistance for mobility, experienced multiple falls over a period of several months. Despite the resident's known risk factors, the facility did not implement timely and effective interventions after each fall, contributing to repeated incidents. The resident sustained falls on several occasions, including an unwitnessed fall shortly after admission, where poor lighting and confusion were identified as factors. The facility did not update the resident's care plan with new interventions until weeks after the initial fall. Subsequent falls were either unwitnessed or witnessed by staff, yet the recommended interventions, such as placing the resident in a recliner or implementing a restorative program, were not promptly executed. This lack of timely action and failure to adhere to care plan recommendations contributed to the resident's continued risk of falls. The most severe incident occurred when the resident attempted to self-transfer in a shower room, resulting in a hip fracture. The shower room door was improperly left open, allowing the resident to enter unsupervised. The facility's failure to secure the environment and provide adequate supervision directly led to this serious injury. The incident highlights the facility's deficiencies in maintaining a safe environment and ensuring that staff follow through with care plan interventions to prevent accidents.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the State Agency in a timely manner. The resident, who was over 65 years old and had multiple medical conditions including severe cognitive impairments, was admitted to the hospital with bilateral hip fractures and a hematoma on her left thigh. The incident occurred on December 29, 2024, but was not reported to the State Agency until January 23, 2025, which was 24 days after the reporting requirements. The facility's policy required that all accidents or incidents involving residents be reported to the administrator and the appropriate agencies within 24 hours. However, the facility did not adhere to this policy. The nursing home administrator (NHA) initiated an investigation by reviewing hallway video and interviewing staff but did not save the interview notes, and the video was only saved for two weeks. The NHA reported the injury late because she did not know it was reportable. Interviews with staff revealed that the resident was fine the evening before the incident and had no reports of pain. However, when staff attempted to get her up the next day, she cried out in pain and was unable to stand. The resident was sent to the hospital, where she was diagnosed with fractures to both hips. The director of nursing (DON) acknowledged that unexplained injuries should have been reported within 24 hours, but this was not done in this case.
Failure to Investigate Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and neglect concerning a resident who sustained an injury of unknown origin. The facility's policy required a comprehensive investigation of all accidents or incidents, including documentation of the circumstances, witness accounts, and any corrective actions taken. However, the investigation into the resident's injuries did not include interviews with staff or residents after the incident, and the facility did not document or investigate a bruise of unknown origin reported by the hospital. The resident, who had severe cognitive impairments and required assistance with activities of daily living, was found to have bilateral hip fractures and a hematoma on her thigh after being sent to the hospital. The facility's records did not indicate any falls or incidents that could have caused these injuries. Staff interviews revealed inconsistencies in the accounts of the resident's condition and care, and the facility did not conduct a fall investigation or a bruise of unknown origin investigation, as required by their policy. The facility's failure to conduct a thorough investigation and document findings led to a deficiency in addressing the resident's injuries. The NHA and DON did not save interview notes or video evidence, and there was a lack of clarity regarding the resident's condition and the events leading to her injuries. The facility's inaction and incomplete investigation did not comply with their policy and procedures for handling incidents and accidents.
Failure to Implement and Follow Fall Interventions
Penalty
Summary
The facility failed to ensure the residents' environment remained as free of accidents/hazards as possible to prevent falls for two residents. Resident #3, who had a history of falling, experienced multiple falls due to the facility's failure to implement and follow appropriate fall interventions. Despite having a care plan that included wearing non-skid socks and a scheduled toileting program, these interventions were not consistently followed. Additionally, after each fall, the facility did not implement new fall interventions in a timely manner, leading to repeated falls and eventually a major injury requiring hospitalization for Resident #3. Resident #3's care plan was not adequately updated or followed. For instance, after a fall on 4/16/23, no new interventions were added until 6/16/23, and even then, the toileting schedule was not specified. Between 7/1/23 and 1/19/24, Resident #3 sustained six more falls, many of which occurred while attempting to go to the bathroom. The facility failed to ensure staff followed the toileting schedule and other care-planned interventions, such as wearing non-skid socks. Additionally, the facility did not address the resident's low oxygen levels, which were identified as a potential factor in the falls. The facility's documentation and investigation of falls were inadequate. For example, the fall occurrence evaluations often lacked details such as the type of footwear the resident was wearing, whether the resident was using oxygen, and when the resident was last toileted. The facility also failed to conduct thorough investigations and implement appropriate new interventions after each fall. This lack of proper documentation and follow-up contributed to Resident #3's repeated falls and eventual major injury. The facility's failure to consistently identify, implement, review, and update fall care plans with effective interventions also affected Resident #58, who experienced similar issues with fall prevention.
Failure to Ensure Residents' Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that three residents had the right to formulate an advance directive. Specifically, the facility did not provide written advance directive forms or discussions to the residents, did not re-evaluate their decision-making capacity periodically, and did not re-evaluate if their advance directives were still in line with their wishes. This deficiency was identified for three of the five residents reviewed for advance directives out of a sample of 41 residents. Resident #36, who was over the age of 65 and had diagnoses including cerebral palsy, osteoarthritis, and generalized muscle weakness, was moderately cognitively impaired. Despite being unable to recall what an advance directive was or if he had one, there was no documentation in his electronic medical record (EMR) indicating an advance directive discussion had been held. Similarly, Resident #37, who had dementia and other cognitive impairments, had multiple progress notes indicating the facility contacted his power of attorney (POA) for consents and appointments, but there was no documentation of an advance directive discussion. Resident #57, who was cognitively intact with a BIMS score of 13 out of 15, had a MOST form signed by a family member identified as the medical durable power of attorney (MDPOA). However, there was no MDPOA form documented in the EMR, nor was there any documentation indicating an advance directive discussion had been held. Interviews with the nursing home administrator (NHA), social services director (SSD), and director of nursing (DON) confirmed that there were no advance directives on file for these residents and that discussions regarding advance directives were not documented or re-offered periodically.
Failure to Test and Vaccinate Residents for COVID-19
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility did not ensure that residents presenting signs and symptoms of an upper respiratory infection were tested for COVID-19. Residents #22, #24, #16, #29, #47, #53, and #58 were identified with upper respiratory infections but were not tested for COVID-19, despite exhibiting symptoms that could potentially indicate the virus. The facility's surveillance mapping and electronic medical records did not document COVID-19 testing for these residents, and the DON confirmed that testing was not conducted unless a staff member reported positive COVID-19 or if local facilities had cases of a COVID-19 outbreak and the physician recommended testing. Additionally, the facility failed to ensure that residents who had consented to receive the COVID-19 vaccination were actually vaccinated. Residents #58, #164, and #165 had consented to receive the COVID-19 vaccine, but the facility did not administer the vaccine to them. Resident #58's responsible party consented for the vaccination on 3/19/24, but the resident was not vaccinated due to the family's initial decision to wait, and the facility did not follow up. Similarly, Resident #164 and Resident #165 had consented for the vaccination on 4/19/24 and 4/11/24, respectively, but were not provided the vaccine since their admission. The DON and the CC acknowledged the deficiencies during interviews. The DON stated that residents with upper respiratory infections were not placed on droplet precautions because there were no recommendations from the providers, and she did not follow up to ask if precautions were needed. The CC emphasized that the facility should test every resident with signs and symptoms of a respiratory infection to rule out COVID-19 and follow CDC recommendations for offering COVID-19 vaccinations to all residents. The facility's failure to test symptomatic residents for COVID-19 and to vaccinate consenting residents represents a significant lapse in infection control practices.
Failure to Ensure CNAs Received Required Annual Training
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received at least 12 hours of annual in-service training, including mandatory dementia management and resident abuse prevention training. A review of training records for five randomly selected CNAs revealed that none of them had completed the required 12 hours of training. Specifically, CNA #2 had only six hours of training with no record of abuse, neglect, or exploitation training; CNA #4 had six hours of training with no dementia management or abuse prevention training; CNA #5 had eight hours of training; CNA #6 had ten hours of training with no dementia management training; and CNA-Med #1 had nine hours of training with no dementia management training. Interviews with the nursing home administrator (NHA), business office manager (BOM), director of nursing (DON), and corporate consultant (CC) revealed a lack of awareness and proper tracking of the required training hours. The BOM admitted to not knowing the necessity of tracking training hours, while the DON was unaware of the 12-hour training requirement. The NHA acknowledged the difficulty in ensuring staff completed the training despite offering paid training sessions and flexible scheduling. The facility planned to implement a computerized training system within six months to improve tracking and consistency, but no immediate corrective actions were in place at the time of the survey.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure care for residents was provided in a manner that maintained or enhanced their dignity and respect. Specifically, staff did not acknowledge or respond to Resident #1 when she spoke to them, failed to treat Resident #23 with respect and dignity during meals, and yelled at or moved Resident #38 hastily when he got stuck on another resident's chair in the dining room. These actions were observed multiple times, indicating a pattern of behavior that did not align with the facility's dignity policy. Resident #1, who had severe cognitive impairments and communication difficulties, was repeatedly ignored by staff when she attempted to communicate. On several occasions, staff members did not respond to her expressions of gratitude or requests for assistance. Additionally, Resident #1 was observed eating food off the floor while waiting for a second plate of food, and no staff attempted to redirect her. The facility's policy and Resident #1's care plans emphasized the importance of allowing time for communication and providing support, but these were not followed. During a group interview, multiple residents reported that staff yelled at them during meals, particularly if they fell asleep or were hard of hearing. Resident #50, a survivor of domestic violence, stated that the yelling triggered her PTSD and made her feel unsafe. Observations confirmed that staff, including RA #1, yelled at residents to wake up and eat their food, and moved Resident #38's wheelchair without his consent. These actions were not in line with the facility's policy of treating residents with dignity and respect.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consents were obtained for the use of psychotropic medications for two residents. Specifically, the facility did not obtain consents that included the risks associated with taking Trazodone for Resident #15 and Seroquel for Resident #20. Resident #15, who was cognitively intact and had diagnoses including chronic kidney disease, dementia, and insomnia, was prescribed Trazodone without documented consent. Similarly, Resident #20, who was moderately cognitively impaired with diagnoses including Parkinson's disease, dementia, and anxiety disorder, was prescribed Seroquel without documented consent until it was obtained during the survey. The facility's Antipsychotic Medication Use policy requires that consents be obtained prior to the administration of psychotropic medications. However, the electronic medical records and paper documentation for both residents failed to include the necessary consents. Interviews with the Director of Nursing, Corporate Consultant, and Nursing Home Administrator confirmed that consents were not obtained for these medications. The Nursing Home Administrator attributed the incomplete documentation to the newness of the Social Services Director in her role, indicating a need for improved documentation practices for psychotropic medications.
Failure to Properly Manage Residents' Personal Funds Accounts
Penalty
Summary
The facility failed to ensure that personal funds accounts were managed adequately for four residents. Specifically, the facility did not have signed written authorizations to manage the personal funds account for one resident and did not have personal funds withdrawal sheets signed to ensure the residents' permission was obtained for withdrawals from their personal needs accounts for four residents. The facility's policy required written authorization from the resident or authorized person before holding any funds and signatures or thumbprints on every receipt or record of the transaction. However, the facility did not comply with this policy, leading to unauthorized management and withdrawals of residents' personal funds. The business office manager (BOM) provided written authorizations for one resident, but these were signed by the previous BOM and not the resident or the resident's legal representative. Additionally, the personal funds withdrawal sheets for four residents showed multiple withdrawals without signed authorization from the residents or two staff members. The nursing home administrator (NHA) and the BOM were unaware of the requirement for signatures on the withdrawal forms and admitted that the facility did not have valid legal supporting documentation of their authority to manage the residents' funds. This lack of compliance with the facility's policy and federal regulations resulted in the mishandling of residents' personal funds accounts.
Failure to Notify Residents of Personal Funds Account Balances
Penalty
Summary
The facility failed to manage the personal funds accounts of two Medicaid-funded residents accurately. Specifically, the facility did not notify Resident #2 and Resident #7 or their legal representatives when their personal funds accounts reached $200 less than the eligibility resource limit for Medicaid. Resident #2 had a balance of $2001.71, which was $1.07 over the Medicaid limit, and Resident #7 had a balance of $1,867.63. There was no documentation indicating that the required notifications were made to either resident or their legal representatives. During interviews, the Nursing Home Administrator (NHA) and Business Office Manager (BOM) acknowledged the oversight. The BOM discovered the discrepancies and stated that she would notify the residents or their legal representatives and audit all residents' accounts to ensure compliance. The facility's policy mandates that residents receiving Medicaid benefits must be notified when their account balance approaches the eligibility resource limit to prevent loss of Medicaid eligibility.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that Resident #1 was free from potential sexual abuse by Resident #20. On 4/19/24, Resident #20 inappropriately touched and attempted to kiss Resident #1 in a high visual common area of the facility. The incident lasted for over ten minutes before a staff member intervened. Resident #1, who was unable to speak and had severe cognitive impairments, was positioned in a recliner when Resident #20, who has a history of inappropriate behaviors, approached her and began to touch her inappropriately. The facility's video surveillance captured the entire incident, and it was reported to the nursing home administrator (NHA) by a certified nurse aide with medication aide authority (CNA-Med) #2. A physical assessment of Resident #1 showed no obvious injury, but the incident highlighted a significant lapse in supervision and protection for the residents involved. Resident #20, who has diagnoses including Parkinson's disease, dementia with behavioral disturbances, and other sexual dysfunctions, had a care plan that included interventions for managing his inappropriate behaviors. However, the care plan did not include new interventions after the 4/19/24 incident to prevent recurrence. The facility placed Resident #20 on 15-minute checks and educated staff to always have two staff members present when providing care for him. Despite these measures, the facility's response was inadequate as it failed to document staff interviews and did not implement sufficient preventive measures. Interviews with staff revealed a lack of awareness and specific precautions regarding Resident #20's behaviors. CNA #2, who was seen on video walking past the incident while using her cell phone, was instructed to be more attentive. The NHA admitted to conducting an informal education huddle with staff but did not document the training provided. The facility's investigation was primarily based on video footage, and the NHA did not document interviews with staff or residents. This lack of thorough documentation and follow-up indicates a failure to ensure a safe environment for all residents, particularly those with cognitive impairments like Resident #1.
Failure to Ensure Residents Are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints unless needed for medical treatment. Specifically, the facility did not evaluate Resident #1 for the use of a restraint, obtain a signed consent, or secure a physician's order for the restraint. Additionally, the facility did not complete quarterly safety risk assessments, document less restrictive measures attempted, or conduct trial periods without the restraints for Resident #1. Observations revealed that Resident #1 was consistently wearing a one-piece outfit with a zipper on the back, which she could not remove herself, effectively acting as a restraint. Interviews with staff indicated a lack of awareness that the outfit was considered a restraint, and there was no documentation of other interventions attempted to prevent the resident from removing her clothes in public areas. Resident #27 was also subjected to physical restraints without proper documentation and evaluation. The resident's care plan included the use of a Lap Buddy and a wanderguard, but the facility failed to document the risks versus benefits of these restraints or conduct trial periods without them. Observations showed Resident #27 using the Lap Buddy and wanderguard daily, and staff interviews confirmed that these restraints were in place due to the resident's history of wandering and poor safety awareness. However, there was no documentation of other interventions attempted or the necessity of continued use of these restraints. The facility's policy on the use of restraints, revised in April 2017, mandates that restraints should only be used for the safety and well-being of the resident after other alternatives have been tried unsuccessfully. The policy also requires a written order from a physician, consent from the resident or their representative, and ongoing re-evaluation of the need for restraints. The facility failed to adhere to these guidelines for both Resident #1 and Resident #27, resulting in the inappropriate use of physical restraints without proper evaluation, documentation, or consent.
Deficiency in Restorative and Occupational Therapy Services
Penalty
Summary
The facility failed to provide appropriate restorative therapy services to two residents with limited range of motion, leading to deficiencies in their care. Resident #57, who had diagnoses including dementia and COPD, was not receiving the required restorative therapy services for bed mobility, transfers, and other activities of daily living (ADLs). Despite a care plan indicating the need for six days a week of therapy, documentation showed that these services were inconsistently provided, with no recorded refusals from the resident. The resident expressed concerns about the lack of therapy and its impact on his mobility and ability to perform ADLs. Similarly, Resident #36, diagnosed with cerebral palsy and osteoarthritis, did not receive the necessary restorative and occupational therapy services. The resident's care plan also required six days a week of restorative therapy, but documentation revealed significant gaps in service provision. Additionally, there was a physician's order error for occupational therapy, which was not corrected, resulting in the resident receiving far fewer therapy sessions than needed. The resident reported increased difficulty with mobility and transfers due to the lack of therapy. Interviews with staff, including the restorative aide, director of rehabilitation, and nursing home administrator, confirmed the inconsistencies in providing restorative and occupational therapy services. The facility faced challenges such as therapy staff shortages and unclear responsibilities among CNAs and NAs regarding restorative care. The director of nursing and the nursing home administrator acknowledged the deficiencies and the impact on the residents' care, highlighting systemic issues in therapy service delivery and documentation.
Failure to Ensure Proper Respiratory Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper respiratory treatment and care. Specifically, the facility did not administer oxygen in accordance with the physician's order, did not ensure staff reminded and encouraged the resident to wear his oxygen, and did not ensure clear communication regarding when the resident should use his oxygen. The resident, who had severe cognitive impairment and multiple diagnoses including chronic obstructive pulmonary disease (COPD) and hypoxemia, was observed multiple times without his oxygen cannula in place, despite having an oxygen canister attached to his wheelchair. Staff members walked past the resident without encouraging or assisting him to wear his oxygen, and the resident himself mentioned that his oxygen comes off his face sometimes. The resident was observed without his oxygen for extended periods, and staff did not check his oxygen saturation levels after these periods of non-use. The resident's care plan and computerized physician orders (CPO) indicated that he required oxygen via nasal cannula at 2 liters per minute and that his oxygen saturation levels should be checked daily and as needed to maintain a saturation level of 90% or greater. However, the CPO did not specify how often the resident needed to wear oxygen. The care plan included various interventions to manage the resident's respiratory status, but it did not address the resident's tendency to remove his oxygen or provide specific interventions for when he refused to wear it. Interviews with staff revealed that they were aware the resident should wear his oxygen at all times but did not consistently remind or assist him to do so. The Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged that the resident's care plan did not include interventions for when he refused his oxygen and that staff should check his oxygen saturation levels when he did not wear his oxygen. The facility's failure to ensure the resident received proper respiratory care was evident in multiple observations and staff interviews. The resident was frequently seen without his oxygen, and staff did not consistently encourage or assist him to wear it. The care plan and CPO lacked clear directives on how often the resident needed to wear oxygen and did not address the resident's tendency to remove it. The DON and NHA admitted that the resident's oxygen needs and refusals had not been adequately discussed in quality assurance meetings, and staff were not consistently checking the resident's oxygen saturation levels after periods of non-use.
Failure to Properly Store and Monitor Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards. Specifically, the facility did not maintain appropriate storage temperatures for refrigerated medications and allowed expired medications to remain in use. Observations revealed that medication storage cart G/H contained an expired bottle of milk of magnesia, and medication storage cart A/B held expired containers of alprazolam and ondansetron. Additionally, the medication room refrigerator lacked a temperature log, and temperature documentation was incomplete for several days in March and April 2024, and entirely missing for May 2024 up to the date of the survey. Interviews with staff, including a registered nurse (RN), a certified nurse aide with medication authority (CNA-Med), the nursing home administrator (NHA), and the director of nursing (DON), confirmed the presence of expired medications and the failure to log refrigerator temperatures. The NHA acknowledged that the responsibility for logging refrigerator temperatures had recently shifted from maintenance to nursing staff, resulting in missed documentation. The DON emphasized the importance of logging temperatures to ensure medication safety and effectiveness, and noted that night shift medication technicians were responsible for checking medication carts, which had not been done consistently.
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What surveyors actually found near you
We read the 1 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
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Illustrative
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Nursing homes near Cortez
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Rehabilitation And Healthcare Center, The | 20.3 mi | ★★★★★ | 1 | 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 October 2026) and official state health department websites.