Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Tolleston Park during CMS and state inspections, most recent first.
Surveyors found that staff failed to consistently provide and document required ADL assistance, including oral care, shaving, nail care, bathing, personal hygiene, and incontinence care, for several dependent residents. One resident repeatedly had unshaven facial hair and no oral care supplies available despite care plan orders for assisted oral hygiene. Another resident was often observed with food and mucus on his face, greasy hair, and wet clothing from incontinence, while a CNA acknowledged checks and changes were not done at the expected two-hour intervals. Additional residents were seen over multiple days with persistent facial hair, dirty or long jagged fingernails, and inconsistent showers or bed baths, even though their MDS assessments and care plans required partial to total staff assistance with personal hygiene and bathing, and there was no documentation of refusals. A review of a discharged resident’s record also showed missed scheduled showers despite a need for substantial to maximum assistance with bathing.
Failure to document post-angiogram assessment and give ordered meds. A resident with heart failure and PVD returned from angiogram appointments, but the chart lacked site assessments after the procedures and lacked documentation for one appointment departure and return. The facility also did not document several scheduled Haldol decanoate doses for one resident with schizoaffective disorder and had insulin administration issues for two residents with diabetes, including held doses without parameters and missed or undocumented blood sugar checks before insulin.
Environmental Cleanliness and Repair Deficiencies: During an environmental tour, multiple rooms in South Unit and PCU were found with dirty or discolored floor tiles, scratched and marred walls and door frames, dusty ceiling vents, stained ceiling tiles, dead insects in light fixtures, and a broken toilet paper holder. The Environmental Supervisor stated the observed conditions were in need of cleaning and/or repair.
Two residents were not adequately protected from accidents when one cognitively impaired, fully dependent resident was left alone on the toilet and sustained an unwitnessed fall while attempting to transfer, despite a care plan identifying her fall risk and need for staff assistance, and another cognitively intact resident with supervision needs injured his foot on a broken closet door that remained hanging off its track in his room for several days, causing pain, swelling, and difficulty ambulating.
A resident with end stage renal disease left the facility for dialysis with documentation indicating no acute distress at the time of departure, but no further progress notes were entered afterward. The resident coded and died while at dialysis and did not return, yet the death was not documented in the progress notes, as confirmed by the DON. Although the resident’s discharge was reflected in the census and a Death in Facility MDS entry was completed, the absence of a progress note documenting the death resulted in an incomplete and inaccurate medical record.
A resident who was cognitively intact and dependent in ADLs was repeatedly observed in bed wearing a hospital gown during the day. The resident stated he did not want to wear a hospital gown and had his own clothes in his closet, but the record lacked documentation that he preferred to wear the gown during the day.
PASARR screening was not properly documented for a resident with PTSD and major depressive disorder. The resident was admitted from another LTC facility, had an MDS showing intact cognition, and a care plan addressing trauma informed care and psychiatry/psychology services. A prior Level 1 PASARR indicated no Level 2 was needed, but a new Level 1 at admission was not available, and the SS Director stated that new Level 1 and Level 2 screenings were not completed because she relied on the prior outcome and was unaware of the resident’s current diagnoses.
A resident with polyneuropathy was receiving hydrocodone-acetaminophen for pain, including scheduled dosing and later PRN dosing, and the MAR showed the opioid was given as ordered. However, record review found no care plan for pain or opioid medication use, and the DON and MDS Consultant confirmed the absence of a care plan.
A resident reported not being invited to or participating in care plan conferences for a while. Record review showed the last documented care plan conference was held in September, with no further meeting documentation found after that, despite a later MDS showing the resident was moderately cognitively impaired.
Failure to provide scheduled one-to-one activities for a dependent resident with anoxic brain damage and persistent vegetative state. The resident was repeatedly observed lying in bed with no staff interaction, while the TV or radio was on or off. The care plan and activities review called for one-to-one room visits, reading, and music for sensory stimulation, but the record showed only limited activity entries, and the Activities Director stated the resident should have been receiving visits three times per week.
Inaccurate admission documentation of pressure ulcers was found for two residents. One resident with stroke, TBI, and severe malnutrition repeatedly refused skin assessments after admission, and later documentation identified Stage 3 pressure areas on both buttocks and the left shin, while the prior facility’s discharge paperwork stated the skin was intact. Another resident’s admission records noted only a skin tear to the breast, but later wound documentation listed bilateral buttock pressure ulcers as present on admission; the wound nurse later stated the staging and present-on-admission documentation were incorrect.
A resident with CKD and anemia had a significant weight loss after returning from the hospital, but the facility did not obtain a timely reweight or document RD notification. The resident weighed 237 pounds before hospitalization and 219 pounds after return, with the next documented weight not until several days later; no supplements were ordered and the RD did not see the resident until later. The DON stated the RD was not notified despite the weight loss, and the facility policy required a reweight as soon as possible after a 5-pound or greater change.
Inconsistent documentation of g-tube feedings affected two residents receiving tube nutrition. One resident with gastrostomy, dysphagia, and adult failure to thrive had an order for Jevity 1.5 at 75 ml/hr for 21 hours, but the chart lacked start/stop times and the MAR entries were inconsistent, with daily totals not matching the ordered volume. Another resident with dysphagia had an order for Osmolite 1.5 at 50 ml/hr for 21 hours, but the MAR also lacked documented times to turn the feeding on or off. An LPN/Nurse Consultant said there was an issue with how the tube feeding orders were entered into the computer.
Unattended Medications Left on Cart During Medication Pass: During medication administration, an LPN left a punch card with two Aricept tablets unattended on top of the med cart, and another LPN left a resident's insulin pen unattended on the cart while completing a blood sugar check. The ADON confirmed the insulin should not have been left out of the nurse's view, and the facility's medication storage policy required medications to be stored safely and securely.
Infection control practices were not followed when urinals and a wash basin were left uncontained in a shared bathroom used by two residents, and an LPN did not cleanse a resident’s PICC port with alcohol before flushing and administering IV antibiotics. The LPN stated she believed the orange cap was an alcohol cap, and the facility policy required cleaning the valve with alcohol and allowing it to dry before flushing and again before inserting the agent.
A facility failed to thoroughly investigate an abuse allegation after a resident with severe cognitive impairment and multiple disabilities was reported to have been inappropriately touched by staff. The investigation was limited to a physical assessment and did not include interviews with other staff or residents, nor was the incident documented in the resident's record or communicated to the family.
Two residents who required substantial to maximum assistance with ADLs, including bathing, did not have showers or bed baths documented over extended periods. The facility relied on weekly skin assessments for documentation, but these did not indicate whether bathing was performed.
Two residents did not receive necessary care and services as ordered, including missed doses of prescribed medications for one resident and incomplete neurological and post-fall assessments for another following an unwitnessed fall. The DON was unable to provide explanations for the missed medication administrations or the incomplete documentation.
A facility failed to follow updated physician orders for a resident's pressure ulcer treatment. The resident had a pressure ulcer on the coccyx, and the physician's order was changed from a duoderm dressing every three days to a daily calcium alginate and border gauze dressing. However, the updated treatment was not transcribed into the resident's record until several days later, and the DON was unaware of the change, leading to the application of incorrect dressings.
A facility failed to ensure correct PPE use by a staff member cleaning a COVID-19 positive resident's room. The staff member wore only a surgical mask instead of the required N95 mask and face shield, despite the room being marked as a Red Zone. The resident's record confirmed COVID-19 diagnosis and droplet precautions, aligning with the facility's policy for PPE in Red Zones.
A facility failed to perform required neurological assessments every four hours for a resident identified as a fall risk after an unwitnessed fall. The assessments were incomplete, with gaps in documentation, contrary to the facility's policy. The DON acknowledged the failure to adhere to the protocol.
The facility was found to have multiple environmental deficiencies across three units, including dirty and discolored floors, marred walls, and missing or broken fixtures. Observations revealed issues such as rusty toilet bolts, missing caulk, and broken mini blinds. The Maintenance Director and Housekeeping Supervisor acknowledged these issues and were working on addressing them.
Two residents reported that staff did not knock before entering their rooms, compromising their privacy. Observations confirmed that a CNA and a housekeeper entered without knocking. Both residents had cognitive impairments, and the DON acknowledged the oversight.
The facility failed to provide adequate personal hygiene for three residents who were dependent on staff for ADLs. One resident was observed with dirty and long fingernails, while another had long facial hair despite recent shaving. A third resident was observed with facial hair, and the family had to assist with shaving. The care plans indicated a need for assistance, but documentation in the EMR was lacking.
The facility failed to complete ordered treatments for a resident with a skin condition and did not obtain a psychiatric consult for another resident on psychiatric medications. A resident's leg treatment was not documented as completed on multiple occasions, and another resident did not receive a timely psychiatric evaluation despite being on several psychiatric medications.
A facility failed to apply a palm protector as ordered for a resident with hemiplegia, observed without the device during a survey. The resident's care plan required a palm protector due to limited range of motion from a stroke. Despite physician orders, documentation was lacking in the Medication and Treatment Administration Records and electronic medical records, with no record of refusal by the resident.
A resident with a Foley catheter was observed multiple times with the catheter bag and tubing on the floor, contrary to the facility's urinary catheter care policy. Despite staff awareness, the issue persisted during various observations, including when the resident was transported for therapy. The resident had multiple medical conditions and required substantial assistance with personal hygiene.
The facility failed to manage feeding tubes properly for two residents. One resident's tube feeding was not administered according to physician's orders, while another resident's PEG tube site was not cleaned as required, leading to inadequate care. Both residents had cognitive impairments and required specific feeding interventions, which were not properly executed.
The facility failed to maintain correct oxygen flow rates for two residents. One resident was observed with oxygen set at 2.5 liters per minute instead of the prescribed 3 liters, while another had oxygen set at 3 liters per minute instead of the prescribed 2 liters. These discrepancies were confirmed by the ADON during observations.
The facility exceeded the acceptable medication error rate with two errors during medication administration. An LPN failed to prime an insulin pen before administering insulin to a resident, contrary to facility policy. Another LPN administered Aldactone to a resident despite a physician's order discontinuing the medication. These errors contributed to a medication error rate of 6.06%.
A resident with missing teeth had not seen a dentist since 2022, despite expressing a desire for dentures. The resident's medical record showed multiple health issues and moderate impairment in decision-making, but lacked a dental care plan. A misunderstanding about insurance delayed dental services, and the resident was not included on the dental list for a recent dentist visit.
A facility failed to maintain accurate clinical records for a resident with a history of aggression who was placed on 15-minute checks after an altercation. The documentation of these checks was either time-stamped incorrectly or left incomplete, as confirmed by the ADON.
The facility failed to ensure proper infection control practices, including hand hygiene during a glucometer check, PPE use for a resident under enhanced barrier precautions, and proper positioning of a Foley catheter drainage bag. An LPN did not sanitize hands before donning gloves, a CNA did not wear a gown for a resident requiring enhanced precautions, and a resident's catheter bag was observed on the floor multiple times.
Failure to Provide Consistent ADL Assistance and Hygiene Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate assistance with activities of daily living (ADLs), including oral care, shaving, nail care, bathing, personal hygiene, and incontinence care, for multiple dependent residents. One resident reported that staff did not set him up to brush his teeth and that shaving with dull razors was "very brutal"; he stated he would like an electric razor but none had been offered. Over several days of observation, this resident repeatedly had a large amount of facial hair and there was no evidence that oral care had been provided, despite care plan interventions specifying oral hygiene in the morning, after meals, and at bedtime, with partial to moderate assistance. When a CNA searched his drawers, no toothbrush or toothpaste could be found, and the CNA acknowledged she had not completed or set up oral care, even though documentation in the CNA task section indicated oral hygiene and personal hygiene had been provided on nearly all days, with no refusals noted. Another resident was repeatedly observed with food on his clothes, crumbs in his beard, a dry face with peeling skin, greasy hair, and dried mucus hanging from his nose while staff were present but did not clean his face. On one occasion, he was returned to the dining room after being checked for incontinence with his nose cleaned, but later the same day he was observed with the front of his pants and between his legs wet. The CNA caring for him stated she was supposed to check and change residents at least every two hours and reported that she had last checked him before lunch when he was dry, and then after lunch when he would not let her check him, with no further checks until the time he was found wet. Documentation showed he required supervision with eating and personal hygiene and substantial to maximum assistance with toileting and toilet transfers, and that he was mostly incontinent. CNA task documentation showed personal hygiene signed out every shift for the last 14 days, with no documentation of refusals, despite repeated observations of unaddressed hygiene needs. Additional residents were observed with persistent facial hair, long or dirty fingernails, and inconsistent bathing. One resident with Alzheimer’s disease and dementia was seen multiple times over several days with a large amount of white facial hair on her chin and face, despite care plan interventions for partial to moderate assistance with personal hygiene and no documentation of refusals for personal hygiene during the review period. Another resident with depressive and psychotic disorders and dementia was observed with a growth of facial hair and dirty fingernails, reported it had been several days since he had been shaved and that he preferred to be clean shaven, and continued to have dirty fingernails even after being shaved; his care plan required substantial to total dependence on staff for personal hygiene, with no refusals documented. A further resident with type 2 diabetes and vascular dementia was repeatedly observed over several days with facial hair on her chin and face and long, jagged fingernails, despite care plan interventions for partial to moderate assistance with personal hygiene and no documentation that she refused shaving. A closed record review for another resident with non-traumatic subarachnoid hemorrhage and chronic respiratory failure showed that the resident, who required substantial to maximum assistance for bathing, did not consistently receive showers at least twice weekly. Facility shower documentation indicated missed showers on multiple scheduled days, with only intermittent showers and bed baths recorded during the admission period. Nurse’s notes referenced a shower and patient care on certain dates, but overall records showed gaps in providing the frequency of bathing consistent with the resident’s assessed needs and care plan interventions. Across these residents, the survey findings showed discrepancies between observed care and documented CNA task entries, as well as failures to carry out care plan interventions for ADLs, including shaving, nail care, showers, personal hygiene, and timely incontinence care, without documented refusals.
Failure to Document Post-Angiogram Assessment and Administer Ordered Medications
Penalty
Summary
The facility failed to ensure a skin assessment was completed after angiogram procedures for a resident with heart failure and peripheral vascular disease. The resident returned to the facility after a vein clinic appointment on 12/1/25, and the record included discharge instructions indicating an angiogram had been performed. There was no documented assessment of the angiogram site after that procedure, and there was also no documentation related to the resident going to the follow-up appointment on 12/23/25, when discharge instructions again indicated a right angiogram had occurred. The record also showed another angiogram appointment on 1/21/26, when the resident left the facility in the morning and returned in the afternoon. There was no documentation of an assessment to the angiogram site after the resident returned. A weekly skin assessment dated 1/22/26 did not address the angiogram site. During interviews, the DON and nurse consultant acknowledged there was no assessment documented after the angiograms and no documentation for the 12/23/25 appointment departure and return. The facility also failed to administer medications as ordered for several residents. One resident with schizoaffective disorder had Haldol decanoate ordered every 28 days, but the MARs for 11/2025, 1/2026, and 2/2026 did not show the injections as given, and there were no eMAR notes for the missed administrations. Another resident with diabetes and dialysis dependence had Lantus insulin ordered daily and Humalog insulin ordered with meals, but Lantus was held on multiple days without parameters or orders to hold it, and Humalog was not given on some mornings with no blood sugar documented. A third resident with diabetes had multiple insulin orders, and the MAR showed several instances where insulin was held or given in a manner inconsistent with the documented blood sugar values and hold parameters.
Environmental Cleanliness and Repair Deficiencies
Penalty
Summary
The facility failed to ensure that the residents’ environment was clean and in good repair in the South and PCU units. During an environmental tour with the Environmental Supervisor, multiple areas were observed with dirty or discolored floor tiles, scratched and marred walls and door frames, dusty ceiling vents, stained ceiling tiles, and dead insects in light fixtures. In South Unit, the bathroom in one room had a broken toilet paper holder detached from the wall and a scratched, marred bathroom door frame; another room had a scratched and marred wall behind one bed and discolored floor tile around the toilet; another room had discolored floor tile at the base of the toilet; and another room had a stained ceiling tile by the window and a scratched, marred bathroom door frame. In PCU, several rooms had dusty bathroom ceiling vents, scratched and marred door frames, and dead insects in light fixtures. One room had dead insects in both the bathroom light fixture and the main room ceiling light, along with a dusty ceiling vent; another had scratched and marred room and bathroom door frames, a dusty bathroom vent, and dead insects in both room and bathroom light fixtures; another had scratched and marred door frames and a dusty bathroom vent; and multiple additional rooms had dusty bathroom ceiling vents. During interview at the time of the tour, the Environmental Supervisor stated that all of the observed conditions were in need of cleaning and/or repair.
Failure to Provide Adequate Supervision and Remove Environmental Hazards
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent falls for one resident and to maintain a safe, hazard‑free environment for another resident. Resident B, who had diagnoses including subarachnoid hemorrhage and chronic respiratory failure, was not cognitively intact for daily decision making and was dependent on staff for toileting and transfers. Her care plan identified her as at risk for falls and required staff to anticipate and meet her needs, keep the call light within reach, respond promptly to requests for assistance, and ensure appropriate footwear. Despite this, she experienced multiple falls, including an unwitnessed fall in the bathroom. The North Unit Manager reported that on one occasion the resident was left alone on the toilet and fell while attempting to transfer herself, even though she should not have been left unattended. The deficiency also includes the presence of an accident hazard in another resident’s room and the resulting injury. Resident C, who was cognitively intact and required supervision with ADLs, was observed with visible swelling of the right foot, ankle, and lower leg and reported that he injured his foot when a broken closet door in his room hit him while he was trying to fix it. The closet door was observed hanging off its track and away from the closet on multiple days, and the resident stated that staff were aware of the issue. He reported difficulty walking due to pain and swelling, at times ambulating with a cane and at other times propelling himself in a wheelchair with only his left shoe on because the right shoe would not fit. A nurse practitioner note documented that the resident had previously reported right foot pain after hurting his foot on the closet in his room, and the closet door remained hanging off the track during subsequent observations.
Failure to Accurately Document Resident Death in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record related to a resident death when documentation of the death was missing from the progress notes. Resident J, who had diagnoses including end stage renal disease, had a Death in Facility MDS entry completed on 12/11/25. A progress note on that date at 9:39 a.m. documented that the resident left the facility to go to dialysis with no acute distress noted at that time, and there were no further progress notes entered afterward. During interview, the Director of Nursing stated that the resident went to dialysis, coded there, died that day, and did not return to the facility, and acknowledged that the resident’s death had not been documented in the progress notes, although the discharge would have been reflected in the midnight census. This deficiency was identified for 1 of 5 residents reviewed for accidents (Resident J) and relates to Intake 2712287 under 3.1-50(a)(1), which requires safeguarding resident-identifiable information and maintaining medical records in accordance with accepted professional standards.
Failure to Maintain Resident Dignity Related to Daytime Hospital Gown Use
Penalty
Summary
The facility failed to maintain a resident's dignity by allowing Resident 35 to remain in a hospital gown during the day despite the resident being cognitively intact for daily decision making and dependent in ADLs. During multiple observations, Resident 35 was seen in bed wearing a hospital gown, and during interviews the resident stated he did not want to wear a hospital gown and had his own clothes in his closet. The resident's record did not contain documentation that he preferred to wear a hospital gown during the day.
PASARR Screening Not Completed at Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not properly documented for one resident reviewed. The resident had diagnoses including PTSD and major depressive disorder, was admitted from another long term care facility, and the admission MDS dated 1/31/26 indicated the resident was cognitively intact for daily decision making. The resident’s care plan dated 2/6/26 identified trauma informed care related to military trauma or exposure, with interventions including emotional support and psychiatry/psychology services. A Level 1 PASARR dated 9/16/24 indicated that a Level 2 was not required, but a new Level 1 at the time of admission was not available for review. During interview, the Social Service Director stated that a new Level 1 and Level 2 were not completed at admission and that she relied on the prior Level 1 outcome, although she was not aware of the resident’s current diagnoses of PTSD and major depressive disorder.
No Care Plan for Pain and Opioid Use
Penalty
Summary
A comprehensive care plan was not in place for pain management for Resident 131, who had diagnoses including polyneuropathy and was receiving hydrocodone-acetaminophen for pain. The resident had a physician order for scheduled hydrocodone-acetaminophen 5-325 mg twice daily from 11/9/25 through 2/12/26, followed by an order on 2/13/26 for hydrocodone-acetaminophen 5-325 mg every 6 hours as needed for pain. The Quarterly MDS dated 1/15/26 indicated the resident had received scheduled pain medication and opioid medication in the past seven days, and the MAR for 2/2026 showed the opioid was administered as ordered. Record review found there was no care plan for pain or opioid medication use, and the DON and MDS Consultant confirmed during interviews that no such care plan was in place.
Missed Quarterly Care Plan Conference
Penalty
Summary
The facility failed to ensure a quarterly care plan conference was held for one resident reviewed for care planning. During an interview, the resident stated he was his own responsible party and had not been invited to or participated in any care plan conferences for a while. Record review showed a care plan meeting progress note dated 9/30/25 indicating a care plan conference was held and the resident attended, and a quarterly MDS assessment dated 1/9/26 indicating the resident was moderately cognitively impaired. However, there was no documentation that the resident had been invited to any further care plan meetings, and no documentation that any care plan meetings had been held since 9/30/25. The Nurse Consultant stated during interview that the last care plan conference was completed in September 2025 and she could not find any additional care plan meeting documentation.
Failure to Provide Scheduled One-to-One Activities
Penalty
Summary
The facility failed to provide activities to support the psychosocial well-being of a cognitively impaired, dependent resident who had diagnoses including anoxic brain damage and persistent vegetative state. The Quarterly MDS dated 2/10/26 indicated the resident was not cognitively intact and was dependent in ADLs. The Quarterly Activities Review dated 2/5/26 stated the resident was to receive one-to-one room visits, with staff reading to her and playing music for sensory stimulation, and the care plan revised on 8/24/24 included one-to-one visits three times per week for little or no activity involvement related to a brain injury. During multiple observations, the resident was repeatedly found lying in bed, blankly staring at the wall or awake with no staff interaction observed. On several occasions the television or radio was on, but staff were not present providing activity engagement. The record showed only a few one-to-one activity entries in January, including music, reading the Daily Chronicle, and making sure the TV was on. During interview, the Activities Director stated the resident should have been getting one-to-one visits three times a week and that the staff member who previously performed those visits had left.
Inaccurate Admission Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate documentation of pressure ulcers was completed upon admission for two residents. Resident 2 was admitted with diagnoses including stroke, history of traumatic brain injury, and severe protein calorie malnutrition. The admission MDS indicated the resident was cognitively intact and had two Stage 3 pressure ulcers present on admission, but the admission assessment documented only an ace wrap to both lower extremities and noted the resident refused a skin assessment. Discharge paperwork from the prior facility stated the resident’s skin was intact with no open areas or treatments, and nursing notes showed repeated refusals of care and skin assessment before wounds were later documented on the buttocks and left shin on 1/30/26. For Resident 2, the wound documentation on 1/30/26 described impaired skin to the right buttock, left buttock, and left shin, and physician orders were written that same day for wound care to the buttocks and shin. The wound rounds notes identified the buttock areas as Stage 3 pressure areas, and the care plan addressed pressure ulcers related to immobility. During interview, the wound nurse consultant stated the resident had refused skin assessments on 1/28, 1/29, and 1/30, and that no one had been able to assess his skin on admission. She also stated she did not contact the prior facility to confirm whether the skin was intact at discharge. Resident 133 was admitted with documentation that only a skin tear to the left breast was present and no other skin issues were noted on the admission observation and progress note. However, later wound rounds assessments documented Stage 3 pressure ulcers to both buttocks as present upon admission, while the MAR and TAR lacked treatment documentation for the buttocks until 2/16/26. During interviews, the DON stated the wounds were documented as present on admission because that was the admission assessment, while the wound care nurse consultant and wound nurse later stated the staging was incorrect and that the wounds were first assessed on 2/16/26. The wound nurse also stated she documented the buttock wounds as present on admission because she believed they likely existed before admission, but acknowledged that documentation was incorrect.
Delayed Reweight and RD Notification After Significant Weight Loss
Penalty
Summary
The facility failed to ensure acceptable nutritional parameters were maintained for a resident with chronic kidney disease and anemia after a hospitalization. The resident was admitted to the facility, had a care plan for a nutritional problem related to a therapeutic diet and dietary restrictions, and the 5-day MDS indicated the resident was moderately impaired for decision-making, held food in his mouth, weighed 219 pounds, had significant weight loss, and received a therapeutic diet. The record showed the resident weighed 237 pounds on 1/30/26 and 219 pounds on 2/7/26, reflecting an 18-pound loss after returning from the hospital on 2/7/26. After the hospital return, the next documented weight was not obtained until 2/14/26, when the resident weighed 227 pounds, and there was no reweight documented after the 18-pound weight loss. There was also no documentation that the RD was notified of the weight loss after the resident returned from the hospital, no supplements had been ordered, and the resident was not seen by the RD until 2/20/26. During interview, the DON stated the RD was not notified after the resident returned even though he had a weight loss, and the resident was not reweighed after the 18-pound weight difference. The facility policy indicated a reweight should be obtained as soon as possible after an unanticipated weight change of 5 pounds or greater and that an undesired or unanticipated weight loss of 5% in 30 days should be reported to the physician and RD.
Inconsistent Documentation of G-Tube Feedings
Penalty
Summary
The facility failed to ensure that residents with gastrostomy tubes received appropriate treatment related to the administration of tube feeding for 2 of 2 residents reviewed. Resident 50 had diagnoses including gastrostomy, dysphagia, and adult failure to thrive, and was cognitively impaired with most nutrition received by tube feeding. The physician’s order dated 2/4/26 directed Jevity 1.5 at 75 ml/hr continuously for 21 hours for a total of 1575 ml per day, but there were no documented times to turn the feeding on or off. The MAR for 2/2026 showed the tube feeding was signed off every shift, but the documentation did not consistently record the amount infused; some entries were in milliliters, some percentages, and some yes/no, and none of the days added up to the ordered daily volume. Resident 133 had dysphagia and a care plan indicating a swallowing problem requiring tube feeding. The physician’s order summary for 2/2026 directed Osmolite 1.5 at 50 ml/hr continuously for 21 hours, but there were no documented times to turn the feeding on or off. The MAR for 2/2026 showed the tube feeding was signed off every shift, yet it also lacked documented start and stop times. During interview, the Nurse Consultant stated there was an issue with how the tube feeding orders had been entered into the computer and that they would be updated. The facility policy titled Gastrostomy Tube-Feeding and Care stated the licensed nurse would review the physician’s order for formula, concentration, rate of flow, and method of administration.
Unattended Medications Left on Cart During Medication Pass
Penalty
Summary
The facility failed to ensure medications were not left unattended on top of the medication cart during medication administration for 2 of 6 residents observed during medication pass, including Residents 7 and 46. On 2/18/26 at 3:52 p.m., a punch card containing two pills was observed unattended on top of the medication cart on the PCU Unit with no name on the punch card. At 4:03 p.m., the Assistant Director of Nursing and LPN 3 were observed sitting behind the nursing station, and the medication was still on top of the medication cart. During an interview at 4:24 p.m., LPN 3 indicated she thought the pills were empty, then pulled them out of the garbage can where she had thrown them away and stated there were 2 pills left and they were Aricept. On 2/18/26 at 3:55 p.m., LPN 4 was observed completing a glucometer blood sugar check for Resident 46. The LPN gathered her supplies and entered the resident's room at 3:59 p.m. to wash her hands, leaving the resident's insulin pen unattended on top of the medication cart while she washed her hands. She exited the room at 4:00 p.m. and then entered the room again and closed the door, while the insulin pen was again left on top of the medication cart during the glucometer check. During an interview at 4:25 p.m., the Assistant Director of Nursing indicated the insulin should not have been left unattended on top of the medication cart while not in view of the nurse. The current and undated Storage of Medications policy stated medications were to be stored safely, securely, and properly following the manufacturer's recommendations.
Infection Control Practices Not Followed for Bathroom Items and PICC Port Care
Penalty
Summary
Infection control practices were not implemented related to the storage of urinals and a wash basin on the South Unit. On 2/16/26 at 2:30 p.m., two urinals were observed hanging from the grab bar in the bathroom and a yellow wash basin was observed on the floor underneath the bathroom sink; neither item was contained. On 2/24/26 at 1:50 p.m., three urinals were again observed hanging from the grab bar in the bathroom and the wash basin remained on the floor underneath the bathroom sink. Two residents lived in the room and used the bathroom. During interview, the DON stated the urinals and wash basin should have been contained in plastic bags when not in use. The facility also failed to cleanse a PICC port before IV antibiotic administration for Resident 7. On 2/18/26 at 7:39 a.m., an LPN administered an IV antibiotic after giving oral medications, removed the cap from the resident’s PICC line port, and flushed the port with normal saline without cleansing it with an alcohol wipe first. The port then touched the resident’s sheets, and the LPN did not cleanse the port before connecting the IV antibiotic tubing. During interview, the LPN stated she thought the orange cap was an alcohol cap and said she did not wipe the single lumen with an alcohol wipe before administering the IV antibiotic. The facility’s Central Venous Catheter policy stated the valve was to be cleaned with alcohol and allowed to dry before flushing and again before inserting the agent.
Failure to Thoroughly Investigate Abuse Allegation Involving Non-Communicative Resident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with severe cognitive impairment and multiple disabilities. An incident was reported in which a resident claimed to have witnessed inappropriate sexual contact between a staff member and another resident who was non-communicative and dependent in all activities of daily living. The facility's investigation was limited to a head-to-toe assessment of the alleged victim, a brief interview in which the resident was unable to respond, and a review of staffing and camera footage. No interviews were conducted with other staff or residents, and there was no documentation of the incident in the resident's record. Additionally, the facility did not perform a psychosocial follow-up assessment or notify the family or responsible party of the abuse allegation or investigation. The resident's medical record lacked any mention of the reported incident, and the facility's own policy required more comprehensive investigative procedures, including interviews with all relevant parties and documentation of all incidents. The administrator confirmed that no further assessments or notifications were made regarding the alleged abuse.
Failure to Complete and Document Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically showers and bathing, were completed and properly documented for dependent residents. For one resident with diagnoses including spinal cord disease, schizophrenia, gout, and depression, records showed the individual required substantial to maximum assistance for most ADLs and was dependent for showering. However, there was no documentation of showers or bed baths for a three-month period, and the weekly skin assessments used by the facility did not indicate whether bathing had occurred, only documenting skin observations. Similarly, another resident with diagnoses such as COPD, depression, adult failure to thrive, dementia, cerebral palsy, and schizophrenia, also required substantial to maximum assistance for showering. Review of this resident's records revealed no documentation of showers over a nearly one-month period. In both cases, the DON confirmed that the facility relied on weekly skin assessments to document showers, but these assessments did not specify if showers or bed baths were completed.
Failure to Complete Medication Administration and Post-Fall Assessments
Penalty
Summary
The facility failed to provide necessary care and services for two residents, resulting in deficiencies related to medication administration and post-fall assessments. For one resident with diagnoses including heart disease, COPD, sepsis, depression, dementia, and anxiety, the Medication Administration Records showed that prescribed medications (aspirin, Zoloft, and Norco) were not documented as administered on multiple occasions. Physician orders required these medications to be given via PEG-tube, but the records for October and November indicated several blank entries where medications were not signed out as completed. The Director of Nursing was unable to provide an explanation for the missed doses. Another resident, with diagnoses such as respiratory failure, COPD, diabetes, kidney disease, dialysis, and dementia, experienced an unwitnessed fall. Although initial neurological checks were started, the Neurological Assessment Form was not completed at several required intervals, and the 72-hour post-fall documentation was discontinued prematurely. The resident's care plan called for ongoing assessment and interventions following the fall, but documentation and follow-up assessments were not completed as required by facility policy. The Director of Nursing confirmed that the required neurological and post-fall assessments were not fully carried out.
Failure to Follow Updated Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident C, who had a pressure ulcer on the coccyx. The deficiency was observed when the Director of Nursing (DON) and Unit Manager 1 were performing pressure ulcer treatments and found that the dressing applied was not as per the physician's updated orders. The physician had ordered a duoderm dressing to be applied every three days, which was later changed to a calcium alginate and border gauze dressing to be applied daily. However, the dressing observed was a border gauze dressing dated 1/22/25, indicating a failure to follow the updated treatment plan. The resident's medical record review revealed a significant change in the treatment order on 1/17/25, which was not transcribed into the resident's record until 1/22/25. The DON was unaware of the change in orders until the day of the observation. The Treatment Administration Record showed that the duoderm dressing was applied on 1/20/25, and the new treatment was supposed to start on 1/23/25. This oversight in updating and following the physician's orders led to the deficiency in providing necessary treatment and services to promote healing of the pressure ulcer.
Failure to Use Correct PPE in COVID-19 Red Zone
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by a staff member when cleaning a room of a COVID-19 positive resident, identified as Resident F, who was under COVID-19 Transmission-Based Precautions. During an observation, Housekeeper 1 was seen mopping the floor in Resident F's room, which was marked as a Red Zone, indicating the need for specific PPE including a N95 mask, gown, gloves, and face shield. However, Housekeeper 1 was only wearing a surgical mask and no face shield. Upon interview, Housekeeper 1 expressed uncertainty about the requirement to wear a N95 mask and face shield. Resident F's medical record confirmed a diagnosis of COVID-19 and required droplet precautions. The facility's COVID-19 policy, dated 7/24/23, specified the necessary PPE for Red and Yellow Zones, which was not adhered to in this instance.
Inadequate Neurological Assessment Follow-Up After Resident Fall
Penalty
Summary
The facility failed to complete adequate follow-up for a fall incident involving Resident B, who was identified as a fall risk due to cancer and medications. Resident B experienced an unwitnessed fall and the facility's neurological assessment protocol required checks every four hours for 24 hours following such an event. However, the documentation showed that neurological assessments were not consistently completed as required. Specifically, assessments were recorded at three intervals on the day of the fall and only once the following day, leaving gaps in the required four-hourly checks. The Director of Nursing confirmed that the assessments should have been completed and documented every four hours, as per the facility's policy.
Environmental Deficiencies in Facility Units
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents across three units: North, South, and PCU. Observations during an environmental tour revealed multiple deficiencies, including dirty and discolored floor tiles, marred walls, and missing or broken fixtures. In the North Unit, several rooms had issues such as discolored floors with dirt and debris accumulation, marred doors, and broken towel racks. Bathrooms in these rooms were particularly problematic, with dirty floors, scuffed tiles, and missing toilet bolt covers. In the South Unit, broken and missing mini blinds were noted, along with marred walls and dirty floors. The PCU also exhibited significant environmental issues, including scuffed floors, rusty toilet bolts, and missing caulk around toilets. The bathroom ceiling vents were found to be dusty and dirty. During an interview, the Maintenance Director and Housekeeping Supervisor acknowledged awareness of these issues and indicated ongoing efforts to address them. These findings relate to a specific complaint, IN00436414.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy of two residents, as staff members did not knock on their doors before entering their rooms. Resident 2 reported that staff did not always knock before entering her room. This was observed when a CNA opened the door without knocking and then closed it, and another staff member partially opened the door without knocking. Resident 2's medical record indicated diagnoses including bipolar disorder, type 2 diabetes, major depressive disorder, and schizophrenia, with a moderate impairment in daily decision-making as per the Quarterly MDS assessment. Similarly, Resident 9 also reported that staff did not always knock before entering her room. This was confirmed when a housekeeper entered the room to replace a trash bag without knocking. Resident 9's medical record showed diagnoses of major depressive disorder and anxiety, with cognitive impairment in daily decision-making according to the Quarterly MDS assessment. The Director of Nursing acknowledged that staff should have knocked before entering the residents' rooms.
Failure to Provide Adequate Personal Hygiene for Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately completed for three residents who were dependent on staff for personal hygiene. Resident 35 was observed multiple times with dirty and long fingernails on both hands. The resident had a history of stroke, aphasia, diabetes, hemiplegia, heart disease, and high blood pressure, and was not cognitively intact for daily decision-making. The care plan indicated a need for staff assistance with personal hygiene, but there was no documentation in the electronic medical record (EMR) that the resident's fingernails had been cleaned or trimmed. The Assistant Director of Nursing (ADON) confirmed the need for nail care. Resident 58 was observed with long facial hair under her chin and neck, despite being shaved two days prior. The resident had diagnoses including type 2 diabetes, stroke, hemiplegia, high blood pressure, UTI, obstructive uropathy, dementia, anxiety, and depressive disorder, and was cognitively impaired for daily decision-making. The care plan noted an ADL self-care performance deficit, but no shaving was documented in the EMR. Similarly, Resident 236 was observed with facial hair, and the resident's daughter indicated that her brother was shaving him. The resident had a care plan indicating an ADL self-care deficit related to mobility and weakness, but no shaving was documented in the EMR. The ADON was unaware of the resident's preference to be clean-shaven.
Failure to Complete Ordered Treatments and Obtain Psychiatric Consults
Penalty
Summary
The facility failed to ensure that non-pressure ulcer treatments were completed as ordered for three out of four residents reviewed for skin conditions. Specifically, Resident 94 was observed with a scaly, scabbed, and inflamed left lower leg without any bandages, despite having a physician's order for Hydrocortisone cream application and wrapping with Kerlix on specific days. The Treatment Administration Records (TAR) for Resident 94 showed multiple instances from April to August 2024 where the treatment was not documented as completed. The resident's care plan indicated resistance to care and refusal of wound care, but the treatments were still not signed out as completed, as confirmed by the Assistant Director of Nursing (ADON) during an interview. Additionally, the facility failed to obtain a psychiatric consult as ordered for Resident 107, who was reviewed for unnecessary medications. Resident 107, diagnosed with multiple conditions including Parkinson's disease and psychotic disorder, was prescribed several psychiatric medications. However, there was no documentation or consents obtained for the resident to seek outside behavior management, and the psychiatric consult was not obtained in a timely manner. The ADON and Nurse Consultant confirmed the oversight during interviews, indicating a lapse in ensuring the resident received the necessary psychiatric evaluation and management.
Failure to Apply Palm Protector as Ordered
Penalty
Summary
The facility failed to ensure that a palm protector was applied as ordered by the physician for a resident with limited range of motion. During an observation, the resident was seen without the required anti-contracture device in her right hand, which was clenched like a fist. The resident's medical history includes stroke, aphasia, diabetes, hemiplegia, heart disease, and high blood pressure. The care plan specified the use of a palm protector for the resident's right hand due to hemiplegia from a stroke. The physician's orders allowed for a palm protector or a rolled washcloth to be used, but there was no documentation in the Medication and Treatment Administration Records for several months to indicate whether the palm protector was applied or removed. The electronic medical record task section also showed that the palm protector was marked as not applicable, with no documentation of refusal by the resident. The Assistant Director of Nursing confirmed the lack of documentation regarding the use of the palm protector.
Improper Foley Catheter Care Observed in Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with a Foley catheter, as the catheter bag and tubing were repeatedly observed on the floor. During multiple observations, the catheter bag and tubing were seen on the floor while the resident was in bed and in a wheelchair. Staff members, including CNAs and the Director of Rehabilitation, were aware that the catheter bag should not be on the floor, yet it remained there during various times, including when the resident was transported to and from therapy. The resident involved had a history of type 2 diabetes, stroke, hemiplegia, high blood pressure, urinary tract infection, obstructive uropathy, dementia, anxiety, and depressive disorder. The resident was cognitively impaired and required substantial assistance with personal hygiene. Despite the facility's urinary catheter care policy, which mandates that catheter bags and tubing should not touch the floor, the deficiency persisted. The Director of Nursing confirmed that the catheter bag and tubing should not be on the floor, indicating a lapse in adherence to the facility's policy.
Deficiencies in Feeding Tube Management and Care
Penalty
Summary
The facility failed to ensure proper management and care for residents with feeding tubes, as observed in two cases. Resident 10, who had a PEG tube due to an intestinal obstruction and was cognitively impaired, was found with his tube feeding pump turned off and not connected to his feeding tube during scheduled feeding times. The physician's order specified that the tube feeding should be administered from 7:00 p.m. to 9:00 a.m., but observations indicated non-compliance with these orders. The resident's care plan required dependency on tube feeding and water flushes, yet these interventions were not properly executed. In the case of Resident 107, who had a PEG tube and was not cognitively intact, there was a lack of appropriate stoma site care. The resident's PEG tube site was observed with dried crusty drainage and no bandage, and there were no physician's orders for cleaning the stoma site. Despite the facility's policy requiring stoma site cleaning, the staff did not perform this care, as confirmed by interviews with the RN and the DON. The resident's care plan indicated the need for tube feeding due to swallowing difficulties, but the absence of orders for stoma care led to inadequate management of the resident's condition.
Oxygen Flow Rate Discrepancies for Two Residents
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate for two residents requiring respiratory care. Resident 236 was observed multiple times with oxygen set at 2.5 liters per minute, despite the physician's order and care plan indicating it should be set at 3 liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an observation. Resident 236 had been admitted with diagnoses including pneumonia and high blood pressure, and the care plan specifically required oxygen therapy at the prescribed rate. Similarly, Resident 55 was observed with oxygen set at 3 liters per minute, contrary to the physician's order of 2 liters per minute. The resident's medical history included anoxic brain damage, dysphagia, hypertension, and COPD, necessitating precise oxygen therapy. The Medication Administration Record indicated that oxygen was documented as being administered at the correct rate of 2 liters, yet observations showed otherwise. The ADON acknowledged the discrepancy and noted that staff had been auditing the oxygen settings.
Medication Error Rate Exceeds 5% Due to Insulin and Discontinued Medication Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by two errors observed during medication administration for two residents. The first error involved an LPN who did not prime an insulin pen before administering 10 units of insulin to a resident. The facility's policy requires that insulin pens be primed to remove air bubbles and ensure proper dosage delivery. This step was omitted during the medication pass, as confirmed by the 200 Unit Manager. The second error occurred when another LPN administered a 25 mg tablet of Aldactone to a resident, despite a physician's order discontinuing the medication. The error was identified upon review of the resident's records, which showed the discontinuation order dated prior to the administration. The Nurse Consultant confirmed that the medication should not have been given, as it was no longer prescribed for the resident.
Failure to Provide Annual Dental Services
Penalty
Summary
The facility failed to ensure that a resident received dental services at least annually, as required. Resident 88, who was observed with missing upper and lower teeth, reported not having seen a dentist since arriving at the facility in 2022 and expressed a desire for dentures. The resident's medical record, reviewed on 9/18/24, included diagnoses such as hypotension, anemia, adult failure to thrive, respiratory failure, heart failure, kidney disease, and dependence on renal dialysis. The Quarterly MDS assessment indicated the resident was moderately impaired in daily decision-making, yet there was no dental care plan in place. A physician's order from 2/5/24 allowed for dental care as needed, but the resident had not been seen by a dentist due to an initial misunderstanding about insurance issues, which was later corrected. Despite signing a new dental agreement on 8/29/24, the resident was not included on the dental list for the dentist's visit on 9/11/24.
Inaccurate Documentation of 15-Minute Checks for Resident
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident who was involved in an abusive incident. Resident 94, who has a history of schizophrenia, morbid obesity, cellulitis, high blood pressure, major depressive disorder, anxiety, osteoarthritis, and bipolar disorder, was not cognitively intact for daily decision-making according to a recent assessment. The resident had a potential for physical aggression as noted in their care plan. An incident occurred where Resident 94 pushed another resident to the ground after a verbal altercation in the bathroom. Following this incident, Resident 94 was moved to a different room and placed on 15-minute checks. However, the documentation of these 15-minute checks was found to be inaccurate and incomplete. The records showed that the checks were either time-stamped before or significantly after the actual observation times. For instance, on one day, the checks were documented at times that did not align with the required 15-minute intervals, with some periods left blank. During an interview, the Assistant Director of Nursing (ADON) confirmed that the time stamps were not accurate, indicating a failure in maintaining proper clinical records as per professional standards.
Infection Control Deficiencies in Hand Hygiene, PPE Use, and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a glucometer blood sugar check for a resident. An LPN was observed entering the resident's room and donning gloves without washing or sanitizing her hands upon entry or before putting on the gloves. The facility's hand hygiene policy, which was identified as current, indicated that hand hygiene should be completed upon room entry. This oversight was confirmed during an interview with the Nurse Consultant, who stated that it would be expected for staff to sanitize their hands prior to donning gloves. Additionally, a CNA failed to don the required personal protective equipment (PPE) for a resident under enhanced barrier precautions (EBP) due to wounds and infection. The CNA provided incontinence care to the resident without wearing a gown, as required by the EBP sign above the resident's bed. The CNA mistakenly believed the EBP was for another resident. Furthermore, a resident with a Foley catheter was observed multiple times with the catheter drainage bag on the floor, contrary to the facility's urinary catheter care policy, which mandates that drainage bags and tubing should not touch the floor. The resident's medical history included stroke, chronic kidney disease, and other conditions, and the resident was not cognitively intact for daily decision-making.
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 1,247 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gary
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Shore Health & Rehabilitation Center | 2.2 mi | ★★★★★ | 36 | 0 |
| Casa Of Hobart | 4.3 mi | ★★★★★ | 27 | 0 |
| Waters Of Hobart Skilled Nursing Facility, The | 4.4 mi | ★★★★★ | 0 | 0 |
| Harbor Health & Rehab | 6.1 mi | ★★★★★ | 38 | 0 |
| Rehabilitation Center At Hartsfield Village | 7 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.