Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pin Oaks Living Center during CMS and state inspections, most recent first.
Insufficient Nursing Staffing and Delayed Response to Resident Needs: The facility did not provide enough direct care staff to meet resident needs, and call lights and incontinence care were often delayed. A resident with bilateral BKA waited hours after using the call light and was found saturated with urine and feces with irritated skin, while other residents with incontinence and transfer needs were also observed with red, soiled skin and long waits for assistance. Staff, including CNAs, CMTs, an LPN, an RN, and the DON, described frequent short staffing, call lights going unanswered for long periods, and incontinent residents being checked and changed about every three hours instead of every two.
A resident with a sternal wound infection after cardiac surgery had ordered biweekly wound vac changes, but the order was transcribed incorrectly and the dressing changes were not consistently completed as ordered. Staff documented some changes, but the wound vac was left in place too long, and the sponge became severely adhered to the wound bed and sternum. The resident required urgent debridement, omental flap mobilization, and skin grafting, along with an extended hospital stay and BH consult after expressing suicidal thoughts.
Resident Council Concerns Not Addressed: The facility did not respond to repeated Resident Council grievances about long call light wait times, delayed toileting and showers, food quality, missing laundry, and housekeeping issues. A resident council president and another resident reported that concerns were raised month after month with no follow-up from the DON, Administrator, or department heads, and one resident described incontinence accidents while waiting for staff assistance. The minutes lacked documented responses or actions taken, and the DON stated she was not aware of her role in council follow-up.
A resident with a history of stroke and mobility issues experienced a fall resulting in injury, but staff did not complete required assessments, documentation, or obtain physician orders for treatment. The responsible party was not notified, and the incident was not properly recorded until after the resident was discharged, with staff interviews confirming that standard procedures were not followed.
Failure to Post Accurate Daily Staffing Information: The facility did not consistently display the daily staffing sheet for public view and repeatedly posted staffing hours that did not match employee time records. The DON said she was responsible for posting and updating the sheets, but they were not always available at the entrance and were not always accurate. The Administrator also added two CMT names to a staffing sheet during the survey interview, then acknowledged they were entered in error after both CMTs said they did not work that day and the time records confirmed it.
The facility failed to ensure the DON served full-time in their role and did not act as a charge nurse despite having over 60 residents. The DON was observed working as a floor nurse, which interfered with her administrative duties. She also served as the Infection Preventionist, working dual roles due to staffing shortages. The Administrator confirmed the extensive working hours and mentioned contacting the corporate office for agency nurse support.
The facility failed to monitor residents on psychotropic medications, affecting five residents. Policies required staff to document and report medication effectiveness, but this was not done. Residents lacked behavior and side effect monitoring, and care plans did not address psychotropic medication use. The DON confirmed expectations for monitoring, but it was not implemented.
The facility failed to secure medications properly, with an unlocked medication cart and an unattended open medication room. Controlled medications were left unsecured on a counter, contrary to policy. An LPN and CMT confirmed these lapses, and the Administrator acknowledged the need for secure storage.
The facility failed to maintain infection control during medication administration, nebulizer equipment handling, and wound care. An LPN administered medication by pouring a tablet into her bare hand, contrary to expected practices. A resident's nebulizer mask was not cleaned or bagged after use, and oxygen tubing was not changed weekly as required. Additionally, the DON/IP did not sanitize hands between glove changes during wound care, violating the facility's infection control policy.
A facility failed to assess and obtain a physician's order for a resident to self-administer medications, as required by policy. Over-the-counter medications were found in the resident's room without proper authorization. A CMT also failed to observe the resident taking prescribed medications. Staff interviews confirmed the oversight, highlighting a lapse in following medication administration guidelines.
The facility failed to properly document and honor the code status of two residents, leading to potential non-compliance with their advance directives. One resident's DNR form lacked a physician's signature, and another resident's code status was inconsistently documented, causing confusion among staff about their resuscitation preferences.
The facility failed to notify two residents of potential non-coverage and financial liability for services not covered by Medicare. Notices of Medicare Non-Coverage were issued, but no Advanced Beneficiary Notices were provided when coverage ended, and the residents continued to receive skilled nursing care. The Administrator admitted to using the wrong form for beneficiary notices.
A resident with severe cognitive impairment was verbally abused by another resident who was cognitively intact. The incident was documented by an LPN but was not investigated or reported as required by the facility's policy. Interviews with the DON and Administrator revealed awareness of the incident, but no clear actions were taken to address the potential abuse.
The facility failed to report abuse allegations involving three residents. A cognitively intact resident reported staff-to-resident abuse, which was not reported to authorities. Another incident involved a cognitively impaired resident verbally abused by another resident, also not reported. The Administrator was unaware of reporting requirements during a survey.
The facility did not investigate an incident of verbal abuse between two residents, one severely cognitively impaired and the other cognitively intact. Despite documentation by an LPN, interviews with the DON and Administrator confirmed the lack of investigation, contrary to facility policy.
The facility failed to provide comprehensive care plans for three residents, leading to potential gaps in care. One resident with COPD did not have a care plan for oxygen use, another lacked plans for mental health conditions and medication administration, and a third did not have updated interventions after a coffee burn incident. Staff confirmed these deficiencies.
A facility failed to complete a discharge summary for a resident who was transferred to another facility. The resident, admitted with multiple diagnoses including sepsis and multiple myeloma, was discharged without a completed discharge summary, as required by the facility's policy. This was confirmed by the Social Services Director during an interview.
The facility failed to implement scheduled activities programs, impacting residents' participation and documentation. A resident with moderate cognitive impairment was not engaged in activities despite documented preferences, and no alternative activities were offered. The Activities Director's absence led to a lack of routine group activities, confirmed by staff interviews.
A resident at risk for pressure ulcers developed a stage 2 ulcer due to inadequate care. The resident's Broda chair lacked a pressure-reducing cushion, contrary to care plan requirements. Facility staff were misinformed about cushion use in Broda chairs, and wound care orders were incomplete.
A resident with chronic obstructive pulmonary disease, using continuous oxygen therapy, was taken to a smoking patio with the oxygen tank still attached to their wheelchair, posing a fire hazard. The staff responsible for supervision had not received formal training on managing smokers with oxygen use, leading to the potential risk. Interviews revealed that staff were only instructed to turn off the oxygen but not to remove the tanks from the smoking area.
A resident with ESRD receiving hemodialysis lacked physician orders for the care and maintenance of their dialysis catheter, leading to potential inconsistent care. Despite facility policy requiring such orders, none were found in the resident's records. The resident's care plan noted frequent attempts to dislodge the catheter, with most care provided by a community dialysis center.
The facility failed to assess and obtain informed consent for bed rail use for two residents, R9 and R53, leading to potential injury risks. R9, with moderate cognitive impairment, had bed rails without documentation of assessment or consent. Similarly, R53 had bed rails without a current assessment or consent, despite an outdated order. The facility's policy requires these steps, which were not followed.
The facility failed to ensure the safety of bed rails for two residents, both moderately cognitively impaired, as their bed rails were found to be loose. Despite the facility's policy for regular inspections, the loose rails were not documented or addressed in the maintenance log. The Maintenance Director confirmed the absence of a formal monitoring process, and the DON stated that bed rails should be maintained and safe.
A resident's medications, including oxycodone/acetaminophen and gabapentin, were found missing in a facility. The medications were brought from home and counted by staff upon admission. However, discrepancies in medication counts and documentation were discovered, and staff interviews revealed that narcotic counts were not consistently conducted at shift changes. The facility could not determine if the medications were miscounted or misappropriated.
A facility failed to properly handle and document medications for a resident, including not completing required narcotic counts at shift changes and not verifying medications brought from home with a pharmacist or physician. This led to discrepancies in medication records and missing medications. Staff interviews revealed a lack of awareness and adherence to facility policies.
The facility failed to ensure staff treated three residents with dignity and respect. A CNA made derogatory comments, ignored call lights, and used inappropriate language, causing emotional distress to the residents. Interviews confirmed the CNA's behavior, and the Interim DON and Administrator were unaware of these incidents.
Insufficient Nursing Staffing and Delayed Response to Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have resident call lights answered and incontinent residents checked and changed in a timely manner. The report states that four residents were affected in a sample of 10, and that the facility census was 89. The Administrator said there was no staffing policy specific to staffing, but expected resident needs to be met and regulatory staffing requirements followed. The Facility Assessment showed an average daily census of 87 and direct care staffing of 8-10 per shift, with staffing based on acuity and continuity of care. Resident #2 was readmitted with diagnoses including bilateral below-the-knee amputations and osteomyelitis. The resident’s care plan said to assist to the bathroom before and after meals, at bedtime, and as needed, and the resident was documented as continent of bowel and bladder. The MDS, however, showed the resident was dependent on toilet transfer and frequently incontinent of bowel and occasionally incontinent of urine. The resident reported turning on the call light around 8:00 A.M. because of a bowel movement need, being told staff would return because two staff were needed for the transfer, and then waiting after turning the call light on again while becoming incontinent of urine and feces. Observation later showed the resident still waiting to be changed, then being transferred back to bed by two CMTs, with urine saturation through the brief and clothing, feces on the perineal area and lower back, and bright red skin where the brief had been. The resident later reported being left in urine and feces for hours, having raw and irritated skin, and feeling upset and hurt by the way staff treated him/her. Resident #3 had diagnoses including Alzheimer’s disease, diabetes, and dementia, and was care planned as incontinent of bowel and bladder and needing staff help with toileting hygiene. Observation showed the resident’s brief removed with bladder and bowel incontinence, dried fecal material to the perineal area, red skin, and creases where the brief had been; staff stated the resident had last been checked and changed about three hours earlier. Resident #4 had diagnoses including end-stage renal disease and hemiparesis after stroke, was cognitively intact, and was dependent on toilet hygiene and chair/bed-to-chair transfer. The resident reported ongoing problems with call lights not being answered in a timely manner, accidents while waiting for staff, feeling ashamed and like a child, and long waits to get back to bed or out of bed. Resident #1 had mixed incontinence and needed assistance with toileting hygiene, dressing, and transfers; observation showed the resident in a wheelchair with a strong urine odor in the hall, a saturated brief, red inner legs and perineal area with creases from the brief, and a urine-soaked cushion and clothing. Staff interviews consistently described short staffing as the reason residents were not checked and changed every two hours and call lights were not answered promptly. CMTs, CNAs, an LPN, an RN, and the DON all stated the facility was short staffed, that call lights could go unanswered for long periods, and that incontinent residents were often checked and changed closer to every three hours. Staffing sheets showed multiple shifts in December 2025 and January 2026 with fewer direct care staff than identified as needed in the Facility Assessment. Resident Council minutes also documented resident complaints about long call light wait times and lengthy waits to be changed and for showers, without documented responses to those concerns.
Missed wound vac changes led to sponge adherence and urgent surgery
Penalty
Summary
The facility failed to follow physician orders for surgical wound care for one resident with a sternal wound infection after cardiac surgery. The resident’s discharge instructions required biweekly wound vac dressing changes, including removal of the old sponge, cleansing with Vashe solution, application of Cavilon to intact skin, placement of a new wound vac sponge, and continuous suction at 125 mmHg. The resident’s record showed the order was transcribed incorrectly on the POS and TAR as wound vac changes twice a day on Monday and Thursday, and staff documented some dressing changes while other scheduled changes were not completed as ordered. The resident’s chart showed inconsistent documentation and missed wound vac care. Staff documented a dressing change on 12/11/25, then later documented that a change was done at the physician’s office on 12/15/25. In January, staff documented that a change had been completed at an appointment, but there was no evidence in the record that the wound vac was changed on the scheduled facility dates. The wound care nurse stated the order was biweekly, not twice a day, and acknowledged the order had been transcribed incorrectly. The care plan did not address wound vac dressing changes or wound vac care. On 01/13/26, the resident was sent to the hospital after the wound vac sponge could not be removed at the facility. Hospital records stated the facility had not performed the wound vac change the prior week because staff believed it had been changed at the clinic, but the wound was not assessed there. During evaluation, the sponge was severely adhered to the wound bed and sternum, and manual debridement could not be fully tolerated. The resident required urgent wound debridement, omental flap mobilization, and skin grafting for final wound closure. The resident remained hospitalized longer and required a behavioral health consult after making statements about wanting to end his/her life due to the situation.
Resident Council Concerns Not Addressed
Penalty
Summary
The facility failed to act promptly on Resident Council grievances and recommendations related to resident care and quality of life, and it did not provide the council with responses or actions taken regarding the concerns raised. The facility census was 89. During an interview, the administrator stated the facility did not have a policy regarding Resident Council meetings and facility response to the meetings, but expected the facility to follow regulatory requirements. Review of the Resident Council minutes showed repeated concerns about long call light wait times, lengthy waits to be changed and for showers, food quality concerns including overcooked or dry chicken and small portions, missing laundry, and housekeeping concerns, but the minutes did not include responses to the residents' concerns. The minutes from one meeting documented that seven residents attended and that Resident Council President Resident #10 led the meeting, while another meeting documented four residents in attendance, including Resident #4, with old business listed for follow-up but no documented follow-up or staff identified as responsible for call lights. Resident #4 stated there was an ongoing issue with staff not answering call lights in a timely manner and that there was never any follow-up from staff to the Resident Council meetings; he/she also reported having incontinence accidents while waiting for assistance and feeling ashamed. Resident #10 stated the same concerns were brought up month after month with no follow-up from the DON, Administrator, or department heads, and that he/she often waited long periods for staff to answer the call light and had accidents while waiting for care. The Activity Director stated he/she typed up letters to departments after each council meeting and spoke with the DON about concerns, but was not sure what the plan of action was. The DON stated she was not aware of her role involving Resident Council concerns, had not received minutes since becoming DON, and was not aware the council had reported ongoing call light issues; the Administrator stated the facility had not addressed the issues identified in the November and December council minutes.
Failure to Assess, Document, and Notify After Resident Fall with Injury
Penalty
Summary
Facility staff failed to follow professional standards of practice by not completing an assessment, documentation, or obtaining physician orders for treatment after a resident experienced a fall with injury. The facility's policy requires staff to observe, record, and report any change in a resident's condition, including after a fall, and to notify the physician and responsible party, complete incident reports, and document all assessments and interventions. In this case, there was no documentation of the fall event, no nursing progress notes regarding the fall or treatment of injuries, and no evidence of physician or responsible party notification on the date of the incident. The resident involved had a history of hemiplegia and hemiparesis following a stroke, was confused, verbally communicative, and had unsteady/unsafe independent transfers. The resident's responsible party reported that the resident fell while attempting to use the bathroom independently, sustained a bruise and skin tears, and was treated with butterfly bandages. However, the responsible party was not notified of the fall or injuries, and the facility's records did not reflect any assessment or treatment orders related to the incident at the time it occurred. Interviews with staff revealed that neurological checks were initiated, but the required documentation, notifications, and incident reporting were not completed. Staff members acknowledged that standard procedure was not followed, with each assuming that the necessary steps would be completed by others. The fall event was only documented retroactively after the resident had been discharged and the incident was brought to the attention of facility leadership.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to routinely post daily staffing sheets at the public entrance and failed to accurately post the number of hours worked by staff who provided care. The facility census was 89. During an email correspondence, the administrator stated the facility did not have a policy specific to posted staffing, but expected the facility to follow the regulatory requirements for posted staffing. On observation, the plastic sleeve at the entrance where staffing was displayed for public view was empty. Review of multiple daily staffing sheets and the corresponding employee electronic time sheets showed repeated mismatches between the posted hours and the actual hours worked. On 1/1/26, the posted sheet listed CNA hours that did not match the hour details report for both day and night shifts. On 1/2/26, the posted CNA hours again did not match the actual hours worked. On 1/3/26, the posted sheet listed RN and CNA hours that did not match the time sheets. On 1/4/26, the posted CNA hours did not match the actual hours worked. On 1/5/26, the posted sheet listed charge nurse, CMT, and CNA hours that did not match the time sheets. On 1/6/26, the posted sheet listed charge nurse and CNA hours that did not match the actual hours worked. During interviews, the DON said she was responsible for posting and updating the staffing sheets and acknowledged they were not always posted for public view and were not always updated to reflect actual hours worked. The Administrator later stated the hours listed as worked on 1/6/26 were incorrect and that two additional CMTs were called in to cover the shift, then wrote those names on the staffing sheet during the interview. However, both CMTs interviewed said they did not work at the facility on that date, and the hour details report showed they did not work that day. The Administrator then stated she had mixed up the days and that the two CMTs were added to the staffing sheet in error.
Failure to Ensure Full-Time Director of Nursing Role
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) served full-time in their role and did not act as a charge nurse when the facility had an average daily occupancy of over 60 residents. This deficiency was identified through observations, interviews, and a review of the DON's job description. The job description required the DON to be present in the facility or engaged in work-related activities for a minimum of eight hours per day, Monday through Friday, and to conduct routine inspections during second and third shifts and weekends. However, during the survey period, the DON was observed working as a floor nurse/charge nurse on Unit 1, which interfered with her ability to fulfill her administrative duties. Interviews with the DON revealed that she was unable to perform daily antibiotic reviews due to her responsibilities as both the interim DON and a floor nurse. She worked on the floor three days a week, performing tasks such as passing medications, providing wound measurements, and handling admissions and discharges. The DON also served as the Infection Preventionist (IP) for 30 hours a week. The dual roles had been ongoing for three and a half months due to staffing shortages, with two day-shift and two night-shift nurses having left. The Administrator confirmed the DON's extensive working hours and mentioned that they had contacted the corporate office regarding the use of agency nurses to supplement staff, but were still awaiting feedback.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring of residents who were administered psychotropic medications, affecting five out of six residents reviewed for unnecessary medications. The facility's policy on antipsychotic medication required staff to observe, document, and report the effectiveness of interventions, including medications, but this was not adhered to. The facility lacked a specific policy for monitoring antidepressant or psychotropic agents, leading to inadequate documentation and monitoring of residents' behaviors and side effects. For Resident 23, there was no routine documentation related to behavior monitoring or side effect monitoring despite being on antidepressant and antipsychotic medications. The Licensed Practical Nurse/Unit Manager confirmed the absence of orders or documentation for monitoring behaviors and side effects. Similarly, Resident 49's care plan did not specify behaviors to be monitored, and there was no evidence of behavior or side effect monitoring in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Resident 56's care plan did not address behaviors or the administration of psychotropic medications, and there was no tracking of specific behaviors or side effects. The Director of Nursing confirmed the expectation for a care plan and tracking of side effects, but this was not implemented. Resident 57 and Resident 48 also lacked evidence of monitoring for behaviors, efficacy, or side effects related to their psychotropic medications, with the Director of Nursing acknowledging the expectation for monitoring and reporting unresolved issues to ensure residents' quality of life.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure proper security measures for medications, as observed in several instances. One medication cart out of five was left unlocked and unattended on Hall 500, South II Wing. An LPN returned to the cart after one minute and realized it was unlocked, despite believing it had been secured. Additionally, a medication room on Hall 100, North Wing, was found with its door wide open and unattended, with no staff present to monitor the area. A CMT returned to the room two to three minutes later and confirmed the door was open, as well as the cabinet containing controlled medications. Further observations revealed that 18 cards of controlled medications were left unsecured on a counter in the medication room. These included medications such as clonazepam, pregabalin, lorazepam, lacosamide, oxycodone, hydrocodone, and tramadol. The LPN/UM confirmed that these narcotic medications were not locked in the cabinet as required. The facility's policy mandates that all medications must be stored securely, and medication carts and rooms should be locked when unattended. The Administrator acknowledged the expectation for medication security and confirmed that controlled medications should be maintained in a double lock manner.
Infection Control Deficiencies in Medication Administration and Equipment Handling
Penalty
Summary
The facility failed to maintain proper infection control during medication administration, as observed when an LPN poured a ferrous sulfate tablet directly into her bare hand before administering it to a resident. The LPN admitted to not recalling any training regarding touching pills with bare hands, and the facility lacked a specific policy addressing this practice. The administrator expected medications to be dispensed directly into a medicine cup without being touched by hands, highlighting a gap in infection control practices. Another deficiency was noted in the handling of nebulizer equipment for a resident with COPD. The resident reported that the nebulizer mask was not cleaned or bagged after use, and observations confirmed the mask was left hanging on the bedrail without being dated or bagged. A CMT confirmed the mask should be bagged and the equipment cleaned after each use, as per the facility's infection control policy. The DON/IP acknowledged the expectation for staff to follow these procedures to prevent respiratory infections. Additionally, the facility failed to ensure proper hand hygiene during wound care. The DON/IP did not sanitize her hands between glove changes while treating a resident's wounds, despite the facility's policy requiring hand washing between glove changes. The DON/IP admitted to being nervous and forgetting to sanitize her hands during the procedure. Furthermore, the facility did not change oxygen tubing weekly as required, with observations showing tubing dated three weeks prior. Both a CNA and LPN confirmed the tubing should be changed weekly, and the DON stated this was the expectation for infection prevention.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R375, had an assessment and a physician's order for self-administration of medications. This deficiency was identified during an observation where over-the-counter medications were found on R375's dresser and bedside table, visible from the hallway, while the resident was not present in the room. The medications included melatonin, low dose aspirin, Miralax, Imodium, lubricant eye drops, and Osteo Bi-Flex. The facility's policy requires an assessment and a physician's order for residents to self-administer medications, which was not completed for R375. Additionally, a Certified Medication Technician (CMT) was observed providing medications to R375 without ensuring the resident took them, as the CMT walked away after placing the medications on the table. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing/Infection Preventionist (DON/IP), confirmed that the medications should not have been at the resident's bedside without proper assessment and order. The DON/IP stated that the admitting nurse should have checked the resident's belongings upon admission to prevent such occurrences.
Failure to Document and Honor Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status and advance directives of residents were properly documented and honored, leading to a deficiency in the care provided. For Resident R375, the facility did not obtain a physician's signature on the Do-Not-Resuscitate (DNR) form, despite the resident having signed it and expressed her wishes not to be resuscitated. The Social Services Director (SSD) acknowledged that the form was faxed to the physician, who was on vacation, and no verbal DNR order was obtained. Consequently, the nursing staff, including Registered Nurse (RN)1, indicated they would perform full resuscitation on R375 due to the lack of a signed DNR form, despite the resident's clear wishes. Similarly, for Resident R48, there was a discrepancy in the documented code status. Although the resident was initially documented as DNR, the electronic medical record (EMR) showed an order for Full Code status. The SSD and RN1 identified that the necessary Out of Hospital DNR form, which should have been signed by both the resident and the physician, was missing from the resident's hard chart. The resident had expressed his preference not to be resuscitated if his heart stopped, but the conflicting documentation and lack of a signed DNR form led to confusion about his code status. Interviews with facility staff, including the SSD, RN1, and the Director of Nursing/Infection Preventionist (DON/IP), revealed that there were expectations for obtaining and documenting code status changes immediately, with appropriate signatures from both the resident and the physician. However, these procedures were not followed, resulting in the potential for residents' advance directive wishes not being honored. The facility's policies on CPR and advance directives were also found to be lacking in clarity regarding the handling of code status and CPR provision.
Failure to Notify Residents of Non-Coverage and Financial Liability
Penalty
Summary
The facility failed to properly notify residents of potential non-coverage and beneficiary financial liability, affecting two of three residents reviewed for beneficiary notification. Resident 225 was admitted and discharged on unspecified dates, and a Notice of Medicare Non-Coverage (NOMNC) dated 09/03/24 indicated a coverage end date of 09/14/24. However, there was no Advanced Beneficiary Notice (ABN) provided when Resident 225's coverage for skilled nursing was due to end, and the resident continued to receive care after the coverage end date. Similarly, Resident 227 was admitted and discharged on unspecified dates, with a NOMNC dated 08/23/24 indicating a coverage end date of 08/25/24. No ABN was provided for Resident 227, who also continued to receive skilled nursing care after the coverage end date. During an interview, the Administrator acknowledged using the wrong form for beneficiary notices for both residents. The facility did not provide a policy related to ABN, which contributed to the oversight in notifying residents of their potential financial liability for services not covered by Medicare.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R25, from verbal abuse by another resident, R49. R25, who was severely cognitively impaired with a BIMS score of two out of 15, was verbally abused by R49, who was cognitively intact with a BIMS score of 15 out of 15. The incident occurred when R49 yelled expletives at R25 and staff, which was documented in a progress note by LPN1/UM. Despite the incident being recorded, there was no evidence of an investigation into the verbal abuse, and it was not included in the facility's reportable incident documentation. Interviews with facility staff, including LPN1/UM, the DON, and the Administrator, revealed that the incident was known to them, but there was uncertainty about whether it constituted verbal abuse. The DON could not recall if the incident was reported to her, and the Administrator acknowledged the incident was discussed in a daily nursing meeting. However, there was no clear action taken to address the potential abuse, and the facility's policy to ensure residents remain free from abuse was not upheld in this case.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse involving three residents. One resident, who was cognitively intact, reported an allegation of staff-to-resident abuse, stating that a Certified Medication Tech was verbally abusive and physically hurt her during care. This incident was not reported to the State Agency, Ombudsman, or local law enforcement in a timely manner. The facility's Administrator was unaware of the requirement to report such incidents during a recertification survey, mistakenly believing that surveyors would handle the reporting. Another incident involved a cognitively impaired resident who was verbally abused by another resident. The incident was documented in a progress note, but there was no evidence that it was reported to the appropriate authorities. The Director of Nursing could not recall if the incident was reported to her and confirmed that it was not reported externally. The Administrator acknowledged awareness of the incident but was unsure of the reporting requirements for resident-to-resident abuse.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident of resident-to-resident verbal abuse involving two residents. One resident, who was severely cognitively impaired with a BIMS score of two, was verbally abused by another resident who was cognitively intact with a BIMS score of 15. The incident was documented in a progress note by an LPN, but there was no evidence that the incident was investigated as required by the facility's policy on abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. Interviews with facility staff, including the LPN who documented the incident, the DON, and the Administrator, revealed that the incident was not investigated. The DON acknowledged that it was the responsibility of the management team to investigate such incidents, but she was unsure if it had been done. The Administrator confirmed awareness of the incident but stated that it had not been interpreted as abuse and was unsure of the investigation procedures for resident-to-resident abuse.
Lack of Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were in place for three residents, leading to potential gaps in care. One resident, who was moderately cognitively impaired and diagnosed with chronic obstructive pulmonary disease (COPD), was receiving oxygen therapy but did not have a care plan addressing the use of oxygen. This was confirmed by multiple staff members, including the Licensed Practical Nurse/Unit Manager and the Director of Nursing, who acknowledged the absence of a care plan for the resident's oxygen use. Another resident, diagnosed with COPD, depressive disorder, and anxiety, did not have a care plan addressing his mental health conditions or the administration of psychotropic medications. This oversight was confirmed by the Registered Nurse and the Director of Nursing/Infection Preventionist. Additionally, a third resident, who had experienced a coffee burn, did not have an updated care plan with interventions to prevent further incidents, despite a lid being added to her coffee cup. The Director of Nursing was unsure if this intervention had been documented in the care plan.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a final discharge summary for a resident at the time of discharge, which is a requirement according to the facility's Resident Discharge/Transfer Policy. The policy mandates that a discharge summary and post-discharge plan of care form be completed and signed by the resident or their representative, with the original placed in the record. However, for one resident, who was admitted with multiple diagnoses including sepsis, palliative care, and multiple myeloma, and later discharged to another facility, the discharge summary was left entirely blank. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the electronic discharge summary was not completed for the resident who transferred to be closer to family.
Failure to Implement Scheduled Activities Programs
Penalty
Summary
The facility failed to implement its scheduled activities programs for residents, as evidenced by the lack of execution of planned activities and inadequate documentation of resident participation. The activity calendars for November showed a variety of activities scheduled, but during the survey period, only a few of these activities were actually conducted. The Activities Director was absent for personal reasons, and it was assumed that other staff members would conduct the activities, but this did not occur. The Activities Director also failed to document activity participation in resident logs for several weeks. One resident, identified as R9, was particularly affected by this deficiency. R9 was moderately cognitively impaired and had specific activity preferences documented in her care plan, including a preference for afternoon activities and interests in group activities, reading, and religious activities. Despite these preferences, R9 was not observed participating in any activities during the survey period, even when activities she was interested in, such as BINGO and a music program, were offered. There was no documentation of her participation in activities from late September to mid-November, and no alternative or one-on-one activities were provided to her during the survey. Interviews with facility staff, including the Activities Director and a Licensed Practical Nurse/Unit Manager, confirmed that group activities were not routinely offered during the Activities Director's absence. The Administrator acknowledged that activities should be provided based on individual assessments and preferences, and participation should be documented. This failure to provide and document activities created the potential for residents, including R9, to experience isolation due to a lack of participation in facility activities.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent skin breakdown for a resident who was at risk for developing pressure ulcers. The resident, who had dementia and type 2 diabetes, was moderately cognitively impaired and was using a Broda chair without a pressure-reducing cushion, despite having a pressure-reducing mattress on their bed. The resident developed a stage 2 pressure ulcer on the coccyx, and the care plan indicated that a pressure-reducing cushion should be applied to the Broda chair, but this was not done. Observations confirmed that the resident's Broda chair did not have a pressure-reducing cushion, and the Licensed Practical Nurse/Unit Manager and Director of Nursing both stated that previous administration had informed them that such cushions could not be used with Broda chairs. However, the manufacturer's instructions did not prohibit the use of pressure-reducing cushions. Additionally, the wound care orders were incomplete, lacking specific instructions for the dressing application, which the LPN/UM acknowledged and intended to update.
Failure to Ensure Safe Smoking Practices for Resident on Oxygen
Penalty
Summary
The facility failed to ensure a safe environment for a resident using oxygen therapy during smoking activities, which posed a potential fire hazard. The resident, who had chronic obstructive pulmonary disease and was receiving continuous oxygen therapy, was observed being assisted to a smoking patio with an oxygen tank still attached to their wheelchair. The Floor Tech, responsible for supervising the resident, had not received formal training on managing smokers with oxygen use and was only verbally instructed to turn off the oxygen. However, the oxygen tank was not removed from the smoking area, and another resident was already smoking nearby. Interviews with various staff members, including the Director of Nursing, Maintenance Director, and Housekeeping staff, revealed a lack of formal training regarding the supervision of residents who smoke while using oxygen. The staff were only instructed to turn off the oxygen but not to remove the tanks from the smoking area. The Administrator confirmed the absence of training related to smokers and oxygen use, acknowledging that oxygen tanks should not be present in the smoking area. This oversight in training and policy implementation led to the potential risk of fire hazards in the facility.
Failure to Provide Comprehensive Dialysis Care
Penalty
Summary
The facility failed to ensure comprehensive dialysis services were provided for a resident with End Stage Renal Disease (ESRD) who required hemodialysis. The resident, who was cognitively intact, had a dialysis catheter in place and was receiving dialysis three times per week at a community dialysis center. However, there were no physician orders in place for the care and maintenance of the resident's intravenous dialysis catheter, as confirmed by both the Licensed Practical Nurse/Unit Manager and the Director of Nursing. This lack of orders created the potential for incomplete and inconsistent care of the resident's dialysis catheter. The facility's policy on the care of a resident receiving dialysis required treatment for cleaning as ordered by the physician and for nurses to maintain the dressing at the access site at all times. Despite this, a review of the resident's records, including the Medication Administration Record and Treatment Administration Record, revealed no documentation indicating routine care and maintenance of the dialysis catheter. The resident's care plan noted that most catheter care would be provided by the dialysis center, but also indicated that the resident frequently attempted to dislodge the catheter or remove the dressing, necessitating reminders not to interfere with the catheter.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to appropriately assess and obtain informed consent for the use of bed rails for two residents, R9 and R53, out of a total of nine residents reviewed for accidents. The facility's policy requires a comprehensive assessment and informed consent before the use of bed rails, but these steps were not followed for the two residents. This oversight created a potential risk for injury due to the unnecessary use of side rails. Resident R9, who was moderately cognitively impaired and required assistance for mobility, was observed with bed rails in use despite no documentation of an assessment, physician's order, or care plan for their use. The resident's electronic medical record (EMR) lacked evidence of a recent assessment or informed consent for the bed rails, and the Licensed Practical Nurse/Unit Manager confirmed these omissions during a review of the EMR. Similarly, Resident R53, also moderately cognitively impaired, was observed with bed rails in use without a current assessment or informed consent. Although there was an order for assist rails dated nearly two years prior, there was no recent assessment or care plan reflecting the use of side rails. The Director of Nursing confirmed that the facility's expectations for bed rail use, including a current assessment and informed consent, were not met for these residents.
Failure to Maintain Bed Rail Safety for Residents
Penalty
Summary
The facility failed to ensure the physical safety of bed rails for two residents, R9 and R53, out of a total of nine residents reviewed for accidents. Observations revealed that the bed rails on both residents' beds were loose, which was confirmed by staff members. R9, who was moderately cognitively impaired and required assistance for mobility, was observed with a loose bed rail despite the assessment indicating that side rails were not in use. Similarly, R53, who was also moderately cognitively impaired and used the rails for mobility, had loose bed rails, although her assessment also indicated that side rails were not in use. The facility's policy required regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment areas. However, the staff failed to document or address the loose bed rails in the maintenance log prior to the observations. The Maintenance Director confirmed the lack of a formal process for routine monitoring of bed safety, and the Director of Nursing expressed that bed rails should be maintained and safe for use. The failure to maintain the bed rails created the potential for injury to the residents.
Misappropriation of Resident Medications
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when 40 tablets of oxycodone/acetaminophen and five tablets of gabapentin were found missing. The medications were in the possession of facility staff, and the incident involved a resident who was admitted to the facility with chronic inflammatory demyelinating polyneuritis, polymyalgia rheumatica, and unspecified pain. The resident's family member brought medications from home to be used until the facility's pharmacy delivered the resident's prescriptions. Upon admission, the resident's medications were counted by RN A and CMT B, who reported 338 tablets of oxycodone/acetaminophen and two bottles of gabapentin with 186 and 85 tablets, respectively. However, the following day, it was discovered that 40 oxycodone/acetaminophen tablets and five gabapentin tablets were missing. The facility's investigation revealed that the narcotic count was not conducted at shift changes, and there were discrepancies in the documentation of medication administration and counts. Interviews with staff indicated that it was common practice not to count narcotics at shift changes, and there was confusion regarding the documentation of medication counts and administration. The DON expressed concerns about whether the initial medication count was accurate and noted that staff did not follow the facility's policies for medication count verification. The facility could not determine if the medications were miscounted upon admission or if they were misappropriated by staff.
Failure to Properly Handle and Document Medications
Penalty
Summary
The facility failed to ensure proper handling and documentation of narcotics and medications brought from home for a resident. Licensed staff did not complete the required narcotic counts at shift changes, which is necessary to detect any missing doses. This failure occurred across multiple shifts, as there was no evidence of verification of the controlled drug count between off-going and on-coming staff. Additionally, the facility did not follow its policy for accepting medications brought from home, as these medications were not examined and positively identified by a pharmacist or physician before use. Resident #1 was admitted to the facility with medications brought from home by a family member. These medications included oxycodone/acetaminophen and gabapentin, which were intended to be used until the resident's medications arrived from the pharmacy. However, the facility staff did not document the acceptance of these medications, including the name, strength, and quantity, nor did they verify them with a pharmacist or physician. This oversight led to discrepancies in the medication records, as the medications brought from home did not match the physician's orders. Interviews with staff revealed a lack of awareness and adherence to the facility's policies regarding medication verification and narcotic counts. It was common practice to use medications brought from home without proper verification, and staff often did not perform narcotic counts at shift changes. This resulted in missing medications, as evidenced by the discovery of unlabeled bags of gabapentin and missing tablets of oxycodone/acetaminophen. The Director of Nursing and the Administrator acknowledged these lapses and expressed expectations for staff to follow the facility's policies.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure staff treated three residents with dignity and respect. Resident #7 reported that a CNA called them a 'fatty' after a fall and threatened to leave them on the floor if they fell again. The CNA also made derogatory comments about the resident's urine odor and used inappropriate language in the resident's presence. Additionally, the CNA ignored the resident's call light and failed to return to provide assistance as promised, leaving the resident feeling disrespected and neglected. Resident #8 experienced similar disrespectful behavior from the same CNA, who made comments about the resident's room odor and cleanliness, despite the resident being bed-bound and unable to clean the room. The CNA's remarks about the resident's colostomy odor and the state of the room caused the resident significant emotional distress, leading them to ask staff to leave the room. The resident felt frustrated and angry due to the CNA's rude and condescending behavior. Resident #9 reported that the CNA refused to change their soiled incontinence brief, stating they had other people to take care of and leaving the resident in a dirty brief. The resident had to use the call light again to receive assistance from another staff member. Interviews with other CNAs and an LPN confirmed the inappropriate behavior of the CNA, including ignoring call lights, using derogatory language, and making residents feel disrespected. The Interim DON and Administrator were unaware of these incidents but emphasized the expectation for all staff to treat residents with dignity and respect.
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 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mexico
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Hall Nursing Center | 13 mi | ★★★★★ | 5 | 0 |
| Wellsville Health Care Center | 19.6 mi | ★★★★★ | 1 | 0 |
| Monroe Manor | 21.2 mi | ★★★★★ | 0 | 0 |
| Fulton Manor Care Center | 21.4 mi | ★★★★★ | 2 | 0 |
| Fulton Nursing & Rehab | 22 mi | ★★★★★ | 4 | 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.