Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Southwestern Veterans Center during CMS and state inspections, most recent first.
A resident with HTN, dementia, and dysphagia had a sign posted above the bed stating, "I only eat pureed food," while the record lacked documentation that the resident or representative approved posting this private health information. An RN confirmed the facility failed to maintain the resident's confidential personal and medical records.
Failure to Communicate Required Transfer Information: The facility did not ensure that required transfer information was sent to the receiving provider for two residents who were sent to the hospital and expected to return. One resident had HTN, obstructive uropathy, and constipation, and the other had HTN, dysphagia, and hemiplegia. The record lacked documentation of key items such as care plan goals, advance directive information, resident representative information, and other needed instructions or resident-specific details.
The facility failed to follow physician orders for two residents. One resident with pneumonia, hypoxemia, and urine retention had a tamsulosin order transcribed incorrectly, and the QA Coordinator confirmed the order was not followed as written. Another resident with HTN, dementia, and low back pain had an order for daily weights at 11 a.m., but weights were missed on multiple days, and an RN confirmed the daily weighing was not completed as ordered.
Failure to implement nutritional interventions and develop a baseline care plan. A resident with Alzheimer’s disease, dementia, HTN, and a stage 2 coccyx wound was admitted on a pureed, thin-liquid diet and was fed by staff. The nutrition assessment noted poor intake, the POA provided food preferences, and the RD added fortified shakes and Gelatein Plus to support wound healing, but the order for Gelatein Plus was not entered and the care plan did not include nutrition-focused goals or interventions. The RD stated she forgot to add the supplement order and forgot to develop the baseline care plan within 48 hours of admission.
A resident with a G-tube and diagnoses including Parkinson's disease, dementia, and a seizure disorder was observed lying flat in bed while Jevity 1.5 was infusing at 120 ml/hr. The resident's orders and care plan directed the HOB to remain at 30 degrees at all times, and the facility's enteral feeding policy addressed required HOB elevation during feedings. An LPN confirmed the resident was flat in bed with the tube feeding running.
Failure to Document Physician Review of Monthly MRRs: The facility did not provide evidence that the attending physician reviewed monthly MRRs for two residents. One resident had HTN, dementia, and low back pain, and the other had HTN, dementia, and dysphagia. The pharmacist’s reviews lacked physician responses, and later CRNP notes addressed lab review, vitamin D, and discontinuation of Voltaren gel.
A nurse aide manually transferred a resident who required a full mechanical lift with two-person assistance, contrary to care plan and physician orders. This action resulted in the resident sustaining a comminuted and angulated fracture of the distal femur, as confirmed by clinical records and staff interviews. The incident was a direct result of not following established transfer protocols for a resident with significant medical needs.
A nurse aide manually transferred a resident with multiple medical conditions, despite physician orders and care plan requiring a full mechanical lift with two staff. This improper transfer led to the resident sustaining a comminuted fracture of the distal femur. Facility records and staff interviews confirmed the required transfer method was not followed.
Anonymous grievance boxes were not accessible on any nursing floor, and the only available box in the lobby was blocked by wheelchairs. Staff were unaware of grievance box locations, and several residents did not know how to file grievances anonymously, contrary to facility policy.
Three residents requiring respiratory support did not have their oxygen or BiPAP/CPAP equipment properly stored in labeled plastic bags as required by facility policy, with items left on nightstands or the floor. Nursing staff confirmed the improper storage, and one resident's care plan lacked interventions for oxygen and CPAP therapy.
The facility did not maintain complete and accurate documentation for multiple residents, including missing monthly weights and vital signs in the EMR and MAR, despite physician orders and facility policy. Staff interviews confirmed the lack of required documentation, and progress notes for some residents with complex care needs were also found to be incomplete or inaccurate.
A resident with hemiplegia, anxiety, and constipation was found to have their call bell on the floor under the bed, making it inaccessible. An LPN confirmed the call bell was not available for use, indicating the facility did not accommodate the resident's call bell needs.
Surveyors found that two residents' MDS assessments were not accurately coded to reflect the care provided. One resident received intermittent oxygen and CPAP therapy, but these were not documented on the MDS. Another resident was incorrectly marked as receiving hospice care, despite no evidence of hospice services in the clinical record. The errors were confirmed by the RN Assessment Coordinator.
The facility did not ensure that care plans addressed all identified needs for two residents. One resident's care plan lacked goals and interventions for prescribed antidepressant and sedative/hypnotic medications, while another resident's care plan did not include the use of TED hose for peripheral vascular disease, despite physician orders. These omissions were confirmed by facility staff.
The facility did not update care plans for three residents to reflect changes in their clinical status, including new antibiotic therapy for bacteremia, delayed addition of a wander guard intervention, and outdated tube feeding instructions. Staff confirmed that care plans were not revised as required.
Two residents with complex medical needs repeatedly requested staff assistance through call bells and direct requests, with staff documenting ongoing, frequent demands for attention and care. Despite staff addressing immediate needs, the residents continued to seek assistance, and the DON confirmed that professional standards of nursing practice were not followed.
The facility failed to ensure that two residents with pressure ulcers received and had documented wound care as ordered, and did not provide necessary preventive measures for another resident at high risk for pressure injury. Nursing staff confirmed that required treatments and preventive interventions, such as the use of Prevalon boots, were not consistently implemented or documented.
The facility did not consistently complete and maintain required dialysis communication forms for two residents receiving regular dialysis treatments. Despite facility policy mandating thorough documentation before and after each dialysis session, multiple treatment dates lacked complete records, as confirmed by nursing staff. This resulted in incomplete medical records for residents with significant renal and related health conditions.
The facility did not provide trauma-informed care for two residents with PTSD by failing to complete timely assessments and develop care plans that identified and addressed triggers for re-traumatization. One resident with PTSD from an accident and assault did not have a care plan or assessment completed within the required timeframe, while another resident with combat-related PTSD had no triggers identified or documented in the care plan.
A nurse aide's personnel record lacked documentation of an annual performance evaluation as required by federal regulations. Review of records and staff interview confirmed that the evaluation was not completed within the mandated timeframe.
A resident with a foley catheter for obstructive uropathy was observed with the catheter collection bag lying on the floor, contrary to facility policy requiring catheter bags and tubing to remain off the floor. This lapse in infection control was confirmed by an RN and involved a resident with multiple medical conditions, including hypertension, cancer, and diabetes.
The facility failed to obtain physician orders for wound care and safety equipment for several residents, and did not develop comprehensive care plans or complete bed safety risk assessments. Observations showed residents with fall mats and alarms without corresponding orders or care plans, confirmed by staff interviews.
The facility failed to provide access to medical records to a resident or their representative within the required time frame. A request for a copy of medical records by a resident's representative was received and never sent due to a misunderstanding of the regulation by a medical records employee.
A facility failed to update a resident's care plan after a dietary change. The resident, with chronic atrial fibrillation and other conditions, had their tube feeding discontinued per a physician's order. However, the care plan still listed tube feeding as active, which was confirmed by a registered dietitian.
The facility failed to provide necessary treatment to prevent a decrease in range of motion for two residents. One resident, with conditions including hemiplegia, was observed without a prescribed palm guard, while another resident with functional quadriplegia was not wearing bilateral palm guards as ordered. Staff interviews revealed a lack of communication and system to ensure compliance with care plans and physician orders.
A facility failed to provide adequate supervision, resulting in a resident with dementia eloping unnoticed and two residents sustaining cat bites while outside. The elopement occurred due to a lack of quarterly assessments and inattentiveness, while the cat bites happened as residents fed cats outside. The Director of Nursing confirmed these supervision failures.
The facility failed to ensure consistent and complete communication with the dialysis center for three residents, resulting in incomplete or missing dialysis communication sheets. Additionally, one resident's care plan and physician orders were inaccurate, lacking documentation for an AV fistula. These deficiencies were confirmed by nursing staff and the Director of Nursing.
Failure to Protect Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records for one of eight residents, Resident R4. Facility policy required staff to maintain the confidentiality and security of private health information in daily practice. Resident R4's clinical record showed diagnoses of high blood pressure, dementia, and dysphagia, and during an observation on 5/11/26 at 1:56 p.m., R4 was seen resting in a wheelchair in his room with a sign posted above his bed stating, "I only eat pureed food." The record did not include documentation that the resident or the resident's representatives approved posting this private health information. During an interview on 5/14/26 at 10:05 a.m., RN Employee E3 confirmed that the facility failed to maintain the resident's confidential personal and medical records.
Failure to Communicate Required Transfer Information
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred from the facility to the hospital and expected to return. Facility policy required that transfer information include the resident’s practitioner contact information, resident representative information, advance directive information, resident status, diagnoses, allergies, medications, recent labs and tests, special instructions and precautions, and the resident’s comprehensive care plan goals. Resident R11 had diagnoses including high blood pressure, obstructive uropathy, and constipation, and was transferred to the hospital and later returned to the facility. The clinical record contained no documented evidence that the facility communicated specific information to the receiving provider, including the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and other information needed to meet the resident’s specific needs. Resident R164 had diagnoses including high blood pressure, dysphagia, and hemiplegia, and was also transferred to the hospital and returned to the facility. The record likewise contained no documented evidence that the facility communicated specific information to the receiving provider, including the resident’s care plan goals. During interview, the Quality Assurance Coordinator confirmed the facility failed to make certain the necessary resident information was communicated for these two residents.
Failure to Follow Physician Orders for Medication and Daily Weights
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders for two residents. For one resident with diagnoses including pneumonia, hypoxemia, and urine retention, the physician order history showed tamsulosin orders that changed over time, including instructions to open the capsule and sprinkle the medication. During an interview, the QA Coordinator confirmed that the facility transcribed the physician order incorrectly and did not follow the physician order. For another resident with diagnoses of high blood pressure, dementia, and low back pain, the physician ordered daily weights at 11 a.m. and to notify the physician if there was a weight gain of five pounds or more in three days. The clinical record showed that weights were not obtained on multiple days in April 2026. During an interview, the RN confirmed that the facility failed to weigh the resident daily as ordered.
Failure to Implement Nutritional Interventions and Care Plan
Penalty
Summary
The facility failed to implement a resident’s specific nutritional interventions in a timely manner and failed to develop an individualized care plan to address the resident’s nutritional concerns. Resident R189 was admitted with diagnoses of Alzheimer’s disease, dementia, and high blood pressure, and had physician orders for a house diet with thin, pureed foods and no straws. The comprehensive nutritional assessment documented that the resident was fed by staff and had a stage 2 coccyx wound, and the nutrition note stated that the resident ate very little for lunch on the day of admission. The assessment also documented that the resident could not provide dietary history or food and beverage preferences, so the POA provided some preferences. The RD added fortified shakes with all meals and Gelatein Plus with lunch to support wound healing, but the physician orders did not include a current order for Gelatein Plus when reviewed later. The resident’s current plan of care also failed to identify focus, goals, and interventions related to nutrition care and services. During interview, the RD stated that she forgot to add Gelatein Plus to the physician orders and forgot to develop a baseline care plan to address nutrition care and services within 48 hours of admission.
Tube Feeding Resident Found Flat During Active Infusion
Penalty
Summary
Resident R149 had a G-tube and diagnoses of Parkinson's disease, dementia, and a seizure disorder. The facility policy for enteral feedings indicated the head of bed should be elevated to at least 45 degrees, or per physician order, during bolus feedings and at all times during continuous feedings unless the pump is stopped for care. The resident's physician order dated 4/20/26 directed that the head of bed be kept at 30 degrees at all times, and the care plan dated 4/21/26 also directed that the head of bed be kept at 30 degrees at all times. A physician order dated 4/22/26 directed Jevity 1.5 at 120 ml/hour from 8:00 a.m. through 8:00 p.m. During observation on 5/11/26 at 10:51 a.m., Resident R149 was found lying flat in bed with the tube feeding connected and the pump infusing at 120 ml/hr. At 10:53 a.m., an LPN confirmed that the resident was lying flat in bed while the tube feeding was running. The facility failed to ensure the resident with an enteral feeding tube received appropriate treatment and services consistent with the resident's orders and the facility's enteral feeding policy.
Failure to Document Physician Review of Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to provide evidence that medication regimen reviews (MRR) were reviewed by the residents’ attending physician monthly for two residents. The facility policy titled Drug Regimen Review, Monthly, dated 1/16/26, stated that the pharmacist would review each resident’s drug regimen every month and report the results to the physician, who would respond in the comment section. Review of the clinical record for Resident R3 showed admission to the facility, diagnoses of high blood pressure, dementia, and low back pain, and a Medication Review Regimen dated 4/3/26 that did not include a response from the attending physician. Review of the clinical record for Resident R4 showed admission to the facility, diagnoses of high blood pressure, dementia, and dysphagia, and a Medication Review Regimen dated 4/16/26 that also did not include a response from the attending physician. For both residents, a CRNP later signed the note to the attending physician and decisions were made to review lab work and start vitamin D for Resident R3, and to discontinue Voltaren gel for Resident R4. During an interview on 5/14/26, the Quality Assurance Coordinator confirmed the facility failed to ensure the residents’ MRRs were reviewed by the attending physician monthly for these two residents.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a nurse aide manually transferred a resident who was dependent for transfers and required the use of a full mechanical lift with two staff assistance, as specified in the resident's care plan and physician orders. The nurse aide admitted to physically picking up the resident from bed and placing them into a wheelchair without using the required Hoyer lift or a second staff member. This action was in direct violation of the facility's transfer policy, which mandates the use of mechanical lifts for residents with total dependence to ensure safety and prevent injury. The resident involved had significant medical conditions, including diabetes mellitus, end stage renal disease, and hepatitis C, and was cognitively intact according to assessment. The resident's care plan and orders clearly indicated the need for a mechanical lift and two-person assistance for all transfers. Despite these documented requirements, the nurse aide failed to follow protocol, resulting in the resident experiencing severe pain and swelling in the left stump, which was later diagnosed as an acute comminuted and angulated fracture of the distal left femur. Facility documentation, staff interviews, and clinical records confirmed that the nurse aide did not use the mechanical lift as required and instead performed a manual transfer. This neglectful action directly led to actual harm to the resident, as evidenced by the fracture and subsequent hospitalization. The deficiency was substantiated through witness statements and interviews with facility leadership, who acknowledged the failure to protect the resident from neglect during care.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and implement effective transfer interventions as ordered by a physician, resulting in a preventable accident and actual harm to a resident. The facility's policy required the use of mechanical lifts for residents who are totally dependent or require extensive assistance for transfers, and specifically prohibited manual lifting to minimize risk of injury. Despite these protocols, a nurse aide physically picked up a resident from bed and placed them into a wheelchair without using the required mechanical lift or a second staff member, as mandated by the resident's care plan and physician orders. The resident involved had significant medical conditions, including diabetes mellitus, end stage renal disease, and hepatitis C, and was assessed as being dependent for transfers, requiring a full mechanical lift with two staff members. The resident was cognitively intact according to the BIMS assessment. Following the improper manual transfer, the resident experienced severe pain and was subsequently diagnosed with an acute comminuted, impacted, and angulated fracture of the distal left femur. Staff interviews and facility documentation confirmed that the nurse aide did not follow the prescribed transfer method, and the resident's care plan and orders were accurate at the time of the incident. The failure to use the mechanical lift as ordered directly resulted in the resident sustaining a serious injury during the transfer process.
Failure to Provide Accessible Anonymous Grievance Boxes
Penalty
Summary
The facility failed to ensure that anonymous grievance boxes were readily accessible for residents, resident representatives, or visitors on all three nursing floors. Observations revealed that no grievance boxes were present on the Second, Third, or Fourth Nursing Floors. The only anonymous grievance box observed was located in the lobby hallway, but it was blocked by six wheelchairs, making it inaccessible. Staff interviews confirmed the absence of grievance boxes on the nursing floors and the inaccessibility of the box in the lobby. The Social Worker and Grievance Officer were not aware of any grievance boxes on the nursing units, and residents reported not knowing where to find a grievance box or how to file a grievance anonymously. The facility's Resident Rights policy states that residents have the right to make complaints without fear of reprisal and that the facility must address grievances promptly. However, the lack of accessible grievance boxes and the staff's lack of awareness regarding their location prevented residents from exercising this right. During a group interview, several residents indicated they were unsure how to file grievances anonymously and typically gave their complaints directly to the social worker.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required supplemental oxygen or noninvasive ventilation therapies. Facility policy required that used cannulas, masks, and tubing be stored in a labeled plastic bag off the floor when not in use. For one resident with coronary artery disease, hypertension, and diabetes, the BiPAP mask was observed sitting on the nightstand and not stored in a plastic bag as required. A second resident with peripheral vascular disease, depression, and sleep apnea also had their BiPAP mask left out on the nightstand without a storage bag. In both cases, nursing staff confirmed the equipment was not properly stored according to policy. A third resident with high blood pressure, COPD, and PTSD had a nasal cannula observed lying on the floor and a CPAP mask left on top of the machine, rather than stored in a labeled plastic bag. The nasal cannula was later moved off the floor, but staff confirmed it had not been properly stored. Additionally, this resident's care plan did not include interventions or a plan of care for oxygen or CPAP therapy, as confirmed by the Registered Nurse Assessment Coordinator. These failures were identified through observations, staff interviews, and clinical record reviews.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate documentation for five of eight residents, as evidenced by missing or incomplete records in the electronic medical record (EMR) and medication administration records (MAR). For several residents, including those with diagnoses such as coronary artery disease, hypertension, diabetes, anemia, hyperlipidemia, constipation, hypocalcemia, Alzheimer's Disease, Parkinson's Disease, depression, and end-stage renal disease, required monthly weights and vital signs were not documented as ordered by physicians and per facility policy. In some cases, the MAR indicated that weights were 'already complete' when no documentation was present in the EMR. Staff interviews, including those with the Registered Dietitian and the Director of Nursing, confirmed that the required documentation was not completed or entered into the EMR for the affected residents. The facility's own policies and job descriptions require that registered nurses record daily care and maintain accurate medical records, but these requirements were not met for the residents identified in the report. Additionally, progress notes for some residents described ongoing behavioral and care needs, such as frequent requests for staff attention and assistance, but the documentation was noted as inaccurate or incomplete by the Director of Nursing. The deficiencies were identified through clinical record review and staff interviews, and were found to be in violation of state regulations regarding the maintenance of medical records and nursing services.
Failure to Ensure Call Bell Accessibility for Resident with Hemiplegia
Penalty
Summary
The facility failed to accommodate the call bell needs of Resident R88, who had diagnoses including hemiplegia, anxiety, and constipation. During an observation, the resident's call bell was found on the floor under the bed, making it inaccessible and unavailable for use. This was confirmed by an LPN, who acknowledged that the call bell was not accessible to the resident. The deficiency was identified through review of facility policy, clinical records, direct observation, and staff interview.
Inaccurate MDS Assessments for Oxygen, CPAP, and Hospice Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the care and services provided to two residents. For one resident with diagnoses including COPD and PTSD, clinical records showed the use of intermittent oxygen therapy and CPAP during the assessment period. However, the resident's quarterly MDS did not indicate that oxygen therapy or non-invasive mechanical ventilator therapy had been provided, despite documentation in the clinical record and confirmation from the Registered Nurse Assessment Coordinator that these treatments were administered. For another resident with diagnoses of high blood pressure, dementia, and bipolar disorder, the MDS indicated that the resident was receiving hospice care. A review of the clinical record, however, did not reveal any orders or documentation supporting that hospice services were provided. The Registered Nurse Assessment Coordinator confirmed that this resident had never received hospice care and that the MDS was marked incorrectly. These findings demonstrate that the facility did not follow its policy or the RAI User's Manual guidelines for accurate MDS coding.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified care needs for two residents. For one resident with diagnoses including anemia, hypertension, and Parkinson's Disease, the clinical record showed active physician orders for antidepressant and sedative/hypnotic medications. However, the resident's care plan did not include goals or interventions related to the use of these medications. This omission was confirmed by the Director of Nursing during an interview. For another resident with difficulty swallowing, vitamin deficiency, and Alzheimer's disease, the clinical record included a physician order for daily application of bilateral lower knee TED hose due to peripheral vascular disease. The care plan for this resident did not reflect the use of TED hose as ordered. This was confirmed by the Registered Nurse Assessment Coordinator. These findings demonstrate that the facility did not ensure care plans were comprehensive and addressed all current physician orders and resident needs as required by facility policy and state regulations.
Failure to Revise Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for three residents to reflect their current clinical needs as required by policy. For one resident with end stage renal disease, hypertension, and diabetes, the care plan did not include interventions, goals, or management strategies for a newly prescribed long-term antibiotic for bacteremia. Another resident with dementia, atrial fibrillation, and pain had a physician order for a wander guard, but the care plan was not updated to include this intervention in a timely manner, with a delay of several months before the intervention was added. A third resident with hemiplegia, anxiety, and constipation had a change in tube feeding orders, but the care plan continued to reflect an outdated feeding rate and did not match the current physician order. Staff interviews confirmed that the care plans for these residents were not revised to reflect their current status as required by facility policy and regulatory standards.
Failure to Meet Professional Standards in Nursing Services
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality for two residents. For one resident with diagnoses including constipation, hypocalcemia, and Vitamin D deficiency, progress notes documented repeated requests for staff assistance, with the resident frequently using the call bell, calling the nurses' station, and flagging down staff in the hallway. Staff described the resident as anxious and continuously making small, individual requests, often immediately after previous needs were addressed. Documentation indicated that staff repeatedly asked the resident to make all needs known at once, but the resident continued to request assistance one task at a time. For another resident with high blood pressure, hyperlipidemia, and end-stage renal disease, progress notes indicated excessive use of the call bell, with the resident requesting assistance multiple times in a short period. Staff documented that the resident was clean, dry, fed, and repositioned, and had received PRN analgesics, but continued to ring the call bell soon after staff left the room. The Director of Nursing confirmed that the facility did not follow standards of professional practice for these residents.
Failure to Provide and Document Pressure Ulcer Treatment and Prevention
Penalty
Summary
The facility failed to ensure that residents received proper treatment for existing pressure ulcers and necessary services to prevent new ulcers from developing. For two residents with pressure ulcers, required wound care treatments were not documented as completed according to physician orders. Specifically, one resident with a sacral wound had missing documentation for wound care on two occasions, with no evidence in the clinical record that the treatment was performed as required. Another resident with a sacral wound also had missing documentation for daily wound care on two separate shifts, and the clinical record did not confirm that the treatments were completed. Additionally, the facility did not provide necessary preventive measures for a resident identified as high risk for pressure injury. This resident had physician orders and a care plan specifying the use of bilateral Prevalon boots while in bed to prevent pressure ulcers due to impaired mobility. However, during two separate observations, the resident was found lying in bed without the prescribed boots on, and staff confirmed that the resident was not receiving the required preventive intervention as ordered. Interviews with nursing staff, including the Director of Nursing, confirmed that the facility did not ensure proper treatment for pressure ulcers and failed to implement necessary preventive services for residents at risk. These deficiencies were identified through review of facility policies, clinical records, direct observations, and staff interviews.
Failure to Maintain Consistent Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain consistent and complete dialysis communication for two residents who required regular dialysis treatments. According to facility policy, licensed staff are required to complete a Dialysis Communication Form prior to each transfer to the dialysis clinic and upon the resident's return, ensuring all relevant treatment information is documented and filed in the clinical record. For one resident with diagnoses including renal failure, stroke, and hemiplegia, the clinical record was missing complete communication forms for thirteen separate dialysis dates. This was confirmed by a registered nurse who acknowledged the absence of the required documentation on those dates. A second resident, diagnosed with high blood pressure, hyperlipidemia, and end-stage renal disease, also had incomplete dialysis communication forms for three treatment dates. The care plan for this resident specified that the entire first page of the communication form should be completed and passed to the next shift nurse, but this was not consistently done. A licensed practical nurse confirmed the missing documentation for the identified dates. These findings indicate that the facility did not ensure consistent communication and documentation for residents receiving dialysis, as required by facility policy and state regulations.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to two residents diagnosed with Post Traumatic Stress Disorder (PTSD). For one resident with a history of hemiplegia and PTSD stemming from an automobile accident and an assault, the facility did not complete a PTSD assessment or develop a care plan within 30 days of admission as required. The resident's care plan eventually identified loud noises as a trigger, but this was not addressed in a timely manner. The Social Work Director confirmed that the assessment and care plan were not completed within the required timeframe, resulting in a lack of interventions to eliminate or mitigate triggers that could cause re-traumatization. For another resident with PTSD related to combat experiences during the Vietnam War, the care plan did not include any identified triggers or documentation indicating that the resident declined to identify triggers. The Social Work Director confirmed that the facility failed to provide trauma-informed care for this resident as well. The facility's policy requires assessment of trauma history and identification of triggers upon admission, annually, and with significant change, but these steps were not followed for the two residents involved.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete an annual performance evaluation for one of three nurse aide personnel records reviewed. Specifically, the personnel record for NA Employee E18, who was hired on a specified date, did not contain documentation of an annual performance evaluation as required by federal regulations. This deficiency was confirmed during an interview with the Human Resources employee, who acknowledged that the annual performance evaluation based on the date of hire was not completed for this nurse aide. The review referenced the requirement under CFR S483.35(d)(7), which mandates that every nurse aide must have a performance review at least once every 12 months, with regular in-service education provided based on the outcomes of these reviews. The absence of the required evaluation was identified through personnel record review and staff interview.
Failure to Maintain Infection Control for Indwelling Catheter
Penalty
Summary
The facility failed to maintain proper infection control practices in the care of an indwelling urinary catheter for one resident. According to facility policy, catheter collection bags and tubing are never to touch the floor to promote a healthy urinary tract and prevent infection. During an observation, a resident with a foley catheter for obstructive uropathy was seen sitting in a wheelchair with the catheter collection bag lying directly on the floor beside him. This was confirmed by a registered nurse, who acknowledged that the facility did not follow its own infection control procedures in this instance. The resident involved had a history of high blood pressure, cancer, and diabetes, and was admitted with a physician's order for a foley catheter. The deficiency was identified through review of facility policies, the resident's clinical record, and direct observation. The failure to keep the catheter bag off the floor was a direct violation of the facility's infection control plan and urinary catheter procedures, as well as relevant state regulations.
Failure to Obtain Physician Orders and Develop Care Plans
Penalty
Summary
The facility failed to obtain physician's orders for five residents, specifically for wound care and safety equipment. For Resident R25, the facility did not include directions for cleansing a wound on the left buttock, despite having orders for applying Medi honey and foam dressing. Similarly, for Resident R94, the orders for a clean dry dressing on a left ankle deep tissue injury lacked instructions for wound cleansing. These omissions were confirmed by Employee E4 during interviews. Additionally, the facility did not develop comprehensive care plans for three residents, R88, R89, and R90, to meet their care needs. Observations revealed that these residents had thick blue fall mats placed on both sides of their beds, and in the case of Resident R89, a silent bed alarm was also noted. However, the physician orders for these residents did not include the use of these safety devices, and there were no current care plans addressing their use. Interviews with RN Employee E3 and RN Employee E14 confirmed the absence of orders and care plans for these safety measures. The facility also failed to complete bed safety risk assessments for Residents R88, R89, and R90, despite the use of thick fall mats. The Director of Nursing confirmed these deficiencies during interviews. The lack of physician orders, comprehensive care plans, and bed safety risk assessments for these residents indicates a failure to adhere to established facility policies and guidelines, as well as state regulations.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide access to medical records to a resident or their representative within the required time frame. Specifically, a request for a copy of medical records by a representative of Resident R202 was received on 11/21/23 and was never sent. During an interview on 5/8/24, Medical Records Employee E2 admitted to receiving the signed request but did not send the records, citing a misunderstanding of the regulation. This failure to comply with the regulation was identified during a review of facility documents and staff interviews.
Failure to Update Care Plan After Dietary Change
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as Resident R119, after a change in dietary needs. According to the facility's policy, care plans should be updated within 30 days following an annual assessment or any changes in the resident's needs. Resident R119, who was admitted with diagnoses including chronic atrial fibrillation, malaise, and dry eye syndrome, had a physician's order dated April 9, 2024, to discontinue tube feeding. However, the care plan still listed tube feeding as active. This discrepancy was confirmed during an interview with a registered dietitian on May 9, 2024, indicating a failure to update the care plan to reflect the resident's current dietary status.
Failure to Provide ROM Treatment for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for two residents, R2 and R25. Resident R2, who has diagnoses including diabetes, peripheral vascular disease, and hemiplegia, was observed without the prescribed left palm guard on multiple occasions, despite physician orders specifying its use from 6:00 a.m. to 8:00 p.m. The care plan for Resident R2 indicated the need for the palm guard to maintain range of motion and prevent skin breakdown, yet observations confirmed the device was not in place as required. Similarly, Resident R25, diagnosed with functional quadriplegia, muscle contractures, and dementia, was observed without bilateral palm guards while out of bed, contrary to physician orders for their use up to four hours per shift. Staff interviews revealed a lack of clarity and communication regarding the schedule for wearing the palm guards, with the Director of Nursing acknowledging the absence of a system to ensure compliance with the prescribed wear schedule. This lack of adherence to care plans and physician orders resulted in the facility's failure to provide necessary services to prevent further decline in residents' range of motion.
Inadequate Supervision Leads to Elopement and Cat Bites
Penalty
Summary
The facility failed to ensure adequate supervision and safety for its residents, resulting in an elopement incident and two cases of cat bites. Resident R140, who was diagnosed with Non-Alzheimer's Dementia, depression, and hyperlipidemia, was not assessed for elopement risk quarterly as required. On one occasion, the resident exited the facility unnoticed by security, as the security guard had left the desk unattended and the resident was not wearing a wander guard device. Staff inattentiveness was also noted as a contributing factor to the elopement. Additionally, two residents, R14 and R119, sustained cat bites while outside feeding cats. Resident R14, with diagnoses including diabetes mellitus and osteoarthritis, was bitten on the right index finger, while Resident R119, diagnosed with chronic atrial fibrillation and depression, was bitten on the left wrist. Both incidents required medical attention, with Resident R119 receiving a rabies series as a precaution. The Director of Nursing confirmed the facility's failure to provide adequate supervision, which led to these incidents. The facility's policies on incidents, accidents, and elopement prevention were not adequately followed, contributing to the deficiencies observed during the survey.
Inadequate Dialysis Communication and Documentation
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for three residents, identified as R35, R81, and R106. For Resident R35, the facility's policy required a Dialysis Communication Form to be completed and returned with each dialysis session. However, between March 25, 2024, and May 8, 2024, nine communication sheets were found incomplete, and two additional sheets were undated. Similarly, for Resident R81, five communication sheets were missing between April 1, 2024, and May 7, 2024. Interviews with registered nurses confirmed the incompleteness of these records. Additionally, the facility failed to maintain accurate physician orders and care plans for Resident R106. The resident was supposed to have a dialysis port in the right upper chest, but it was discovered that the resident had an AV fistula instead, which was not documented in the physician orders or care plan. The care plan also failed to include management instructions for the AV fistula. This lack of documentation and communication was confirmed by interviews with nursing staff and the Director of Nursing.
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 1,327 citations issued within 25 miles in the last 12 months — including the 25 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 Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East End Health & Rehab Center | 1.3 mi | ★★★★★ | 15 | 0 |
| Champion City Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 56 | 0 |
| Burgh Care Center | 2.3 mi | ★★★★★ | 47 | 0 |
| Ivy Park Post Acute | 2.6 mi | ★★★★★ | 10 | 1 |
| Canterbury Place | 3.2 mi | ★★★★★ | 19 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Southwestern Veterans Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.