Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Accel At Willow Bend during CMS and state inspections, most recent first.
Call Light Not Kept Within Reach: A resident with dementia, severe cognitive impairment, diabetes, and a history of falls was observed multiple times sitting in her wheelchair with her call light lying on the floor on the opposite side of the bed. The resident stated she could use the call light when it was on the bed but could not reach it on the floor, and staff confirmed it should always be within reach.
Failure to Provide Timely Incontinence Care: A resident with dementia, epilepsy, anxiety, and schizophrenia was fully dependent on staff for toileting hygiene and was supposed to be checked and changed regularly. Staff found her brief full of urine and feces, with urine soaked through to the draw sheet and fitted sheet, after about 6 hours without incontinence care; CNA and nursing leadership stated residents were expected to be checked at least every 2 hours.
Overfilled sharps containers were observed in 5 of 20 rooms reviewed, including containers with syringes and needles protruding through the safety flap and one container whose flap could not be operated. The Wound Care Nurse, ADON, and DON stated staff were responsible for monitoring and changing sharps containers before they became overfilled, and the facility policy stated sharps containers are discarded when 3/4 or less filled.
Missed Blood Glucose Monitoring and Insulin Administration: Multiple residents with diabetes had repeated missed blood sugar checks and missed insulin doses despite physician orders for scheduled monitoring and sliding-scale insulin. Records showed omitted checks before meals and at bedtime, including days with no documented glucose monitoring or treatment, and EHR reviews found no nursing notes explaining the missed doses. Residents and staff interviews reflected concern that insulin was not always being given as ordered.
Failure to Monitor Ordered Weights: A resident with DM, post-op spinal surgery, and chronic pain was admitted on a regular diet with an order for weekly weights x4. Her weight was recorded only at admission, and a later observation showed a 4.8% loss. The ADON and DON stated new admissions were to be weighed weekly for the first four weeks, and the facility policy required admission weights and weekly monitoring x4.
Staff failed to follow infection control practices when a medical assistant used a blood pressure cuff on a resident without disinfecting it after wearing it on her own wrist, and when CNAs provided incontinence care to two residents with bowel and bladder needs without performing required hand hygiene before contact, between care steps, and with glove changes. The residents involved had significant medical conditions, including HTN, anemia, diabetes, and severe cognitive impairment, and their care plans required peri care and keeping them clean and dry. In interviews, the staff acknowledged they knew the expectations for disinfecting reusable equipment and performing hand hygiene but stated they forgot, and facility training records showed they had not attended prior in-services on hand washing and device cleaning.
Surveyors found that a main entry door could be unlocked by anyone using a four-digit code that was visibly posted next to the keypad, allowing unmonitored access into the building without alarms or staff notification. A surveyor entered using the posted code and was able to remain in the lobby and adjacent halls for several minutes without encountering staff. Staff interviews revealed that the code had been posted for months on both sides of the door, that the front desk was only staffed during daytime hours, and that no one specifically monitored the door in the evenings or at night. Several staff members, including LVNs and the ADON, reported personal and resident/family concerns about unknown individuals entering at night and the lack of monitoring, while the Administrator acknowledged the practice but did not view it as a true safety concern.
A cognitively impaired resident with dementia, diabetes, and hypertension, care planned to need extensive one-person assistance for transfers due to generalized and unilateral weakness and a prior fall, was observed being transferred between a wheelchair and bed by a CNA without use of a gait belt as required by facility policy. Instead, the CNA held the resident’s arm, pulled on the back of the resident’s pants, and then lifted the resident by placing both arms around the resident while the resident, described as very unsteady and shaky, tried to hold bed and wheelchair supports. The CNA later stated she had been trained on gait belt transfers, knew staff should not lift under the arms, and did not see a gait belt in the room, despite the facility’s written procedure specifying gait/transfer belt use and stand-and-pivot technique for bed-to-chair transfers.
The facility did not develop or accurately complete baseline care plans within 48 hours of admission for three residents, including one who was admitted with psychotropic medication that was not documented on the care plan, and two others who had no baseline care plans at all. Staff interviews revealed confusion over responsibilities and difficulties with a new electronic records system, leading to incomplete or missing care plans for newly admitted residents.
A resident with multiple chronic conditions and complex care needs did not have a comprehensive care plan completed within the required 7 days after the comprehensive assessment. The MDS Coordinator, responsible for care plan completion, overlooked this task, and other staff confirmed the omission, which was not in accordance with facility policy.
Surveyors found that insulin pens on two medication carts were in use without being labeled with the date they were opened, as required by facility policy and manufacturer instructions. Nursing staff and the DON confirmed that it was their responsibility to date insulin pens upon opening, but this was not consistently done, potentially leading to the use of insulin beyond its effective period.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident requiring maximal assistance with bathing and self-care was found with long, discolored fingernails containing residue, despite expressing a preference for clean, short nails. Staff interviews confirmed that nail care responsibilities were not fulfilled, and the facility's ADL policy did not address fingernail care, resulting in a lapse in personal hygiene services.
A resident did not receive the necessary care to maintain or improve range of motion or mobility, and the facility did not ensure that a decline was medically unavoidable.
A resident with severe cognitive impairment and frequent incontinence did not receive proper perineal care after an incontinent episode, as a CNA failed to separate the labia and clean appropriately, and wiped from back to front instead of front to back, contrary to facility policy. This lapse was confirmed by both the CNA and the DON during interviews.
A resident with a G-tube did not receive the physician-ordered water flushes between each medication during administration by an LVN, who administered multiple crushed medications sequentially without the required flushes. The LVN later acknowledged overlooking the order, and the DON confirmed that staff are expected to follow such orders to prevent complications.
A licensed pharmacist did not conduct the required monthly drug regimen review, including reviewing the medical chart, and the facility did not follow its policies for reporting irregularities found during the review.
A medication aide failed to sanitize a blood pressure cuff before and after use when checking the blood pressure of three residents with various medical conditions, including multidrug-resistant organism infection and diabetes. This action was contrary to facility policy, which requires cleaning of non-critical equipment between residents to prevent cross-contamination.
A working call system was not available in each resident's bathroom and bathing area, as required. This deficiency was observed during the survey and no further details about affected residents or their conditions were provided.
A resident with anxiety disorder and moderate cognitive impairment was prescribed Quetiapine Fumarate for insomnia even though the chart did not show an adequate indication for antipsychotic use. The record also lacked behavior and side effect monitoring, and staff interviews confirmed there was no monitoring order and that the diagnosis listed for the medication was not appropriate.
A resident with COPD and impaired cognition was ordered oxygen at 2 LPM by nasal cannula every shift, and his care plan and MAR reflected that order. Surveyors observed the concentrator set at 4 LPM on two separate occasions while the resident was receiving oxygen. RN and leadership interviews confirmed staff were expected to verify the concentrator setting each shift and follow the physician’s oxygen order, but no matching order for 4 LPM was found.
A medication cart review found an insulin pen for a resident with an expired open date on the 200 Hall Nurses Cart. The pen had been used, and the label instructed it to be discarded after 28 days of use. An LVN stated nurses were responsible for checking open dates before giving insulin, and the DON stated opened insulin pens and vials had to be dated because they had a specific shelf life and could lose effectiveness if not discarded on time.
A nurse used a syringe with a plunger seal that had fallen to the ground and reused a syringe beyond the 24-hour protocol for a resident with a jejunostomy tube, despite being aware of infection control risks. The facility could not provide a written infection control policy when requested, and staff interviews confirmed knowledge of proper procedures, highlighting lapses in both practice and documentation.
The facility failed to ensure call lights were within reach for three residents, including a male with impaired cognition and muscle weakness, a male with dementia and stroke history, and a female on hospice care. Observations revealed call lights were tangled or on the floor, preventing residents from calling for assistance. Staff acknowledged the importance of accessible call lights, yet did not consistently ensure they were within reach.
A facility failed to provide proper catheter and incontinence care, risking urinary tract infections. A resident's catheter bag was placed above the bladder during a transfer, causing urine backflow. Another resident was left in a saturated brief due to improper care, and a therapist placed a catheter bag on the floor, risking contamination. Staff acknowledged their errors, highlighting training lapses.
The facility failed to ensure controlled drugs were counted and documented at every shift change for Med Aide cart hall 500. LVN S and LVN R did not sign the narcotic sheets after counting, as required by the facility's policy. The DON confirmed the importance of this procedure to prevent drug diversion, although no diversion was detected.
The facility's kitchen failed to meet food safety standards by not discarding expired food, improperly labeling and dating items, and leaving food uncovered. Staff interviews revealed lapses in protocol adherence, with the Dietary Manager citing staffing shortages as a contributing factor.
The facility failed to maintain an effective infection prevention and control program, with staff neglecting to disinfect blood pressure cuffs between residents and not adhering to hand hygiene protocols during care. These actions could lead to cross-contamination and infection spread among residents.
A facility failed to create a comprehensive care plan for a resident with Alzheimer's and anxiety, neglecting to address her resistance to care and eating. Despite known behaviors and preferences, such as using Ensure when meals were refused, these were not documented in the care plan. Staff interviews highlighted inconsistent care approaches due to poor communication and documentation, contrary to facility policy requiring comprehensive care plans.
A resident with intact cognition and a need for supervision in personal hygiene did not receive adequate nail care, resulting in long and chipped fingernails. Despite the facility's policy requiring nail care on shower days and as needed, staff interviews revealed inconsistencies in the execution of this care. The resident did not request assistance due to fear of repercussions, and her nails were only trimmed after the issue was highlighted.
A resident requiring tracheostomy care did not receive appropriate respiratory care due to a nurse's failure to maintain a sterile field. The nurse contaminated her gloves and did not follow proper procedures, risking respiratory infections. Despite training, the nurse did not adhere to the sterile technique required for tracheostomy care.
A resident requiring extensive assistance with ADLs and G-tube feeding was neglected for over 13 hours, with no incontinent care or repositioning provided. The neglect was discovered by the resident's family through video footage and confirmed by staff interviews and record reviews. The incident revealed significant communication and policy adherence issues within the facility.
A resident with extensive care needs was found soaked in urine and bowel movement due to a lack of proper incontinent care during the night shift. Despite being totally dependent on staff for ADLs, the resident was not changed or repositioned, leading to distress and a rash. Staff members failed to report the neglect immediately, resulting in a deficiency for the facility.
A resident with severe cognitive impairment and multiple medical conditions was left without incontinence care for over 13 hours due to the inaction of a CNA and lack of proper communication among staff. The resident was found soaked in urine and with a bowel movement, leading to significant discomfort and potential health risks.
A resident requiring extensive assistance was left without incontinent care for 13 hours, and the staff failed to report the neglect immediately. Interviews revealed that the neglect was known but not communicated or reported promptly, leading to a delay in addressing the issue and investigating the incident.
The facility failed to maintain an infection control program, as staff did not follow proper PPE and hand hygiene protocols for two residents. One staff member improperly donned a face mask in a COVID-19 isolation room, and two staff members did not perform hand hygiene during incontinence care, despite recent training.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure Resident #2 had her call light within reach. Resident #2 was an [AGE]-year-old female admitted to the facility and, according to her annual MDS, had Non-Alzheimer's Dementia, Diabetes Mellitus, a BIMS score of 3 indicating severe cognitive impairment, and required moderate to maximal assistance with ADLs. Her care plan, dated 05/28/26, included interventions to orient her to the call light and keep it within reach because she had falls on 09/09/25 and 12/15/25. During observation on 05/28/26 at 9:47 AM, Resident #2 was sitting in her wheelchair next to her bed eating breakfast, and her call light was observed on the opposite side of the bed lying on the floor. Additional observations at 10:54 AM and 1:44 PM again showed the resident in her wheelchair beside the bed with the call light on the floor on the opposite side of the bed. Resident #2 stated she could push the call light when it was on the bed but could not reach it when it was on the floor. Staff interviews confirmed the call light should always be within residents' reach, that Resident #2 could not reach it on the floor, and that all staff were responsible for ensuring it remained accessible. The facility policy, Call Lights Answering revised 01/19/23, stated that when leaving the room, the call light should be placed within the resident's reach.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for toileting hygiene received timely incontinence care. The resident had diagnoses including non-Alzheimer's dementia, seizure disorder or epilepsy, anxiety, and schizophrenia, and the annual MDS reflected that she was always incontinent of bowel and bladder and dependent on staff for toileting hygiene. Her care plan directed staff to assist with toileting needs, check and change her, keep her clean and dry, and apply barrier cream after each incontinent episode. On the day of the observation, the resident was seen lying in bed, and later during incontinence care her brief was found full of urine and feces with a strong urine odor. The urine had soaked through her brief, draw sheet, and fitted sheet, and redness was noted to her sacral area without open areas. CNA A stated she had last changed the resident about 6 hours earlier and acknowledged that the resident was fully dependent on staff for incontinence care and needed to be checked to confirm whether she was wet. LVN B and the DON both stated residents were expected to be checked and changed at least every 2 hours, and the DON stated it was unacceptable for the resident to go 6 hours without incontinence care.
Overfilled Sharps Containers in Resident Rooms
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for 5 of 20 rooms reviewed for accident hazards: Rooms #501, #508, #510, #705, and #712. In each of these rooms, the sharps container used to store used needles was observed to be overfilled. On 05/18/26 at 9:10 AM, the sharps container in one room was overfilled and two syringes were protruding out of the safety flap. At 9:13 AM and 9:15 AM, two additional rooms had overfilled sharps containers in which the safety flap could not be operated. At 9:28 AM and 9:30 AM, two more rooms had overfilled sharps containers with multiple syringes and needles protruding out of the safety flap. During interviews, the Wound Care Nurse stated nursing staff were responsible for changing sharps containers when they reached the fill line and said overfilling placed residents at risk of being stuck with a used needle and exposed to possible bloodborne pathogens. The ADON stated nursing staff and Central Supply staff were responsible for changing sharps containers before they became overfilled and described the risk of needles protruding from an overfilled container as a serious risk to residents, potentially exposing them to blood or infectious materials. The DON stated all staff were responsible for checking sharps containers and alerting nursing staff if one needed to be changed out, and that nursing staff were responsible for changing them before they were overfilled. The facility's Regulated Waste policy stated sharps containers are discarded when 3/4 or less filled.
Missed Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
Pharmaceutical services were not provided consistently to meet the needs of residents who required blood glucose monitoring and insulin administration. The facility failed to ensure that blood sugar levels were checked and insulin was administered according to physician orders for 4 of 10 residents reviewed for medication administration. The report identified repeated missed glucose checks and missed insulin doses for residents with diabetes, and noted that no nursing progress notes were found to explain why the doses were missed. Resident #1 was admitted with diabetes, had a BIMS score of 15, used a wheelchair, and relied on staff assistance with some ADLs. Her care plan and physician orders required blood sugar checks before breakfast, lunch, and dinner with insulin given by sliding scale. The insulin administration record showed missed glucose checks and missed insulin administration on multiple dates, including missed midday checks and days when no treatment was needed based on the recorded glucose values. The EHR contained no nursing documentation explaining the missed doses. During interview, the resident stated staff did not always give her insulin properly and that some days her blood sugar was checked after meals or not checked more than once or twice. Resident #2 was admitted with diabetes, had a BIMS score of 15, and required minimal assistance with ADLs. His orders required blood sugar checks before meals and insulin per sliding scale, with Lantus before breakfast. The record showed repeated missed checks and missed fast-acting insulin administration on several dates, with no nursing progress notes explaining the omissions. Resident #2 stated he felt he was not always getting insulin as ordered, though he sometimes became confused and relied on staff statements. Resident #3 had diabetes, was fully dependent on staff for ADLs, and had orders for blood sugar checks before meals and at bedtime with insulin per sliding scale and long-acting insulin at bedtime. His record also showed repeated missed glucose checks and missed insulin administration, with no documentation explaining the missed doses. Resident #4 had severe cognitive impairment, was totally dependent for ADLs, and had orders for blood sugar checks and fast-acting insulin before meals. His record showed missed glucose checks and missed insulin administration, including entire days when no checks or treatment were documented, and no nursing documentation explained the omissions. Staff interviews confirmed that missing insulin doses was not acceptable, but the DON stated she had no idea doses were being missed.
Failure to Monitor Ordered Weights
Penalty
Summary
The facility failed to ensure acceptable nutritional status for one resident by not monitoring weight as ordered. Resident #1 was admitted with diagnoses including diabetes, post-operative spinal surgery, and chronic pain. Her admission MDS showed she was 64 inches tall, weighed 189.2 pounds, had a BIMS score of 15, used a wheelchair for mobility, and needed some staff assistance with ADLs. Her care plan identified nutritional risk related to diabetes and impaired mobility related to spinal surgery. Physician orders included weekly weights for 4 weeks and a regular diet. The resident’s weight record showed she was weighed only once after admission, at which time her weight was 189.2 pounds. When she was weighed during an observation, her weight was 180.0 pounds, reflecting a 4.8% loss. During interviews, the ADON and DON stated newly admitted residents were to be weighed weekly for the first four weeks to establish a baseline, and that failure to monitor weight loss could result in malnutrition. The facility’s Weight Monitoring policy stated newly admitted and re-admitted residents were to be weighed upon admission and weekly x4, then monthly thereafter unless otherwise indicated by physician order.
Failure to Disinfect Equipment and Perform Hand Hygiene During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper disinfection of reusable equipment and adherence to hand hygiene practices. A male resident with hypertension and anemia, cognitively intact with a BIMS score of 14, had his blood pressure taken by a medical assistant (MA A) using a blood pressure cuff that had just been removed from the assistant’s own wrist. The assistant did not disinfect the cuff before entering the resident’s room and applying it. In interview, the assistant acknowledged she was supposed to use disinfectant wipes to clean the cuff after removing it from her wrist and before applying it to the resident, and stated she had received training on care and disinfection of reusable equipment but could not recall when. The deficiency also includes failures in hand hygiene during incontinence care for two residents with bowel and bladder care needs. One female resident with severe cognitive impairment (BIMS score of 7), hypertension, and diabetes had a care plan identifying risk for bowel and bladder elimination problems and directing peri care after each incontinent episode. A CNA (CNA B) entered this resident’s room to provide incontinence care, put on gloves without washing hands, and cleansed the resident’s abdominal folds and perineal area using wet wipes. After removing a soiled brief, the CNA did not perform hand hygiene or change gloves before applying a clean brief and repositioning the resident. The CNA later stated she knew she was supposed to perform hand hygiene before resident contact, between care, and after glove removal, but said she forgot, and acknowledged that failure to do so could lead to contamination and spread of infection. A third resident, a male with severe cognitive impairment (BIMS score of 0) and hypertension, had a care plan focused on bowel and bladder with interventions to check, change, and keep him clean and dry. During observed incontinence care, another CNA (CNA C) prepared supplies, entered the room, and donned gloves without washing hands. The CNA cleansed the resident’s abdominal area, penis, and Foley catheter, then turned the resident, cleansed the buttocks after a bowel movement, and changed gloves between care without performing hand hygiene. After the resident was clean, the CNA again removed gloves and put on new gloves without hand hygiene before applying a clean brief and cream, and only washed hands after removing gloves at the end of care. In interview, this CNA stated he was supposed to perform hand hygiene before contact and with each glove change, but forgot, and acknowledged that failure to perform hand hygiene during incontinence care could lead to cross contamination and infection. The DON stated her expectation that staff perform hand hygiene before resident contact, between care, and with glove changes, and that reusable equipment be disinfected before and after use, and training records showed the involved staff had not attended prior in-services on these topics.
Unmonitored Public Access Through Posted Entry Code at Main Door
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, secure, and monitored entry environment at Door #1, where a four-digit access code was posted next to the keypad on the outside of the building. During observation, a surveyor used the posted code to unlock Door #1 and enter the facility without any staff presence at the front desk or in the adjacent halls and without any alarm or notification sounding to alert staff of the entry. The surveyor waited approximately 7–10 minutes before locating a staff member in an office behind the front desk, demonstrating that individuals could enter the building unobserved. The facility’s Resident Rights policy, provided in lieu of a physical environment policy, stated that staff would abide by resident rights in accordance with CMS guidance but did not address the specific physical environment or access control procedures. Multiple staff interviews confirmed that the code to Door #1 had been posted on the inside and outside of the door for several months so that staff and visitors could enter without difficulty, and that there was no system in place to reliably monitor who entered through this door when the front desk was not staffed. A staff member reported being very concerned about resident safety, especially after 4 p.m. when no one was stationed at Door #1, and relayed complaints from relatives, including one family member who was worried about the safety of her loved one because the entry code was visible to the public and usable after hours, including near midnight. The social worker reported a resident complaint over the summer about unknown people in the hall at night talking, and stated that there were no staff at the front desk in the evenings and at night, with nurses expected to monitor Door #1 from the nurses’ stations. The Director of Maintenance stated that all doors, including Door #1, had alarms that would sound if someone attempted entry without the code, but acknowledged that once the posted code was entered, there was no alarm or bell to notify staff that someone had come in, and he was unsure how the facility monitored such entries. Nursing staff, including LVNs, stated that no one specifically monitored Door #1 after hours, that they only knew someone had entered if the person came to the nurses’ station, and that they personally felt unsafe because anyone could enter using the posted code. The ADON confirmed that staff were present by Door #1 only during daytime hours and that after that time it was everyone’s responsibility to monitor the door, while acknowledging it was a safety concern that no one monitored Door #1 after hours. The Administrator stated the code had been posted for several months due to staff and family forgetting it, reported no known incidents of harm related to the posted code, and expressed the view that having the code posted and the door unmonitored did not present a true safety concern to residents.
Improper Transfer Technique Without Gait Belt Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer techniques and adequate supervision for a cognitively impaired resident who required assistance with transfers. The resident was an elderly female with dementia, diabetes, and hypertension, severely cognitively impaired with a BIMs score of 3, and care planned to require the assistance of one staff member and extensive assistance for transfers due to generalized and unilateral weakness. Her MDS reflected a history of at least one prior fall without injury, and her care plan interventions included providing an appropriate level of assistance to promote safety during transfers. During interview, the resident reported she had fallen recently and that staff and family had instructed her not to get up by herself, and she acknowledged she was trying to comply by asking for help. On the observed date, a CNA assisted the resident from her wheelchair to the bed and back without using a gait belt, contrary to the facility’s written transfer policy requiring a gait/transfer belt for bed-to-chair transfers. The CNA instead held the resident’s arm, pulled on the back of the resident’s pants, and later placed both arms around the resident to lift her from the bed to the wheelchair while the resident attempted to hold the bed rail and wheelchair arm for support. The resident was described as very unsteady and shaky, and the CNA struggled to complete the transfer. The CNA acknowledged in interview that staff were not supposed to lift residents under their arms because of potential injury, stated she had been trained on gait belt transfers, and reported she did not see a gait belt in the room. The facility’s policy specified use of a snugly applied gait belt at the waist with stand-and-pivot technique, which was not followed during the observed transfers.
Failure to Complete Timely and Accurate Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three out of five residents reviewed for care planning. Specifically, one resident was admitted with a diagnosis of anxiety disorder and prescribed Quetiapine Fumarate, a psychotropic medication, but the baseline care plan did not indicate the presence of psychotropic therapy, despite physician orders and medication administration records confirming its use. Two other residents did not have baseline care plans completed at all upon admission, despite having significant medical conditions such as moderate cognitive impairment and chronic obstructive pulmonary disease. Interviews with facility staff revealed confusion and inconsistency regarding responsibility for completing baseline care plans, with both the MDS Coordinator and nursing staff indicating that nurses were responsible for this task. Staff also reported challenges with a new electronic records system, which contributed to difficulties in timely and accurate completion of care plans. The facility's policy requires baseline care plans to be developed within 48 hours of admission and to include essential healthcare information such as physician orders, but this was not consistently followed for the residents in question.
Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for one resident. Record review showed that the resident, an older male with multiple diagnoses including anxiety disorder, atrial fibrillation, heart failure, diabetes, and asthma, was admitted with several medications and required continuous oxygen. The resident was also developing a pressure ulcer. While a baseline care plan was completed upon admission, there was no evidence of a comprehensive care plan being completed within the required timeframe after the comprehensive assessment. Interviews with facility staff revealed that the MDS Coordinator was responsible for completing the comprehensive care plan but had overlooked this task for the resident in question. The MDS Coordinator acknowledged the omission and described the process typically used to complete care plans, including the use of CAAs, physician notes, and orders. Other staff, including the LVN and DON, confirmed that the comprehensive care plan had not been completed as required and recognized that this failure could impede the resident's treatment. Facility policy requires that a person-centered care plan be developed within seven days after the comprehensive assessment.
Failure to Label Insulin Pens with Open Dates on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to properly label insulin pens with the date they were opened on two medication carts. Specifically, several insulin pens for multiple residents were found in use without an open date, despite instructions on the pens indicating they should be discarded 28 days after opening. Both direct observation and interviews with nursing staff confirmed that it was the nurses' responsibility to label insulin pens with the open date to ensure proper tracking of expiration, but this was not consistently done. The Director of Nursing also acknowledged that insulin pens and vials needed to be dated upon opening due to their limited shelf life after being opened. Record review of the facility's own policy confirmed that insulin products should be labeled with the date when first used. The pharmacy consultant was noted to check the carts monthly, and the DON reported conducting random checks, but these measures did not prevent the observed lapses. The lack of open dates on insulin pens could result in the use of insulin beyond its effective period, as the pens were observed to be in use without proper labeling.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events leading to the deficiency are provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was found that the care plan did not comprehensively cover all identified needs of the resident.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required maximal assistance with bathing and had a self-care deficit was observed to have long, discolored fingernails with brownish residue underneath. The resident, who had a history of cerebrovascular accident and elevated blood pressure, expressed dissatisfaction with the condition of his nails but did not inform staff because they appeared busy. The resident's care plan included assistance with grooming and hygiene, but on the day of observation, his fingernails had not been cleaned or trimmed. Interviews with staff revealed that both CNAs and nurses were responsible for nail care, but the assigned nurse had not noticed the resident's nails and acknowledged the risk of infection and injury. The DON stated that nail care should be performed as needed and during handwashing, with daily observation of nail condition. The facility's policy on ADLs and bathing did not address fingernail care, contributing to the failure to provide necessary services for maintaining the resident's personal hygiene.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care was provided to prevent a decline in these areas unless such decline was medically unavoidable. The report notes that the necessary interventions or services to support or enhance the resident's ROM or mobility were not implemented as required.
Inadequate Perineal Care Provided to Incontinent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was frequently incontinent of bowel and bladder. The resident, who had severe cognitive impairment due to dementia and other medical conditions, required thorough incontinence care as outlined in her care plan and the facility's policy. During an observed episode, the CNA did not separate the resident's labia or clean down the middle, and wiped the resident's buttocks from back to front, contrary to the required front-to-back technique. The resident's brief was also found to be soaked through, indicating a need for prompt and proper care. The facility's policy specifically required staff to separate the labia and wash downward in the center and on each side, using a different wipe for each stroke, and to clean the buttocks in an upward motion towards the back. The CNA acknowledged during an interview that she did not follow these procedures and recognized the importance of proper cleaning. The Director of Nursing confirmed that the observed care did not meet facility standards and that such lapses could place residents at risk for urinary tract infections, skin breakdown, and poor hygiene.
Failure to Follow G-Tube Flush Orders During Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician orders for water flushes during medication administration via a gastrostomy tube (G-tube) for a male resident with a history of traumatic brain dysfunction, respiratory failure, and gastroesophageal reflux. The resident's care plan and physician orders specified that the G-tube should be flushed with 30 cc of water before and after medications, and 15 cc of water between each medication. During observation, the LVN prepared and crushed six medications, administered them sequentially through the G-tube, but did not flush the tube with water between each medication as ordered. Instead, the LVN only performed a flush before the first medication and after the last, omitting the required flushes between each medication. Upon interview, the LVN acknowledged overlooking the physician's orders and admitted not flushing the G-tube as required, which could result in tube clogging. The Director of Nursing (DON) confirmed that staff are expected to follow physician orders for G-tube flushes and that failure to do so could lead to complications. The facility's policy also required irrigation of the feeding tube before, between, and after medication administration, which was not followed in this instance.
Failure to Complete Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its developed policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified based on the surveyor's observation that the required pharmacist review and irregularity reporting were not completed according to established guidelines.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the improper disinfection of reusable medical equipment. Specifically, a medication aide (MA) did not sanitize a blood pressure cuff before or after use when checking the blood pressure of three residents during a morning medication pass. This was observed as the MA moved from one resident to another, using the same blood pressure cuff without cleaning it between uses, despite the facility's policy requiring such equipment to be cleaned between residents. The MA later acknowledged awareness of the requirement but stated she forgot to sanitize the cuff between uses. The residents involved had various medical conditions, including elevated blood pressure, multidrug-resistant organism infection, wound infection, cerebrovascular accident, and type 2 diabetes mellitus. Their cognitive statuses ranged from severely impaired to intact. The facility's policy, revised in March 2025, clearly stated that non-critical items such as blood pressure cuffs must be kept clean, but this protocol was not followed during the observed incident.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The report does not provide additional details about specific residents affected, their medical history, or their condition at the time the deficiency was observed.
Unnecessary antipsychotic use without adequate indication or monitoring
Penalty
Summary
The facility failed to ensure that Resident #3’s drug regimen was free from unnecessary drugs because Quetiapine Fumarate was ordered for insomnia without an adequate indication documented in the record. Resident #3 was an [AGE]-year-old male admitted to the facility with a diagnosis of anxiety disorder, a BIMS score of 11, and no behavioral symptoms noted on the admission MDS. The baseline care plan reflected no psychotropic therapy, yet the physician’s order dated 7/28/25 directed Quetiapine Fumarate 50 mg at bedtime for insomnia. The record did not contain documented evidence of behavior monitoring or side effect monitoring related to the antipsychotic medication. Review of progress notes from 7/28/25 through 8/21/25 did not show behavioral or psychotic issues. The MAR reflected the medication was administered as ordered each day, but no order for monitoring behaviors or side effects was found, and no documented monitoring was present in the record. During interviews, LVN B stated Resident #3 had no significant behavioral issues and that she was not currently charting behaviors because she was learning the facility’s new electronic record system. ADON F stated insomnia was not an appropriate diagnosis for Seroquel and that the corrected diagnosis needed to be entered on the orders; she also stated there should have been an order to monitor behaviors and side effects. The DON and ADON G similarly stated that antipsychotic medications should have an appropriate diagnosis and that behavior and adverse reaction monitoring should be documented in the TARs and MARs.
Oxygen Flow Set Above Physician Order
Penalty
Summary
The facility failed to ensure that Resident #42 received respiratory care consistent with the physician’s order, the comprehensive care plan, and professional standards of practice. Resident #42 was an [AGE]-year-old male with diagnoses including COPD and seasonal allergic rhinitis, and his quarterly MDS reflected moderately impaired cognition with a BIMS score of 9. His order dated 7/21/25 directed oxygen at 2 liters per minute by nasal cannula every shift, and his care plan identified breathing patterns related to COPD with oxygen at 2 liters per minute every shift. On 8/19/25 at 10:13 AM, Resident #42 was observed in his room in a wheelchair with oxygen via nasal cannula, and the concentrator was set at 4 liters per minute instead of the ordered 2 liters per minute. On 8/20/25 at 8:48 AM, he was again observed asleep in his wheelchair with oxygen on via nasal cannula, and the concentrator was still set at 4 liters per minute. The medication record for 8/1/25 through 8/31/25 reflected oxygen at 2 LPM by nasal cannula continuous every shift. During interview, RN A stated he should have checked the concentrator at least once every shift and confirmed that the resident’s oxygen was set at 4 liters per minute, not the ordered 2 liters per minute. He said he could not find an order for 4 liters per minute and would clarify it with the doctor. LVN B, ADON F, the DON, LVN C, and ADON G all stated that staff were expected to follow the physician’s oxygen order and check the concentrator every shift when oxygen was continuous. The facility’s policy stated licensed staff would provide the prescribed amount of oxygen therapy and turn the liter flow to the prescribed amount.
Expired Open-Date Insulin Pen on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of medications on 1 of 4 medication carts reviewed. During observation of the 200 Hall Nurses Cart, surveyors found an insulin pen for Resident #44 with an expired open date. The pen was observed to have been used, and the instructions on the pen stated it should be discarded after 28 days of use. During interview, an LVN stated nurses were responsible for checking medication carts and insulin pens for open dates before administering insulin, and that insulin was good for only 28 days after opening because its effectiveness decreased after that time. The DON stated insulin flex pens and vials had to be dated when opened because each had a specific shelf life and could lose effectiveness if not discarded by that time. The facility policy on Medication Storage stated outdated, contaminated, discontinued, or deteriorated medications were to be immediately removed from stock and disposed of according to medication disposal procedures.
Failure to Maintain Infection Control Program and Adherence to Syringe Protocol
Penalty
Summary
The facility failed to establish and maintain an effective Infection Prevention and Control Program, as evidenced by multiple lapses in infection control practices and the absence of a written infection control policy. During a medication administration, a registered nurse knowingly used a syringe with a plunger seal that had fallen to the ground to administer medication to a resident with a jejunostomy tube. The nurse attempted to rinse the contaminated plunger seal with water before use, despite being aware of the infection control risk. The nurse stated that he used the contaminated syringe because it was the only one available and was unsure whether to use facility or hospice-supplied syringes due to confusion about the resident's hospice status. Additionally, the same nurse failed to follow proper syringe protocol by using a syringe for more than 24 hours for medication administration, tube flushing, and placement checks, contrary to facility policy requiring syringes to be changed every 24 hours. The nurse acknowledged the lapse and cited confusion over supply responsibility as a contributing factor. Other staff interviews confirmed that all nurses had received in-service training on infection control and were aware that contaminated or expired syringes should not be used. The facility was unable to provide a written infection control policy when requested by surveyors, despite multiple requests made in person and via email to the administrator and director of nursing. The lack of a written policy, combined with observed lapses in infection control practices, placed residents at risk for the spread of infection through cross-contamination.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for three residents were within reach, which is a critical aspect of accommodating resident needs and preferences. Resident #323, a male with moderately impaired cognition and several medical conditions including chronic kidney disease and muscle weakness, was observed with his call light and bed remote wrapped around the bottom of the bed rail, out of his reach. Despite his contracted hands and partially paralyzed left arm, which made it difficult for him to reach the call light, staff did not consistently ensure it was accessible, leading to his frustration and inability to call for assistance. Similarly, Resident #25, who had a history of dementia, stroke, and other medical issues, was found with his call light hanging from the bed rail, not within his reach. He was unable to locate or use the call light to request help. An LVN confirmed that the call light should always be within reach, yet it was not consistently placed appropriately for Resident #25. Resident #18, a female with severely impaired cognition and on hospice care, was observed with her call light on the floor, obstructed by wheelchair footrests and trash bags. Despite the importance of having the call light accessible, a CNA admitted to leaving it on the floor with plans to return later. The charge nurse and other staff acknowledged the importance of keeping call lights within reach, yet this was not consistently practiced, as evidenced by the observations and interviews conducted during the survey.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for residents with catheters and incontinence, leading to potential risks of urinary tract infections. In one instance, the Staffing Coordinator and a CNA did not maintain the foley catheter drainage bag below a resident's bladder during a mechanical lift transfer. This oversight caused urine to flow back towards the resident's bladder, increasing the risk of infection. Both staff members acknowledged their mistake, with the Staffing Coordinator admitting she was trained to keep the bag below the bladder but failed to do so during the transfer. Another deficiency involved a resident who was not provided timely incontinence care. A CNA placed a wadded-up brief over the resident's penis, which was not standard practice, and failed to return to check and change the resident before the end of her shift. This resulted in the resident being left in a saturated brief, with redness observed on the scrotum and buttocks. The CNA admitted to her error, stating she knew it was wrong but did not have assistance at the time. Additionally, a therapist placed a urine catheter bag on the floor during a transfer, which is against the facility's policy. The therapist acknowledged the mistake, stating she was trained to keep the bag off the floor to prevent cross-contamination. The Director of Nursing confirmed that placing the catheter bag on the floor or above the bladder could lead to urinary tract infections and emphasized the importance of proper catheter care and hand hygiene.
Failure to Document Narcotic Counts at Shift Changes
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that controlled drugs were counted and documented at every shift change for one of the medication carts, specifically Med Aide cart hall 500. This deficiency was identified through interviews and record reviews, which revealed missing signatures on the narcotic count sheet for several dates in July 2024. LVN S and LVN R, who were responsible for the cart, admitted to not signing the narcotic sheets after counting the drugs, which is a critical step to prevent drug diversion. The Director of Nursing (DON) confirmed that the expectation was for nurses to sign the narcotic count sheet at the beginning and end of their shifts after completing the count with the incoming and outgoing nurse. The facility's policy on controlled medication storage, dated September 2007, requires a physical inventory of all Schedule II drugs at each shift change, which was not adhered to in this case. Although no drug diversion was noticed during a medication count, the lack of documentation could potentially lead to such an issue.
Food Safety Lapses in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. Specifically, the facility did not discard expired food items, such as a half-used container of chopped garlic in water with an expiration date that had passed. Additionally, food items in the walk-in refrigerator were not properly labeled or dated, including a white, cream-like substance in a Ziplock bag and hard-boiled eggs that were not securely covered. These lapses were identified during an inspection of the facility's kitchen. Interviews with kitchen staff and management revealed a lack of consistent adherence to food safety protocols. A staff member admitted to forgetting to cover the hard-boiled eggs and was unable to identify the unlabeled food item. The Dietary Manager acknowledged the oversight and attributed it to staffing shortages on the morning of the inspection. The facility's policy requires all food items to be labeled, dated, and covered, but these procedures were not followed, posing a risk of food contamination and potential food-borne illness for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper sanitation and hand hygiene practices. Specifically, medical assistants failed to disinfect blood pressure cuffs between use on different residents. For instance, MA L did not sanitize the blood pressure cuff before and after using it on two residents, despite acknowledging the importance of doing so to prevent the spread of germs. Similarly, MA M also neglected to sanitize the blood pressure cuff between residents, admitting that this oversight could lead to cross-contamination and infection spread. Additionally, the facility's staff did not adhere to proper hand hygiene protocols during resident care. CNA K failed to perform hand hygiene between glove changes while providing incontinence care to a resident, despite being aware of the requirement to wash hands before and after care to prevent infection spread. The Staffing Coordinator also neglected to perform hand hygiene after handling a catheter drainage bag and completing a mechanical lift transfer for a resident, which could lead to cross-contamination. The facility's policies on hand hygiene and disinfecting resident care equipment were not followed, as evidenced by the staff's actions. The Director of Nursing confirmed that staff were trained on these protocols, yet the observed practices did not align with the facility's expectations. These deficiencies in infection control practices could place residents at risk of cross-contamination and infection.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #50, who was admitted with multiple diagnoses including Alzheimer's disease, anxiety disorder, and severely impaired cognition. The care plan did not address the resident's resistance to care and eating, which were significant issues observed and reported by staff and the resident's representative. Despite the resident's known behaviors of resisting meals and care, these were not documented or included in the care plan. Observations and interviews revealed that Resident #50 often resisted eating and care, requiring significant cuing and prompting. The resident's representative had requested specific feeding strategies, such as placing food on the resident's lip and providing Ensure if meals were refused, but these preferences were not reflected in the care plan. Staff interviews indicated a lack of communication and documentation regarding the resident's preferences and behaviors, leading to inconsistent care approaches. The MDS Nurse, responsible for creating care plans, acknowledged that the care plan did not include interventions for the resident's resistance to care or specific food preferences. The facility's policy required comprehensive care plans with measurable objectives and timeframes, but this was not adhered to in Resident #50's case. The deficiency in care planning could potentially impact the resident's psychosocial health and wellbeing, as the care plan did not adequately address her individual needs.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene, specifically nail care. The resident, a female with intact cognition, expressed dissatisfaction with her long fingernails, which she was unable to trim herself. Despite requiring supervision with personal hygiene, the resident did not request assistance due to fear of getting into trouble. Observations revealed that her nails were approximately 0.5 centimeters long and chipped, indicating a lack of proper nail care. Interviews with facility staff, including CNAs, RNs, the DON, and the ADON, revealed inconsistencies in the provision of nail care. Staff members acknowledged that both CNAs and nurses were responsible for nail care, except in cases involving diabetic residents, where only nurses were permitted to perform the task. Despite this, the resident's nails were not trimmed until after the issue was brought to the attention of the staff. The facility's policy required nail care to be performed during shower days and as needed, but this was not adhered to, leading to the deficiency.
Failure to Maintain Sterile Technique in Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring tracheostomy care, as observed during a survey. The resident, a male with severe cognitive impairment and respiratory failure with hypoxia, required tracheostomy care and oxygen therapy. The facility's Licensed Vocational Nurse (LVN) did not maintain a sterile field while performing tracheostomy care and suctioning, which could lead to respiratory infections. Specifically, the LVN contaminated her sterile gloves by touching non-sterile surfaces and did not follow proper procedures for tracheostomy care and suctioning. During the observation, the LVN was seen performing tracheostomy care without maintaining sterility. She contaminated her gloves by handling non-sterile items and did not change gloves or perform hand hygiene when moving from dirty to clean tasks. The LVN also improperly used a trach brush and placed the suction catheter in a plastic bag, which was not part of the standard procedure. These actions were inconsistent with the facility's policy and professional standards of practice for tracheostomy care. Interviews with the LVN, the Director of Nursing (DON), and the facility's Respiratory Therapist (RT) Consultant revealed that the LVN had been trained but failed to adhere to the sterile technique required for tracheostomy care. The RT Consultant noted that the LVN had initially failed a competency test and required additional training. Despite this, the LVN did not follow the correct procedures, posing a risk of respiratory infections to the resident.
Neglect of Resident Over 13-Hour Period
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically neglect, as evidenced by the lack of care provided to a resident over a period of more than 13 hours. The resident, who required extensive assistance with activities of daily living (ADLs) and was dependent on a G-tube for feeding, was not checked on or provided with incontinent care from 9:05 PM on 12/31/23 until 10:22 AM on 1/1/24. This neglect was confirmed through interviews, record reviews, and video footage from a camera placed in the resident's room by the family. The resident's family discovered the neglect when they found the resident's support pillow and chair soaked in urine and reviewed the camera footage, which showed no care being provided during the specified time frame. The resident's medical history included critical illness myopathy, hypertension, pneumonia, diabetes mellitus, aphasia, cerebrovascular attack, respiratory failure, dysphagia, and G-tube feeding dependency. The resident was always incontinent of urine and bowel and required a two-person assist for all ADLs. Despite these needs, the assigned CNAs and LVNs failed to provide the necessary care. CNA A, who was assigned to the resident during the night shift, did not provide any care, citing a previous incident with the resident's family as the reason. However, this decision was not communicated to the charge nurse or other staff members. LVN C, who was the charge nurse during the night shift, also did not check on the resident for incontinent care, assuming the CNA would handle it. The neglect continued into the morning shift, where CNA B did not check on the resident until 10:22 AM, despite the resident being a two-person assist and visibly in need of care. The resident was found soaked in urine and had a small bowel movement, indicating that no care had been provided for an extended period. Interviews with the staff revealed a lack of communication and understanding of the facility's policies on abuse and neglect. The DON and Administrator were not made aware of the incident until days later, highlighting a significant breakdown in the reporting and handling of abuse and neglect allegations within the facility.
Failure to Implement Policies and Procedures to Prevent Neglect
Penalty
Summary
The facility failed to implement written policies and procedures to prevent abuse, neglect, and theft, resulting in a deficiency for one resident. The incident involved a resident who was found soaked in urine and bowel movement, indicating a lack of proper incontinent care. The resident, who required extensive assistance with activities of daily living (ADL) and was totally dependent on staff for transfers and bathing, was not provided the necessary care during the night shift. This failure was reported by multiple staff members, including CNAs and LVNs, who observed the resident's condition and reported it to the Administrator, who serves as the Abuse Coordinator. The resident's medical history included critical illness myopathy, hypertension, pneumonia, diabetes mellitus, aphasia, cerebrovascular attack, respiratory failure, dysphagia, and tube feeding dependency. The resident was always incontinent of urine and bowel and required two-person assistance for all ADL care. Despite these needs, the resident was not changed or repositioned from the night shift until the following morning, leading to a distressed state and a rash in the perineal area. The family members of the resident expressed their concerns and reviewed camera footage, which confirmed the lack of care provided during the night shift. Interviews with staff members revealed a breakdown in communication and adherence to facility policies. CNA A, who was assigned to the resident, did not provide care due to a previous incident with the resident's family and failed to communicate this to the charge nurse. Other staff members, including LVNs and the Staffing Coordinator, acknowledged the neglect but did not report it immediately to the Abuse Coordinator as required by the facility's policy. The DON and Administrator were made aware of the incident after the fact and began investigating the allegations. The facility's failure to ensure proper care and timely reporting of neglect placed the resident at risk for harm and compromised their dignity and comfort.
Failure to Provide Incontinence Care for Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically incontinence care, for over 13 hours. The resident, a male with severe cognitive impairment and multiple medical conditions including critical illness myopathy, hypertension, pneumonia, diabetes mellitus, aphasia, cerebrovascular attack, respiratory failure, dysphagia, and G-tube feeding dependency, was left without incontinence care from 9:05 PM on 12/31/23 to 10:22 AM on 01/01/24. During this period, the resident's clothing and bedding were found soaked in urine, and the resident had a bowel movement that was not attended to, leading to significant discomfort and potential health risks. The deficiency was primarily due to the inaction of CNA A, who was assigned to the resident but failed to provide the necessary care during the night shift. CNA A did not communicate her decision to not care for the resident to the charge nurse, LVN C, or any other staff members. This lack of communication and failure to provide care resulted in the resident being left in a soiled state for an extended period. Additionally, LVN D, who was responsible for the resident during the morning shift, did not physically check the resident for incontinence despite being aware of the resident's needs and the family's concerns. Interviews with various staff members, including LVN D, CNA B, and the Staffing Coordinator, revealed a lack of adherence to the facility's policies on incontinence care and reporting neglect. The DON confirmed that there was no specific facility policy on how often residents should be checked for continence, but expected that dependent residents be changed as needed. The failure to provide timely incontinence care and the lack of proper communication among staff members led to the resident's prolonged discomfort and potential health risks, constituting a clear case of neglect.
Failure to Report Neglect in a Timely Manner
Penalty
Summary
The facility failed to ensure all alleged violations involving neglect were reported immediately, as required by regulations. Specifically, the staff did not report a 13-hour delay in providing incontinent care to a resident who required extensive assistance with activities of daily living. The resident, who had severe cognitive impairment and multiple medical conditions, was left without necessary care, leading to a family member discovering the neglect and reporting it to the staff. Interviews with various staff members revealed that the neglect was not communicated or reported promptly. The charge nurse, LVN, and CNA involved in the resident's care all acknowledged the failure to provide care and the subsequent neglect. However, they did not report the incident to the abuse coordinator immediately, as required by the facility's policy. The staff members admitted to being aware of the neglect but delayed reporting it, citing reasons such as being busy or assuming others would handle the situation. The facility's administration, including the DON and the facility administrator, were not made aware of the incident until days later. The administrator confirmed that the incident was reported to the state regulatory agency only after being notified by the family. The facility's policy on reporting abuse and neglect was not followed, leading to a delay in addressing the neglect and investigating the incident. The failure to report the neglect immediately placed the resident at risk and highlighted a significant lapse in the facility's adherence to regulatory requirements.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two residents. For Resident #3, a staff member (MA BB) did not don the face mask correctly when entering the resident's isolation room. Resident #3, an elderly female with multiple diagnoses including cancer and heart failure, was on droplet precautions due to a positive COVID-19 status. MA BB entered the room with improper PPE, wearing a surgical mask under an N95 mask and without goggles or a face shield, contrary to the facility's policy and recent in-service training on isolation precautions. For Resident #1, the facility failed to ensure proper hand hygiene during incontinence care. Resident #1, a male with severe cognitive impairment and multiple health issues, required extensive assistance with activities of daily living. During an observation, CNA O and ADON B did not perform hand hygiene or change gloves appropriately while providing incontinence care. Both staff members admitted to not following proper hand hygiene protocols, which were confirmed by the DON as necessary to prevent the spread of infection. The facility's policies on COVID-19 PPE and hand hygiene were not adhered to by the staff, leading to potential risks of cross-contamination and infection. The staff involved acknowledged their lapses in following the protocols, despite recent in-service training on infection control measures. The DON confirmed the importance of these procedures in preventing the spread of infection within the facility.
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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.
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Illustrative
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Nursing homes near Plano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prestonwood Rehabilitation & Nursing Center Inc | 1 mi | ★★★★★ | 0 | 0 |
| Mustang Park Therapy And Living Center | 2 mi | ★★★★★ | 21 | 0 |
| Brookhaven Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 5 | 1 |
| The Legacy At Willow Bend | 3.3 mi | ★★★★★ | 4 | 0 |
| Carrara | 3.3 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.