Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Afton Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with paraplegia, generalized muscle weakness, contractures, dysphagia, cognitive communication deficit, and a need for extensive ADL assistance was care planned and assessed as requiring supervision and two-person assist for bed mobility, transfers, toileting, dressing, and personal hygiene. During personal care, a CMA provided care alone, despite the documented two-person assist requirement, and the resident became agitated and fell from the bed to the floor, landing face down and sustaining an upper lip laceration that required stitches. Interviews and records confirmed that the resident’s need for two-person assistance was documented in the MDS, care plan, and Kardex, and that this requirement was not followed at the time of the incident.
A resident with significant cognitive impairment and a history of wandering eloped from the facility after staff failed to provide adequate supervision and did not ensure required monitoring devices were in place. The resident exited the building without a wander guard, was not identified by staff as leaving, and was later found outside by a staff member and police. Facility policies for monitoring and door alarms were not effectively implemented, resulting in the resident's unsupervised exit.
A resident with multiple complex medical conditions, including ESRD, sepsis, and numerous wounds, did not receive ordered IV antibiotics, wound care, or pain management upon admission. Facility staff failed to notify the physician of missed medications, missed hemodialysis, and incomplete wound care, and did not document pain assessments or administer pain medication prior to wound treatments. These failures led to the resident's transfer to the hospital with sepsis and subsequent bilateral amputations.
Two residents experienced neglect due to the facility's failure to initiate timely wound care, administer prescribed IV antibiotics, and notify physicians of missed treatments and changes in condition. One resident did not receive wound care for several days after admission, while another with multiple wounds and end-stage renal disease did not receive necessary antibiotics, wound treatments, or pain management, and missed a scheduled hemodialysis session without physician notification. Staff interviews revealed confusion about responsibilities and a lack of comprehensive clinical review for new admissions.
Two residents with multiple pressure ulcers and complex wounds did not receive timely wound care or treatment orders upon admission. Wound care orders, wound consults, and necessary medications were delayed for several days, and staff interviews revealed confusion about responsibilities and a lack of follow-up to ensure prompt care. These failures resulted in significant delays in wound management and treatment.
A resident with multiple severe wounds and cognitive impairment did not receive appropriate pain assessment or management during wound care. Staff failed to assess pain, did not administer ordered pain medication, and did not stop procedures when the resident showed signs of distress. There was no care plan for pain, and staff were unclear about pain management responsibilities and documentation, resulting in unmanaged pain during treatments.
A resident with end-stage renal disease did not receive prescribed hemodialysis for four days due to an elevated heart rate and subsequent failures in staff communication, documentation, and physician notification. The breakdown in following facility policy and lack of timely intervention led to a missed critical treatment and placed the resident at risk.
A resident with severe wounds, sepsis, and on dialysis did not receive ordered IV antibiotics for several days after admission due to failures in order entry, communication, and medication administration. Staff did not ensure timely IV access or notify providers about missed doses, and the resident's complex condition and nonverbal status further complicated care. This resulted in a significant medication error as the facility did not follow physician orders or its own medication administration policies.
Two halls were found to have significant deficiencies in maintaining a safe, clean, and homelike environment. On one hall, persistent foul odors from two residents' rooms, due to refusal of care and wound treatment, spread throughout the area despite increased cleaning efforts. On another hall, ongoing construction exposed residents and staff to dust and noise, with incomplete barriers and no clear communication or protective measures, resulting in missed wound care visits for two residents. Staff and residents were not adequately informed or protected during these events.
The facility did not maintain a safe and comfortable environment on two halls, with persistent foul odors from two residents who refused care on one hall and unsafe renovation practices on another, including inadequate communication, lack of protective equipment, and barriers that prevented wound care for two residents. Additionally, a dining room door was improperly propped open for an extended period, and staff were unclear about interventions to address these issues.
The facility did not maintain an effective pest control program, resulting in live flies being observed in a hallway and in the rooms of two residents, both of whom had significant medical needs and required assistance with daily activities. Despite ongoing pest control treatments, flies continued to be present in resident care areas, indicating a deficiency in the facility's pest management practices.
A resident who was legally blind and cognitively intact was not consulted about designating a responsible party at admission, resulting in a family member being listed without consent. This led to an unauthorized insurance change and a delay in necessary eye surgery. Staff interviews confirmed the resident was capable of making his own decisions and should have been consulted, but the process failed to include his input.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. The report notes that the environment posed risks and staff oversight was insufficient, but does not specify the hazards or individuals involved.
Staff failed to ensure that medications, including Latanoprost eye drops and Humalog KwikPen insulin, were properly labeled with open and expiration dates or removed when expired on two medication carts. Multiple residents' medications lacked required labeling, and an expired medication was not removed as per facility policy, as confirmed by observations, record reviews, and staff interviews.
A resident with quadriplegia and anxiety disorder received duplicate Buspirone orders, leading to administration of the medication both two and three times daily due to failure to discontinue the previous order. Staff interviews confirmed the duplicate orders and acknowledged the error, with facility policy requiring daily review of new physician orders for accuracy.
Surveyors found that the facility failed to maintain food service safety standards, including leaving dirty dishes with leftover food in the dining room overnight, allowing grease buildup on kitchen vent hood rails, and not properly labeling or dating food items in the refrigerator and freezer. Expired food was also found in the dry goods pantry. Staff interviews confirmed these practices were not in line with facility policy.
A resident with multiple chronic conditions was discharged from hospice services, but the facility did not complete a Significant Change MDS assessment or update the care plan within the required 14-day period. The MDS nurse, who was new to the role, was unaware of the discharge until after the deadline had passed, resulting in the assessment being completed late and the care plan remaining outdated.
A resident with diagnoses of bipolar disorder and schizoaffective disorder was admitted and readmitted to the facility, with documentation confirming mental illness on her records and care plan. Despite these findings, the required PASARR Level II (PE) screening was not completed, as confirmed by the MDS coordinator and review of the clinical record.
A resident with multiple chronic conditions was admitted without a completed baseline care plan within the required 48-hour timeframe. The baseline care plan document was left blank, and the comprehensive care plan was not started until after the deadline. Staff interviews revealed confusion about which nurse was responsible for initiating the care plan, and the resident's admission MDS was also incomplete.
A resident with multiple chronic conditions was discharged from hospice and began receiving therapy, but the care plan was not updated to reflect this change. Staff interviews revealed a lack of awareness and communication regarding the resident's status change, resulting in the care plan continuing to indicate hospice care despite the resident's new therapy regimen.
A resident with quadriplegia and anxiety disorder received duplicate orders for Buspirone, with both twice-daily and three-times-daily regimens being administered concurrently. The consultant pharmacist did not identify or report this irregularity during the monthly drug regimen review, and staff interviews confirmed the duplicate orders were not discontinued as required. The issue was discovered through record review and staff interviews, revealing a lapse in medication review and reporting processes.
A resident with advanced dementia and a history of wandering accessed and ingested hand sanitizer that was not properly secured, leading to hospitalization. The resident's care plan identified her as at risk for unsafe wandering and required staff redirection, but hand sanitizer was left accessible on medication carts. Staff interviews confirmed the resident's known behaviors and the unsecured sanitizer, resulting in a failure to prevent the accident.
A resident with significant physical and cognitive impairments did not receive scheduled showers on multiple occasions, despite requiring substantial assistance for ADLs. Interviews with the resident and staff confirmed that the resident did not refuse care, and documentation was lacking for the missed showers. Staffing shortages and lack of follow-up contributed to the failure to provide necessary hygiene services.
A resident with advanced dementia and a history of wandering was found with a bottle of hand sanitizer, appearing to drink from it, and was later hospitalized after being found hard to awaken. Staff interviews and documentation revealed that hand sanitizer was not always secured, and the incident was not thoroughly investigated or reported as neglect to the state agency, despite facility policy requiring such actions.
A resident experienced significant weight loss and was prescribed Ozempic for diabetes, but the facility failed to update the care plan to address these issues. The resident's care plan did not reflect the weight loss or the medication's side effects, despite the resident being cognitively aware and requiring assistance with daily activities. Interviews with staff revealed a lack of experience and oversight in updating care plans.
The facility failed to administer medications as ordered for two residents, leading to blanks in the MARs without documentation of reasons. A resident did not receive his inhaler and supplement, while another missed a dose of Carvedilol. Interviews with staff confirmed the expectation for complete documentation, highlighting a lapse in following the facility's medication administration policy.
A resident with cognitive and physical impairments did not receive proper incontinent care, as CNAs failed to clean the perineal area thoroughly, increasing the risk of UTIs. Despite the facility's training programs, the CNAs did not follow the correct procedures, and the facility could not provide a documented perineal care policy.
A CNA in a long-term care facility failed to perform hand hygiene after removing soiled gloves during incontinence care for a cognitively impaired resident. Despite recent training, the CNA left the room without sanitizing her hands, risking cross-contamination. The facility's infection control policy emphasizes hand hygiene as crucial for preventing infection spread, but this protocol was not followed.
A resident reported missing personal property, including important identification and financial cards, but the facility failed to adequately follow up or assist in replacing the items. Despite reporting the incident to the state and police, the facility did not complete the grievance process, leaving the resident unable to replace all missing items, affecting his ability to renew his citizenship.
Failure to Follow Two-Person Assist Requirements Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents. A male resident with diagnoses including immobility syndrome (paraplegic), generalized muscle weakness, cognitive communication deficit, contractures, dysphagia (oral phase), hyperlipidemia, and a need for assistance with personal care was admitted on an unspecified date. His MDS assessment showed he required supervision and two-person assistance with bed mobility, transfers, toileting, dressing, and personal hygiene, and his care plan documented that he was at risk for falls and required two-person assistance with all ADLs except eating. On the date of the incident, a CMA (CMA-A) was providing personal care to this resident. According to CMA-A’s signed statement, the resident became agitated during care, so she stopped to calm him. After he calmed down, she resumed care, but the resident became agitated again, and as she was wiping him, he fell from the bed to the floor, landing face down and on his left side. CMA-A reported observing blood and calling for help. The facility’s Provider Investigation Report later documented that CMA-A had provided care to the resident alone, despite the care plan requirement for two-person assistance, and that the resident rolled out of bed onto the floor during this episode of care. As a result of the fall, the resident sustained a laceration to his upper lip. Hospital records documented a diagnosis of a fall with an upper lip laceration, and the resident received stitches to treat the injury. A progress note recorded that he returned to the facility with one stitch to his upper lip following the fall. During interviews, the Administrator and ADON stated that the resident was supposed to receive two-person assistance for care, that this requirement was reflected in the Kardex and care plan, and that CMA-A did not follow these directions when providing care at the time of the fall.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent a resident from eloping. The resident involved had significant cognitive impairment, as indicated by a BIMS score of six out of fifteen, and diagnoses including Parkinson's Disease with dyskinesia, dementia with agitation, and a traumatic brain injury. The care plan identified the resident as an elopement risk, with interventions such as a wander guard and monitoring per shift, but these were not effectively implemented at the time of the incident. On the day of the incident, the resident was observed in the lobby, pacing, and later left the facility at an unknown time. Multiple staff interviews revealed that the resident exited the building without a wander guard in place and was not identified by staff as leaving. The resident was later found outside the facility by a staff member and a police officer, having crossed a street and nearly reached a freeway. Staff were unable to determine which door the resident used to exit, and it was noted that someone would have had to unlock the door for the resident to leave, but no staff could confirm who did so or how the resident was able to exit undetected. Facility policy required the use of door alarms, monitoring devices, and regular checks of wander guard devices, but these measures were not followed or were ineffective in this case. Staff interviews confirmed that the resident did not have a wander guard on at the time of elopement, and the required monitoring and documentation were not completed. The failure to supervise and monitor the resident according to the care plan and facility policy resulted in the resident's unsupervised exit from the facility.
Failure to Notify Physician and Administer Critical Treatments
Penalty
Summary
The facility failed to immediately notify the resident's physician and representative of significant changes in the resident's condition, as well as failures in administering ordered treatments and medications. Specifically, a resident with a history of cerebral infarction, sepsis due to E. coli, end-stage renal disease (ESRD) requiring hemodialysis, multiple pressure ulcers, and a recent hospital stay for sepsis was admitted with orders for IV antibiotics (Zosyn), wound care, and pain management. Upon admission, the facility did not administer the ordered IV antibiotic Zosyn from admission through several days, nor did they notify the physician of this failure. Additionally, wound care orders for the resident's 14 wounds were not entered or implemented in a timely manner, and the physician was not informed of these omissions. The resident also missed a scheduled hemodialysis treatment due to an elevated heart rate, but the physician was not notified of the missed treatment or the change in condition. Documentation and interviews revealed confusion among nursing staff regarding roles and responsibilities for wound care and medication reconciliation, leading to delays in treatment initiation. The resident did not receive any pain medication prior to wound care treatments, and no pain assessments were documented, despite the presence of multiple severe wounds. The only pain medication ordered was oral acetaminophen, which was not administered, and the resident was gastrostomy status, making oral administration inappropriate. Interviews with staff, including the admitting nurse, treatment nurses, DON, and medical director, confirmed a lack of communication and clinical review following the resident's admission. The medical director and nurse practitioners were not informed of missed medications, missed dialysis, or incomplete wound care, and there was no evidence of a care plan for pain management. Observations of wound care procedures showed the resident exhibiting signs of pain without appropriate pain management. These failures were identified as an Immediate Jeopardy situation, as they resulted in the resident being transferred to the hospital with sepsis and ultimately undergoing bilateral above-knee amputations due to necrotic tissue and lack of blood flow.
Failure to Provide Timely Wound Care, Medication Administration, and Physician Notification
Penalty
Summary
The facility failed to protect two residents from neglect by not ensuring timely and appropriate medical care and communication with physicians. One resident was admitted with a pressure ulcer but did not have wound care orders or treatment initiated until several days after admission. Documentation shows that the wound was identified upon admission, but no orders for wound care or wound consult were entered until nearly a week later, resulting in a delay in treatment. Interviews with nursing staff and administration confirmed that wound care should have been initiated within 24 hours of admission, and the lack of documentation indicated that the treatment did not occur as required. Another resident with multiple complex medical conditions, including end-stage renal disease, sepsis, and numerous wounds, was admitted without all necessary medication and treatment orders being entered or implemented. This resident did not receive prescribed IV antibiotics (Zosyn) or wound care treatments for several days after admission. Additionally, the facility failed to notify the resident's physician when the resident missed a scheduled hemodialysis session and when wound care orders were not implemented. The resident also did not receive adequate pain management, as only PRN oral acetaminophen was ordered, which was not appropriate for a resident with a gastrostomy tube, and no pain assessments were documented prior to wound care procedures. Interviews with facility staff revealed confusion and lack of clarity regarding roles and responsibilities for wound care and admission processes. There was no evidence of a comprehensive clinical review of new admissions to ensure all necessary orders and treatments were in place. The failures in communication, documentation, and timely implementation of physician orders led to significant lapses in care for both residents, as confirmed by staff interviews and record reviews.
Failure to Provide Timely Pressure Ulcer Care and Treatment Orders
Penalty
Summary
The facility failed to provide necessary and timely pressure ulcer care for two residents, resulting in delayed treatment and lack of appropriate wound management. One resident was admitted with a stage 2 pressure ulcer and additional wounds, but did not have wound care orders or treatments initiated until several days after admission. Documentation shows that from the time of admission, there were no wound care orders, no wound consult, and no wound care documented on the Medication Administration Record (MAR) until nearly a week later. Facility staff, including the ADON, DON, and Administrator, confirmed that wound care orders should be in place upon admission or within 24 hours, and acknowledged that the lack of orders and treatment placed the resident at risk for wound deterioration and infection. Another resident was admitted with multiple complex wounds, including two stage 4 pressure ulcers, several unstageable wounds, venous and arterial ulcers, and a diabetic foot ulcer. The initial skin assessment identified these wounds, but orders for wound care and a wound consult were not entered or implemented until several days after admission. Additionally, the resident was prescribed IV antibiotics for wound infection, but the medication was not administered until several days after admission. Interviews with nursing staff and practitioners revealed confusion and lack of clarity regarding responsibility for entering and implementing wound care orders, as well as a lack of communication and follow-up to ensure that all necessary treatments were started promptly. Observations and interviews further revealed that there was no consistent process for clinical review of new admissions to ensure accuracy and completeness of wound care orders and treatments. Staff members were unclear about their roles and responsibilities in the wound care process, and there was no timely follow-up to identify and correct errors or omissions in the admission process. As a result, both residents experienced significant delays in receiving appropriate wound care and treatment, as documented by the lack of orders, delayed administration of medications, and missed wound consults.
Failure to Provide Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple severe wounds, resulting in a deficiency identified by surveyors. The resident, a female with a history of cerebral infarction, sepsis, end-stage renal disease requiring dialysis, and multiple stage four pressure ulcers and arterial wounds, was admitted with significant medical complexity and was nonverbal with severe cognitive impairment. Despite her extensive wounds and high risk for pain, there was no care plan for pain, and her pain was not assessed or managed according to professional standards or her needs. Observations revealed that during wound care procedures, the resident exhibited clear signs of pain, such as wincing, deep breathing, and tears, particularly when bandages were removed and wounds were treated. Staff failed to assess her pain prior to wound care, did not provide timely or appropriate pain medication, and did not stop procedures to reassess or address her pain when she showed distress. Documentation showed that although there were orders for acetaminophen, these were not administered, and staff were unclear about pain assessment tools and procedures. Interviews with nursing staff indicated confusion about responsibilities for pain management, lack of documentation, and a failure to communicate or follow up on the resident's pain needs. The attending physician and wound care doctor were not notified of the resident's pain, and no additional pain management interventions were implemented until after the surveyor's intervention. The facility's own policy required assessment and management of pain, including for nonverbal residents using the PAINAD tool, but this was not followed. The deficiency was identified as Immediate Jeopardy due to the failure to provide pain management consistent with professional standards, the resident's care plan, and her goals and preferences, resulting in unmanaged pain during daily wound care treatments.
Removal Plan
- The treatment where the resident was experiencing pain was stopped until adequate pain relief could be achieved.
- Primary care provider was contacted by the director of nurses and Tylenol order changed to Extra Strength 650 mg every 8 hours scheduled and an additional dose prior to wound care.
- 100% review of residents receiving wound care for PRN pain medication orders that may be given prior to wound care was completed by Regional Compliance nurse/DON/Designee.
- Residents identified requiring wound care received new orders/order clarifications to ensure adequate pain management prior to wound care from audit completed.
- Resident identified in the audit has an allergy to acetaminophen.
- Care plans for facility residents with wounds were updated by Regional Compliance Nurse and DON with interventions to monitor, assess, and report pain during care, including wound care, and what to do if pain management is not effective.
- Regional Compliance Nurse provided in-service to DON/ADON regarding pain management during care and procedures following facility's policy for enforcement, requiring no change in company policy as the policy was effective but not being followed.
- Communication with medical provider for any resident that is experiencing uncontrolled pain during care and/or procedures using the SBAR as communication tool.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool.
- All nurses (LVN/RNs), including PRN nurses, who are not in serviced will not be allowed to provide resident care until training has been completed.
- The Medical Director was notified by the Administrator regarding the immediate jeopardy citation.
- An Ad-hoc QAPI meeting was held by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will observe wound care to ensure any residents that is receiving wound care receive effective pain management during the procedure.
- DON/Designee will review order listing report in point click care (facility electronic medical record) to see any new wound care orders and ensure that pain management orders are in place.
Failure to Provide and Document Hemodialysis Services as Ordered
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, dependent on hemodialysis, did not receive her prescribed dialysis treatment for a period of four days. The resident, who was severely cognitively impaired and fully dependent on staff for activities of daily living, was admitted with multiple complex medical conditions, including a central line for dialysis access. On the scheduled dialysis day, the resident was unable to receive treatment due to an elevated heart rate, and although the nephrologist and facility nurse attempted interventions, the dialysis session was not completed. Following the missed dialysis session, there was a breakdown in communication and documentation among facility staff. The charge nurse did not clearly document the missed dialysis or the resident's change in condition in the 24-hour report or other required communication tools. The nurse also failed to ensure that the physician or nurse practitioner was adequately notified regarding the missed dialysis and did not follow up on orders for medication administration or alternative interventions. Other staff members, including the DON and ADON, were unaware of the missed treatment until after the fact, and there was no evidence that the resident's care plan or medical record was updated to reflect the missed dialysis or any follow-up actions. The facility's policies required prompt notification of a physician in the event of a change in status or missed treatment, as well as thorough documentation of all communication and interventions. These procedures were not followed, resulting in the resident missing dialysis for four consecutive days. The failure to provide dialysis as ordered and to communicate and document the missed treatment placed the resident at risk for delayed treatment and actual harm, as identified by surveyors.
Removal Plan
- Review all facility residents receiving dialysis to identify any other residents receiving dialysis treatments.
- Assess all facility residents ordered to receive hemodialysis treatments to ensure no other residents missed hemodialysis treatments.
- Regional Compliance Nurse provides in-service to DON, ADON, and Administrator regarding Change of Condition (when to Report to MD/NP/PA and follow-up communication), Abuse/Neglect, and Dialysis (facility's dialysis policy in-serviced for enforcement).
- DON/ADON will in-service facility staff by phone and/or in person regarding facility policy on Abuse/Neglect. Facility staff, including PRN staff, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding Change of Condition to include when to Report to MD/NP/PA. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RN) by phone and/or in person regarding facility's dialysis policy. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR).
- Notify the Medical Director regarding the immediate jeopardy citation.
- Hold an Ad-hoc QAPI meeting by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will monitor changes of condition to ensure changes of condition have been reported to the MD and followed up.
- DON/Designee will monitor Dialysis residents to ensure that residents did not miss any dialysis or had any incomplete dialysis session, if dialysis sessions were missed or incomplete that an SBAR was completed, and was the resident monitored.
Failure to Administer Prescribed IV Antibiotic Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including sepsis due to E. coli, severe wounds, and dependence on renal dialysis, was admitted to the facility. Upon admission, the resident had physician orders for IV antibiotic therapy (Piperacillin-Tazobactam/Zosyn) to treat infections related to wounds, urinary tract, and pneumonia. Despite these orders, the resident did not receive the prescribed IV antibiotic from the time of admission for several days. Record reviews showed that the medication was not administered as ordered, and there was no documentation of administration for multiple scheduled doses. Additionally, there was confusion regarding IV access, with delays in arranging for a midline catheter and issues with the pharmacy dispensing the correct antibiotic dosage. Interviews with facility staff revealed that the admitting nurse did not ensure all admission orders were entered before the end of her shift, and there was a lack of timely communication with the medical provider regarding the inability to administer the antibiotic. The medical director and nurse practitioners were not notified of the missed doses or the issues with medication availability and IV access. The wound care physician was also unaware that the resident had not received the ordered antibiotic therapy. Progress notes indicated that the resident had no IV access for the antibiotic, and there was a delay in obtaining the correct medication from the pharmacy. The facility's policy required medications to be administered as prescribed and for staff to notify providers of any issues, but these procedures were not followed. The resident's condition was further complicated by extensive wounds, including stage four pressure ulcers and necrotic tissue, and she was nonverbal and dependent on staff for all care. Observations documented the severity of her wounds and her lack of response to painful procedures, likely due to her cognitive and physical impairments. The failure to administer the prescribed IV antibiotic as ordered was identified as a significant medication error, and the facility was cited for not ensuring residents were free from such errors.
Removal Plan
- SBAR/Change of condition assessment completed with notification of provider and responsible party regarding the missed IV antibiotics.
- Correct dosage of IV antibiotics have been obtained by facility and are being administered as ordered.
- 100% audit completed of facility residents to identify any residents with IV antibiotics. No additional residents identified as receiving IV antibiotics.
- 100% audit completed of facility residents to identify any missed medications and/or treatments. Providers for residents identified as missing medications/treatments were notified and medication error documentation completed on facility residents identified as missing medications/treatments.
- Regional Compliance Nurse provided in-service to DON, ADON, and Administrator regarding: admission Process to include reconciling treatment and medication orders.
- Medication Administration policy in-serviced for enforcement (no revision of policy required, as policy is effective but not being followed).
- DON/ADON will in-service facility staff by phone and/or in person regarding facility policy on Abuse/Neglect. Facility staff, including PRN staff, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding the admission Process to include reconciling treatment orders and medication orders. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RN) by phone and/or in person regarding Medication Administration. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- The Medical Director was notified by Administrator regarding the immediate jeopardy citation.
- An Ad-hoc QAPI meeting was held by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will monitor admission Process daily to ensure any new admissions and readmissions had reconciled treatment and medication orders.
- Nursing administration designee will complete admission checklist audit to ensure medication reconciliation has been double checked from what was ordered versus what the facility staff enters into the facility's electronic record.
- DON/Designee will monitor Medication & Treatment Administration Records daily to ensure all medications & treatments were signed out, administered, and available by utilizing the Missed Med Report during morning clinical meeting.
Failure to Maintain Safe, Clean, and Homelike Environment During Odor and Construction Issues
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on two of its four halls, specifically Hall 300 and Hall 400. On Hall 300, persistent foul odors of urine, feces, and body odor were observed, particularly emanating from the room of two residents with significant wound care needs and a history of refusing care such as bathing, grooming, and wound treatment. Multiple interviews with staff, residents, and family members confirmed that the odor was longstanding, noticeable throughout the hallway, and had not been effectively addressed by increased cleaning or the use of odor neutralizers. Housekeeping staff reported cleaning the affected rooms twice daily and using multiple bottles of odor neutralizer per week, but these efforts did not resolve the issue. Residents and family members expressed dissatisfaction with the living conditions, describing the environment as unpleasant and not reflective of a homelike setting. On Hall 400, the facility failed to ensure that ongoing construction and renovation activities did not negatively impact residents' comfort and access to care. During the renovation, a section of the hallway was closed off with plastic sheeting, and workers were observed spraying texturizer on the ceilings while wearing N95 or respirator masks. The area was filled with dust and noise, and residents remained in their rooms behind incomplete plastic barriers, with no clear communication or protective measures provided to them or the staff. Staff members were unaware of the nature of the work or the need for personal protective equipment, and residents were not given the option to move or provided with masks. The construction activities resulted in at least two residents missing scheduled wound care visits, as the wound care physician was unable to access their rooms due to the barriers. The report details that the facility administration did not provide adequate notice or information to staff or residents regarding the renovation activities, and there was a lack of signage indicating the type of work being performed. Staff interviews revealed confusion and concern about the safety of the environment, and residents reported increased discomfort, including noise, dust, and respiratory symptoms. The administration acknowledged the renovations but was unable to specify the materials being used or the necessary precautions. The facility also failed to provide a policy for maintaining a homelike environment when requested by surveyors.
Failure to Maintain Safe, Sanitary, and Comfortable Environment During Odor and Renovation Issues
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment on two of four halls, specifically Hall 300 and Hall 400. On Hall 300, persistent foul odors were observed, described as urine, bowel movement, and body odor, emanating from a specific resident room and spreading into the hallway and other rooms. Multiple staff, residents, and family members confirmed the ongoing odor issue, with some stating it had been present for an extended period. The source of the odor was attributed to two residents who consistently refused care, including bathing, wound care, and incontinence care. Despite additional cleaning and the use of odor neutralizers, the problem persisted, and staff were unclear about any effective interventions being implemented by facility management. On Hall 400, the facility failed to ensure that construction and renovation activities were conducted safely and with proper communication. Residents and staff were not informed in advance about the nature of the work, which involved spraying a texturizer on ceilings, creating dust and loud noise. Plastic barriers were erected, but they did not fully seal resident rooms, allowing dust and sprayed material to enter. Some residents were confined to their rooms without being offered masks or the option to relocate, and staff were not provided with information or appropriate personal protective equipment. The construction activities also resulted in at least two residents not receiving scheduled wound care, as the wound care physician was unable to access their rooms due to the barriers. Additionally, the facility failed to maintain the physical environment in the dining area, where a door was propped open with a zip tie and an extension cord was zip tied to the door hinges, preventing the door from closing. This situation had persisted for approximately two months, and staff were aware of the issue but had not addressed it. Throughout the report, staff interviews revealed a lack of communication and awareness regarding environmental safety and infection control practices during renovations, as well as ongoing issues with odor management and resident care refusals.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live flies in one of the hallways (Hall 300) and in the rooms of two residents. Observations revealed approximately 16 flies in Hall 300, as well as multiple live flies on the blankets and walls in the rooms of two residents. Both residents reported seeing flies in their rooms frequently, with one resident attributing the presence of flies to towels used by staff to wipe tables. Record reviews indicated that one resident was cognitively intact and had multiple pressure ulcers, requiring varying levels of assistance with daily activities. The other resident had moderately impaired cognition, multiple pressure ulcers, chronic venous ulcers, and required substantial assistance with personal care. The presence of flies was directly observed during interviews and room inspections, confirming the ongoing pest issue in these areas. Facility records showed that pest control services were being provided, with treatments for various pests including flies, roaches, and ants. However, the frequency and scope of treatments appeared insufficient to prevent the recurrence of flies, as evidenced by the continued presence of pests in resident care areas. The facility's pest control policy focused on maintaining an insect and vermin-free environment, but the observed conditions demonstrated a failure to achieve this standard.
Failure to Ensure Resident's Right to Designate a Representative
Penalty
Summary
The facility failed to ensure that a resident was given the right to designate a representative or responsible party at the time of admission, despite the resident being alert, oriented, and cognitively intact. The resident, who was legally blind due to bilateral retinal detachment, was admitted with the ability to make his own decisions, as evidenced by a BIMS score of 15 and documentation of being alert and oriented. However, there was no documentation or evidence that the resident was consulted about his wishes regarding the designation of a responsible party during the admission process or at the 72-hour care plan meeting. As a result of this omission, a family member was listed as the responsible party without the resident's explicit consent. This led to confusion and a grievance when the resident discovered his health insurance had been changed without his knowledge, resulting in a delay of a scheduled eye surgery. The resident and the alleged responsible party both denied authorizing the insurance change, and the responsible party stated he was only next of kin and not authorized to make decisions on the resident's behalf. Multiple staff interviews confirmed that the resident was capable of making his own decisions and should have been consulted about the responsible party designation at admission. Facility staff, including the admissions coordinator, business office manager, MDS coordinator, and social worker, acknowledged that the resident was not asked about his preferences for a responsible party, and that this was a violation of resident rights. The facility's policy required that residents be allowed to exercise their rights without interference, and staff interviews confirmed that the process for establishing a responsible party did not include direct consultation with the resident, despite his capacity to make such decisions.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents and that staff did not provide sufficient oversight to mitigate these hazards. Specific details regarding the nature of the hazards, the supervision provided, or the residents affected were not included in the report.
Failure to Label and Remove Expired or Undated Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper labeling and removal of expired or undated medications on two out of three medication carts reviewed. Specifically, Latanoprost ophthalmic solution, used to treat glaucoma, was not labeled with an expiration date for three residents, and an expired bottle was not removed from the cart for another resident. Additionally, a Humalog KwikPen (insulin lispro) was found on a medication cart without an open date, despite manufacturer instructions requiring it to be discarded 28 days after removal from refrigeration. Observations revealed that multiple bottles of Latanoprost for several residents lacked open dates, and one bottle remained on the cart past its recommended use-by date. The Humalog KwikPen for a resident with diabetes was also undated after being placed on the medication cart, contrary to storage guidelines. These findings were corroborated by record reviews, which confirmed the medication orders and the absence of required labeling. Interviews with facility staff, including the ADON, DON, and the facility pharmacist, indicated that responsibility for medication cart oversight was shared among staff and managers, with periodic audits conducted. The facility's own policy required immediate removal of outdated medications and proper labeling with open and expiration dates, but these procedures were not consistently followed, resulting in the identified deficiencies.
Failure to Discontinue Duplicate Buspirone Orders Resulting in Excessive Dosing
Penalty
Summary
A deficiency occurred when a resident with quadriplegia and generalized anxiety disorder received duplicate orders for Buspirone 5 mg, resulting in the medication being administered both two times a day and three times a day over a period of time. Record reviews showed that both orders were active and being administered concurrently, with documentation on the Medication Administration Records (MAR) confirming that the resident received both regimens. The issue was identified when a nurse placed a call to the physician to clarify the Buspirone orders, and the duplicate order was subsequently discontinued. Interviews with facility staff, including an LPN, medication aide, ADON, DON, and the Administrator, revealed that the previous Buspirone order should have been discontinued when the new order was entered, but this did not occur. Staff acknowledged the presence of duplicate orders and the risk of medication errors, with the facility's policy indicating that new physician orders are to be reviewed for accuracy during daily clinical meetings. At the time of observation, the resident was alert and showed no signs of distress, and did not report any concerns regarding his medications.
Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations. The dining room was found to have dirty dishes with leftover food left overnight, and gnats were seen flying around the dishes while residents were present waiting for coffee. Additionally, there was a buildup of grease along the vent hood rails in the kitchen. In the kitchen's refrigerator and freezer, several food items, including a large bowl of salad and fruit, were found undated and unlabeled. Tuna salad was found with a date range, but other items such as cookies were discovered without proper identification and were discarded. In the dry goods pantry, a container of creamy peanut butter was found to be expired. Interviews with dietary staff confirmed that the vent hood was supposed to be cleaned and that all food items removed from their original containers should be labeled and dated with the date opened and a use-by date. The facility's own policies require that all food preparation and storage areas be maintained in a clean and sanitary condition and that food be stored and labeled according to FDA Food Code standards. These observations and staff statements indicate that the facility did not adhere to its own policies or professional standards for food safety and sanitation.
Failure to Timely Complete Significant Change MDS After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days after a resident was discharged from hospice services, as required. The resident in question had multiple diagnoses, including Alzheimer's disease, dementia, hypertension, osteoarthritis, anxiety disorder, COPD, bipolar disorder, muscle weakness, and abnormal posture. The resident was admitted to hospice services and later discharged due to medical stability, but the facility did not update the MDS or the comprehensive care plan to reflect this significant change in condition within the required timeframe. Interviews with facility staff revealed that the MDS nurse was new to the position and was still learning the process, and only recently became aware of the resident's discharge from hospice. The care plan continued to indicate the resident was receiving hospice care, and the Significant Change MDS was completed more than 14 days after the resident's discharge from hospice. The facility's policy and the RAI manual guidelines both require timely completion of the MDS following a significant change in a resident's status.
Failure to Complete PASARR Level II Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of mental illness received a required PASARR Level II (PE) screening. The resident, a female with diagnoses including bipolar disorder and schizoaffective disorder, was admitted and later readmitted to the facility. Her records, including the face sheet, PASARR Level I screening, MDS assessment, and care plan, all indicated the presence of mental illness. Despite this, there was no evidence in the clinical record that a PASARR Level II evaluation had been completed for her. Interviews with the facility's MDS coordinator confirmed that the PASARR Level II assessment was not performed. The coordinator acknowledged responsibility for completing PASARR screenings and stated that she would have checked for the Level II assessment if she had been present during the resident's comprehensive assessment. The facility's policy requires that a PASARR be completed for all patients with mental illness, and a Level II assessment is specifically required for those with new mental health diagnoses upon readmission, but this process was not followed for the resident in question.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours of admission, as required. The resident, a male with diagnoses including acute on chronic systolic heart failure, chronic kidney disease, and chronic obstructive pulmonary disease, was admitted with physician orders and an incomplete baseline care plan document. Review of the care plan revealed that no information was completed on the baseline care plan form, and the comprehensive care plan was not initiated until after the 48-hour window had passed. Interviews with facility staff revealed confusion regarding responsibility for initiating the baseline care plan. The DON stated that the admission nurse was responsible, while an LVN indicated that RNs should complete the care plan but was unsure who was responsible for the resident in question. The DON later clarified that either an RN or LVN could open the baseline care plan. Additionally, the resident's admission MDS was incomplete, with the BIMS section left blank. The facility's policy referenced the CMS guidelines for the care area assessment process.
Failure to Update Care Plan After Discharge from Hospice
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after a significant change in a resident's status. Specifically, a resident with multiple diagnoses, including Alzheimer's disease, dementia, hypertension, osteoarthritis, anxiety disorder, COPD, bipolar disorder, muscle weakness, and abnormal posture, was discharged from hospice services after being deemed medically stable. Despite this change, the resident's care plan continued to reflect hospice care and was not updated to reflect the discharge and the initiation of therapy services. Interviews with facility staff revealed that the MDS nurse was unaware of the resident's discharge from hospice until the week of the survey and had not updated the care plan accordingly. The interim DON confirmed that care plans should accurately reflect the resident's current condition. The facility's policy referenced the RAI manual for care plan accuracy, but no specific care plan policy was provided during the survey.
Failure to Identify and Report Duplicate Medication Orders
Penalty
Summary
The facility failed to ensure that a licensed pharmacist accurately identified and reported drug regimen irregularities for a resident with multiple medication orders. Specifically, a male resident with quadriplegia and generalized anxiety disorder had two active orders for Buspirone 5 mg: one to be administered twice daily and another three times daily, both without end dates. Medication administration records showed that both orders were being followed concurrently, resulting in duplicate administration of the same medication. Despite the presence of duplicate orders, the consultant pharmacist's monthly drug regimen review did not identify or report this irregularity. The pharmacist stated that only the three times daily order was documented in her notes and denied awareness of the twice daily order, even though both were present in the facility's electronic medical record and being administered. Interviews with nursing staff and medication aides confirmed the existence of duplicate orders and acknowledged that the previous order should have been discontinued when the new one was entered. The facility's policies required new physician orders to be reviewed for accuracy during daily clinical meetings, but the duplicate orders for Buspirone were not identified or addressed until after the issue was brought to attention. The resident was alert and showed no signs of distress at the time of observation, and staff interviews indicated a lack of ongoing training regarding medication management for some personnel. The deficiency was identified through record review and staff interviews, highlighting a lapse in the facility's medication review and reporting processes.
Failure to Prevent Resident Access to Hazardous Substance Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with significant cognitive impairment. The resident, diagnosed with late-stage Alzheimer’s disease, bipolar disorder, type 2 diabetes, and acute kidney failure, had a history of wandering and poor safety awareness. Her care plan identified her as at risk for elopement and wandering, requiring a wander guard and staff redirection when she entered unsafe areas or other residents’ rooms. Despite these interventions, the resident was able to access and ingest hand sanitizer, which was not secured as required. On the day of the incident, the resident was observed with a bottle of hand sanitizer up to her mouth and sanitizer on her shirt, suggesting ingestion. Staff immediately intervened, removed the sanitizer, and monitored her for adverse effects. The resident was later found in the lobby, hard to awaken, and was subsequently sent to the hospital for evaluation. Hospital records indicated a small amount of alcohol in her system, but not at a harmful level. Interviews with staff revealed that hand sanitizer was typically kept on top of or inside medication carts, but not always secured, and that the resident was known to wander and seek out items in her environment. The facility’s failure to secure hazardous materials such as hand sanitizer and to provide adequate supervision allowed the resident to access and potentially ingest a dangerous substance. Staff interviews confirmed that hand sanitizer was accessible on medication carts and that the resident’s wandering behavior was well known. The care plan interventions for supervision and redirection were not sufficient to prevent the incident, resulting in the resident’s hospitalization.
Failure to Provide Scheduled Showers and Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADLs) independently received the necessary assistance to maintain good hygiene. Specifically, one resident with chronic obstructive pulmonary disease, sequelae of cerebral infarction, type 2 diabetes mellitus, hemiplegia, hemiparesis, and muscle weakness, and who required substantial/maximal assistance for bathing, did not receive scheduled showers on three documented occasions. The resident's care plan indicated scheduled showers on Mondays, Wednesdays, and Fridays during the 6a-2pm shift, but there was no documentation of showers being provided on the specified dates. The resident's medical record and care plan confirmed his need for assistance and outlined interventions to maintain hygiene. Interviews with the resident, CNAs, RN, DON, and Administrator revealed that the resident did not refuse showers and enjoyed being clean. Staff interviews indicated that showers were sometimes missed due to staffing shortages and that refusals were to be reported to nursing staff. The DON acknowledged receiving complaints about missed showers and stated that refusals should be care planned. The Administrator was not aware of missed showers but confirmed that a schedule was in place and that staff were expected to follow up on incomplete ADLs. The lack of documentation and missed showers resulted in the resident not receiving necessary services to maintain good hygiene as required.
Failure to Investigate and Report Potential Neglect After Resident Accessed Hand Sanitizer
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate and report an incident involving a resident with late-stage Alzheimer’s disease, diabetes, acute kidney failure, and bipolar disorder. The resident, who was at risk for wandering and had a history of entering other residents’ rooms, was found with a bottle of hand sanitizer, appearing to drink from it. Staff observed hand sanitizer on her shirt and the bottle upturned at her mouth. The resident was later found in the lobby, hard to awaken, and was subsequently sent to the hospital for evaluation. Hospital records indicated a chief complaint of drug overdose, but laboratory results showed no significant ethanol in her system. The facility’s documentation revealed that the hand sanitizer was typically kept on or near medication carts, sometimes not secured as required. Staff interviews confirmed that hand sanitizer was accessible and not always stored in locked areas, despite the presence of cognitively impaired residents. The incident was not witnessed directly, but staff assumed ingestion based on the resident’s behavior and physical evidence. The resident’s care plan identified her as a wander risk with poor safety awareness, and interventions included redirecting her and monitoring her use of a wander guard. Despite the incident, the facility did not report the event as neglect to the state agency, citing the lack of harm as the reason. The facility’s abuse and neglect policy required reporting and investigation of all alleged violations, but the administrator and DON determined that reporting was unnecessary. The investigation was incomplete, with unsigned statements and a lack of clear documentation regarding the source of the hand sanitizer and the exact circumstances of the incident. The failure to report and thoroughly investigate the incident constituted a deficiency, as it did not comply with regulatory requirements for addressing alleged violations of abuse and neglect.
Failure to Update Care Plan for Resident's Weight Loss and Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's significant weight loss and the use of the medication Ozempic, which was prescribed for diabetes management. The resident experienced a 15-pound weight loss over two months, and the care plan did not reflect this change or the potential side effects of Ozempic, such as decreased appetite. The resident, a cognitively aware male with multiple diagnoses including diabetes and anxiety, was on a mechanically altered diet and required assistance with activities of daily living. Despite the resident's weight loss and the known side effects of Ozempic, the care plan only included general nutritional goals and interventions without specific measures to address the actual weight loss or the medication's impact. The resident's weight log showed a consistent decrease in weight, yet the care plan remained unchanged. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that the care plan was not updated to reflect the resident's weight loss and medication use. The MDS Coordinator admitted to being new in the position and acknowledged the oversight in updating the care plan. The DON confirmed the need for the care plan to be updated and recognized the inexperience of the MDS nurses in their roles. The facility lacked a specific policy for care planning, relying instead on the RAI manual for guidance.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in deficiencies in medication administration. Resident #3, a cognitively aware male with multiple diagnoses including chronic obstructive pulmonary disease and diabetes, was not administered his Proair inhaler and house supplement as ordered by his physician. The medication administration record (MAR) for February and March 2025 showed blanks for several doses of these medications, with no documentation in the nurse's notes explaining the omissions. During an interview, Resident #3 reported issues with receiving his Clonazepam medication as ordered, which had only been corrected recently. Resident #5, a cognitively intact male with conditions such as hypertension and heart failure, was not administered his Carvedilol oral tablet as ordered. The MAR for March 2025 showed a blank for the 8:00 pm dose on a specific date, with no documentation in the progress notes explaining why the medication was not given. Interviews with nursing staff, including LVNs and the Director of Nursing (DON), confirmed that there should be no blanks on the MARs, and any medication not given should be documented with reasons. The facility's policy and procedure on the standard of practice require compliance with physician's orders for medications. The lack of documentation and failure to administer medications as ordered could lead to residents not receiving necessary treatments, potentially affecting their health and recovery. The DON acknowledged the issue and indicated plans to in-service the staff to address these documentation and administration deficiencies.
Inadequate Incontinent Care Poses UTI Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infections. During an observation, two CNAs did not properly clean the resident's perineal area, specifically failing to spread the labia and clean the urinary meatus. This oversight was acknowledged by one of the CNAs, who attributed the lapse to nervousness and admitted to not having undergone competency checks for incontinent care at the facility. The resident involved was an elderly female with cognitive communication deficits, bipolar disorder, and weakness, requiring substantial assistance with personal hygiene and dressing. Her care plan indicated she was always incontinent of bowel and bladder, with a goal to prevent skin breakdown due to incontinence. Despite the facility's policy and in-service training on perineal care, the CNAs did not adhere to the proper procedures, and the facility was unable to provide a documented policy on perineal care upon request.
Infection Control Lapse Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not perform hand hygiene after removing soiled gloves. This incident occurred during incontinence care for a resident who was cognitively impaired and required substantial assistance with daily activities. The resident was always incontinent of both bowel and bladder, necessitating frequent incontinence care to prevent skin breakdown. During the care, CNA A removed soiled gloves and left the resident's room without sanitizing or washing her hands, which could lead to cross-contamination and the spread of infection. Interviews with the CNA and the Director of Nursing (DON) revealed that the CNA acknowledged forgetting to sanitize her hands and recognized the risk of cross-contamination. The DON confirmed that staff were expected to sanitize their hands before entering a room, after touching a dirty area, and between glove changes during incontinence care. The facility's infection control policy emphasized the importance of hand hygiene as a primary means to prevent infection spread. Despite having completed recent in-service training on infection control, the CNA did not adhere to these protocols, highlighting a lapse in the facility's infection control practices.
Failure to Resolve Resident's Grievance Regarding Missing Property
Penalty
Summary
The facility failed to promptly resolve grievances for a resident who reported missing personal property, including a wallet containing important identification and financial cards. The resident, who was moderately cognitively impaired and required assistance with daily activities, reported the loss of his wallet, which included his social security card, green card, cash app card, bank card, $10.00, and food stamp card. Despite the resident's report, the facility did not adequately follow up to ensure the items were found or replaced, nor did they assist the resident in replacing the missing items. The facility's grievance process was not completed as required. Although the administrator reported the incident to the state and police and conducted interviews with staff, there was no further investigation or assistance provided to the resident. The social worker acknowledged that the grievance process could have been more thorough, and the resident confirmed that he was unable to replace all his missing items, specifically his social security and green card, which affected his ability to renew his citizenship. The business office manager indicated that the resident's identification documents were copied and uploaded to his files upon admission, but when the surveyor requested these documents, the administrator refused to provide them. The facility's policy on filing grievances and complaints states that they will assist residents in filing grievances without fear of reprisal, but in this case, the facility did not adequately support the resident in resolving his grievance.
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 675 citations issued within 25 miles in the last 12 months — including the 58 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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Courtyard | 0.7 mi | ★★★★★ | 8 | 0 |
| Avir At Golfcrest | 1.1 mi | ★★★★★ | 1 | 1 |
| Harmony Care At Golfcrest | 1.5 mi | ★★★★★ | 7 | 0 |
| Paradigm At Faith Memorial | 5.5 mi | ★★★★★ | 18 | 0 |
| Garden Terrace Healthcare Center Of Houston | 6 mi | ★★★★★ | 8 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.