Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Alta Vista Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dysphagia, gastrostomy status, and diabetes had TPN discontinued after the last bag was completed, but an LVN later documented that TPN was still infusing at 40 cc/hr. Interviews showed the LVN assumed the resident was still receiving TPN without seeing the resident, while other nurses reported the TPN had already been stopped and the MAR showed the last administration had ended earlier.
A resident with a history of stroke-related hemiplegia, T2DM, and lack of coordination, and documented as moderately cognitively impaired, was started on Trazodone 25 mg at bedtime for insomnia based on a physician order. The medication was administered before the resident’s legal representative signed the psychoactive medication informed consent form, and when the form was later signed, the section indicating whether consent was granted was not completed. During interview, the DON confirmed that the consent for Trazodone was not properly completed prior to administration, despite facility policy requiring review of psychotropic orders and efforts to obtain and document prior informed consents on admission.
A resident with a history of stroke-related hemiplegia, type 2 DM, and lack of coordination, and who was moderately cognitively impaired and required moderate ADL assistance, received Trazodone 25 mg at bedtime for insomnia based on a physician order. The medication was administered before an informed consent for psychoactive medication was signed by the resident’s legal representative, and when the consent was later completed it indicated that the representative did not consent to the Trazodone. During interview, the DON stated that medications were not supposed to be given without a consent form, and facility policy required review of psychotropic orders and efforts to obtain and document prior informed consents on admission.
Surveyors found a wound care treatment cart left unlocked and unattended in a hallway, containing medications and wound care supplies. An RN responsible for the cart acknowledged she was expected to lock it when walking away and that an unsecured cart could allow a resident to access medications not prescribed for them. The DON confirmed that she, the ADON, and other staff were responsible for ensuring medication carts remained locked when not in use, consistent with the facility’s medication storage policy requiring medication supplies to be secured and accessible only to authorized personnel.
Kitchen sanitation deficiencies were identified when dented cans were stored with usable dry goods, an employee beverage cup was left under the prep table, and clean cups were found with debris inside. Raw ground beef was also observed thawing in the produce-only sink with no running water and liquid draining into the sink, rather than being thawed in accordance with food safety standards.
Failure to Notify RP of Wanderguard Placement: A resident with severe cognitive impairment, schizoaffective disorder, and major depressive disorder was identified as a wander risk and placed on a Wanderguard on the left foot. The EMR did not show that the RP was notified, and the DON acknowledged no progress note documenting notification could be found, despite the facility policy requiring family/RP notification when a Wanderguard is placed.
A resident with severe cognitive impairment, schizoaffective disorder, and major depressive disorder was not coded on the MDS as having wandering behaviors or a wander alarm, even though the care plan, MD order, and elopement evaluation documented wandering risk and Wanderguard use. The MDS Coordinator said she forgot to code the Wanderguard and wandering behaviors, and the DON agreed the assessment should have reflected both.
Care Plan Missing PTSD Triggers: A resident with PTSD, schizophrenia, diabetes, and HTN had a care plan that addressed mood problems and behavioral health referrals but did not include her identified PTSD trigger. The social worker stated Spanish ballads caused the resident to cry and become anxious, yet CNA staff, an RN, and the MDS coordinator were unaware of the trigger and confirmed it was not listed in the care plan.
A resident with Alzheimer's disease, severe cognitive impairment, and extensive ADL assistance needs was observed in bed with the call light placed on the bed frame and out of reach. The ADON stated the resident usually used the call light when needing something, and the DON acknowledged that if call lights are not within reach, residents might need help and could have fallen. The facility policy required the call device to be placed within the resident's reach before leaving the room.
Incomplete Nutritional Supplement Order: A resident with dementia, anemia, and malnutrition had an active order for a nutritional supplement TID for weight loss, but the order was missing the route of administration and dose. Staff reviewed the record and confirmed the order was incomplete, while the eMAR showed the supplement was being given three times daily and the DON acknowledged the missing elements.
An LVN failed to use the required gown during wound care for a resident with a sacral wound on enhanced barrier precautions and did not lather hands for the required 20 seconds. The resident had a stage 4 sacral pressure ulcer and was receiving ordered wound care with NPWT. The DON stated residents with wounds required enhanced barrier precautions and that staff had been trained on gown use and hand hygiene.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. A resident with respiratory failure was observed receiving oxygen at a lower rate than prescribed, and the care plan did not include oxygen therapy. Another resident with vascular dementia received oxygen at a higher rate than ordered, with an outdated care plan. A third resident with severe cognitive impairment received oxygen at a lower rate than prescribed due to an adjustment error. These discrepancies highlight lapses in following established procedures for oxygen administration.
The facility failed to update care plans for two residents receiving oxygen therapy, despite their medical needs. One resident with severe aortic stenosis and another with cognitive impairment were both observed using oxygen, but their care plans lacked necessary updates. Interviews revealed that MDS nurses were responsible for care plan updates, and the oversight was acknowledged by the DON.
A resident's care plan was not updated to reflect a new oxygen order, leading to discrepancies in the oxygen settings administered. The resident, with multiple health conditions, had a physician's order for oxygen at 2L/min, but the care plan still indicated 4L/min. Observations showed the oxygenator set at 3L/min, and staff interviews revealed a lack of timely monitoring and updating of the care plan.
A nurse in an LTC facility failed to check gastric residuals before administering medication via G-tube to a resident with severe cognitive impairment and a feeding tube. Despite being trained and evaluated on this procedure, the nurse did not follow the facility's protocol, which requires checking residuals before medication administration. This oversight was identified during an observation and confirmed through interviews with the nurse and the DON.
A resident's mini refrigerator contained unlabeled and undated food items, contrary to the facility's policy requiring all outside food to be labeled and dated by the charge nurse. The resident, with severe cognitive impairment and multiple health conditions, had food brought by his daughter that was not properly managed, posing a risk of foodborne illnesses. Staff interviews revealed a breakdown in the process, as the Business Office Coordinator noticed the issue but failed to address it.
A facility failed to report an alleged neglect incident involving a resident within the required 24-hour timeframe. The incident involved two CNAs, one of whom alleged abuse by the other. The resident, who had mild cognitive impairment, denied any abuse. The DON did not report the allegation, and the administrator reported it only after returning from vacation.
Inaccurate Documentation of TPN Status
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident. Resident #1 was admitted with diagnoses including adult failure to thrive, gastrostomy status, dysphagia, and diabetes mellitus, and had severe cognitive impairment on MDS assessment. Nursing progress notes showed that a physician ordered TPN to be discontinued after the last bag was empty, and the last TPN was administered on 4/12/2026 at 9:17 a.m. However, a nursing progress note entered on 4/15/2026 at 7:24 p.m. by LVN A stated that the resident continued on TPN at 40 cc/hr, which did not match the medication administration record or the prior discontinuation order. During interviews, LVN A stated he documented the TPN because he assumed the resident was still receiving it and had not seen the resident before documenting. LVN B stated she had received the physician order to discontinue TPN once the current bag was completed, that the last bag was hung on 4/12/2026, and that TPN was no longer administered after the bag finished on 4/13/2026. LVN C stated she had received report to discontinue TPN once the bag was finished and that the resident was no longer receiving TPN on 4/13/2026. The DON stated the resident was across from her office and that she would have discarded any empty IV medication seen hanging, and the facility policy required a complete account of the resident's care, treatment, response to care, signs, and symptoms.
Failure to Obtain Informed Consent Before Administering Psychoactive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was fully informed in advance and that consent was obtained prior to administering a psychoactive medication. Resident #1 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and lack of coordination. An admission MDS assessment documented that the resident was moderately cognitively impaired, required moderate assistance with most ADLs, and received antipsychotic and antidepressant medications for seven days during the assessment period. The consolidated physician orders showed an order dated 03/08/26 for Trazodone 25 mg by mouth at bedtime for insomnia, unspecified. Record review showed that the informed consent for psychoactive medication form for Trazodone was signed by Resident #1’s legal representative on 03/10/26, and the section indicating whether the representative consented to the medication was not completed. The medication had already been administered to the resident on 03/09/26, before the consent form was signed and completed. During an interview, the DON acknowledged that the informed consents for Trazodone were not completed and did not show if the medication was consented to by the responsible party, and stated that informed consents should have been completed prior to administering the medication. The facility’s policy on Chemical Restraints and Psychotropic Medication Management stated that on admission, the admitting nurse will review transfer orders for psychotropic medications and make all efforts to obtain history and prior informed consents, documenting any information obtained in the clinical record.
Psychotropic Medication Administered Without Informed Consent
Penalty
Summary
Surveyors identified a deficiency related to the use of a psychotropic medication without proper informed consent. Resident #1, admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and lack of coordination, had an admission MDS showing moderate cognitive impairment and a need for moderate assistance with most ADLs. The MDS also reflected that the resident received antipsychotic and antidepressant medications for seven days during the assessment period. The consolidated physician orders showed an order dated 03/08/26 for Trazodone 25 mg by mouth at bedtime for unspecified insomnia. Record review showed that the informed consent for psychoactive medication for Trazodone was signed by the resident’s legal representative on 03/10/26, and the form indicated that the legal representative did not consent to the medication. Despite this, Trazodone had already been administered to the resident on 03/09/26, prior to obtaining a signed consent. During an interview, the DON acknowledged that medication was not supposed to be given without a consent form because it could cause an adverse effect to the resident. The facility’s policy on Chemical Restraints and Psychotropic Medication Management stated that on admission the admitting nurse would review transfer orders for psychotropic medications and make all efforts to obtain history and prior informed consents, documenting any information in the clinical record, but this process did not prevent administration of Trazodone before consent was obtained.
Unlocked and Unattended Wound Care Medication Cart
Penalty
Summary
Surveyors observed that a wound treatment cart on the 300 hallway was left unlocked and unattended by an RN at 6:03 p.m. The cart contained medications needed for residents’ wound care and wound care supplies. When the surveyor notified the RN that the cart was unlocked, the RN locked it and acknowledged she was responsible for the treatment cart and was expected to lock it whenever she walked away. She stated that if the cart was left unlocked, a resident could open a drawer and take a medication that was not prescribed for them. In a subsequent interview, the DON stated that numerous staff, including herself and the ADON, were responsible for ensuring medication carts were locked and that her expectation was that staff lock the cart when walking away from it. The DON stated that if the cart was left unlocked, a resident or visitor could grab medication from the cart and it could harm them. Review of the facility’s “Medication Storage” policy showed that medications and biologicals must be stored properly and that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended only by persons with authorized access. The observed unlocked and unattended wound care cart was not in accordance with this policy or with accepted professional principles for medication storage and security.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards during a kitchen sanitation observation and record review. In the dry food storage area, 1 of 2 applesauce cans, 1 of 3 tuna cans, and 3 of 11 noodle soup cans were dented and were stored on the same shelf area as non-dented cans rather than in a separate storage area. A plastic cup with a straw belonging to an employee was also found underneath the prep table in the food preparation area, and 2 of 30 cups in the clean area and ready to use had debris inside them. The facility also failed to properly thaw raw meat. A log of ground beef was observed in the sink labeled for produce only, with no running water and red liquid draining into the sink drain. In interviews, dietary staff stated that dented cans are not supposed to be used because they may contain small pieces of metal, that personal cups should be kept in staff storage areas rather than around food prep areas, and that meat should be thawed in the refrigerator or under cool running water using a colander rather than placed directly in a sink.
Failure to Notify RP of Wanderguard Placement
Penalty
Summary
The facility failed to inform Resident #12’s responsible party in advance that a Wanderguard had been placed on the resident. Resident #12 was admitted with diagnoses including age related physical debility, schizoaffective disorder, and major depressive disorder. Her initial MDS assessment left the BIMS score blank, indicating severely impaired cognition, and her care plan identified that she wandered the hallways, entered other residents’ rooms and offices, and had a Wanderguard placed on her left foot on 08/27/25. Her physician’s order also reflected the Wanderguard order date of 08/27/25. The resident was observed on 09/22/25 lying in bed with a Wanderguard on her left ankle, and she was not interviewable because she kept repeating words. Review of the electronic medical record on 09/22/25 did not show that her RP had been notified of the Wanderguard placement. During interview on 09/23/25, the DON stated the facility did not require consent for a Wanderguard because it was not considered a restraint, but acknowledged that the resident’s RP needed to be notified and could not find a progress note showing that notification occurred. The facility’s Wandering Residents-Wanderguard policy stated that the family/responsible party shall be notified of the risk for wandering and that the Wanderguard has been placed on the resident.
MDS Did Not Reflect Wandering Behavior and Wanderguard Use
Penalty
Summary
The facility failed to ensure Resident #12’s assessment accurately reflected her status on the MDS. Resident #12 was an [AGE]-year-old female admitted on 08/25/25 with diagnoses including age related physical debility, schizoaffective disorder, and major depressive disorder. Her initial MDS assessment dated [DATE] had the BIMS score left blank, indicating severely impaired cognition, but she was not coded as having wandering behaviors or a wander alarm. Record review showed Resident #12’s care plan identified that she wandered through hallways, entered residents’ rooms and offices, and had a risk/wanderer problem related to disorientation to place and impaired safety awareness. The care plan included monitoring Wanderguard placement on her left foot, and the physician had an order for a Wanderguard dated 08/27/25. An elopement/wandering evaluation dated 09/04/25 showed a score of 11, indicating high risk for elopement. During observation on 09/22/25, Resident #12 was seen in bed with a Wanderguard on her left ankle. The MDS Coordinator stated she must have forgotten to code the Wanderguard and wandering behaviors on the MDS, and the DON agreed the assessment should have reflected both.
Care Plan Missing PTSD Triggers
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with diagnoses including Type 2 diabetes mellitus, hypertension, schizophrenia, and PTSD. Review of the quarterly care plan showed it addressed mood problems related to PTSD, anxiety disorder, and schizophrenia with interventions such as administering medications as ordered, assisting the resident to identify strengths and positive coping skills, documenting or reporting mood patterns, and referring to behavioral health services as needed, but it did not include the resident’s PTSD triggers. The social worker stated the resident had identified Spanish ballads as a trigger that caused her to cry and increased her anxiety because it took her back to an incident involving relatives. The social worker said this trigger had been documented in her report binder and that the resident had been referred to a local counseling agency and psychiatric nursing service. The social worker also stated the care plan was written broadly because the resident was a poor historian. During interviews, CNA staff and an RN stated they did not know the resident had PTSD triggers, and the MDS coordinator reviewed the care plan and confirmed no triggers were listed. The MDS coordinator stated triggers should have been added so staff would be aware of what might cause behavior changes. The DON stated she did not recall the triggers being voiced and said it would be beneficial to have PTSD triggers listed in the electronic medical record for staff awareness.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #79 had the call light within reach while in bed in the resident's room. Resident #79 was admitted with diagnoses including Alzheimer's disease, muscle wasting and atrophy multiple sites, need for assistance with personal care, and difficulty walking. The quarterly MDS reflected a BIMS score of 3, indicating severe cognitive impairment, and the resident used a wheelchair. The care plan stated the resident required extensive assistance with all ADLs and needed assistance with transfers using weight bearing, pivoting, and taking two steps. During observation on 9/22/25 at 10:10 a.m., Resident #79's call light device was on the bed frame and the resident was not able to reach it. During interview, the ADON stated the resident usually used the call light when needing something and that she always makes sure residents have it within reach and reminds them to use it. The ADON also stated that if a resident cannot reach the call light, then they cannot get help and may have a fall and be at risk of getting hurt. The DON later stated that if call lights are not within reach, residents might need help and Resident #79 could have fallen. The facility policy stated the call device should be placed within the resident's reach before leaving the room.
Incomplete Nutritional Supplement Order
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for one resident. Resident #35, an elderly female with dementia, anemia, and moderate protein-calorie malnutrition, had an active order for a nutritional supplement three times a day for weight loss. Review of the order summary showed the order was incomplete because it did not include the route of administration or the amount/dose. Her care plan identified that she was on a mechanically altered diet and at risk for weight fluctuation, malnutrition, and dehydration, and her eMAR showed she received the nutritional supplement three times daily from February through September 2025. During observation and interview, the resident stated she received a nutritional drink several times a day. MA E reviewed the record and stated the order was incomplete because it lacked the route and dosage, and she had not noticed this until the interview. LVN F also reviewed the record and stated the order was not complete because it did not include the route of administration and dosage, although the eMAR showed administration three times a day. The DON likewise confirmed the order was missing the amount and route and was not considered a complete order. The facility policy stated admission orders must include medication name, strength/dose, frequency, and route of administration, and that unclear or erroneous orders must be clarified before filling.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to maintain its Infection Prevention and Control Program for one resident with a sacral wound. Resident #71 was a female admitted on 01/28/25 with diagnoses including dysphagia, a stage 4 pressure ulcer of the sacral region, and muscle weakness. Her physician orders directed wound treatment to the sacrum with cleansing, skin prep, transparent dressing, white foam to the tunnel, black foam to the wound bed, and negative pressure wound therapy at 125 mmHg continuous every Monday, Wednesday, and Friday and as needed for dislodgement. During wound care observation on 09/22/25, LVN A washed hands before and after treatment and sanitized hands between glove changes, but did not don the required gown for enhanced barrier precautions. The wound dressing was labeled and had no drainage or odor, and the wound care was performed according to the physician order. During handwashing, LVN A lathered her hands for 13 seconds. In interview, LVN A stated residents with wounds required enhanced barrier precautions, that she should have worn a gown, and that she knew handwashing should include 20 seconds of lathering. The DON stated any resident with a wound was placed on enhanced barrier precautions and that contact required gown and gloves, and she confirmed staff had received training on enhanced barrier precautions and hand hygiene.
Deficiencies in Oxygen Administration for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. Resident #225, a male with multiple health conditions including respiratory failure and severe aortic stenosis, was observed receiving oxygen at a rate lower than the prescribed 4 liters per minute (LPM). The resident was found with oxygen set between 2.5 and 3 LPM, which was confirmed by LVN B, who admitted not checking the oxygen rate at the start of her shift. The resident's care plan did not include oxygen therapy, and the Director of Nursing (DON) acknowledged that the charge nurse was responsible for checking oxygen settings every shift. Resident #18, a female with respiratory failure and vascular dementia, was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The discrepancy was noted by a staff member who had not checked the oxygen setting since the start of his shift. The resident's care plan was outdated, and the DON confirmed that the care plan did not reflect the correct oxygen rate. Despite the incorrect oxygen administration, the resident did not exhibit any immediate distress, and the DON conducted an assessment to ensure the resident's condition was stable. Resident #48, a female with severe cognitive impairment and multiple health issues, was receiving oxygen at 3.5 LPM instead of the prescribed 4 LPM. LVN B, responsible for the resident's care, admitted to adjusting the humidifier, which may have altered the oxygen setting. The DON and other staff members routinely checked oxygen settings, but the discrepancy was not corrected in time. The facility's policy on oxygen administration emphasized the importance of adhering to physician orders, yet the failure to maintain correct oxygen levels for these residents highlighted a lapse in following established procedures.
Failure to Update Oxygen Therapy in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their physical needs. Resident #225, a male with multiple diagnoses including respiratory failure and severe aortic stenosis, was prescribed oxygen therapy at 4LPM via nasal cannula as needed. However, his care plan, dated 8/2/24, did not reflect this oxygen use. Observations confirmed the resident was using oxygen, but the care plan was not updated to include this critical aspect of his care. Interviews with the ADON and MDS/RN revealed that the responsibility for updating care plans lay with the MDS nurses, and the oversight was acknowledged by the DON. Similarly, Resident #48, a female with severe cognitive impairment and a history of cerebral infarction and dementia, was receiving continuous oxygen therapy at 4L/min via nasal cannula. Despite this, her care plan, dated 5/30/24, lacked any focus, goals, or interventions related to her oxygen therapy. Observations confirmed her use of oxygen, and interviews with the MDS/RN and DON indicated that the care plan had not been updated to reflect her current needs. The MDS/RN acknowledged the potential negative effects of not having oxygen therapy care planned, such as hypoxia and respiratory distress. The facility's Comprehensive Person-Centered Policy, dated December 2023, mandates the development of a comprehensive care plan for each resident, including measurable objectives and timeframes. This policy was not adhered to in the cases of Residents #225 and #48, as their care plans did not include necessary information regarding their oxygen therapy, potentially placing them at risk of not receiving appropriate care.
Failure to Update Resident's Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. Specifically, the care plan for a resident was not updated to reflect a new oxygen order effective on a specified date. The resident, an elderly female with multiple health conditions including respiratory failure, vascular dementia, congestive heart failure, and end-stage renal disease, had a physician's order for oxygen at 2L/min continuous. However, her care plan still reflected an outdated intervention of oxygen therapy at 4L/min. Observations and interviews revealed discrepancies in the oxygen settings being administered to the resident. On one occasion, the oxygenator was set at 3L/min, contrary to the physician's order of 2L/min. The LVN acknowledged the discrepancy and noted that the nursing staff should monitor oxygen settings once per shift, but had not done so since the start of his shift. The MDS/RN confirmed that the care plan was not updated in a timely manner, and the DON acknowledged the oversight, noting that the care plan should have been updated on the day the new oxygen order was received to prevent confusion.
Failure to Check G-Tube Residuals Before Medication Administration
Penalty
Summary
The facility failed to ensure that a nurse, LVN A, demonstrated competency in administering medication via a G-tube for Resident #48. LVN A did not check for gastric residual before administering medication, which is a required procedure according to the facility's protocol. Resident #48, who was admitted with diagnoses including moderate protein-calorie malnutrition, dysphagia, and gastrostomy status, was dependent on staff for all activities of daily living and had a feeding tube for nutritional support. The resident's care plan specifically required checking for tube placement and gastric contents/residual volume before feeding, with instructions to hold feeding if residuals exceeded 150 mL and notify the physician. During an observation, LVN A was seen administering medication without checking for residuals, and she confirmed in an interview that she did not perform this check, believing it was only necessary before feeding. However, the facility's policy and the Director of Nursing (DON) clarified that checking residuals is mandatory before administering medications via G-tube. The DON stated that nurses were trained and evaluated on this skill, and LVN A had been checked off on the competency checklist for enteral med pass, which included checking gastric residuals. Despite this, LVN A did not follow the protocol, leading to the deficiency.
Failure to Label and Date Food in Resident's Mini Refrigerator
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as evidenced by the improper handling of food in a resident's mini refrigerator. The resident, who had severe cognitive impairment and multiple health conditions, including chronic obstructive pulmonary disease, dementia, and end-stage renal disease, had a mini refrigerator in his room containing unlabeled and undated food items. These included a plastic container with beans and several mini containers with salsa, which were brought by the resident's daughter. The facility's policy required that all outside food be labeled and dated by the charge nurse to prevent foodborne illnesses. Interviews with various staff members, including the Dietary Manager, LVN, DON, and the Business Office Coordinator, revealed a breakdown in the process of managing outside food brought into the facility. The staff confirmed that the procedure involved the front receptionist handing over the food to the resident's charge nurse, who was responsible for checking the food against the resident's diet plan and labeling and dating it if approved. However, this process was not followed in the case of the resident's mini refrigerator, as the food items were neither labeled nor dated, and the Business Office Coordinator admitted to noticing the unlabeled food but failing to address it. The facility's policy on food brought by family or visitors, revised in 2007, stipulated that non-perishable foods should be stored in plastic containers with tight-fitting lids and that perishable foods must be destroyed daily. Despite this policy, the facility did not maintain a log of outside food, and the oversight in labeling and dating the food in the resident's mini refrigerator posed a risk of foodborne illnesses. The administrator acknowledged the importance of labeling and dating food to track how long it had been stored, but the deficiency in this case highlighted a lapse in the facility's adherence to its own procedures.
Failure to Timely Report Alleged Neglect
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident to the State Survey Agency within the required 24-hour timeframe. The incident involved a resident who was reportedly found on the floor by two CNAs, one of whom later alleged that the other CNA had verbally and physically abused the resident. The Director of Nursing (DON) at the time did not report the allegation to the State, and the facility administrator only became aware of the situation upon returning from vacation, at which point she reported it. The resident involved was a male with a history of sepsis, requiring assistance with personal care, and had mild cognitive impairment. During the facility's investigation, the resident denied any abuse from the CNAs involved, and no other staff or residents reported abuse by the accused CNA. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be reported immediately, but this protocol was not followed, leading to a deficiency in the facility's compliance with reporting requirements.
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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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Nursing homes near Brownsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesa Hills Post Acute | 1.4 mi | ★★★★★ | 6 | 0 |
| Las Alturas Nursing & Transitional Care Brownsvill | 1.4 mi | ★★★★★ | 2 | 0 |
| Ebony Lake Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 14 | 0 |
| Fox Hollow Post Acute | 1.7 mi | ★★★★★ | 12 | 3 |
| Spanish Meadows | 2.2 mi | ★★★★★ | 16 | 0 |
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