Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ashford Gardens during CMS and state inspections, most recent first.
A resident with quadriplegia and intact cognition required substantial to maximal assistance with toileting hygiene and was totally dependent on staff for personal hygiene. He reported his brief had not been changed since the prior day, and when a CNA checked him, the brief was full of urine and had soaked through to the bed sheet. The resident had redness and burning to the scrotal area, and the CNA noted redness on the buttocks.
Restricted After-Hours Visitation: Staff interviews showed that a resident's family members were not allowed to enter after 8:00 p.m. because the doors were locked, despite facility policy stating that residents have the right to receive visitors of their choosing at the time of their choosing and that family members are not subject to visiting hour limits. The Assist ED later said family could still come in after hours by ringing the doorbell, but other staff said visits after 8:00 p.m. were not permitted except in limited situations.
Expired medications were found on two medication carts, including opened insulin, artificial tears, Pro-Stat, and multiple eye drops that had passed their allowed use period after opening. An LVN and an MA both stated the medications were expired and could be less effective, and the DON said staff were expected to date bottles when opened and check carts each morning for expired medications. Facility policy required medications to be stored per manufacturer recommendations and for expired medications to be identified and reported.
Pest Control Program Failed to Keep Facility Free of Flies, Roaches, and Bed Bugs: Surveyors observed live flies in multiple hallways and the conference room, and a cockroach in the conference room. A resident with impaired cognition and extensive ADL needs reported being bitten in her room, which had been deep cleaned and sprayed by maintenance; the DON later learned pest control found 8 bedbugs on the back of her mattress. The facility’s pest control policy referenced control of seasonal pests, but pests were still present in common areas and the resident room.
Incomplete Care Plans for Resident Diet Orders: Two residents had diet orders and MDS triggers for mechanically altered and therapeutic diets, but their care plans did not include diet-related focus, goals, or interventions. One resident had dysphagia and a ground-texture diet order, and the other had encephalopathy, HF, and a liberal cardiac diet order. Staff including RN F, the Unit Manager, the MDS Coordinator, and the DON confirmed that diet needs should be reflected in the care plan.
A resident with severe cognitive impairment and a G-tube for dysphagia received multiple morning meds via the tube without placement being checked first. An LVN said he skipped the check because the tube was hard to assess and he was familiar with the resident, while the DON confirmed facility policy and the MD order required placement verification before meds or feedings.
Medication administration errors exceeded the allowed rate when an MA omitted ordered meds for one resident and an LVN gave another resident the wrong dosage form and dose while also missing an ordered insulin dose. Observations and interviews showed omitted aspirin and supplement administration, crushed meds given instead of ordered liquid formulations, and a double dose of valproic acid during the med pass.
Significant medication errors occurred when an LPN gave a resident Valproic Acid in capsule form instead of the ordered oral solution and administered a double dose by using the capsule strength while referencing the liquid order. The LPN also omitted the resident’s ordered insulin glargine during the morning med pass. The resident had severe cognitive impairment, a feeding tube, epilepsy, and diabetes, and the chart showed the medication error was documented as a change in condition.
Failure to Use EBP PPE During G-Tube Medication Administration: Two residents with feeding tubes and wounds were on EBP, with signs posted at their rooms/beds and orders in place for targeted gown and glove use during high-contact care. An LVN gave G-tube meds to one resident and another LVN gave G-tube meds to a second resident without wearing a gown. Both nurses stated they should have worn a gown for the care but forgot, and the DON confirmed that G-tube medication administration required PPE during close contact care.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that several medication carts were left unlocked or not properly secured, allowing unauthorized access to prescription and over-the-counter medications. Staff interviews revealed lapses in following procedures for locking carts and reporting mechanical issues, with some carts having malfunctioning battery-powered locks. The facility's policy required all medications to be stored securely, but this was not consistently enforced.
Staff failed to follow enhanced barrier precautions and infection control protocols when caring for a resident with multiple medical conditions and an intravenous access device. Soiled gloves, gowns, and linens were left inappropriately in the resident's room and transported through another resident's room, and staff did not perform required hand hygiene or use PPE correctly during care activities, contrary to facility policy.
A resident with multiple chronic conditions and moderate cognitive impairment was found to have half bed rails in use on both sides of her bed without a physician's order or documented assessment. Staff interviews revealed the bed rails were used to keep the resident in bed, and the resident confirmed she had not requested them. The facility's policy requires an assessment and physician's order for bed rail use, but these were not in place for this resident.
A resident with significant mental health diagnoses left the facility without being provided his required medications, despite facility policy requiring medications and instructions to be given to residents leaving on pass. Staff interviews confirmed the resident was at risk without his medications, and the nurse was responsible for ensuring both sign-out and medication provision, but these procedures were not followed.
The facility failed to maintain an effective infection prevention and control program, lacking a documented water management program and proper PPE use. A housekeeper cleaned a resident's room without PPE due to language barriers and inadequate training, while an LVN administered IV medication without a gown, misunderstanding enhanced barrier precautions. These deficiencies highlight significant gaps in staff training and policy implementation.
The facility failed to develop comprehensive care plans for two residents, neglecting to include critical medical information such as gastrostomy status and tube feeding for one resident, and failing to document an incident where another resident alleged a car ran over his foot. Staff interviews revealed confusion over care plan responsibilities, exacerbated by a transition to a new electronic medical records system.
A resident reported that a car ran over his foot, but LVN A did not notify the physician or document the incident, as he found no apparent injury. The resident, with a history of multiple sclerosis and seizures, was later assessed by LVN O and NP A, who ordered an x-ray. The facility's policy on notifying physicians of health changes was not followed, leading to a communication breakdown.
A resident with moderate cognitive impairment was found smoking unsupervised in a non-designated area, contrary to the facility's smoking policy requiring direct supervision. Despite previous issues with non-compliance, the resident accessed smoking materials, indicating a lapse in supervision and policy enforcement.
A LTC facility reported a 6% medication error rate involving two residents and two staff members. One resident received incorrect eye drop dosage due to lack of instructions, while another received crushed Lansoprazole DR ODT via PEG tube, contrary to guidelines. Staff interviews revealed non-compliance with medication administration protocols.
A facility failed to document an incident where a resident alleged a car ran over his foot. An LVN assessed the resident and found no injury but did not report or document the incident. The resident, with a history of multiple sclerosis and seizures, had a moderate cognitive impairment. The facility's policy requires documentation of all incidents, which was not followed, potentially risking resident safety.
A facility failed to provide adequate care for two residents with pressure ulcers, leading to significant health deterioration. One resident did not receive an air mattress for 20 days, worsening their Stage 4 ulcers, while another resident's wound dressings were not changed as ordered. The facility's lack of proper wound care and communication with family members contributed to the residents' declining health.
Incontinent Resident Left in Wet Brief
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received the necessary assistance to maintain good personal hygiene. The resident was a male with diagnoses including acute cystitis without hematuria, deficiency of other vitamins, pain, and quadriplegia C5-C7 incomplete. His MDS assessment showed a BIMS score of 15, indicating intact cognition, and he required substantial to maximal assistance with toileting hygiene and chair/bed-to-chair transfers. His care plan identified an ADL self-care performance deficit related to limited mobility, with total dependence on staff for personal hygiene and a risk for altered skin related to bowel and bladder incontinence. On observation, the resident stated his brief had not been changed that day and said staff had not changed it since the prior day. When the CNA checked him, his brief was full of urine and some urine had soaked through onto the bed sheet. The CNA noted redness on the buttocks and applied barrier cream. The resident later complained of burning and redness to the testicles and said the burning may have come from not being changed during the night. The facility’s staffing coordinator stated residents should be checked and changed every two hours or when they are hitting their call light, and the facility policy stated incontinent residents should receive perineal care during routine bath and as needed.
Restricted After-Hours Visitation
Penalty
Summary
The facility failed to provide residents access to visitors of their choosing at the time of their choosing because it did not allow any visitors in the building after 8:00 p.m. Staff interviews showed that the doors were locked at 8:00 p.m., and family members were not permitted to enter after that time except for EMS personnel or family of a resident who was passing away. One LVN stated visitation hours were from 8:00 a.m. to 8:00 p.m. and that family members were not allowed in after 8:00 p.m. The receptionist gave the same account and said family visits after hours were only allowed for a resident who was care planned for a particular reason or if the resident was actively dying. A later interview with the Assist ED conflicted with the other staff statements, as he said the doors were locked at 8:00 p.m. for security reasons but family members were still allowed in whenever they wanted by ringing the doorbell and being let in by nursing staff. He also stated that staff were misinformed about visitation and that he was not sure where they got the information that family members were not allowed after 8:00 p.m. The facility policy stated that residents have the right to receive visitors of their choosing at the time of their choosing, that family members are not subject to visiting hour limitations, and that if visits infringe on other residents' rights, staff will find another location for the visit.
Expired Medications Stored on Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for 2 of 8 medication carts reviewed. On the Hall 2300/2400 Nurse cart, surveyors found expired medications stored with current medications, including opened insulin lispro, opened insulin lantus, opened artificial tears, and Pro-Stat that had expired. During the observation, an LVN stated insulin was only good for 28 days after opening and eye drops were good for 30 days after opening, and said expired medications could be harmful or less effective. She also stated she tried to check her cart every day but was not aware of an actual policy or procedure for checking carts for expired medications. On the Hall 2100/2200 Med Aide cart, surveyors found expired eye drops stored on the cart, including brimonidine, bimatoprost, latanoprost, another latanoprost bottle, and Simbrinza. The MA stated the eye drops expired 30 days after opening and said expired medications would not be as effective. She also stated she checked her cart every morning for expired eye drops. The DON stated eye drops were only good for 30 days after opening and insulin was only good for 28 days after opening, and said staff were expected to date bottles when opened and check carts every morning for expired medications before starting their shift. Facility policy stated medications were to be stored according to manufacturer recommendations and that medication rooms were routinely inspected for outdated medications; the medication administration policy stated staff should identify expiration dates and notify the nurse manager if expired.
Pest Control Program Failed to Keep Facility Free of Flies, Roaches, and Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free of pests in 2 of 4 hallways, the conference room, and 1 resident room. Survey observations identified live flies on Hall 1200, Hall 2400, and in the conference room, and a cockroach was later observed crawling on the floor in the conference room. The facility’s pest control policy stated that it would use a variety of methods to control seasonal pests such as flies through indoor and outdoor methods deemed appropriate by the outside pest service and applicable regulations. Resident #44 was a [AGE] year-old female admitted with diagnoses including idiopathic hypotension, hyperkalemia, cellulitis of the right toe and right lower limb, muscle weakness, elevated white blood cell count, and Pseudomonas aeruginosa. Her MDS showed a BIMS score of 09, indicating moderately impaired cognition, and she required extensive assistance with multiple ADLs including toileting hygiene, bathing, dressing, and rolling. Progress notes documented that she developed red raised bumps on both arms with scratching and scabbed areas on the left arm, and she was started on Hydroxyzine for itching. During interview, Resident #44 stated she had been moved out of her room earlier in the week because it was deep cleaned and sprayed by maintenance, and that she had been getting bitten by something about a month earlier. She reported the bites were from ants and said the bites on her shoulder and leg had healed. The Maintenance Director stated he treated the room, found sugar ants, and noted the resident had many snacks in the dresser. He also stated pest control was coming to check the room that day. The facility’s service ticket later documented that pest control found 8 bedbugs on the back of the mattress in Resident #44’s room, and the Administrator acknowledged that active bed bugs were found in the room and that the resident was moved to another room.
Incomplete Care Plans for Resident Diet Orders
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for 2 of 8 residents reviewed, Resident #101 and Resident #146, to address their diet orders. Resident #101 was a [AGE]-year-old female admitted on 05/20/2022 with hypertension and dysphagia. Her Quarterly MDS showed a BIMS score of 15 and triggered her for a mechanically altered diet. Her physician order dated 04/23/2025 specified a regular diet with ground texture, regular/thin consistency, and permission for baked whole fish, but her undated care plan did not include a focus, goal, or interventions for her diet. Resident #146 was a [AGE]-year-old male admitted on 01/22/2026 with encephalopathy, heart failure, and a cardiac pacemaker. His Quarterly MDS showed a BIMS score of 07 and triggered him for a therapeutic diet. His physician order dated 01/22/2026 specified a liberal cardiac diet with regular texture, regular/thin consistency, and divided plate with all meals, but his undated care plan also did not include a focus, goal, or interventions for his diet. Interviews with RN F, the Unit Manager, the MDS Coordinator, and the DON confirmed that residents should have diet-related care plan focuses, goals, and interventions, and that the MDS Coordinator was responsible for updating care plans. The facility policy titled Comprehensive Care plans, dated 10/01/2025, stated that the facility is to develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs and all services identified in the comprehensive assessment. The policy further stated that the care plan should describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate care for a resident who was receiving nutrition and medications through a G-tube. Resident #97 was admitted with diagnoses including sepsis, type 2 diabetes, cerebral infarction, metabolic encephalopathy, epilepsy, and a pressure ulcer, and his MDS assessment showed a BIMS score of 00 out of 15, indicating severely impaired cognition. His care plan identified that he required tube feeding due to dysphagia and included checking tube placement per facility protocol before use. On 4/30/26, LVN A was observed administering multiple morning medications through the resident’s G-tube without first checking for tube placement. During interview, LVN A stated he did not check placement because it was hard to check residual with the type of G-tube the resident had and said he was used to the resident, so he felt it was safe to proceed. The DON stated the facility policy required checking G-tube placement before giving medications, and the physician order also directed staff to check tube placement prior to instilling medication or initiating a feeding.
Medication administration errors exceeded the allowed rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors calculated an 18% medication error rate, based on 5 errors out of 27 opportunities, involving 2 residents and 2 staff members observed during medication administration. The errors included omitted medications, incorrect dosage form, and incorrect dose during observed medication passes. For one resident with diagnoses including multiple myeloma, protein-calorie malnutrition, hypertension, weakness, and depression, the morning medication pass on 4/29/26 showed that the MA administered multiple ordered medications but did not give the ordered Supplement Pass 90 ml or Aspirin 81 mg. During the observation, the MA stated she did not have the Supplement Pass available at the time and later gave it at 11:30 AM, stating it would count as the lunch dose and that the morning dose was not given. She also stated she did not realize she had not given the Aspirin and believed she may have checked it off without administering it. For another resident with diagnoses including sepsis, type 2 diabetes, cerebral infarction, metabolic encephalopathy, and a pressure ulcer, the morning medication pass on 4/30/26 showed that the LVN administered Vitamin C 500 mg crushed via G-tube, Valproic Acid 250 mg capsules via G-tube, and did not administer Insulin Glargine 10 units. The ordered Vitamin C and Valproic Acid were both prescribed in liquid form, but the LVN crushed tablets/capsules and administered them via the feeding tube instead. The LVN stated he did not see the Insulin Glargine order and said he did not have the liquid Valproic Acid or liquid Ascorbic Acid, then later the liquid Valproic Acid was found in his medication cart. He also stated he gave the wrong dosage of Valproic Acid because he looked at the dosage for the liquid order and acknowledged the resident could have side effects from receiving a double dose.
Significant Medication Errors During G-Tube Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for one resident reviewed for pharmacy services. Resident #97 was a male admitted on 4/13/26 with diagnoses including sepsis, type 2 diabetes, cerebral infarction, metabolic encephalopathy, epilepsy, and a pressure ulcer. His admission MDS dated 4/20/26 showed a BIMS score of 00 out of 15, indicating severely impaired cognition. He was dependent for all ADLs, had a feeding tube, and was receiving most of his nutrition and fluids through the tube. His care plan included orders for insulin glargine and insulin lispro for diabetes and valproic acid oral solution for anticonvulsant therapy. On 4/30/26 during morning medication administration, an LVN was observed crushing and giving Valproic Acid 250 mg, 2 capsules via the g-tube. The medication was ordered as Valproic Acid oral solution 250 mg/5 ml, and the LVN stated he was trying to get the liquid out of the capsules because he believed the liquid was not available. He did not look in the medication cart or ask anyone about it before administering the medication. The LVN also did not administer the resident’s insulin glargine during that morning medication pass. Later, the LVN stated he did not see the insulin glargine order and that it did not flag on his MAR. Record review showed the consultant pharmacist had recommended discontinuing Divalproex DR 500 mg BID via g-tube because there was already an order for Valproic Acid oral solution 4 times daily, and the NP agreed, but the blister pack remained in the medication cart. The facility later found the liquid Valproic Acid in the LVN’s cart at the bottom with other liquid medications. The LVN stated he gave the wrong dosage because he gave the capsules but looked at the dosage for the liquid order. The DON and NP were interviewed regarding the medication error, and the resident’s chart documented a change in condition for a medication error with a head-to-toe assessment, vital signs, and monitoring for 72 hours. The physician orders in the chart showed Valproic Acid oral solution 250 mg/5 ml via g-tube, insulin glargine 10 units SQ daily, and Divalproex sodium 500 mg BID via g-tube discontinued on 4/20/26.
Failure to Use EBP PPE During G-Tube Medication Administration
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 28 resident rooms reviewed for infection control. The deficiency involved two residents who were on Enhanced Barrier Precautions (EBP) because of feeding tubes and wounds. The report states that LVN AB did not wear a gown while giving G-tube medications to Resident #42, and LVN A did not wear a gown while giving G-tube medications to Resident #97. Resident #42 was a female admitted with diagnoses including acute kidney failure, aphasia, diabetes mellitus, pressure ulcer of the sacrum, dysphagia, and gastrostomy. Her MDS showed a BIMS score of 00, indicating severely impaired cognition, and she was dependent for all ADLs. She had a feeding tube, received 51% or more of her calories through it, and received 501 cc/day or more of fluid intake through it. Her care plan and physician orders identified EBP for her G-tube feeding and pressure ulcer, and an observation showed an EBP sign on her door while she was receiving continuous Jevity 1.2 via PEG tube. During an observation on 4/29/26, LVN AB performed a medication pass for Resident #42 without wearing a gown. In interview, LVN AB stated that EBP was to protect the resident and staff from infection and that she should have had a gown on when giving G-tube meds but forgot. The DON stated that EBP signs were posted for residents with devices or wounds and that PPE would be worn when staff provided close care, including giving G-tube meds. Resident #97 was a male admitted with diagnoses including sepsis, type 2 diabetes, cerebral infarction, metabolic encephalopathy, and pressure ulcer of unspecified site and stage. His MDS showed a BIMS score of 00 out of 15, indicating severely impaired cognition, and he was substantial/max assist for all ADLs. He had a feeding tube, received 51% or more of his calories through it, received 501 cc/day or more of fluid intake through it, and had one stage 3 unhealed pressure ulcer and one unstageable pressure ulcer. His care plan and physician orders identified EBP for wounds and a G-tube, and an observation showed an EBP sign over his bed while he was receiving continuous Diabetasource via feeding tube. During an observation on 4/30/26, LVN A performed a medication pass for Resident #97 without wearing a gown. LVN A stated that EBP was for G-tubes, wounds, and indwelling devices, that he was supposed to wear a gown during G-tube care and medication administration because it protected the resident and himself from infection, and that he forgot to put a gown on. The facility policy stated that EBP uses targeted gown and gloves during high-contact resident care activities, including feeding tube care, and that staff are expected to comply with designated precautions.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Secure Medication Carts and Ensure Proper Drug Storage
Penalty
Summary
Surveyors observed that multiple medication carts (MC #1, MC #2, MC #3, MC #5, and OFMC #4) were not properly secured and were left unlocked or with drawers not fully closed, making medications accessible to unauthorized individuals. Specific observations included a medication cart with an unlocked bottom drawer containing various medications and a reconciliation binder, as well as carts that appeared locked but could be easily opened by manipulating the locking mechanism. Some carts had prescription and over-the-counter medications belonging to residents, and one cart contained medications for a resident who was no longer at the facility. Interviews with staff revealed that medication carts were expected to be locked at all times when not in use, and only authorized personnel should have access. However, staff admitted to overlooking proper locking procedures, such as not ensuring drawers were fully closed before locking or not reporting malfunctioning locks. The Director of Nursing (DON) and other staff acknowledged that some carts had ongoing mechanical issues, particularly with battery-powered locks that could be disrupted if the carts were bumped against walls, causing the locking mechanism to fail. Further interviews indicated that staff were responsible for checking and maintaining the security of medication carts, including replacing or adjusting batteries as needed. Despite this, some staff were unaware of or did not report issues with the locking mechanisms, and at least one cart was found to contain medications for a discharged resident. The facility's policy required all medications to be stored in locked compartments with access limited to authorized personnel, but these procedures were not consistently followed, resulting in unsecured medications.
Failure to Follow Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in standard and enhanced barrier precautions by staff caring for a resident with significant medical needs. The resident in question was a female with a history of dependence on renal dialysis, chronic kidney disease, encephalopathy, and cirrhosis of the liver, and had an intravenous access device for hemodialysis. She was placed on enhanced barrier precautions due to her medical devices and multiple wounds. Observations revealed that soiled gloves, gowns, and linens were left inappropriately in the resident's room, including on the floor and on top of furniture, rather than being immediately bagged and removed to designated areas. A CNA entered the room without performing hand hygiene or donning appropriate PPE, handled soiled linens, and then transported contaminated items into another resident's room before disposing of them, contrary to facility policy and infection control standards. Interviews with the involved CNA confirmed that she did not follow proper infection control procedures, including failing to wear a gown and gloves when handling soiled linens and not immediately removing contaminated items from the resident's room. The CNA admitted to being in a hurry and acknowledged the risk of infection transmission due to her actions. She also confirmed that she had received in-service training on enhanced barrier precautions and infection control but could not recall the date. The Infection Control Nurse corroborated that the CNA's actions were not in line with facility protocols, emphasizing that soiled linens and garbage should not be left in resident rooms or transported through other resident areas, and that staff must wear appropriate PPE and perform hand hygiene when caring for residents on enhanced barrier precautions. A second CNA was observed entering the same resident's room to provide toileting assistance without performing hand hygiene before donning PPE. She touched her clothing and the outside and inside of gloves with unwashed hands before providing care. In an interview, this CNA also acknowledged the lapse in infection control practices and the potential for cross-contamination. The Director of Nursing confirmed that staff are expected to follow strict hand hygiene and PPE protocols, and that soiled linens and garbage must be handled and disposed of according to infection control policies. Facility policy on enhanced barrier precautions was reviewed and outlined the required use of gowns and gloves during high-contact care activities, which was not followed in these instances.
Unauthorized Use of Bed Rails as Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints imposed for staff convenience and not required to treat a medical symptom. Specifically, half bed rails were used on both sides of the resident's bed without a physician's order or proper assessment. The resident, a female with multiple diagnoses including type 2 diabetes, hypertension, gastrointestinal disease, pain, constipation, hyperlipidemia, and atrial fibrillation, was moderately cognitively impaired and dependent on staff for bed mobility, repositioning, and transfers. Her care plan did not address the use of bed rails or identify her as a fall risk, and there was no documentation of a medical need for the bed rails. Observations on two occasions confirmed that the half bed rails were up on both sides of the resident's bed. The resident reported that she had not requested the bed rails and was told by staff that they were used to keep her in bed and prevent her from getting up. She stated that the bed rails did prevent her from getting up, but she had not been injured or attempted to get out of bed herself. She also indicated that she did not use the bed rails to reposition herself and did not have a preference regarding their use. Interviews with staff revealed inconsistent understanding and application of the facility's restraint and bed rail policies. A CNA stated that bed rails were used to keep residents in bed, especially if they were a fall risk, and that a physician's order was required, which was not present for this resident. The RN and DON both confirmed that an assessment and physician's order were required for bed rail use, but neither knew when or why the bed rails were initiated for this resident. The facility's policy prohibits the use of physical restraints for convenience and requires medical justification and proper authorization for their use.
Failure to Provide Medications and Follow Sign-Out Policy for Resident Leaving Facility
Penalty
Summary
A deficiency occurred when the facility failed to establish and follow a written policy regarding the return of residents after hospitalization and the provision of medications for residents leaving the facility. Specifically, a male resident with diagnoses including metabolic encephalopathy, psychosis, schizophrenia, and schizoaffective disorder, who was cognitively intact with a BIMS score of 14, was not provided with his required medications when he left the facility on pass. The resident had a history of behavioral and mental health issues that necessitated consistent medication administration. Record review showed that the resident's care plan identified him as a smoker at risk of injury, but there was no smoking assessment uploaded to his medical record. Interviews with the resident's primary care provider (PCP), a registered nurse (RN), and the director of nursing (DON) revealed that the facility's policy required residents to sign out when leaving and to receive their medications if they were cognitively able. The PCP and RN both expressed concerns that the resident was not safe without his medications, and the RN noted that the resident required education to take his medications properly. The DON confirmed that the nurse was responsible for ensuring the resident signed out and received medications, but was unsure who monitored compliance with this policy. On the day of the incident, the resident expressed a desire to leave, refused assistance from the social worker (SW), and exited the facility despite staff attempts to persuade him to stay. The facility's policy stated that medications needed during the resident's absence should be provided, along with instructions, but this was not done. The failure to provide the resident with his medications and to ensure proper sign-out procedures were followed constituted the deficiency.
Infection Control Deficiencies in PPE Use and Water Management
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which led to several deficiencies. Firstly, the facility did not have a documented water management program to prevent water-borne pathogens such as Legionella. Interviews with the maintenance staff and the Infection Preventionist revealed a lack of awareness and understanding of the need for such a program. The Administrator also admitted to not knowing about the requirement for a Water Management System, indicating a systemic oversight in infection control practices. Additionally, the facility did not ensure that staff wore appropriate personal protective equipment (PPE) when required. Housekeeper L was observed cleaning the room of a resident on contact isolation without wearing any PPE. The housekeeper was new and unaware of the requirement to wear a gown and gloves, as her trainer did not demonstrate this practice. Furthermore, the isolation signs were in English, which Housekeeper L could not read, leading to a misunderstanding of the necessary precautions. Another incident involved LVN S, who administered IV medication to a resident on enhanced barrier precautions without wearing a gown, only gloves. The resident had a PICC line and was receiving IV antibiotics for a surgical site infection. The lack of PPE use was due to the absence of a PPE cart in the resident's room and a misunderstanding of the enhanced barrier precautions protocol. These lapses in infection control practices could potentially expose residents to infectious diseases, highlighting significant gaps in staff training and policy implementation.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which is a violation of the resident rights set forth at S483.10(c)(2) and S483.10(c)(3). For Resident #105, the facility did not include his gastrostomy status or tube feeding in his care plan, despite having a diagnosis of dysphagia and being on a feeding tube. The care plan from 10/8/24 lacked any mention of these critical aspects of his care, even though there were specific medical orders related to his gastrostomy and tube feeding. Interviews with staff revealed a lack of clarity and responsibility regarding who was updating care plans, especially during the transition to a new electronic medical records system. For Resident #72, the facility did not document or care plan an incident where the resident alleged that a car ran over his foot while he was out of the facility. Although the resident reported foot pain and an x-ray was ordered, the incident was not included in his care plan. Interviews with staff, including the Social Worker and the Administrator, indicated that they were unaware of the incident until it was brought to their attention by surveyors. The lack of documentation and communication among staff members contributed to the failure to address the resident's allegation in his care plan. The facility's policy requires that a comprehensive, person-centered care plan be developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission. However, the facility did not adhere to this policy, as evidenced by the deficiencies in the care plans for Residents #105 and #72. The failure to properly document and update care plans could place residents at risk of not receiving individualized care and services, as the care plans did not reflect the residents' current medical, nursing, and psychosocial needs.
Failure to Notify Physician of Resident's Health Change
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a change in the resident's health status. A resident reported to LVN A that a car ran over his foot while he was out of the facility. Despite this report, LVN A did not notify the resident's physician, the Director of Nursing (DON), or the Administrator, as he assessed the resident and found no apparent injury. LVN A did not document the incident or report it because he believed nothing was wrong. This lack of notification and documentation could place residents at risk of injury, hospitalization, or death. The resident, who has a history of multiple sclerosis and seizures, was later assessed by LVN O, who also found no apparent injury but was informed by NP A of the incident. NP A then notified the resident's physician and ordered an x-ray, which showed no fractures. The facility's policy requires nursing staff to notify the physician, patient, and patient representative of any change in condition, which was not followed in this case. The DON and Administrator were unaware of the incident until the surveyors investigated, highlighting a communication breakdown within the facility.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to smoking protocols for a resident, leading to a deficiency in accident prevention. The resident, a male with moderate cognitive impairment and multiple health conditions, was observed smoking unsupervised in a non-designated area. Despite the facility's policy requiring direct supervision during smoking and prohibiting residents from retaining smoking paraphernalia, the resident managed to access a cigarette and lighter, indicating a lapse in supervision and policy enforcement. Interviews revealed that the resident had a history of non-compliance with smoking protocols, and the facility had previously confiscated cigarettes from him. On the day of the incident, a CNA, unfamiliar with the residents' smoking schedule, failed to notice the resident smoking unsupervised. The facility's administrator acknowledged the established smoking times and supervision requirements but downplayed the risk, citing the resident as a 'safe smoker.' This incident highlights a failure in implementing and monitoring the facility's smoking policy, potentially placing residents at risk for injuries.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6% error rate. This was based on two errors out of 29 opportunities involving two residents and two staff members. One incident involved a medication aide (MA D) who handed eye drops to a resident without providing instructions, leading to the resident administering an incorrect dose. The resident was supposed to apply two drops in each eye but only applied one in the left eye and two in the right eye. The resident had no cognitive impairment and was independent with activities of daily living, but there were no orders for self-administration of the eye drops. Another incident involved a licensed vocational nurse (LVN R) who crushed and administered Lansoprazole DR ODT to a resident via a PEG tube, despite the medication being a delayed-release formulation that should not be crushed. The resident had severe cognitive impairment and required assistance with activities of daily living. The LVN did not recognize the significance of the delayed-release label and proceeded to crush the medication, potentially affecting its therapeutic efficacy. Interviews with staff revealed a lack of adherence to medication administration protocols, including the need to provide instructions to residents and verify medication orders. The Director of Nursing (DON) and the Administrator emphasized the importance of following the facility's medication administration policy, which includes verifying the six rights of medication administration and ensuring residents are instructed on medication use. The facility's policy also highlighted that certain medications, like enteric-coated and delayed-release formulations, should not be crushed, which was not adhered to in the case of the Lansoprazole administration.
Failure to Document Resident Incident and Assessment
Penalty
Summary
The facility failed to maintain complete medical records for a resident, identified as Resident #72, in accordance with accepted professional standards and practices. The deficiency was identified during a review of the resident's medical records, which revealed that a Licensed Vocational Nurse (LVN A) did not document an incident where the resident alleged that a car ran over his foot while he was out of the facility. Despite assessing the resident and finding no signs of injury, LVN A did not report the incident to the medical director, director of nursing (DON), or the administrator, nor did he document the assessment in the resident's medical record. This lack of documentation and communication could potentially place residents at risk of injury, hospitalization, or death. Resident #72, a male with a history of multiple sclerosis and seizures, was admitted to the facility with a moderate cognitive impairment as indicated by a BIMS score of 12 out of 15. The resident's care plan noted a risk for injury related to falls and resistance to care, but did not include documentation of the alleged incident. Interviews with the DON and the administrator revealed that they were unaware of the incident until the surveyors began their investigation. The facility's policy on charting and documentation requires that all services, progress, and changes in a resident's condition be documented to facilitate communication among the interdisciplinary team, which was not adhered to in this case.
Inadequate Pressure Ulcer Care Leads to Health Deterioration
Penalty
Summary
The facility failed to provide adequate care for two residents with pressure ulcers, leading to significant health deterioration. One resident, with multiple Stage 4 pressure ulcers, did not receive an air mattress for 20 days, despite having severe wounds on the sacrum, right heel, and ischium. The resident's sacral ulcer worsened significantly, increasing in size and showing signs of infection. The facility also failed to initiate necessary precautions for pressure sores, such as obtaining an order for an air mattress, which contributed to the progression of the resident's ulcers. The resident's medical history included diabetes, hypertension, and impaired mobility, requiring substantial assistance for daily activities. Despite these needs, the facility did not adequately monitor or address the resident's nutritional status, which is crucial for wound healing. The resident was found to have severe protein malnutrition and was not receiving sufficient nutritional supplements. Additionally, the facility did not communicate effectively with the resident's family regarding the resident's declining condition and the need for potential interventions like a feeding tube. Another resident's pressure wound dressings were not changed according to the physician's orders, further indicating a lack of adherence to proper wound care protocols. The facility's failures in identifying, treating, and preventing pressure ulcers placed residents at risk of severe health complications, including infection and hospitalization. These deficiencies were identified during a survey, highlighting significant lapses in the facility's care practices.
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.
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What surveyors actually found near you
We read the 759 citations issued within 25 miles in the last 12 months — including the 69 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) |
|---|---|---|---|---|
| Caraday Of Houston | 0.8 mi | ★★★★★ | 1 | 0 |
| West Janisch Health Care Center | 2.1 mi | ★★★★★ | 19 | 4 |
| Highland Park Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Houston Heights Nursing And Rehabilitation Center | 3.7 mi | ★★★★★ | 2 | 0 |
| Avir At Veterans Memorial | 4.7 mi | ★★★★★ | 22 | 3 |
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.