Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Hall during CMS and state inspections, most recent first.
Unsecured Maintenance Room With Hazardous Equipment and Chemicals: A maintenance room near a dining room exit and smoking area was observed propped open and unattended, with no barriers blocking access. The room contained a plugged-in grinder with the blade facing up, a key making machine with an exposed cutting blade, open paint and paint stripper cans, and sharp tools such as a pickaxe and flat head axe. The door remained open or unlocked during repeated observations, and the ED/maintenance leadership stated the room should be kept locked when not in use.
Improper Food Storage and Open Trash Cans in Kitchen: The facility's kitchen had dry goods and delivered food items stored on the floor, food items fallen behind shelving, unlabeled and undated beverages in the refrigerator, and unsealed, unlabeled, undated cheesecake in the freezer. A storage room also contained used latex gloves on the floor and unsealed leftover containers near a mouse trap. Two kitchen trash cans were left without lids while in use, and the Dietary Mgr and CEO/Interim Administrator both identified staff responsibility for maintaining proper food storage and covered trash receptacles.
Inaccurate MDS Anticoagulant Assessment: Two residents had quarterly MDS assessments that documented anticoagulant use in Section N even though record review showed no anticoagulant orders in the facility record and no anticoagulant care plans. One resident had diagnoses including sepsis, dementia, atrial fibrillation, and heart failure, while the other had COPD, dementia, respiratory failure, and metabolic encephalopathy. MDS staff stated the medication review was based on medications received in the last 7 days and believed a recent hospital stay may have explained one resident’s anticoagulant entry.
Failure to care plan nicotine dependence: A resident with intact cognition and diagnoses including post-stroke cognitive impairment and nicotine dependence was identified as a smoker who used a vape, but her care plan did not address smoking status or nicotine dependence. Staff observed her using a vape during smoke breaks, and interviews confirmed she smoked four times daily and that vaping should have been included in the care plan for communication among staff.
A resident admitted after neck surgery with COPD and chronic respiratory failure did not have physician orders properly reviewed at admission, and the hospital discharge instruction for a neurosurgery follow-up was not carried out. Staff interviews showed nurses were expected to review admission paperwork, verify orders, and communicate follow-up appointments, but the resident’s chart and facility calendar did not show the required surgeon follow-up had been arranged. The resident said she expected to see the surgeon weeks after surgery but had not done so and did not know who performed the procedure.
A resident with dementia and severe cognitive impairment, who had a documented history of verbal and physical aggression and an existing behavioral care plan, repeatedly engaged in aggressive acts toward three other cognitively impaired residents. In separate incidents, this resident pulled another resident’s hair in the dining room, scratched a resident’s face causing redness and agitation, and later grabbed a resident by the throat, pulled her hair, and verbally threatened to cut her throat. These episodes of resident-to-resident physical and verbal abuse occurred despite the facility’s abuse-prevention policy and the known behavioral history of the aggressor, and the DON acknowledged that failure to update and communicate care plan interventions after such acute incidents placed residents at risk.
A resident with dementia and severe cognitive impairment had a longstanding behavioral care plan listing general interventions for verbal and physical aggression, but the plan was not revised after three separate aggressive episodes toward three different residents, including hair pulling, scratching another resident’s face causing redness, and grabbing a resident by the throat while making verbal threats. Progress notes by nursing staff documented each incident and the immediate separation and assessment of the involved residents, who showed no documented injuries beyond transient redness and agitation. The care plans for the other involved residents did not reflect new behavioral concerns related to these events. The DON acknowledged that comprehensive care plans are supposed to be updated for acute incidents and that failure to update interventions poses a risk, yet the behavioral care plan for the aggressive resident contained no updates or new interventions following these repeated aggressive behaviors.
A resident with severe cognitive impairment and multiple neurologic and psychiatric diagnoses alleged through another resident that the Maintenance Director exposed himself to her. The allegation was reported up the chain from a CNA to the Social Worker and then to the Administrator, and the investigation was handed off to an Executive Assistant. Despite a written policy requiring immediate notification of the resident’s representative about abuse allegations and ongoing investigation status, the responsible party was not informed on the day the allegation was made and instead learned of it only after the resident called to report that police were present to question her. Staff interviews revealed that the Executive Assistant was new to the investigation process, the appropriate incident documentation template was not initiated, and nursing staff were not directed to notify the family, resulting in a failure to follow the facility’s abuse reporting and notification procedures.
Two residents were subjected to abuse by another resident with a history of aggression and psychiatric diagnoses. One resident had coffee thrown at him, resulting in temporary redness, while another was struck in the face with a closed fist. The aggressive resident repeatedly refused psychotropic medications and psychiatric services, and despite staff interventions and monitoring, the facility failed to prevent these incidents of abuse.
A facility failed to maintain accurate accountability of controlled narcotic drugs for a resident with severe cognitive impairment and cervical cancer. The narcotic count sheet for hydromorphone lacked required nursing staff signatures, and there was a discrepancy between the recorded and actual amounts. Interviews revealed that recent hires and insufficient training contributed to the oversight. The facility's policy requires signatures for administering medications to prevent errors and diversion.
The facility failed to provide Medicare Provider Non-Coverage letters to two residents, leaving them uninformed about their right to appeal coverage decisions. One resident had intact memory and multiple medical conditions, while the other had severe cognitive impairment. The deficiency was due to the absence of the former MDS Coordinator and lack of documentation or proof of notice delivery.
A resident with severe cognitive impairment and cervical cancer was found with a nephrostomy bag incorrectly placed on the bed, contrary to professional standards requiring it to be below the kidney. Staff interviews revealed inconsistent understanding and training regarding proper nephrostomy care, leading to a deficiency in maintaining professional standards and risking infection.
A resident's feeding tube was replaced due to malfunction, but the facility failed to confirm its placement by x-ray before use, leading to the administration of water, medications, and feedings. Despite the facility's policy requiring x-ray confirmation, staff relied on auscultation and residual checks, resulting in a deficiency. The resident had multiple medical conditions and was dependent on the feeding tube for nutrition.
A facility failed to ensure that nurses had the necessary competencies for g-tube replacement and verification, leading to a resident's g-tube being used without proper placement verification. An LVN replaced the g-tube without recent training, and other staff used it before x-ray confirmation, highlighting systemic training deficiencies.
A facility failed to conduct accurate and timely smoking assessments for a resident with nicotine dependence and dementia. The resident's assessments were not completed quarterly, and errors were found in the records, incorrectly identifying the resident as a non-smoker. The Activity Director, responsible for these assessments, acknowledged the mistakes, citing absence due to illness and misunderstanding of the EMR system. This deficiency could risk residents' safety due to lack of appropriate interventions.
A confidentiality breach occurred when a computer on a medication cart was left unlocked and unattended by an RN, displaying residents' medication information. This incident took place on a secured unit, allowing unauthorized access to sensitive information by staff, residents, and visitors. The facility's policy requires computers to be locked when unattended to protect electronic protected health information (e-PHI).
A resident with severe cognitive impairment was moved to a secured unit in a memory care facility without a physician's order, constituting involuntary seclusion. The resident's care plan noted behaviors of trying to leave, but there was no documented evidence of wandering or exit-seeking behaviors. The move was made due to a perceived risk of elopement, despite the resident's limited mobility. The facility's staff failed to obtain the necessary physician order prior to the move.
A medication cart in the secured unit was found unlocked and unattended, posing a risk for unauthorized access. RN E admitted to leaving the cart unlocked while assisting another nurse. The DON, new to the position, was unaware of the incident but confirmed that carts should always be locked when unattended, as per facility policy.
A resident with a history of cerebral infarction and end-stage renal disease was transferred to a hospital without a discharge notice or physician documentation indicating unmet needs at the facility. The resident exhibited aggressive behaviors and refused dialysis, leading to challenges in care. Despite these issues, the facility failed to follow proper discharge procedures, resulting in the resident not being readmitted after hospital treatment.
A resident with severe cognitive impairment and multiple health conditions had a wound on their left great toe that was not identified or treated by the facility staff. Despite the care plan requiring weekly skin assessments, the wound developed osteomyelitis and led to the amputation of the toe. Interviews with staff revealed a lack of awareness of the wound prior to the resident's hospital visit.
A resident with multiple medical conditions received wound care without privacy, as the ADON failed to close the door or curtain. This oversight occurred while several individuals passed by, despite the facility's policy on maintaining resident dignity and privacy.
A facility failed to ensure a resident receiving G-tube feeding was positioned correctly, risking aspiration. The resident was found lying flat while feeding, against care plan instructions. Staff interviews confirmed the need for upright positioning during feeding, as per facility policy.
A medication cart was left unlocked and unattended by an LVN in a hallway, contrary to facility policy requiring all drugs to be stored securely. The LVN admitted to being distracted and forgetting to lock the cart. Interviews with the ADON and DON confirmed that this action violated the facility's policy, which mandates that medication carts must be locked when not in use and when unattended.
A facility failed to maintain an effective infection control program when a CNA did not sanitize or wash her hands and failed to change gloves while providing incontinent care to a resident. The CNA handled supplies and performed perineal care without following proper hand hygiene protocols, as confirmed by interviews with facility staff. The facility's hand hygiene policy, which emphasizes preventing healthcare-associated infections, was not adhered to during this incident.
A facility failed to implement an effective discharge process for a resident with osteomyelitis and pressure ulcers, leading to an improper discharge. The resident was discharged home without the results of a pending appeal and without home health services. The social worker faced challenges in securing placement due to the resident's out-of-network insurance. The facility's discharge policy did not address the appeal process, contributing to the issue.
A resident identified as a fall risk experienced multiple unwitnessed falls due to the facility's failure to implement necessary interventions and provide adequate supervision. Despite a history of repeated falls and being on hospice care, staff did not consistently assess or document the resident's condition following falls, nor did they ensure the use of prescribed fall prevention measures. The facility's oversight failures placed residents at risk of harm.
The facility failed to provide adequate supervision and implement care plan interventions for fall-risk residents, leading to multiple incidents involving two residents. One resident, a 94-year-old male with dementia and mobility issues, sustained injuries from unwitnessed falls due to inconsistent implementation of safety measures. Another resident, a 76-year-old female with cognitive impairment, experienced a fall resulting in head trauma. The facility's failure to oversee care policies and ensure staff followed protocols contributed to these incidents.
A resident with multiple health issues, including a Stage IV sacral pressure ulcer, did not receive adequate wound care for 30 days, leading to hospitalization with sepsis and fluid overload. Facility records showed lapses in documentation and communication, with staff and physicians unaware of the resident's deteriorating condition.
A resident with multiple health issues developed severe pressure ulcers and was not added to the wound care physician's list, resulting in a lack of proper wound care for 30 days. This led to the resident being hospitalized with sepsis and fluid overload, eventually leading to her death.
Unsecured Maintenance Room With Hazardous Equipment and Chemicals
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent accidents for one maintenance room reviewed. The maintenance room, located outside by the smoking area, contained plugged-in power tools, harmful chemicals, and sharp tools, and its door was left propped open and unattended by staff. The room was within about 25 feet of an unlocked, unalarmed dining room exit door and within about 30 feet of the open smoking area, with no barriers blocking access to the door. During observation, an electric grinder with the blade facing upward was plugged into an outlet and sitting on sheetrock near the entry door, and a key making machine with an exposed cutting blade was also plugged in. The room also contained various 5-gallon paint cans, spray paint cans with lids off, paint stripper cans, a pickaxe, and a flat head axe. No residents were observed in the immediate area when the maintenance room was observed open and unattended. The maintenance room door remained propped open at 9:00 AM and was still propped open at 11:00 AM, when the Director of Environmental Services was notified by the state surveyor that it was a potential hazard to residents. Although a staff member was radioed to secure the door, a later observation showed the door opened about 6 inches, unattended, and not secured. The next day, the door was observed closed but unlocked and still easily accessible to residents. The Director of Environmental Services and the Interim Administrator both stated that maintenance staff were responsible for keeping the room secured and that the door should remain locked when staff were not in the room.
Improper Food Storage and Open Trash Cans in Kitchen
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards in its only kitchen. During observation, dry storage contained loose food items on the floor, including potato chips, a cheese puff, multiple delivered boxes of food sitting on the floor, and several food items that had fallen behind a large food shelf. In the walk-in refrigerator, a multi-level rolling tray held approximately 50 beverages that were unlabeled and undated. In the freezer, a tray of 25 slices of cheesecake was unsealed, undated, and unlabeled. In a second storage room used for plasticware and storage containers, a used pair of latex gloves was on the floor and a bag of plastic containers used for leftovers was unsealed near a mouse trap. The kitchen also had two large trash cans that were in use without lids. One trash can was located in the dishwashing area and the other was by the back door. The Dietary Manager stated that a mouse had recently been caught in the room housing the plasticware and plastic containers. The Dietary Manager explained that the beverages were not dated and labeled because they were intended to be used the same day, but she could not identify what the beverages were. She also stated that the cheesecake was not sealed, labeled, or dated because it had been used the previous night and staff did not think to seal, date, or label it. The Dietary Manager said she was primarily responsible for ensuring proper food storage, with dietary aides also responsible for implementation. She stated that food in dry storage should be kept off the floor and that food in the refrigerator and freezer should be sealed, dated, and labeled. She also stated that trash can lids should remain on kitchen trash cans when not in use, and that failure to do so could attract insects and rodents and cause resident food to be infected and make residents sick. The CEO/Interim Administrator stated that the Dietary Manager was responsible for ensuring proper food storage regulations were followed and that trash can lids should be kept on kitchen trash cans whenever they were not in use. The facility's policy required dry foods to be stored at least 6 inches off the floor and refrigerated or frozen foods to be covered, labeled, and dated.
Inaccurate MDS Anticoagulant Assessment
Penalty
Summary
The facility failed to ensure that quarterly MDS assessments accurately reflected the anticoagulant medication status for 2 residents. For Resident #3, the quarterly MDS indicated use of an anticoagulant in Section N, but record review of active and discontinued orders from 01/01/2026 through 04/09/2026 showed no anticoagulant was prescribed. The resident had diagnoses including sepsis, dementia, cognitive communication deficit, atrial fibrillation, and hypertensive heart disease with heart failure. Her medication history showed aspirin 81 mg daily from 04/16/2023 through 02/03/2026, and the care plan dated 02/24/2026 did not include an anticoagulant medication care plan. For Resident #4, the quarterly MDS also documented anticoagulant use in Section N, but record review of active and discontinued orders from 10/05/20265 through 04/09/2026 showed no anticoagulant order. Resident #4’s diagnoses included COPD, non-Alzheimer’s dementia, acute and chronic respiratory failure, and metabolic encephalopathy. Her care plan dated 04/01/2026 did not include a care plan for an anticoagulant medication. During interview, Resident #4 stated she was not receiving an anticoagulant and denied awareness of any history of blood thinners, stroke, atrial fibrillation, or blood clots. During interview, the MDS coordinators stated that the medication review for the quarterly MDS was completed by looking at medications given in the last 7 days. One coordinator said Resident #3 had recently been in the hospital and likely received heparin there, which he believed explained the anticoagulant selection on the MDS. He also stated aspirin would not be considered an anticoagulant under the MDS assessment. The other coordinator stated that medications given in the hospital during the 7-day period could be claimed on the MDS, while also noting that Section N referred to medications within the last 7 days and did not specify medications taken only in the facility. The CEO/Interim Administrator stated the facility used the RAI manual for guidance when completing MDS assessments and that accurate MDS assessments were important.
Failure to Care Plan Nicotine Dependence
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #11 that addressed nicotine dependence and smoking status, with measurable objectives and timeframes. Resident #11 was a [AGE]-year-old female with diagnoses including attention and concentration deficit following cerebral infarction, cognitive communication deficit, need for assistance with personal care, contracture of the right hand, muscle weakness, and nicotine dependence. Her admission MDS dated [DATE] showed a BIMs score of 15, indicating intact cognitive ability. A smoking assessment dated 02/28/2026 identified her as a smoker who used a vape and determined she was a safe smoker, but her care plan dated 04/07/2026 did not include nicotine dependence or smoking status. Observations on 04/07/2026 and 04/08/2026 showed Resident #11 using an electronic vape during smoke breaks. During interview, she stated she smoked using a vape, went on smoke breaks four times a day, had no issues with it, and staff provided her with the vape for smoke breaks. The interim DON stated that whether Resident #11 was considered nicotine dependent or a smoker, it should have been included in her care plan, and that nicotine inhalation needed to be care planned because of how it could affect a medical diagnosis. The Activities Director stated the care plan should include that she vaped and that vaping had to be considered smoking. RN A stated care plans were important so staff knew what care to provide and that without them there would be a lack of communication between nursing shifts.
Failure to Follow Admission Orders and Surgical Follow-Up Instructions
Penalty
Summary
The facility failed to ensure that Resident #12 had physician orders in place for immediate care at the time of admission and failed to follow the hospital discharge instructions for a neurology surgeon follow-up. Resident #12 was admitted with a primary diagnosis of fracture of the neck, along with COPD, chronic respiratory failure with hypoxia, difficulty walking, and cognitive communication deficit. Progress notes stated she had fallen at home, underwent surgery on 1/19/2026, developed respiratory insufficiency after surgery, and continued to require skilled nursing services for neurological monitoring, respiratory assessment, pain management, and reinforcement of neck precautions. Hospital discharge instructions dated 1/27/2026 stated that the patient was okay to be discharged from a neurosurgery standpoint and was to be seen in neurosurgery clinic in 4 weeks for further evaluation and recommendation. During an observation and interview, Resident #12 said she wanted to see her doctor for her neck surgery, stated she had 4 screws placed, and said she was supposed to see the surgeon a couple weeks after surgery but it had been a couple months since the surgery. She also said she did not know who the surgeon was who performed the procedure. At the time of observation, she was sitting upright in bed and did not appear to be in distress or pain. During interviews, LVN B said admitting nurses were expected to review diagnoses, diets, orders, allergies, and progress notes, and to review orders and send them to the DON and doctor for approval. He said staff were also supposed to communicate follow-up appointments, notify transportation, and inform the family. The interim DON said nurses were expected to review new admissions' paperwork, input medically necessary items, review medication and admission orders, and communicate follow-up appointments and transportation. She reviewed Resident #12's record and the facility calendar and said she could not find a follow-up appointment for the resident. RN C said she reviewed the resident's paperwork at admission but could not recall a hospital follow-up appointment, and the MD said he had just heard a staff member making a follow-up appointment for Resident #12 and did not know how it had not already been in place.
Failure to Prevent Repeated Resident-to-Resident Abuse by a Behaviorally Symptomatic Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse by another resident with known behavioral symptoms. Resident #1, an elderly female with dementia, generalized anxiety disorder, and severe cognitive impairment (BIMS score of 0), had an active care plan identifying behavioral symptoms including verbal and physical aggression and calling 911. Her care plan included various behavioral interventions such as removal from group activities when behavior was unacceptable, moving her to a quiet environment when verbally abusive, avoiding power struggles, avoiding overstimulation, and assessing whether her behavior endangered herself or others. Despite these identified behavioral issues and interventions, Resident #1 engaged in multiple aggressive acts toward other residents. On 03/01/26, Resident #1 was involved in an incident with Resident #2, an elderly female with Alzheimer’s disease, severe cognitive impairment (BIMS score of 0), and a care plan that identified behavioral symptoms including physical aggression and sexually inappropriate behaviors. According to a progress note by RN A, a CNA/Medication Aide reported that Resident #2 was walking in front of Resident #1 in the dining room when Resident #1 suddenly stood up, ran toward Resident #2, and pulled her hair. RN A heard Resident #2 screaming loudly and believed the scream sounded like it was due to pain from having her hair pulled. Staff separated the residents, and a head-to-toe assessment revealed no injuries, bruises, or need for treatment, but the event constituted resident-to-resident physical aggression. On 03/05/26, Resident #1 engaged in another aggressive incident, this time with Resident #3, an elderly female with dementia, bipolar disorder, generalized anxiety disorder, severe cognitive impairment (BIMS score of 0), and a history of aggression noted in her care plan. LVN B reported observing Resident #1 yelling at Resident #3 and, before she could reach them, witnessing Resident #1 scratch Resident #3’s face with her fingernails. Resident #3 was noted to have red marks on her face without skin break, and she was angry and agitated for about forty minutes following the incident. On 03/10/26, Resident #1 again acted aggressively toward Resident #4, an elderly female with Alzheimer’s disease, epilepsy, mood disorder, and an admission MDS showing no mood or behavioral symptoms. LVN B reported that Resident #1, without provocation, grabbed Resident #4 by the throat, pulled her hair, and verbally threatened her, telling her to stop looking at her and threatening to cut her throat. Resident #4’s breathing was not restricted and no injuries were observed, but the incident involved physical and verbal aggression. These repeated episodes of resident-to-resident abuse occurred despite Resident #1’s known behavioral history and existing care plan, and the DON acknowledged that failing to update interventions in Resident #1’s care plan after such acute incidents would be a risk because the care plan is the means to communicate necessary interventions to all caregivers. The facility’s own policy titled “Abuse, Neglect, Exploitation and Misappropriation Prevention Program” stated that residents have the right to be free from abuse and included an objective to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including other residents. Nevertheless, Resident #1 was able to pull Resident #2’s hair, scratch Resident #3’s face, and grab Resident #4 by the throat and pull her hair while verbally threatening her. Staff interviews confirmed that these events occurred and that Resident #1’s behavior was described as random and unpredictable. The DON stated she had not been aware of at least one of the aggressive incidents at the time of interview and indicated that the comprehensive care plan is supposed to be updated for acute incidents. The combination of Resident #1’s known aggressive behaviors, the occurrence of multiple aggressive episodes toward other residents, and the lack of timely, effective care plan updates and interventions to prevent further abuse formed the basis of the deficiency under the facility’s obligation to protect residents from abuse by anyone, including other residents.
Failure to Revise Behavioral Care Plan After Repeated Resident Aggression
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with dementia and severe cognitive impairment who exhibited repeated aggressive behaviors toward other residents. Resident #1, an elderly female with diagnoses including dementia, generalized anxiety disorder, diabetes mellitus, and hyperlipidemia, had an admission MDS that did not reflect mood or behavioral symptoms other than often feeling lonely or isolated, and a BIMS score of zero indicating severe cognitive impairment. Her active care plan, with a behavioral symptoms problem initiated months earlier, listed interventions such as reminding her not to call 911, praising appropriate behavior, removing her from group activities when behavior was unacceptable, moving her to a quiet environment when verbally abusive, administering medications as ordered, assessing whether behavior endangered herself or others, avoiding power struggles and overstimulation, obtaining psychiatric consults, and offering preferred music when upset. However, this care plan contained no updates or revisions to address new or escalating aggression following three specific aggressive incidents on 03/01/26, 03/05/26, and 03/10/26. On 03/01/26, a progress note by RN A documented that Resident #1 suddenly stood up in the dining room, ran toward Resident #2, and pulled her hair while Resident #2 was walking in front of her. Staff separated the residents, and head-to-toe assessments revealed no injuries, though Resident #2 screamed loudly in what staff believed was pain from having her hair pulled. On 03/05/26, a progress note by LVN B recorded that Resident #1 was observed yelling at Resident #3; before LVN B could reach them, she witnessed Resident #1 scratch Resident #3’s face, resulting in redness without skin break. Resident #3 was angry and agitated for about forty minutes following the incident, and the redness remained for about 24 hours. On 03/10/26, a progress note by RN B described Resident #1, without provocation, grabbing Resident #4 by the throat, pulling her hair, and verbally threatening her with profane language. The residents were separated, and no injuries were documented for Resident #4. These three episodes of aggression toward different residents occurred despite an existing behavioral care plan, and there is no indication in the care plan that it was revised or expanded to address these specific behaviors or patterns. Additional record reviews and interviews confirmed that the care plans for the other involved residents did not identify new behavioral symptoms related to these incidents. Resident #2’s care plan listed behavioral symptoms including physical aggression and sexually inappropriate behaviors, with the last behavior dated months earlier, and did not reflect new issues arising from being the target of hair pulling. Resident #3’s care plan noted a history of aggression with the last incident dated 10/24/25, and Resident #4’s care plan identified wandering but no verbal or physical aggression or other behavioral symptoms. Observations on 03/24/26 showed Residents #2, #3, and #4 without obvious signs of abuse, neglect, bruises, or injuries, and family interviews for Residents #2 and #4 indicated no observed trauma or behavioral changes after the incidents. The DON, interviewed on 03/24/26, stated that the comprehensive care plan is updated by herself and assistant directors of nursing for acute incidents and acknowledged that failing to update interventions in Resident #1’s care plan would be a risk because the care plan is a way to communicate the plan of care to anyone providing care. Despite this, the documentation showed no revisions to Resident #1’s behavioral care plan after the three aggressive episodes, constituting the cited failure to develop and implement a comprehensive person-centered care plan consistent with resident rights and identified needs.
Failure to Notify Resident Representative of Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its own written abuse investigation and reporting policy by not immediately notifying a resident’s responsible party of an allegation of sexual abuse. The facility’s policy, revised July 2017, required the Administrator to keep the resident and representative informed of the progress and status of any abuse investigation and to report all alleged violations of abuse, neglect, exploitation, or mistreatment to the resident’s representative. An allegation was made that the Maintenance Director had exposed himself to a resident, and this information was relayed through another resident to a CNA, then to the Social Worker, and then to the Administrator. Despite this, the resident’s responsible party was not notified on the day the allegation was reported. The resident involved was an elderly female with diagnoses including unspecified dementia, Alzheimer’s disease, chronic pain, depression, and sequelae of cerebral infarction. Her MDS showed a BIMS score of 3, indicating severe cognitive deficits, and documented that her preferred language was Spanish and that she required an interpreter for communication with healthcare staff. She required partial or moderate assistance with several ADLs, including toileting, bathing, dressing, transfers, and walking short distances, and had a history of refusing incontinence care and showers. Her care plans also noted mild depression and a preference for in-room, self-led activities, including Spanish-language media. According to interviews and record review, the allegation that the Maintenance Director exposed himself to the resident originated when the resident reportedly told another resident, who then informed a CNA. The CNA reported it to the Social Worker, who reported it to the Administrator. The Administrator, who is married to the Maintenance Director, left the facility after learning of the allegation and handed the investigation over to the Executive Assistant. The Executive Assistant acknowledged that she did not notify the resident’s responsible party on the day the allegation was made and stated that she was new to the investigation process. Nursing staff who learned of the allegation later that day attempted to assess the resident, but the resident refused assessment and denied that anything had happened; the nurse was not instructed to notify the family and did not know whether they had been notified. The resident’s responsible party later reported that she first learned of the allegation when the resident called her and said that the police were at the facility trying to speak with her about the allegation, and that the resident did not want to talk to them. The responsible party stated that facility staff routinely called her for relatively minor issues, such as the resident refusing showers, but no one contacted her about the abuse allegation. The Executive Assistant later confirmed that she met with the responsible party after the police involvement but had not contacted her on the day the allegation was reported. The Administrator also acknowledged that, in the usual process, the family would be notified immediately as part of completing the incident documentation, but that this did not occur because the appropriate incident template was not opened and the nursing portion of the investigation was not followed through. As a result, the facility did not implement its own abuse and neglect prevention policy regarding timely notification of the resident’s representative.
Failure to Prevent Resident-to-Resident Abuse Due to Ongoing Aggressive Behaviors
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving aggressive behavior by one resident towards others. In the first incident, a male resident with a history of physically and verbally aggressive behaviors, moderate cognitive impairment, and multiple psychiatric diagnoses, threw coffee at another male resident, resulting in redness to the face and chest. The nursing assessment completed the same day found no injury or changes in the skin assessment from baseline. The aggressive resident had a documented pattern of agitation and aggression, with care plan interventions in place, but continued to exhibit behaviors such as hitting, throwing objects, and verbal outbursts. In the second incident, the same aggressive resident struck another male resident on the left side of the face/jaw with a closed fist during an activity. The resident who was struck had a history of traumatic subdural hemorrhage, dementia, and unsteadiness on his feet, and was noted to be rarely or never understood. The nurse assessed no injuries following the incident. The aggressive resident had a care plan that included interventions for behavioral symptoms, but he consistently refused his prescribed psychotropic medications and psychiatric services, and his aggressive behaviors persisted despite staff attempts at redirection, monitoring, and environmental modifications. Staff interviews and record reviews revealed that the aggressive resident had a long-standing pattern of combative and disruptive behaviors, including multiple episodes of aggression towards both staff and other residents. Despite frequent monitoring, care plan updates, and attempts to accommodate his preferences and needs, the facility was unable to prevent further incidents of resident-to-resident abuse. The aggressive resident's refusal of medication and psychiatric intervention, combined with his independence and quick actions, contributed to the facility's inability to ensure the safety and protection of other residents from abuse.
Inadequate Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in maintaining accurate accountability of controlled narcotic drugs for a resident with severe cognitive impairment and a primary diagnosis of cervical cancer. The narcotic count sheet for hydromorphone, a Schedule II controlled substance, lacked required nursing staff signatures from a specific period, and there was a discrepancy between the recorded remaining amount and the actual amount in the bottle. This inconsistency was identified during an observation and interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). Interviews with nursing staff revealed that the lack of signatures was due to recent hires and insufficient training. The DON, who had been at the facility for two weeks, acknowledged the oversight in training and management. The facility's Controlled Substances policy requires signatures for administering medications and reconciling controlled substances to prevent loss or diversion. The absence of signatures and discrepancies in narcotic counts could lead to medication errors, including potential overdoses or diversion of narcotic medications.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide Medicare Provider Non-Coverage letters (CMS 10123 or CMS 10055) to two residents, which included information about their right to appeal. This deficiency was identified through interviews and record reviews, revealing that the facility did not ensure the delivery and receipt of these important notices. The absence of these notifications could potentially leave residents uninformed about their rights regarding Medicare coverage and their ability to appeal decisions. Resident #71, a female with a BIMS score indicating intact memory, was admitted to the facility and discharged from skilled services without receiving the required notice. Her medical conditions included unspecified cirrhosis of the liver, chronic respiratory failure with hypercapnia, and end-stage renal disease. Similarly, Resident #95, a male with a severely impaired cognitive status, was also discharged from skilled services without receiving the necessary notification. His diagnoses included hypertensive urgency, unspecified encephalopathy, and dementia. Interviews with facility staff revealed that the former MDS Coordinator, responsible for completing the NOMNCs, had left the facility, and the Admission Coordinator could not locate the completed forms or proof of their delivery. The facility's failure to provide these notices was confirmed by the absence of documentation and evidence of delivery, as required by Medicare guidelines. This oversight highlights a significant lapse in ensuring residents are informed of changes in their Medicare coverage and their rights to appeal.
Improper Nephrostomy Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate nephrostomy care for a resident, leading to a deficiency in maintaining professional standards of practice. Resident #350, a female with severe cognitive impairment and a primary diagnosis of cervical cancer, was observed with a nephrostomy bag placed incorrectly on the bed near her shoulder, rather than below the kidney as required. This improper placement was noted during an observation and interview, where the resident confirmed the presence of a nephrostomy tube. The facility's policy and professional standards dictate that the nephrostomy bag should be positioned below the kidney to ensure proper drainage and prevent infection. Interviews with facility staff revealed a lack of consistent understanding and training regarding the correct positioning of nephrostomy bags. LVN A was unsure of the consequences of incorrect bag placement, while CNA G had been misinformed to keep the bag above the kidney. RN F and the DON both acknowledged the importance of keeping the bag below the kidney to prevent infection and ensure proper drainage. The facility's policy, last revised in October 2010, also emphasized the need for the drainage bag to be below the kidney level. The Administrator confirmed the necessity of proper bag placement for effective urine flow, highlighting a gap in staff training and adherence to established care protocols.
Failure to Confirm Feeding Tube Placement Before Use
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received appropriate treatment and services. Specifically, the facility did not confirm the placement of a newly inserted feeding tube by x-ray before administering water, medications, and bolus feedings. This oversight involved a resident with multiple medical conditions, including acute respiratory failure, critical illness myopathy, and dementia, who was dependent on a feeding tube for nutrition. The resident's feeding tube was replaced by an LVN due to leakage and malfunction. Although the LVN obtained a verbal order from the physician to replace the tube and requested an x-ray to confirm placement, the x-ray was not completed before the tube was used. The LVN and other staff members, including an RN, proceeded to use the feeding tube based on auscultation and residual checks, despite the facility's policy requiring x-ray confirmation of tube placement before use. Interviews with facility staff revealed a lack of clear communication and understanding of the policy regarding feeding tube placement verification. The DON and ADON were not aware of the tube replacement until after it occurred, and there was confusion among staff about whether it was permissible to use the tube before x-ray confirmation. The physician indicated that while x-ray confirmation was not always necessary for mature stomas, the facility's policy required it, and the failure to adhere to this policy led to the deficiency.
Inadequate G-Tube Competency and Training
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to replace a g-tube and to follow g-tube verification of placement procedures. This deficiency was identified in the case of a resident who had a g-tube replaced by an LVN without having completed a competency validation course. The LVN had not received recent training or competency check-offs for g-tube replacement, relying instead on outdated training from another facility. The LVN replaced the g-tube based on a physician's verbal order but without the necessary verification of placement through an x-ray before use. Additionally, the facility did not provide adequate training for other nursing staff, including an RN and another LVN, regarding the safe use of a g-tube for feeding and medication administration. These staff members used the g-tube before its placement was verified via x-ray, relying on residual checks instead. The RN involved had not been checked off for competency in g-tube management and was new to the facility, indicating a lack of proper orientation and training. Interviews with facility staff, including the DON and ADON, revealed a lack of awareness and adherence to facility policies regarding g-tube management. The DON acknowledged the potential risks of using a g-tube without verified placement and expressed concern over the lack of communication and training among the nursing staff. The facility did not have documentation of training or competencies for g-tube management, highlighting systemic issues in ensuring staff are adequately trained and competent in critical nursing procedures.
Inaccurate Smoking Assessments for Resident
Penalty
Summary
The facility failed to ensure complete and accurate smoking assessments for Resident #26, who was one of two residents reviewed for smoking assessments. The deficiency was identified through observation, interview, and record review. Resident #26's smoking assessments were not conducted quarterly as required, and the assessments that were completed contained inaccuracies. This failure could potentially place residents who smoke at risk due to inaccurate information, leading to a lack of appropriate safety interventions. Resident #26, a male resident with a history of nicotine dependence, dementia, and epilepsy, was admitted to the facility with a care plan indicating he was a smoker at risk for injury. The care plan included goals and interventions to assist and supervise him during smoking activities. However, discrepancies were found in his smoking risk assessments. The assessment completed on 03/13/24 indicated he was a safe smoker, but subsequent assessments on 06/14/24 and 01/22/25 incorrectly noted him as a non-smoker, with no information about his smoking capability or behaviors. Interviews with the Activity Director revealed that she was responsible for conducting smoking assessments and arranging smoke breaks. She admitted to errors in Resident #26's assessments, attributing them to her absence due to illness and a lack of understanding of the electronic medical record system. The facility's policy required smoking assessments to be conducted quarterly and upon significant changes, but these were not consistently followed, leading to the deficiency.
Confidentiality Breach Due to Unattended Computer
Penalty
Summary
The facility failed to protect the confidentiality of residents' personal and medical records, as observed during a survey. Specifically, a computer on a medication cart was left unlocked and unattended by RN E, displaying residents' medication information. This incident occurred on the secured unit, with the computer facing the hallway, allowing unauthorized access to sensitive information by other staff, residents, and visitors passing by. RN E acknowledged the oversight, admitting that he left the computer unlocked while assisting another nurse. The Director of Nursing (DON), who had been in the position for only four days, was unaware of the incident until informed. The facility's policy on safeguarding electronic protected health information (e-PHI) mandates that computers be locked when unattended to prevent unauthorized access. The policy emphasizes the importance of maintaining the confidentiality, integrity, and availability of e-PHI. The incident highlights a lapse in adherence to this policy, as the computer was not secured, potentially compromising residents' privacy and dignity.
Resident Moved to Secured Unit Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident in the locked memory care unit was free from involuntary seclusion. The resident, a female with severe cognitive impairment and multiple diagnoses including unspecified dementia with behavioral disturbance and schizoaffective disorder, was moved to a secured unit without a physician's order. The resident's care plan indicated behaviors of trying to leave the facility, but there was no documented evidence of wandering or exit-seeking behaviors prior to the move. The resident's move to the secured unit occurred on 11/21/24, but the physician order for the secured unit was not placed until 01/12/25. Interviews with facility staff revealed that the move was made due to a perceived risk of elopement, although the resident was not ambulatory and unable to propel herself in her wheelchair. The resident's primary care physician stated that he did not recall giving an order for the move and was not aware of any wandering or elopement attempts. The facility's social worker and ADON were involved in the process, with the social worker responsible for notifying the family and documenting the move, and the ADON placing the order in the system after reconciling physician orders. However, there was a lack of communication and documentation regarding the necessity and authorization for the resident's move to the secured unit, leading to the deficiency of involuntary seclusion.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were stored securely in a locked compartment, as observed with one of the four medication carts reviewed. Specifically, the Secured Unit medication cart was found unlocked and unattended near a resident's room. RN E, who was responsible for the cart, admitted to leaving it unlocked while assisting another nurse, which could have allowed unauthorized access to medications by residents, staff, or visitors. During interviews, RN E acknowledged the oversight and the potential risk it posed. The Director of Nursing (DON), who had been in the position for only four days, was unaware of the incident but confirmed that medication carts should always be locked when unattended. The facility's policy, revised in April 2007, clearly states that medication carts must be locked at all times when not in use or out of the nurse's view, to prevent unauthorized access.
Improper Discharge of Resident Without Adequate Documentation
Penalty
Summary
The facility failed to adhere to proper discharge protocols for a resident, leading to a deficiency in care. The resident, a female with a history of cerebral infarction, end-stage renal disease, and mood disorder, was transferred to a hospital without being provided a discharge notice. The facility did not document any physician's indication that the resident's needs could not be met at the facility, which is a requirement for discharge. This lack of documentation and communication resulted in the resident not being readmitted to the facility after hospital treatment. The resident exhibited aggressive behaviors, including refusal of dialysis and medication, yelling, and threatening staff, which were documented in her care plan. Despite these challenges, the facility's policy required that a discharge notice be given, and a physician's documentation was necessary to justify the discharge. The facility's failure to provide these documents and follow the proper procedure for discharge placed the resident at risk of unnecessary transfer and unmet needs. Interviews with facility staff, including the Social Worker and Administrator, revealed that the resident was non-compliant with care and exhibited behaviors that were challenging for the staff to manage. The Administrator admitted to instructing the hospital not to return the resident, indicating a lack of adherence to the facility's policy on resident discharge. The facility's policy clearly states that residents sent to acute care settings are expected to return unless a formal discharge process is followed, which was not done in this case.
Failure to Identify and Treat Wound Leads to Amputation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for a resident reviewed for quality of care. The facility did not identify and treat a wound on the resident's left great toe before the resident was sent to a local hospital, where the wound was found to have developed osteomyelitis. This led to the amputation of the resident's left great toe. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was admitted to the facility with multiple diagnoses, including cerebrovascular disease, end-stage renal disease, essential hypertension, and type 2 diabetes mellitus. Despite the resident's care plan indicating the need for weekly skin assessments and monitoring for changes, the facility's records showed that the resident's skin was documented as clear and free of problems. However, upon hospital admission, the resident was found to have a chronic necrotic ulcer on the left great toe, which was not previously identified by the facility staff. Interviews with facility staff, including CNAs and nurses, revealed that none of them recalled noticing any skin integrity issues or wounds on the resident's left foot prior to the hospital visit. The facility's wound care nurse and the IDON were also unaware of any issues with the resident's left great toe before the amputation. The resident himself stated that he had informed the facility staff about the wound on his toe, but could not remember specific details. The lack of proper identification and treatment of the wound by the facility staff led to a delay in necessary care, resulting in the resident's toe amputation.
Privacy Violation During Wound Care
Penalty
Summary
The facility failed to protect the personal privacy rights of a resident during medical treatment. Specifically, during wound care for a resident with multiple medical conditions, including encephalopathy, pressure ulcer, type 2 diabetes mellitus, peripheral vascular disease, and end-stage renal disease, the Assistant Director of Nursing (ADON) did not ensure privacy. The resident, who had a moderate cognitive impairment and required substantial assistance with activities of daily living, received wound care without the door or curtain being closed. This lack of privacy occurred while several staff members, residents, and visitors passed by the open door. The ADON acknowledged the oversight, stating that she normally would have closed the door or pulled the curtain to provide privacy. The resident expressed indifference to the door being open, as long as his foot was checked as needed. However, the facility's policy on dignity, which emphasizes treating residents with respect and maintaining their privacy during care, was not followed. The incident was reported to the Interim Director of Nursing (IDON) and the Administrator, who both confirmed the expectation of privacy during care.
Improper Positioning During G-Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding through a G-tube was positioned correctly to prevent complications such as aspiration. On the date of observation, the resident was found lying flat sideways in bed while the G-tube feeding was running, contrary to the care plan and physician's orders which required the head of the bed to be elevated. This improper positioning was observed by a Licensed Vocational Nurse (LVN) who was not informed of the correct positioning requirements for the resident. Interviews with facility staff, including another LVN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that residents with G-tubes should be in an upright position during feeding to prevent aspiration. The staff acknowledged that the resident frequently repositioned himself, necessitating more frequent checks to ensure proper positioning. The facility's policy also required residents to be positioned in a semi-Fowler's or higher position during feeding, which was not adhered to in this instance.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, LVN B was found to have left a medication cart unlocked and unattended in the hallway of Station 100. LVN B walked away from the cart to attend to a resident without securing it, leaving it unattended for two minutes. When questioned, LVN B admitted to being distracted and forgetting to lock the cart but refused to discuss the potential consequences of this action. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's policy mandates that medication carts must be locked when not in use and when unattended. Both the ADON and DON expressed that leaving medications unsecured could allow unauthorized access, potentially leading to harm if medications were ingested by residents not prescribed those medications. The facility's policy on medication labeling and storage, as well as the security of medication carts, clearly states that all medications must be stored in locked compartments and that medication carts must be locked when out of the nurse's view.
Infection Control Lapse During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during the provision of incontinent care for Resident #1. CNA A did not sanitize or wash her hands and failed to change gloves appropriately while providing care. Specifically, CNA A donned double gloves without sanitizing her hands, handled various supplies, and performed perineal care without changing gloves or sanitizing her hands between tasks. This lapse in protocol was observed during an incident where CNA A provided care to a resident who was always incontinent of bowel and urine and required total assistance with personal hygiene due to physical and cognitive impairments. Interviews with facility staff, including CNA A, LVN C, the ADON, and the DON, confirmed that the facility's expectations and policies regarding hand hygiene and glove use were not followed. CNA A acknowledged the failure to change gloves and sanitize hands, recognizing the risk of infection to residents. The facility's policy on hand hygiene, which emphasizes its importance in preventing healthcare-associated infections, was not adhered to during the incident. The policy outlines specific instances when hand hygiene is required, including before and after resident contact and after glove removal, which were not observed in this case.
Improper Discharge Due to Ineffective Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge process for a resident, leading to an improper discharge. The resident, a cognitively intact male with osteomyelitis and pressure ulcers, was admitted to the facility with plans to discharge to the community. However, the care plan did not address discharge planning. The resident was given a notice of Medicare non-coverage, although he did not have Medicare, and was informed that skilled services would end. Despite an appeal being completed, the resident was discharged home without the results of the appeal and without home health services. Interviews revealed that the social worker attempted to find a nursing home and set up durable medical equipment (DME) for the resident, but faced issues due to the resident's insurance being out of network. The resident's family was offered the option to pay for respite care, which they declined. The administrator stated that the resident was discharged after staying a week past the last coverage date, as the facility could not secure placement due to insurance issues. The facility's policy on discharge and transfer did not discuss the appeal process, contributing to the improper discharge.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide resident-centered care and services according to the residents' preferences, goals, and professional standards of practice, which resulted in unmet physical, mental, and psychosocial needs for two residents. Specifically, a resident identified as a fall risk experienced multiple unwitnessed falls, including incidents in the dining room and from a wheelchair. Despite being identified as a fall risk, the facility did not implement necessary interventions such as frequent observation and supervision when the resident was out of bed. The resident had a history of repeated falls and was admitted to hospice care with diagnoses including dementia, anxiety, and unsteadiness on feet. The facility's staff, including LVNs and CNAs, failed to assess, evaluate, and document necessary care following the resident's falls. On several occasions, the resident fell without immediate staff intervention or proper assessment of injuries, such as vital signs and range of motion checks. Video surveillance revealed that staff were not in a position to prevent or respond promptly to the falls, and interventions like Dycem mats were not consistently used. The resident's care plan included interventions to prevent falls, but these were not effectively implemented or monitored. Additionally, the facility did not ensure protection from harm during abuse or neglect investigations. The resident experienced a significant head injury from a fall, which was not promptly addressed by the facility's staff. Communication with the resident's primary care physician and hospice services was delayed, and necessary medical evaluations, such as a skull x-ray, were not immediately ordered. The facility's failure to oversee and implement resident care policies placed residents at risk of serious injury or harm.
Inadequate Supervision and Care Plan Implementation for Fall-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of assistive devices for residents identified as fall risks, leading to multiple incidents involving two residents. One resident, a 94-year-old male with a history of repeated falls, dementia, and other mobility issues, sustained several injuries, including skin tears and head trauma from unwitnessed falls. Despite being identified as a fall risk, the resident's care plan interventions, such as keeping the bed in the lowest position and using a Dycem mat in the wheelchair, were not consistently implemented. Video surveillance revealed that the resident was often left unsupervised or inadequately supervised, contributing to the falls. Another resident, a 76-year-old female with severe cognitive impairment and a history of repeated falls, also experienced an unwitnessed fall resulting in head trauma and a laceration. The facility's failure to oversee the implementation of resident care policies was evident when staff did not assess, evaluate, or document the necessary follow-up after the falls. For instance, a Licensed Vocational Nurse (LVN) did not assess vital signs or initiate an investigation after the incidents, contrary to the facility's policies. The facility's deficient practices placed residents at significant risk of serious injury or harm. The lack of adequate supervision and failure to implement effective care plan interventions for residents identified as fall risks were critical factors leading to these incidents. The facility's inability to ensure that staff followed established protocols for assessing and responding to falls further exacerbated the situation, highlighting a pattern of non-compliance with safety standards.
Neglect in Wound Care Management
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, specifically in the context of wound care management. The resident, an elderly female with a history of hypertension, chronic respiratory failure, dysphagia, and end-stage renal disease, had a Stage IV sacral pressure ulcer, a skin tear on the right knee, and a pressure ulcer on the left foot. Despite these conditions, the facility did not provide adequate wound care monitored by a physician for 30 days. This neglect led to the resident being sent to the hospital with symptoms of lethargy, disorientation, anorexia, and hypotension, where she was admitted to the ICU as septic with fluid overload and shortness of breath. The facility's records revealed multiple lapses in wound care documentation and management. The resident's electronic medical records showed a history of pressure ulcers and skin tears, but there were significant gaps in weekly documented skin checks from early February to early March. Physician orders for wound care were not administered as required, and the resident's condition deteriorated without appropriate medical intervention. Interviews with facility staff, including the ADON and the contracted wound care physician, highlighted issues in communication and documentation, with the wound care physician not being aware of the resident's condition due to her not being included in the rounding list. The resident's primary care physician was also unaware of her wounds, and the responsible party reported that the resident had been in excruciating pain for a month without adequate care. The facility's ADON acknowledged the documentation issues and stated that efforts were being made to improve communication and documentation practices. However, these deficiencies in wound care management and communication placed the resident at significant risk and resulted in actual harm, as evidenced by her critical condition upon hospital admission.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care according to professional standards to prevent and manage pressure ulcers. The resident, who had a history of hypertension, chronic respiratory failure, dysphagia, and end-stage renal disease, developed a Stage IV sacral pressure ulcer, a skin tear on the right knee, and a pressure ulcer on the left foot. Despite having wound care orders in place, the facility did not add the resident to the wound care physician's list, resulting in a lack of physician-monitored wound care for 30 days. This lapse in care led to the resident being sent to the hospital with symptoms of lethargy, disorientation, anorexia, and hypotension, where she was diagnosed with sepsis and fluid overload and subsequently admitted to the ICU. The resident continued to decline and was eventually discharged to hospice care, where she expired shortly after. Interviews with facility staff revealed that the wound care orders were not properly followed, and the resident was not referred to the wound care physician as required. The facility's ADONs and other staff members acknowledged the oversight and the failure to ensure the resident received timely and appropriate wound care. The facility's failure to provide adequate wound care and monitoring placed the resident at significant risk and contributed to her decline in health.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,451 citations issued within 25 miles in the last 12 months — including the 64 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Irving
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Irving | 1.1 mi | ★★★★★ | 10 | 0 |
| The Villages On Macarthur | 1.4 mi | ★★★★★ | 1 | 0 |
| Avante Rehabilitation Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Northgate Plaza | 2.1 mi | ★★★★★ | 16 | 0 |
| Las Brisas Rehabilitation And Wellness Center | 3.6 mi | ★★★★★ | 4 | 0 |
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.