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 Barton Valley Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to provide resident-centered activity programs: Four fully dependent residents with severe cognitive and physical impairments had documented preferences for music, sensory stimulation, religious activities, outdoor time, and one-on-one visits, but activity records and repeated observations showed little to no participation and no meaningful in-room engagement. Staff reported relying on CNAs to get residents out of bed, noted there was no backup plan when the AA could not assist, and acknowledged that one-on-one visits were not being used thoroughly.
Missing Dialysis Care Plan Interventions: A resident with ESRD and HTN was admitted with ongoing hemodialysis needs, but the baseline/comprehensive care plan did not include nursing interventions or a dialysis focus. The plan only addressed dietary needs, even though the resident attended HD three times weekly and staff acknowledged the care plan should have included the dialysis diagnosis and related nursing input.
Failure to provide nail care for two residents: one resident with dementia and another resident with multiple cognitive and physical impairments were both observed with long, jagged, and dirty fingernails. Their care plans directed staff to check, clean, and trim nails on bath day and as needed, but the POC system had no nail care task documented for either resident. Both residents stated staff had not offered or completed nail trimming, and the DON stated nail care should have been offered with baths and documented when offered.
Fall mats were not kept beside the bed for two residents on fall precautions. One resident with MS, DM2, COPD, malnutrition, and intact cognition had a care plan calling for a fall mat beside the bed, but staff observed the mat folded up at the foot of the bed on multiple occasions. Another resident with DM2, COPD, muscle wasting, osteomyelitis, and severe cognitive impairment also had a care plan for a fall mat beside the bed, but the mat was observed on the other side of the room away from the bed. Staff, including an LPN, CNA, DON, and ADM, stated the mat should be placed next to the bed when the resident is in bed.
A resident with a G-tube, dysphagia, aphasia, and severe cognitive impairment received meds and Glucerna through a syringe by an RN who did not verify tube placement or flush between meds. The RN crushed and mixed multiple meds, pushed them through the syringe with the plunger instead of gravity, and wiggled the syringe side to side and in circles while administering the tube feeding. The DON, ADON, and facility policy all described checking placement, checking residual, giving each med separately, and flushing between meds.
Missing physician order for scheduled hemodialysis: A resident with ESRD and HTN was dependent on hemodialysis three times weekly, but the EMR initially lacked a physician order for the M-W-F dialysis schedule. The care plan and progress notes documented the resident's dialysis dependence, and the resident stated she attended dialysis every M-W-F, while the NP and DON acknowledged the order had not been entered when the resident was admitted.
A resident receiving scheduled Tramadol for pain had a dose removed from the controlled substance supply, but it was not documented on the MAR or the narcotic count sheet at the time of observation, and the RN was found with the pill in her pocket before later stating she had administered it. The facility also had expired Flonase stored in a medication room fridge. Staff interviews showed inconsistent responsibility for narcotic documentation and expired medication checks, despite policy requiring controlled substances to be documented and outdated drugs removed.
RN C failed to follow hand hygiene and glove-changing practices while giving meds and G-tube feeding to one resident with stroke, epilepsy, DM2, aphasia, dysphagia, and a G-tube, and while preparing meds for another resident with quadriplegia, dysphagia, and hospice status. During the first event, she spilled formula on the resident, used the same paper towel on the resident and the med table, and continued care without hand hygiene or changing gloves. During the second, she removed Tramadol from her pocket and prepared meds without hand hygiene. The DON, ADON, and RN C all acknowledged the actions were not appropriate infection control practice.
A resident with severe CP, IDD, Rett syndrome, dysphagia, malnutrition, epilepsy, and a PEG tube was observed in her room with one housefly and multiple fruit flies swarming around her and landing on her and nearby bedding. The ADON said it was the first time she had seen insects in the room, while maintenance and the pest control service manager acknowledged an ongoing fruit fly problem in the facility and reliance on staff reports and pest control logs.
A resident with multiple comorbidities, including seizure disorder, intellectual disability, schizoaffective disorder, right AKA, and significant mobility limitations, had a care plan requiring the bed to be kept in the lowest position with wheels locked. The resident fell from bed when the bed brakes were not set, reported pain, and was sent to the ER, where imaging showed no acute findings. The facility’s incident report documented a fall without injury but did not include any investigation of possible neglect or notification to the state agency. Later observation and interviews with the resident, the legal guardian, CNAs, an LVN, and the administrator confirmed that the bed wheels had been unlocked at the time of the fall, that staff were trained to keep bed wheels locked, and that there was no specific facility policy on bed wheel locking, despite an abuse prohibition policy requiring investigation and reporting of alleged neglect.
A resident with multiple comorbidities, including epilepsy, intellectual disability, morbid obesity, and a right above‑knee amputation, fell from bed when the bed brakes were not locked, despite a care plan requiring the bed to be kept in the lowest position with wheels locked. The resident, who was bedfast and required at least a two‑person assist for transfers, reported that nurses failed to lock the bed wheels, and the legal guardian confirmed the fall occurred due to unlocked wheels, with the resident complaining of pain afterward. ED records noted left hip and back pain and tenderness after the fall. Staff interviews confirmed the bed wheels were unlocked, revealed uncertainty about any policy on locking bed wheels, and showed that although CNAs had training that included bed locks, there was no facility policy specifically requiring bed wheels to be locked, leading surveyors to cite a failure to provide adequate supervision and prevent accident hazards.
A resident with multiple chronic conditions and severe lower extremity wounds did not consistently receive wound care as ordered by the physician and wound care NP. Staff observed soiled dressings with drainage and blood on several occasions, but PRN dressing changes were not performed or documented. Inconsistencies in order entry, communication, and lack of a clear policy contributed to missed and delayed wound care.
A resident with multiple complex medical conditions did not have documentation of a care plan conference in their medical record, despite staff interviews confirming the meeting took place. Facility staff acknowledged that it was their responsibility to document such meetings, but the required note was missing, resulting in incomplete clinical records.
The facility failed to ensure resident privacy as staff did not consistently knock before entering rooms. During lunch tray distribution, staff entered the rooms of three residents without knocking, despite being trained on resident rights. Interviews revealed that one resident was upset by this, while another preferred knocking but was not upset. Staff cited reasons such as being preoccupied or wanting to deliver trays quickly for not following the protocol.
A facility failed to complete a resident's MDS assessment within the required timeframe, leading to a deficiency. The resident's assessment was not signed off by the RN Assessment Coordinator by the survey exit. Interviews revealed confusion among staff about the responsibility and timing for completing MDS assessments, with corporate handling the process but lacking coordination and clarity. The facility's policies were not effectively followed, resulting in the deficiency.
The facility failed to conduct proper PASRR screenings for two residents with mental illness diagnoses. One resident was readmitted without a correct PASRR Level 1 screening, and another was admitted without any PASRR screening. Staff interviews revealed a lack of clarity and responsibility in the PASRR process, leading to the deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound on the left thigh, which had sanguineous drainage. Despite the facility's policy requiring EBP for such conditions, staff did not use PPE during wound care, and there was no EBP signage outside the resident's room. Misunderstandings of the EBP policy by the Treatment Nurse and DON contributed to this deficiency, as confirmed by the Corporate Nurse IP.
A resident with legal blindness and multiple health conditions was inadequately supervised, as the assigned CNA was found asleep during 1:1 care. The resident, at risk for wandering and falls, was observed navigating the room unsupervised, bumping into furniture, and potentially endangering himself. Despite the care plan's requirements for extensive assistance, the CNA's inattentiveness was corroborated by video evidence and staff interviews.
A resident with a double amputation was not allowed to participate in group outings using the facility van, leading to feelings of discrimination and isolation. The facility cited safety concerns, although no specific policy restricted double amputees. Alternative transportation was offered but declined by the resident, who felt it was not equivalent to traveling with peers.
Failure to Provide Resident-Centered Activity Programs
Penalty
Summary
The facility failed to provide an ongoing activity program that supported each resident’s choice of activities, including facility-sponsored group activities, individual activities, and independent activities, for four residents who were completely dependent on staff. The deficiency was identified for residents with severe cognitive and physical impairments who had documented activity preferences, but whose records and observations showed little to no participation in activities during the review period. Resident #17 was a female with spastic quadriplegic cerebral palsy, severe intellectual disabilities, Rett syndrome, dysphagia, cognitive communication deficit, protein-calorie malnutrition, epilepsy, depressive episodes, gastrostomy status, and chronic pain. Her activity preferences included listening to music and spending time outdoors. Her care plan stated she required one-on-one activities, enjoyed cartoon soundtracks, cartoon movies, sensory stimulation, hand massage, soft music in her room, and a morning stroll once a week. However, the activity record from 03/17/2026 to 04/16/2026 showed only one one-on-one music/sensory visit and no other activities. Multiple observations showed her lying in bed or in a tilt-back wheelchair with no music playing and no activity occurring in her room. Resident #10 had diagnoses including cerebral infarction due to embolism of the right middle cerebral artery, parkinsonism, epilepsy, aphasia, and gastrostomy status. Her activity preference assessment indicated she enjoyed listening to music, but the activity record from 03/17/2026 to 04/16/2026 documented no activities of any type. Observations repeatedly showed her lying in bed connected to her PEG tube with no music playing and the television off. Resident #1 had Alzheimer’s disease, anxiety disorder, depression, and muscle weakness, with severe cognitive impairment on MDS. Her interests included listening to music and religious activities, and her care plan noted she enjoyed observing in common areas and participated in the furry friends program. Despite this, observations showed her in bed without activity or interaction, and no music was playing. Resident #63 had encephalopathy, cerebral infarction, protein-calorie malnutrition, aphasia, muscle weakness, dysphagia, gastrostomy status, cognitive communication deficit, adult failure to thrive, and dysarthria/anarthria. Her preferences included music, religious activities, and time outdoors, and her care plan called for one-on-one socialization, sensory stimulation, music, and going outside for fresh air. Observations repeatedly showed her lying in bed with no music or television on and no response to attempts to communicate. During interviews, the AA stated she documented activities in the POC and sometimes entered them later from notes, but she also stated she relied on staff to get residents out of bed for activities and that the CNAs did not always have time to do so. She said there was no backup plan while she was unable to assist residents due to surgery. She further stated she had not addressed inviting the four residents to activities during one morning invitation round. The AD stated residents needed more one-on-one visits and acknowledged that the one-on-one visits were not being utilized thoroughly. The ADM stated nursing staff had a role in ensuring residents could get to activities and that the potential negative impact of not receiving activities could be depression.
Missing Dialysis Care Plan Interventions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #2 within 48 hours of admission that included the instructions needed to provide effective and person-centered care for dialysis. Resident #2 was a [AGE]-year-old female admitted on [DATE] with end-stage renal disease and hypertension, and her admission MDS dated 03/30/2026 did not reflect that she was receiving dialysis. Her care plan dated 3/30/2026 noted that she attended dialysis on Mondays, Wednesdays, and Fridays and was initiated by DM on 04/01/2026, but the plan addressed dietary needs only and did not include a dialysis focus developed by a doctor or nurse or any nursing interventions. Record review showed progress notes dated 4/13/2026 documented that Resident #2 had a past medical history including type 2 diabetes mellitus and ESRD and was dependent on hemodialysis Monday, Wednesday, and Friday for end-stage renal disease. During interview and observation, the resident stated she had been going to dialysis appointments for the last two years and attended every Monday, Wednesday, and Friday. The MDS A coordinator stated the baseline care plan should have included the diagnosis of dialysis and that it needed to come from a nurse or medical professional, not the dietary manager. The ADON stated she did not know why there was not a current care plan and noted that if residents did not have a care plan or related dialysis checks, they could be at risk for infection. The facility’s Dialysis Management Policy stated that dialysis center recommendations and treatment plans would be incorporated into the resident’s care plan.
Failure to Provide Nail Care for Two Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received needed nail care to maintain good personal hygiene for Resident #19 and Resident #78. Resident #19 was a male with diagnoses including dementia, muscle wasting and atrophy, age-related physical disability, persistent mood disorder, and chronic viral hepatitis C. His quarterly MDS dated 01/16/2026 showed a BIMS score of 09 and that he required partial to moderate assistance with personal hygiene. His care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, but the POC system had no nail care task documented for him. On 04/15/2026, he was observed with fingernails about 1/4 inch long and stated he liked them trimmed short, could not cut them himself, and sometimes bit them because staff had not offered to cut them. Resident #78 was a male with diagnoses including cognitive communication deficit, epilepsy, schizophrenia, weakness, contracture of multiple muscle sites, cerebral palsy, lack of expected normal physiological development in childhood, paraplegia, borderline personality disorder, intermittent explosive disorder, generalized anxiety disorder, bipolar disorder, and moderate intellectual disabilities. His annual MDS dated 07/26/2025 showed a BIMS score of 09 and that he was completely dependent on staff for all ADLs, including personal hygiene. His care plan also directed staff to check nail length and trim and clean nails on bath day and as necessary, but the POC system had no nail care task documented for him. On 04/14/2026 and again on 04/15/2026, he was observed with long, jagged, and dirty fingernails, and he stated he wanted his fingernails cut but they had not been done and he did not know when someone would cut them.
Fall mats not placed beside bed for two residents on fall precautions
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for two residents who were on fall precautions. Resident #99, a male with diagnoses including multiple sclerosis, type 2 diabetes mellitus, COPD, and unspecified protein calorie malnutrition, had a BIMS score of 14 and was dependent on staff for self-care and mobility. His care plan identified him as high risk for falls and included interventions for the call light to be within reach, the bed to be in the lowest position, and a fall mat to be in place beside the bed. However, during observations on 04/14/2026 and 04/15/2026, he was seen lying in bed while the fall mat was folded up at the foot of the bed between the wall and dresser rather than beside the bed. Resident #52, a male with diagnoses including type 2 diabetes, COPD, muscle wasting and atrophy, and osteomyelitis, had a BIMS score of 07 and was severely cognitively impaired. He was dependent on staff for self-care and mobility, and his care plan, initiated 01/23/2026, identified him as at risk for falls with an intervention for a fall mat to be in place beside the bed and the call light within reach. During observations on 04/14/2026, he was lying in bed while the fall mat was on the floor on the other side of the room away from the bed. Staff interviews confirmed the expectation that when a resident is in bed, the bed should be lowered and the fall mat placed right next to the bed, and the DON and ADM stated that both residents were on fall precautions and that the fall mats should be beside the bed when the residents were in bed.
Unsafe G-tube Medication and Feeding Administration
Penalty
Summary
The facility failed to ensure a resident with a G-tube received enteral medications and feeding safely and according to the ordered procedure. Resident #10 was a female with diagnoses including cerebral infarction due to embolism of the right middle cerebral artery, epilepsy, type 2 diabetes mellitus, aphasia, dysphagia, and gastrostomy status. Her MDS reflected short- and long-term memory problems, severely impaired cognitive skills for daily decision making, total dependence for all ADLs, aphasia, and that she received 51% or more of her intake via tube feeding. During observation, RN C prepared multiple medications for the resident, including crushed tablets and liquid medications, and then entered the resident’s room. The resident was non-verbal and displayed a flat facial expression and some nonverbal sounds. RN C dissolved each medication with water and mixed them with the same spoon, then connected a syringe to the G-tube port and poured medication into the syringe barrel. She did not check G-tube placement or residual before administering the medications, and she did not flush the syringe before and between medications. She pushed the medications through the syringe using the plunger. RN C then administered Glucerna enteral feeding by pouring it directly into the syringe from the container. She wiggled the syringe from side to side and moved it in a circular motion while it was attached to the G-tube, and she used the plunger to push the feeding through. The DON and ADON stated that staff were expected to verify tube placement, check residual, and flush between medications, and the facility policy required verifying tube placement, administering each medication separately, administering by gravity flow, and flushing between medications. RN C stated she did not auscultate the resident prior to administering medications and described using forceful techniques when resistance was encountered.
Missing physician order for scheduled hemodialysis
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease and hypertension had a physician's order for hemodialysis three times per week on Mondays, Wednesdays, and Fridays. Record review showed the resident's admission MDS dated 03/30/2026 did not reflect that she was receiving dialysis, even though the resident was dependent on renal dialysis. The care plan dated 3/30/2026 stated that the resident attends dialysis on Mondays, Wednesdays, and Fridays, with the intervention initiated on 04/01/2026. Progress notes dated 4/13/2026 documented that the resident had a history including type 2 diabetes mellitus and ESRD and was dependent on hemodialysis Monday, Wednesday, and Friday for end-stage renal disease. During interview and observation, the resident stated she attended dialysis every Monday, Wednesday, and Friday and had been going to these appointments for the last two years. Facility staff later updated the EMR to reflect dialysis three days a week at a dialysis center under the care of a nephrologist, and the NP and DON stated the dialysis orders had not been entered into the EMR when the resident was admitted.
Controlled Substance Documentation and Expired Medication Storage
Penalty
Summary
The facility failed to establish a system for the receipt, disposition, and reconciliation of controlled drugs for one resident receiving Tramadol. Resident #90 was admitted with diagnoses including quadriplegia, major depressive disorder, dysphagia, cognitive communication deficit, and pain, and was in hospice care with no spoken words. Her order summary included Tramadol 50 mg via G-tube three times daily for pain and Hydrocodone-Acetaminophen as needed. During observation of the medication storage area, the controlled substance record showed 19 tablets of Tramadol remaining, while the blister pack contained 18 tablets. RN C stated the medication had been given at 8:00 a.m., but at the time of review it was not charted on the MAR. RN C was observed searching for the medication, then removed a white oval pill from her pocket and stated she had forgotten she put it there. During interview, RN C stated she had kept Resident #90’s Tramadol tablet while administering medications and enteral feeding to another resident in that resident’s room. She stated there was a 4-hour window to administer the medication and that she did administer it to Resident #90, but she could not explain why she kept the Tramadol in her pocket. ADON B stated the expected process was to verify the order, remove the narcotic from the locked box, document it in the narcotics book, administer it, and then chart it in the resident’s record. The ADM stated narcotic medication should be stored safely locked and that it is not acceptable to place narcotics in staff pockets. He also stated narcotics must be counted by two nurses at the end of the shift. The facility also failed to ensure expired medication was removed from the medication storage area. During observation of the C&D nurses’ station medication room, expired fluticasone prop 50 mcg (Flonase) was found in a mini fridge with an expiration date of 02/12/2026. ADON B stated the pharmacy consultant and DON were responsible for removing expired medications from nursing and medication carts. The ADM stated charge nurses or ADONs were responsible for checking for expired medications, and the pharmacy consultant stated she was not responsible for removing expired medications but could recommend removal if she located them. The facility policy stated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Infection Control Lapses During Medication Administration and G-Tube Feeding
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents observed for infection control. During observation of one resident with a history of cerebral infarction, epilepsy, type 2 diabetes, aphasia, dysphagia, gastrostomy status, severe cognitive impairment, total dependence for ADLs, and tube feeding, RN C administered crushed medications and then began enteral feeding via G-tube. While doing so, RN C spilled Glucerna on the resident’s stomach, used a paper towel from the bedside table to wipe the spill, and continued the feeding without performing hand hygiene or changing gloves. RN C also used the same paper towel to wipe a stain on the medication table multiple times while continuing the feeding. A second resident, who had quadriplegia, major depressive disorder, dysphagia, cognitive communication deficit, pain, and hospice status, was observed during morning medication preparation. RN C removed Tramadol from her pocket, placed it in a medication cup, and began preparing the resident’s medications without performing hand hygiene. The resident had no spoken words and was documented as cognitively intact on the quarterly MDS. During interviews, the DON stated nurses are expected to perform hand hygiene before and after each patient, clean area, off gloves, and hand hygiene again, and that wiping a resident’s body and then cleaning the work area with the same paper towel without hand hygiene and changing gloves is not acceptable. The ADON stated the actions were unacceptable and an infection control issue. RN C acknowledged she did not follow appropriate infection control practice, stated she should have discarded the Tramadol pill she pulled from her pocket and obtained a new one, and stated nurses must perform hand hygiene before administering medications. Facility staff also stated they had received infection control training, including hand hygiene and PPE use, and the facility policy on handwashing/hand hygiene required hand hygiene immediately before touching a resident, after touching a resident, after touching the resident’s environment, and immediately after glove removal.
Pest Control Program Failed to Keep Resident Room Free of Flies
Penalty
Summary
The facility failed to maintain an effective pest control program when Resident #17’s room was observed to have one housefly and at least seven fruit flies swarming around her and landing on her and the pillow on the bed next to her. Resident #17 was a [AGE]-year-old female with spastic quadriplegic cerebral palsy, severe intellectual disabilities, Rett syndrome, dysphagia, cognitive communication deficit, protein-calorie malnutrition, epilepsy, depressive episodes, gastrostomy status, and chronic pain. Her MDS reflected severe cognitive impairment and total dependence on staff for bed mobility and personal hygiene, and her care plan stated she required total assistance for all ADLs and mobility. During interviews, the ADON stated it was the first time she had seen insects in the room and did not know why the CNA who had visited the room did not notice them. The maintenance staff stated the facility had been working on getting rid of fruit flies, that pest control was coming out as needed, and that he relied on staff to report sightings in the pest control log. The pest control company service manager stated there was a fruit fly problem in the facility and that the facility had increased pest control visits to twice monthly. The facility policy stated it maintained an ongoing pest control program to ensure the building was kept free of insects and rodents.
Failure to Investigate and Report Fall Related to Unlocked Bed Wheels
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report an alleged incident of neglect related to a resident fall. The resident was an adult male with multiple significant diagnoses, including seizure disorder, epilepsy with status epilepticus, intellectual disability, generalized anxiety disorder, schizoaffective disorder bipolar type, persistent mood disorder, personality disorder, obstructive sleep apnea, insomnia, peripheral vascular disease, right above-knee amputation, muscle wasting and atrophy of both upper arms, and a cognitive communication deficit. His care plan, dated 01/04/26, directed that his bed be kept in the lowest position with wheels locked, and noted a behavior problem of self-adjusting the head of the bed and keeping it in a high position, with interventions to encourage and redirect him to keep the bed low. On 01/03/26, the resident experienced a fall from bed without documented injury in the facility’s incident report, which did not include any information related to an investigation of neglect or notification to the state agency. The resident was sent to the ER, where he was evaluated for pain in his left hip and femur, with imaging (CT brain and cervical spine) showing no acute abnormalities. The ER documentation indicated he fell when rolling in bed and landing on his left side, complained of hip and back pain, and remained intermittently agitated but hemodynamically stable. The hospital discharge record identified the visit reason as a fall and provided fall prevention instructions and follow-up recommendations. Subsequent interviews and observations confirmed that the bed wheels were not locked at the time of the fall, despite the care plan requirement. On observation later in the month, the resident was seen in bed against the wall with bed wheels locked, and he stated that two nurses had failed to lock the bed wheels, causing his fall and pain at that time. His legal guardian reported that he was morbidly obese, an amputee, bedfast, and at least a two-person assist for transfers, and that he scraped his elbow and complained of pain after the fall. Staff interviews revealed that CNAs and the LVN understood that bed wheels should be locked and that leaving them unlocked could result in a resident fall, and the LVN stated the wheels were not locked at the time of the incident based on the incident report. The administrator acknowledged that no staff were disciplined because responsibility could not be determined, that there was no facility policy specific to locking bed wheels, and that the incident was not reported to the state agency because the resident returned from the ER with no injuries, despite the facility’s abuse prohibition policy requiring investigation and notification of alleged or suspected neglect according to regulations.
Failure to Lock Bed Brakes Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s bed wheels were locked, resulting in a fall from bed. The resident was a middle‑aged male with extensive medical and psychiatric diagnoses, including other seizures, epilepsy with status epilepticus, insomnia, obstructive sleep apnea, intellectual disability, generalized anxiety disorder, schizoaffective disorder bipolar type, persistent mood disorder, personality disorder, right above‑knee amputation, peripheral vascular disease, muscle wasting and atrophy of both upper arms, and a cognitive communication deficit. His care plan directed that his bed be kept in the lowest position with wheels locked, and identified that he had a behavior of self‑adjusting the bed height and keeping it high. The care plan also documented a history of an actual fall and a goal of no further fall‑related injuries. On the date of the incident, the resident fell out of bed and was found on the floor. Facility incident documentation and staff interviews confirmed that the bed wheels were not locked at the time of the fall. The resident was described as morbidly obese, an amputee, bedfast, and at least a two‑person assist for transfers, and his legal guardian stated he was fully dependent on the bed being in place and leaned on the wall for comfort. The resident reported that two nurses failed to lock his bed wheels, causing his fall. The legal guardian reported that he scraped his elbow and complained of pain after the fall. Emergency department records documented complaints of left hip and back pain, tenderness to palpation of the left hip and femur, intermittent agitation, and that he apparently rolled too far while sleeping on his left side, landing on his left side on the floor. Staff interviews revealed gaps in practice and knowledge related to bed wheel locking. An LVN stated that the wheels on the resident’s bed were not locked at the time of the fall and acknowledged that leaving bed wheels unlocked could result in a resident falling out of bed, but she was unaware of any facility policy on locking bed wheels. CNAs reported receiving training that included bed locks, and one CNA stated that the resident had a fall mat on one side of the bed but not on the wall side. The administrator confirmed that no staff were disciplined because responsibility for failing to lock the bed wheels could not be determined and also stated there was no facility policy related to bed wheels being locked. Surveyors concluded that the facility failed to provide adequate supervision and to maintain the environment free from accident hazards when the resident’s bed brakes were not locked, leading to the fall.
Failure to Provide Wound Care per Physician Orders and Professional Standards
Penalty
Summary
The facility failed to provide wound care to a resident in accordance with physician orders and professional standards of practice. The resident, an elderly male with multiple diagnoses including vascular dementia, peripheral vascular disease, and a history of severe lower extremity wounds, was admitted with specific wound care instructions from the hospital and subsequent orders from the wound care nurse practitioner (NP). These orders included cleaning and dressing the wounds at specified intervals (ranging from every 72 hours, three times a week, to daily, depending on the dressing type and wound status) and performing dressing changes as needed (PRN) when dressings became soiled. Documentation and interviews revealed that wound care was missed on several ordered dates, and PRN dressing changes were not performed or documented when dressings were visibly soiled with drainage or blood, as evidenced by photographs and staff observations. Multiple staff interviews confirmed that the resident's dressings were observed to be soiled on several occasions, with visible blood or drainage on the outer bandages. Despite this, there was no documentation of PRN dressing changes on the treatment administration records (TAR) or in progress notes. Staff, including LVNs, RNs, and CNAs, reported seeing soiled dressings and, in some cases, notifying the nurse responsible, but the dressings were not always changed as required by the physician's orders. The wound care NP and other nursing staff clarified that the frequency of dressing changes should have matched the wound care orders, and that soiled dressings should have been changed promptly to prevent complications. However, inconsistencies in order entry, communication, and follow-through led to lapses in care. Further review of facility processes revealed that wound care orders were sometimes entered incorrectly or not updated to reflect the most current recommendations from the wound care NP. There was confusion among staff regarding the correct frequency for dressing changes, particularly when orders changed from one type of dressing to another (e.g., from xeroform to calcium alginate). The facility lacked a policy to ensure that physician orders were consistently reviewed and updated in the electronic health record, contributing to the failure to provide wound care as ordered. Interviews with administrative staff confirmed that there was no formal policy on following or updating physician orders, and that responsibility for reviewing and reconciling orders was not clearly defined or consistently executed.
Failure to Document Care Plan Conference in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed for clinical records. Specifically, there was no documentation of a care plan conference that was reportedly held for a male resident with multiple complex diagnoses, including systolic heart failure, a history of poliomyelitis, cognitive communication deficit, dysphagia, vascular dementia, and peripheral vascular disease. The resident was at risk for pressure ulcers and had multiple venous and arterial ulcers, as well as other open lesions. While the baseline care plan and an initial care plan conference were documented, there was no record of a subsequent care plan conference that staff members stated had occurred. Interviews with facility staff, including the LMSW, DOR, ADON, MDS nurse, DON, and ADM, confirmed that a care plan meeting took place but was not documented in the resident's medical record. Staff indicated that it was the responsibility of the MDS nurse or LMSW to document such meetings, and acknowledged the importance of recording the occurrence, participants, and any concerns discussed. The facility's policy required that all services provided, progress towards care plan goals, and changes in the resident's condition be documented in the medical record, but this was not followed in this instance.
Failure to Ensure Resident Privacy by Not Knocking Before Entering Rooms
Penalty
Summary
The facility failed to uphold resident rights to personal privacy for three residents, as staff did not knock before entering their rooms. This deficiency was observed during the distribution of lunch trays, where staff members entered the rooms of three residents without knocking. The residents involved had varying degrees of cognitive impairment, with one resident having severe cognitive impairment, another with moderate impairment, and the third with intact cognitive responses. Interviews with the residents revealed mixed reactions to the staff's failure to knock. One resident expressed that it upset him when staff entered without knocking, especially if he was engaged in an activity or sleeping. Another resident mentioned that staff always knocked, while the third resident stated a preference for staff to knock but did not get upset when they failed to do so. These interviews highlight the inconsistency in staff adherence to the facility's policy on knocking before entering residents' rooms. Staff interviews indicated that they were aware of the policy requiring them to knock and wait for a response before entering a resident's room. However, reasons such as being preoccupied or wanting to deliver meal trays quickly were cited for not following the protocol. The Director of Nursing and other staff members acknowledged the importance of knocking to respect residents' privacy and mentioned that management monitors compliance through observations and reviews. Despite this, the deficiency persisted, as staff did not consistently adhere to the policy.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment of a resident within the required timeframes, specifically within 14 calendar days after admission and not less than once every 12 months. This deficiency was identified for one resident who was reviewed for comprehensive annual assessments. The facility did not complete the resident's Annual/5 Day Assessment MDS within 14 days of the Assessment Reference Date (ARD), as the signature of the RN Assessment Coordinator verifying assessment completion was missing by the time of the survey exit. Interviews with facility staff revealed a lack of clarity and coordination regarding the completion of the MDS assessments. The Director of Nursing (DON) and the Administrator (ADM) acknowledged that the facility did not have an MDS coordinator and that corporate was responsible for completing the MDS assessments. However, there was confusion about the specific timeframes for completing the assessments, and the staff were unsure why the resident's MDS had not been completed. The facility's policy and procedures were not effectively followed, leading to the deficiency in timely assessment completion.
Failure to Conduct Proper PASRR Screenings
Penalty
Summary
The facility failed to properly identify and document mental illness diagnoses in the PASRR assessments for two residents. Resident #78, a female with a history of schizoaffective disorder bipolar type and anxiety, was readmitted to the facility without a correct PASRR Level 1 screening, which incorrectly marked 'no' for mental illness. Despite her active diagnoses and use of psychotropic medications, the PASRR was not flagged appropriately due to an oversight by a new MDS nurse. Resident #85, a male with major depressive disorder, developmental disorder, and anxiety disorder, was admitted without any PASRR screening being completed. The facility's administrator admitted that the admission process was rushed, and the PASRR was overlooked because the resident came from home. The facility's PASRR policy requires a PL1 to be conducted before admission, but this was not adhered to in this case. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process. The administrator and clinical nurse coordinator both acknowledged the importance of PASRR screenings for residents with mental illness to receive necessary services. However, there was a failure in executing these procedures, leading to the deficiency noted in the report.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wound
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with a chronic wound. The resident, a male with diabetes, peripheral vascular disease, and intellectual disabilities, had a wound on his left thigh that was draining and could not be covered with a dressing. Despite the presence of drainage and the chronic nature of the wound, Enhanced Barrier Precautions (EBP) were not implemented as required by the facility's policy. Observations revealed that there was no signage for EBP outside the resident's room, and staff did not don personal protective equipment (PPE) when entering the room to perform wound care. The Treatment Nurse and CNA entered the room without PPE, exposing the resident's wound, which had sanguineous drainage. Interviews with the Treatment Nurse and the Director of Nursing (DON) indicated a misunderstanding of the facility's EBP policy, which led to the failure to initiate EBP for the resident's wound. The Corporate Nurse Infection Preventionist (IP) confirmed that EBP should have been initiated for the resident due to the chronic wound with drainage. The facility's policy required EBP for residents with chronic wounds, even if not infected or colonized with multidrug-resistant organisms. The lack of EBP implementation was attributed to a failure to appropriately follow the facility's policy, putting the resident at risk for infection.
Inadequate Supervision of Resident Leads to Safety Risks
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who was legally blind and had multiple other health conditions. The resident, who was on a 1:1 supervision plan due to wandering risk and other vulnerabilities, was left unsupervised on multiple occasions. Video evidence showed that the assigned CNA was asleep during shifts, allowing the resident to move around the room unsupervised, bumping into furniture and potentially putting himself at risk of injury. The resident's care plan highlighted the need for extensive assistance due to legal blindness, cognitive impairment, and a high risk for falls. Despite these documented needs, the CNA responsible for 1:1 care was observed sleeping, with feet propped up on a chair, and not actively supervising the resident. On one occasion, the resident was seen getting out of bed, bumping into furniture, and attempting to navigate the room without assistance, which could have led to serious injury. Interviews with staff and family members corroborated the lack of supervision. The family member monitoring the resident's room via a device reported the CNA's inattentiveness and inappropriate handling of the resident. Other staff members, including housekeeping and nursing staff, acknowledged the inappropriateness of sleeping on the job and the potential risks it posed to residents, yet there was no immediate corrective action taken to address the CNA's behavior during the incidents in question.
Resident Denied Participation in Group Outings Due to Disability
Penalty
Summary
The facility failed to ensure that residents had the right to self-determination and did not adequately support resident choice, particularly for a resident who was a double amputee. This resident was not allowed to participate in group outings with peers using the facility van, which led to feelings of anger and being viewed as less important due to his disability. The facility's policy was reportedly based on safety concerns, although there was no specific documentation or policy statement that explicitly restricted double amputees from using the van. The resident, who had been at the facility for years, expressed that he felt discriminated against and isolated because he could not join his friends on outings. The facility staff, including CNAs and the administrator, cited safety concerns as the reason for the restriction, referencing an incident at another facility involving a double amputee. However, the facility's policy did not contain any specific language about double amputees, and the van manufacturer's report on seatbelt adequacy was not provided when requested. Interviews with staff and the resident revealed that alternative transportation was offered through an outside vendor, but the resident declined this option, feeling it was not equivalent to traveling with peers. The facility's social worker noted that the resident was unhappy about not going on trips but had refused the alternative transportation. The facility's administrator maintained that the policy was for the resident's protection, although the resident's rights policy emphasized dignity, respect, and self-determination.
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What surveyors actually found near you
We read the 325 citations issued within 25 miles in the last 12 months — including the 18 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brush Country Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 23 | 1 |
| Brookdale Westlake Hills | 2.4 mi | ★★★★★ | 9 | 0 |
| West Oaks Nursing And Rehabilitation Center | 4.4 mi | ★★★★★ | 13 | 0 |
| Southpark Meadows Nursing And Rehabilitation Cente | 5 mi | ★★★★★ | 5 | 0 |
| Querencia At Barton Creek | 5.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.