Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beacon Hill during CMS and state inspections, most recent first.
A resident with intact cognition and ADL care needs was treated disrespectfully when a CNA yelled at her, used loud speech and pointing gestures, and walked away without helping after she asked to get up. Another CNA set up her meal tray, threw napkins onto her lap, and told her, “I have better things to do,” before leaving the room. Leaders later acknowledged the conduct was inappropriate and a dignity and resident rights issue.
Failure to Provide Nail Care and Personal Hygiene: A resident with dementia and severe cognitive impairment, who needed maximal assistance with personal hygiene, was observed with fingernails that were long, discolored, and had residue under and around the nail beds. The CNA stated she had not noticed the nails, and the DON stated CNAs were responsible for nail care unless the resident had diabetes, with charge nurses monitoring the care.
The facility failed to post the most recent survey results in an area readily accessible to residents, families, and legal representatives and did not inform residents of their right to review these results. In a group interview, several residents reported they were unaware of this right and did not know where survey results were kept. The Activity Director, responsible for reviewing resident rights in resident council, acknowledged she had not informed residents about this right and did not know the survey results’ location. The Administrator stated the results were in the front lobby, but they were found stored in a closed cabinet with no notice explaining how to access them, and the facility did not provide the resident rights policy before survey exit.
Surveyors found that residents were not informed about how to file grievances and were unaware of the facility’s grievance policy. In a group interview, multiple residents reported they did not know who to approach with concerns and wanted the ability to write and submit their own grievances, but no forms were available. A binder labeled for grievances in the activity room contained only blank coloring pages and no grievance information. The DON and Administrator stated that residents could report grievances verbally to staff, who would enter them into a computerized system, but confirmed there was no resident-accessible grievance form. The Activity Director, who attended resident council meetings, had not discussed grievances or the grievance policy with residents and was unfamiliar with the specific policy, despite the facility’s written policy requiring that information on how to file a grievance or complaint be made available.
Surveyors found an open vial of Tuberculin PPD in a medication room refrigerator that had been dated more than 30 days earlier but was still in use for resident TB skin testing. The infection prevention LVN, who performed all TB tests, acknowledged she opened, dated, and then failed to discard the vial after 30 days as required, and continued using it on multiple residents. The DON confirmed facility practice and policy require multi-dose vials to be dated when opened, discarded after 30 days unless otherwise directed by the manufacturer, and prohibit use of outdated drugs, with nursing staff responsible for monitoring medication storage.
A resident with severe cognitive impairment and multiple diagnoses was discharged to a memory care facility without receiving the required written 30-day discharge notice, explanation of appeal rights, or notification in a language and manner understood by the resident and responsible party. The facility also failed to notify the Ombudsman of the discharge, and staff interviews revealed confusion about notification responsibilities.
A resident with severe cognitive impairment and multiple medical conditions, who was totally dependent on staff for personal hygiene, was observed with a brown substance under all fingernails on one hand while the other hand’s nails were clean. The care plan and facility policy required staff to provide daily nail cleaning and regular trimming, and to check nails on bath days and as needed. A CNA and an LVN stated that CNAs and nurses were responsible for daily nail checks and nail care, and the DON confirmed expectations that nail care be done on shower days or as needed. Staff had not noticed or addressed the dirty fingernails, resulting in a failure to provide necessary ADL services to maintain grooming and personal hygiene.
Surveyors found that staff failed to label multi-use eye drop bottles with open dates and follow manufacturer discard instructions on two medication carts. A CMA administered TheraTears eye drops from an undated bottle to a resident with dry eye syndrome, while the resident’s active orders listed a different ophthalmic gel. On one cart, open, undated bottles of Latanoprost for a resident with ocular hypertension and Pataday for a resident with dry eye syndrome were observed; on another cart, an open, undated Latanoprost bottle for a resident with glaucoma was found. A CMA, an LVN, and the DON all acknowledged that multi-use eye drops must be dated when opened and discarded within 30 days or per manufacturer directions, and the facility’s medication storage policy prohibits use of outdated or deteriorated drugs and assigns nursing staff responsibility for medication storage.
A resident with Alzheimer’s disease, CVA, anxiety disorder, and moderate cognitive impairment who was frequently incontinent of bladder received urinary incontinence care during which a CNA failed to change gloves and perform hand hygiene between cleaning the front pubic area, removing a soiled brief, cleaning the buttocks, and applying a clean brief. Although the CNA initially washed hands and donned gloves, she continued the entire sequence of care with the same gloves and only performed hand hygiene after removing them at the end, contrary to facility policy and acknowledged expectations for hand hygiene and glove changes when moving from contaminated to clean body sites.
A resident with severe cognitive impairment, dementia, hypertension, and anxiety, care planned as a fall risk with an intervention to keep the call light within reach, was observed in bed with the call light button on the floor and not accessible. A CNA found the call light on the floor and acknowledged the resident would not be able to call for help in that position. The DON and Administrator both stated that staff are responsible for ensuring call lights are always within residents’ reach, consistent with facility policy requiring a system that allows residents to call staff directly from their bed and toileting/bathing areas.
The facility failed to provide necessary nail care for several residents, resulting in long and dirty fingernails. Despite being dependent on staff for personal hygiene, residents did not receive adequate assistance, leading to potential infection risks. Staff interviews revealed a lack of awareness and documentation regarding residents' care needs.
The facility failed to maintain food safety and sanitation standards, with issues including unsealed food storage, improper hand hygiene, and failure to check food temperatures. Dietary staff did not change gloves or wash hands after contamination, and gravy was not temped before serving, risking food-borne illness.
The facility failed to maintain an effective infection prevention and control program, with lapses in hand hygiene and equipment sanitization by staff. An LVN did not sanitize glucose test strips or perform hand hygiene during a blood sugar test and insulin administration for a diabetic resident. A CNA failed to change gloves or perform hand hygiene during incontinence care for another resident. The DON confirmed these actions increased infection risk, contrary to the facility's hand hygiene policy.
A resident's right to self-determination was not respected when the facility rescheduled his medical appointment without his consent and insisted on having a staff member attend his appointments, despite his objections. The resident, who was independent in mobility, expressed his desire to manage his own appointments, but the facility's outdated policies and lack of clear communication led to a deficiency in respecting his rights.
A facility failed to develop a comprehensive care plan for a resident, neglecting her preferences for bed baths and staying in bed. Despite being severely cognitively impaired and dependent on assistance for ADLs, her care plan did not reflect these preferences. Interviews with staff revealed a lack of awareness and documentation, highlighting a breakdown in communication and adherence to the facility's care planning policy.
A resident with severe cognitive impairment and multiple health conditions did not receive adequate foot care, resulting in dry, flaky skin and long, thick toenails. Despite being dependent on staff for personal hygiene, there was no referral to a podiatrist or documentation of wound care treatment. Staff were aware of the issue but failed to ensure proper care, leading to a deficiency in maintaining the resident's foot health.
A resident with an indwelling catheter did not receive appropriate care during a mechanical lift transfer, as the catheter drainage bag was placed above the bladder, risking urine backflow. Staff involved were unaware of the correct procedure, highlighting a training gap. The DON confirmed the importance of keeping the bag below the bladder to prevent UTIs.
The facility failed to label and store medications properly, as observed in a medication room where an open vial of Tuberculin PPD and four syringes with an unknown liquid were found without proper labeling or dating. The infection prevention nurse admitted to overdrawing and not discarding the syringes, while the DON confirmed the requirement to date multi-use vials and discard unused pre-drawn medications.
A facility failed to ensure proper medication administration for a resident with a feeding tube. The resident, who was severely cognitively impaired and dependent on tube feeding, did not receive medications correctly as LVN C did not clamp the tube between administrations, allowing air to enter the stomach. This was against the facility's policy and standard practices, as confirmed by the DON.
Disrespectful Response to Resident Requests for Assistance
Penalty
Summary
The facility failed to treat one resident with respect and dignity when CNA B and CNA C responded disrespectfully to the resident’s requests for assistance. Resident #1 was an elderly female with diagnoses including shortness of breath, muscle weakness, and cognitive communication deficit, and her BIMS score was 14, indicating intact cognition. Her care plan showed she required assistance with toileting, turning and repositioning, eating, and personal hygiene. Camera footage showed CNA B entered the resident’s room after she asked for help getting up, yelled at her for being impatient, used loud speech and pointing gestures, and then left without assisting her. The resident asked if CNA B was mad at her, and CNA B replied that she was not mad before walking away. Camera footage also showed CNA C enter the resident’s room with the dinner tray, set it up, and throw napkins onto the resident’s lap. When the resident asked for assistance and told him not to go away, CNA C responded, “I have better things to do,” and left the room. Interviews confirmed the behavior was inappropriate and disrespectful; the Regional Nurse, Administrator, DON, CNA B, and CNA C all acknowledged the conduct was not acceptable and that it was a dignity and resident rights issue. The resident’s responsible party stated he had not reported concerns to the DON or Administrator, and no grievance was found in the record. The resident was later discharged from the facility and subsequently died in the hospital related to hospital acquired infection complications.
Failure to Provide Nail Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary ADL services to maintain good grooming and personal hygiene for Resident #2, who was dependent on staff for personal care. Resident #2 was an [AGE]-year-old male admitted on 07/28/2022 with diagnoses including dementia and need for assistance with personal care. His Quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and his care plan identified an ADL self-care performance deficit related to impaired mobility with an intervention to check nail length and trim and clean nails on bath day and as necessary. During observation on 05/26/2026 at 9:33 AM, Resident #2 was sitting in his wheelchair and his fingernails on both hands were approximately 0.3 cm long, extending from the tips of his fingers, and were discolored with tan and green-brown residue under and around the nail beds. The resident was unable to answer questions. A CNA stated that CNAs and nurses were responsible for cleaning and cutting residents’ nails and that she had not noticed Resident #2’s nails. The DON stated that ADL care was expected as needed, that CNAs were responsible for nail care unless the resident had diabetes, and that charge nurses were responsible for monitoring this care. The facility policy stated that routine nail care would be provided on a regular schedule and as needed between scheduled occasions.
Failure to Provide Accessible Survey Results and Inform Residents of Review Rights
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives, and failed to ensure residents were informed of their right to review these survey results. During a confidential group interview with six residents, all residents reported they were not aware they had the right to review recent survey results, that this right had not been discussed with them, and that they did not know where the survey results were located. They stated they would like to know where the results were kept so they could access and review them. In an interview, the Activity Director, who was designated to review resident rights at resident council meetings, stated she had not informed residents about their right to review recent survey results and was unsure where the survey results were located in the facility. The Administrator stated that survey results were accessible in the front lobby and that residents should be aware they can review them without having to ask. However, observation with the Administrator showed that she had to search for the most recent state survey result binder, which was found in a closed cabinet in the front lobby, and there was no notice posted to inform residents or others how to access the survey results. Additionally, the facility failed to provide the resident rights policy prior to exit of the survey.
Failure to Inform Residents of Grievance Process and Provide Accessible Grievance Forms
Penalty
Summary
The facility failed to ensure residents were informed on how to file a grievance or complaint and were not made aware of the facility’s grievance policy, as required by its own policy and resident rights regulations. In a confidential group interview with six residents, all residents reported they did not know how to file a grievance and were unaware of who to approach with individual grievances. All six residents stated they wanted the ability to write down their grievances themselves and submit them to the facility, but reported the facility had not informed them of its grievance policy. Three of the six residents reported there was a binder labeled “grievance” in the resident activity room, but that it did not contain grievance forms. Observation of the grievance binder in the resident activity room showed it contained only blank coloring pages and no grievance forms or information on grievances. The DON stated residents could report grievances to any staff member, who would then enter the grievance into a computerized system, and confirmed there was no specific grievance form available for residents to complete on their own. The Activity Director, who attended resident council meetings, stated she had not discussed grievances or the grievance policy with residents, was unaware of the specific grievance policy, and identified the Administrator as responsible for grievances. The Administrator confirmed she was responsible for overseeing grievances and the grievance policy, stated residents could report grievances orally to staff who would write them down, and acknowledged there was no form available for residents to independently submit written grievances, despite the facility’s policy stating information on how to file a grievance or complaint must be made available to the patient.
Failure to Discard Expired Multi-Dose PPD Vial Used for TB Testing
Penalty
Summary
The deficiency involves the facility’s failure to follow pharmaceutical procedures for multi-dose medications, specifically a vial of Tuberculin Purified Protein Derivative (PPD) stored in the medication room refrigerator for Halls 600-700-800. During an observation with an LVN, surveyors found an open vial of PPD that had been dated more than 30 days earlier, indicating it had not been discarded within the required timeframe. Review of six residents’ immunization records showed that all six had received TB skin tests using PPD from the same lot number as the expired vial on various dates after the 30-day period had passed. In interviews, the LVN responsible for infection prevention stated she performed all TB skin tests, had opened and dated the PPD vial, and acknowledged that facility practice required dating the vial upon opening and discarding it 30 days later. She admitted she forgot to discard the vial and continued to use it beyond 30 days. The DON confirmed that all multi-use vials must be dated when opened and discarded after 30 days unless manufacturer instructions differ, and that all medications must be labeled and checked by nurses for expiration and proper storage. Review of the facility’s “Storage of Medications” policy showed it prohibited the use of discontinued, outdated, or deteriorated drugs or biologicals and assigned nursing staff responsibility for maintaining medication storage, which was not followed in this instance.
Failure to Provide Required Written Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide required written notification of discharge, including the reasons for the move and the right to appeal, to a resident and her responsible party. The notification was not given in writing, in a language and manner they could understand, nor was it provided at least 30 days prior to the discharge as required. Additionally, the facility did not send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman. Interviews revealed that the social worker verbally informed the family member about the need for alternate placement and recommended memory care, but did not initiate a formal 30-day notice. The finance manager and DON were unaware of who was responsible for notifying the Ombudsman, and the family member confirmed that no written notice was received. The Ombudsman also stated she did not receive notification of the discharge. The resident involved was an elderly female with severe cognitive impairment, dementia, Alzheimer's disease, depression, hyperlipidemia, and vitamin deficiency. Her care plan did not include discharge goals or plans, and she was ultimately discharged to a memory care facility. Facility staff cited the lack of a physical address for the responsible party as a reason for not providing the written notice, and there was confusion among staff regarding the process for notifying the Ombudsman. The facility's policy on transfer or discharge was requested but not provided prior to the survey exit.
Failure to Maintain Resident Nail Hygiene and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services to maintain grooming and personal hygiene for a resident who was dependent on staff for care. The resident was an elderly male with a history of cerebrovascular accident, type 2 diabetes, and PTSD, and his MDS assessment documented severe cognitive impairment with no BIMS score recorded. He required extensive assistance of two staff for personal hygiene and was care planned as totally dependent on staff for personal hygiene and oral care, with specific interventions directing staff to check nail length and trim and clean nails on bath day and as necessary. The facility’s written policy on fingernail/toenail care required daily cleaning and regular trimming to keep nails clean and prevent infection. During an observation, the resident was seen lying in bed with a brown substance under all fingernails on his left hand, while the fingernails on his right hand were clean. A CNA, upon viewing the nails, acknowledged they needed to be cleaned and admitted she had not noticed this previously, despite stating that CNAs and nurses were responsible for checking residents’ fingernails daily and providing nail care on shower days or as needed. An LVN confirmed that CNAs were responsible for nail care for non-diabetic residents and nurses for diabetic residents, and that staff were supposed to do daily rounds to check nails for cleanliness and appropriate length. The DON stated her expectation that nail care be provided on shower days or as needed, and that she or her designee conducted routine monitoring rounds, and acknowledged that long and dirty fingernails could be an infection control issue. These observations and interviews showed that staff did not carry out the planned and policy-required nail care for this resident, resulting in unclean fingernails on his left hand.
Failure to Label and Date Multi-Use Ophthalmic Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and labeling of multi-use ophthalmic medications on two medication carts. On one occasion, a CMA administered TheraTears eye drops to a resident with dry eye syndrome; the bottle showed a manufacturer expiration date of 01-2027 but was not labeled with an open date, despite manufacturer instructions to discard 45 days after opening. The resident’s active physician orders instead listed Refresh Liquigel Ophthalmic Gel 1% for dry eye syndrome of bilateral lacrimal glands. During inspection of the Hall 600 medication cart with the same CMA, surveyors observed open, undated bottles of Latanoprost 0.005% eye drops for a resident with ocular hypertension and Pataday allergy eye drops for a resident with dry eye syndrome whose active orders also specified Refresh Liquigel Ophthalmic Gel 1%. The CMA stated that all eye drop solutions should be labeled with the open date and discarded 30 days after opening or per manufacturer instructions, and acknowledged that giving expired medication may not be effective and could be a source of infection. On the Hall 100 medication cart, surveyors observed an open, undated bottle of Latanoprost 0.005% eye drops for a resident with glaucoma, during an observation with an LVN. The LVN reported that the eye drops were administered by evening shift nurses and that she was not the one who opened the bottle, but confirmed that eye drops should be labeled with the open date and discarded 30 days after opening or according to manufacturer labeling, and that failure to do so could result in ineffective medication or infection. In an interview, the DON stated that once a multi-use vial or bottle is opened, staff are required to date it and discard it 30 days after opening unless otherwise directed by the manufacturer, and that all medications must be labeled. The DON further stated that opened TB PPD vials must be dated and discarded after 30 days to prevent use of expired medication, and that use of medication solutions beyond their post-opening expiration could be a source of infection. The facility’s “Storage of Medications” policy stated that discontinued, outdated, or deteriorated drugs or biologicals shall not be used and must be returned to the pharmacy or destroyed, and that nursing staff are responsible for maintaining medication storage.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during urinary incontinence care for one resident. The resident was an older female with Alzheimer’s disease, cerebrovascular accident, anxiety disorder, moderate cognitive impairment (BIMS score of 12), and a need for assistance with personal care. She was frequently incontinent of bladder. During an observed episode of urinary incontinence care, CNA A entered the resident’s room, performed hand hygiene, and donned gloves. CNA A then unfastened the resident’s brief and cleaned the front pubic area using several peri wipes. After cleaning the front pubic area, CNA A did not change gloves or perform hand hygiene before proceeding with the rest of the care. She assisted the resident onto her side, removed and discarded the soiled urine-saturated brief, and cleaned the resident’s buttocks with peri wipes, still without changing gloves or performing hand hygiene. CNA A then placed a clean brief under the resident, repositioned and covered her, and lowered the bed, continuing to use the same gloves. She gathered dirty clothes and trash, then removed her gloves and washed her hands only at the end of care. In interviews, CNA A and the DON both acknowledged that facility policy and expected practice required hand hygiene and glove changes when moving from a contaminated to a clean body site and between dirty and clean tasks, consistent with the facility’s Handwashing/Hand Hygiene policy dated August 2019.
Call Light Not Kept Within Reach of Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system was readily accessible to a resident at the bedside, as required by facility policy and the resident’s care plan. Record review showed the resident was an elderly female with non-Alzheimer’s dementia, hypertension, and anxiety, with a BIMS score of 3/15 indicating severe cognitive impairment. Her comprehensive care plan identified her as being at risk for falls related to impaired mobility and included an intervention to ensure a safe environment by keeping the call light within reach. During an observation, the resident was found sleeping in bed with the call light button on the floor to the right side of the bed, not within her reach. During an interview and observation, a CNA entered the resident’s room, located the call light cord and button on the floor, and then placed it within the resident’s reach. The CNA stated that with the call light on the floor, the resident would not be able to call for help, including if she was incontinent or having an emergency. The DON stated that the expectation was that residents should always have the call light within reach and placed on the resident’s dominant side, and that it was the responsibility of all staff members to ensure this. The Administrator similarly stated that the call light button should always be within residents’ reach, clipped to their clothes or linen where they could reach it. Review of the facility’s “Resident Call light System” policy confirmed that each resident must be provided with a means to call staff directly for assistance from the bed and toileting/bathing facilities, which was not met in this instance.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in four residents who were dependent on staff for assistance with activities of daily living. The residents had long and dirty fingernails, which were not trimmed or cleaned as required. The facility's policy required daily cleaning and regular trimming of nails to prevent infections, but this was not adhered to. Resident #16, a moderately cognitively impaired male, had not received personal hygiene care for the month of September, as evidenced by his long and dirty fingernails. Despite being scheduled for showers and nail care, the staff failed to notice or address his nail condition. Interviews with CNAs and LVNs revealed a lack of awareness and documentation regarding the resident's care needs, leading to the neglect of his personal hygiene. Similarly, Resident #93, who was severely cognitively impaired, had discolored and chipped nails with residue underneath. The staff did not notice the need for nail care until it was pointed out during the survey. Resident #94, who had diabetes, also had long and dirty nails, and the nurse responsible for diabetic residents admitted to not offering nail care recently. Resident #57, who was severely cognitively impaired, had long and thick nails with a brown substance underneath, and despite expressing a desire for nail care, the staff failed to provide it. The facility's failure to adhere to its own policies and procedures for nail care resulted in these deficiencies.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, affecting three of four dietary staff members reviewed for kitchen sanitation. Observations revealed that graham cracker crumbs were not sealed in dry storage, and sugar and flour container lids were sticky with white particles, indicating a lack of proper sanitation. Interviews with the Dietary Manager confirmed that these items should have been sealed and cleaned to prevent contamination. During lunch meal service, dietary staff failed to perform proper hand hygiene. Dietary staff members were observed touching various surfaces with gloved hands and not changing gloves or washing hands afterward. One staff member touched the stove knob and continued to serve food without changing gloves, while another handled meal trays without washing hands. Additionally, a staff member had a torn glove and continued to serve food without changing it. These actions were confirmed through interviews with the staff, who acknowledged the lapses in hand hygiene and glove use. The facility also failed to ensure that food was served at the correct temperature. Specifically, gravy was not checked for temperature before being served, which could lead to food-borne illness. The Dietary Manager acknowledged that the gravy should have been temped to ensure it was hot enough for serving. The facility's policies on food storage, hand washing, and food temperatures were reviewed, highlighting the discrepancies between the policies and the observed practices.
Infection Control Lapses in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene and equipment sanitization by staff members. Specifically, an LVN did not sanitize a bottle of glucose test strips after taking it into a resident's room and failed to perform hand hygiene after removing gloves during a fingerstick blood sugar test and insulin administration for a resident with diabetes. The LVN admitted to forgetting to perform hand hygiene and acknowledged that taking the entire bottle of test strips into the room was a mistake, as it could lead to cross-contamination. Additionally, a CNA did not change gloves or perform hand hygiene while providing incontinence care to another resident. The CNA cleaned the resident's pubic area and buttocks without changing gloves, then proceeded to handle clean items and reposition the resident. The CNA admitted to being nervous and acknowledged the importance of changing gloves and performing hand hygiene to prevent infection spread. Interviews with the Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene after glove changes, after cleaning equipment, and when transitioning between procedures. The DON emphasized that failing to adhere to these protocols posed a risk of cross-contamination and increased infection risk. The facility's hand hygiene policy outlined the necessity of handwashing in various situations, including after glove removal and contact with medical equipment.
Resident's Right to Self-Determination Not Respected
Penalty
Summary
The facility failed to uphold a resident's right to self-determination by not allowing him to schedule his own medical appointments and by involving him inadequately in the rescheduling process. The resident, who had moderately impaired cognition but was independent in mobility, expressed his desire to manage his own appointments, a preference that was not respected by the facility staff. This led to a situation where his appointment with a liver specialist was rescheduled without his consent, causing him distress and a sense of loss of control over his personal affairs. The resident had informed the facility staff about his appointment with a hepatologist and had arranged for a friend to transport him. However, due to a scheduling conflict, the facility's driver rescheduled the appointment without consulting the resident, which upset him. The resident was also informed that the driver would need to attend his appointments, a requirement he disagreed with, as he valued his privacy during medical consultations. Despite his objections, the facility staff did not accommodate his preferences, leading to further frustration. Interviews with facility staff revealed a lack of clear communication and understanding of the resident's rights. The driver and nursing staff were responsible for scheduling and attending appointments, but there was no specific protocol for informing residents about changes or involving them in the decision-making process. The facility's transportation policy was outdated and did not adequately address the resident's rights to self-determination, contributing to the deficiency identified in the report.
Failure to Implement Comprehensive Care Plan for Resident Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #57, which included measurable objectives and timeframes to meet her medical, nursing, and psychosocial needs. Resident #57, a severely cognitively impaired female with multiple diagnoses including acute kidney failure, dementia, and anxiety disorder, was admitted to the facility with a preference for bed baths and staying in bed. However, her care plan did not reflect these preferences, which were identified during observations and interviews. Interviews with various staff members, including CNAs, an LVN, and the DON, revealed a lack of awareness and documentation regarding Resident #57's preferences for bed baths and staying in bed. The facility's policy requires that care plans be reviewed and updated quarterly or upon any change in condition, but this was not adhered to in Resident #57's case. The Patient Care Coordinator was only made aware of these preferences after being informed by the DON, indicating a breakdown in communication and documentation within the care planning process.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, leading to a deficiency in maintaining good foot health. The resident, an elderly female with severe cognitive impairment and multiple health conditions, was admitted to the facility with a need for assistance in activities of daily living, including personal hygiene. Despite these needs, the resident did not receive adequate foot care, as evidenced by her dry, flaky skin and long, thick toenails, which had not been trimmed since her admission. The resident's care plan included interventions for personal hygiene, but there was no documentation of a referral to a podiatrist or any wound care treatment orders. Interviews with staff revealed that the resident's dry and flaky skin had been an ongoing issue since admission, and although lotion was applied, it did not alleviate the condition. The staff, including CNAs and LVNs, were aware of the resident's foot condition but failed to ensure she was seen by a podiatrist or received appropriate nail care. The Director of Nursing (DON) acknowledged the deficiency, noting that CNAs should report skin issues to the charge nurse, who should then assess and contact a physician. The facility's policy on nail care emphasized the importance of regular cleaning and trimming to prevent infections, but this was not adhered to in the resident's case. The lack of proper foot care placed the resident at risk for potential skin and infection control issues.
Improper Catheter Care During Transfer
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, specifically in maintaining the foley catheter drainage bag below the bladder during a mechanical lift transfer. This deficiency was observed during a transfer of a female resident who was moderately cognitively impaired, dependent on two-person assistance for transfers, and had an indwelling catheter. During the transfer, the catheter drainage bag was placed on the arm of the mechanical lift, above the resident's bladder, causing urine to flow back toward the bladder. Interviews with the staff involved revealed a lack of knowledge and training on the proper handling of the catheter drainage bag during transfers. The Unit Manager and CNA involved admitted to not knowing the correct procedure for keeping the bag below the bladder during a mechanical lift transfer. The Director of Nursing confirmed that the catheter drainage bag should always be maintained below the bladder to prevent urinary tract infections, and acknowledged that the facility conducts skills checks annually and as needed when training issues are identified.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with accepted professional principles, specifically in one of the medication rooms. During an observation, an open vial of Tuberculin Purified Protein Derivative (PPD) and four syringes filled with an unknown liquid were found in the medication room refrigerator without proper labeling or dating. LVN B, who was present during the observation, indicated that the infection prevention nurse, Unit Manager D, was responsible for TB skin tests and did not know what was in the syringes. Unit Manager D admitted to drawing up the syringes of Tuberculin PPD and acknowledged that she should have discarded them after overdrawing the previous day. She also admitted to failing to date the vial upon opening it. The Director of Nursing (DON) confirmed that staff were required to date multi-use vials once opened and that pre-drawn medications should be used immediately or discarded. The DON emphasized that unlabeled syringes posed a risk as their contents and the duration since they were drawn were unknown, potentially leading to the use of expired medication.
Failure in Medication Administration via G-tube
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident who required medication administration through an enteral feeding tube. The resident, a severely cognitively impaired female, was dependent on all activities of daily living and received more than half of her total calories through a feeding tube. The resident's care plan and physician's orders specified that medications should be crushed and administered via the G-tube with appropriate flushing before and after each medication. However, during an observation, LVN C did not clamp the tubing between each medication administration, allowing the tube to empty completely, which could introduce air into the stomach. LVN C was observed preparing and administering multiple medications to the resident without clamping the tube between administrations, contrary to the facility's policy and standard nursing practices. The Director of Nursing confirmed that the proper procedure was to clamp the tube to prevent air from entering the stomach, which could cause reflux and discomfort. Despite having been deemed competent in the procedure, LVN C was unaware of the need to clamp the tube, leading to a deficiency in the facility's pharmaceutical services.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 127 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Denison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlands Place Rehabilitation Suites | 2 mi | ★★★★★ | 14 | 0 |
| Denison Nursing And Rehab | 2.2 mi | ★★★★★ | 3 | 0 |
| The Terrace At Denison | 3.3 mi | ★★★★★ | 23 | 0 |
| The Homestead Of Denison | 3.5 mi | ★★★★★ | 9 | 0 |
| Avir At Sherman | 3.7 mi | ★★★★★ | 5 | 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.