Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bear Creek Nursing And Rehabilitation during CMS and state inspections, most recent first.
Therapeutic Supplement Not Served With Meal: A resident with severe cognitive impairment, malnutrition, adult failure to thrive, and recent weight loss had an order for Magic Cups with lunch and dinner, but the lunch meal ticket did not include the supplement and it was not served. Staff interviews confirmed the supplement was missed because it was not reflected on the meal ticket, and the DM, Dietitian, ADON, and previous DM all stated the order should have been communicated through the meal ticket system for the kitchen to include it.
A resident with ESRD, DM, and severe cognitive impairment received hemodialysis, but the chart lacked a dialysis order and the dialysis pre/post communication forms were not completed. Staff and leadership confirmed the resident went to dialysis on a regular schedule, yet the EHR did not include the required dialysis details, and several dialysis forms had only the pre-dialysis section filled in or had blank post-dialysis sections. The DON and ADON stated the forms were meant to communicate the resident’s condition and monitor for changes after dialysis.
Expired Simethicone and Benzonatate were found in a nurse cart, including a PRN cough medication prescribed to a resident with COPD and dementia. The LVN said nurses were responsible for checking expiration dates, the ADON said one cart was missed during audit, and the DON said nursing management was responsible for cart audits and staff were expected to verify expiration dates when administering meds.
A resident with severe cognitive impairment, malnutrition, adult failure to thrive, and recent weight loss had an order for Magic Cups with lunch and dinner. Staff confirmed the lunch supplement was not served because it was missing from the meal ticket, yet an RN signed the MAR as if it had been given. The RN said he assumed the resident received it without checking the tray, and the ADON and DON confirmed the documentation was inaccurate.
A resident with Alzheimer’s disease and Parkinson’s disease was receiving hospice services, but the EHR did not contain a physician order for hospice care. Staff interviews confirmed the order was never entered, even though the resident had been on hospice for months, and the facility’s hospice policy required coordination with hospice and obtaining hospice-specific physician and attending physician orders.
A resident with multiple complex medical conditions was administered several medications not prescribed to him after a nurse entered orders from mixed-up transfer records without proper verification, and the physician signed off without reviewing diagnoses. The error was discovered after the resident became unresponsive and was hospitalized with acute renal failure, aspiration pneumonia, and sepsis. The facility's investigation confirmed that the medication errors resulted from inadequate verification and reconciliation processes during admission.
A resident with multiple complex medical conditions was administered several medications not prescribed to him after admission, due to a failure in verifying and reconciling physician orders and medication lists. The error occurred when another patient's MAR was mixed into the admission paperwork, leading to the entry and administration of incorrect medications. The resident was later found unresponsive and required hospitalization for acute renal failure, aspiration pneumonia, and sepsis.
A resident with severe cognitive impairment had multiple grievances filed by her responsible party regarding medication administration, unexplained bruising, and the need for a podiatrist appointment. Facility staff failed to promptly resolve these grievances or keep the responsible party informed of progress or outcomes, with no documented communication or resolution provided.
A resident with severe cognitive impairment was found to have two prescribed medications, Labetalol HCl and Pantoprazole Sodium, on the floor near her bed. The medications were discovered by the resident's friend, who notified an LVN. The LVN confirmed the medications had been documented as administered and did not re-administer them, but documentation of the incident was missing from the 24-hour report. This event demonstrated a failure to store medications securely and ensure proper documentation.
Two residents in an LTC facility experienced significant medication errors involving Lorazepam. One resident received the medication without an active order, while another was given an incorrect dosage on two occasions. The errors were due to nurses not verifying orders and failing to follow medication administration policies. No adverse effects were reported.
The facility failed to provide full visual privacy for four residents due to missing privacy curtains, despite the presence of curtain rails and clips. Observations and interviews revealed that residents were left exposed during personal care, and staff were unaware of the missing curtains. The facility's Dignity policy did not specifically address privacy curtains, contributing to the deficiency in maintaining resident privacy and dignity.
A facility failed to include a resident's use of the antidepressant Sertraline in her care plan, despite her severe cognitive impairment and diagnoses of dementia and major depressive disorder. The resident received Sertraline daily without adverse effects, but the omission in the care plan meant staff might not have been fully informed about her care needs. Interviews with staff confirmed the oversight, highlighting the importance of complete and accurate care plans.
The facility failed to maintain safe sharps disposal practices, resulting in overfilled sharps containers in residents' bathrooms. Observations showed that the containers were filled past the fill line, with used lancets placed on top, creating a safety hazard. Interviews with staff revealed confusion about responsibility for changing the containers, and the facility's policy was not followed, posing a risk of exposure to bloodborne pathogens.
A facility failed to follow physician orders for a resident's enteral feeding tube, which required flushing with 55 mL of water every hour. Instead, the water flush rate was set at 100 mL every 4 hours. The charge nurse admitted to not checking the settings, and the ADON and DON were unaware of the issue until it was reported. This oversight could potentially lead to dehydration for the resident.
A resident with severe cognitive impairment and a need for scheduled pain medication was administered a Lidocaine 4% patch instead of the prescribed 5% patch due to a shortage. The medication aide did not inform the charge nurse or obtain a new order, leading to a failure in providing the intended therapeutic benefit. The ADON and DON were unaware of the issue, and there was no schedule for auditing medication carts, contributing to the oversight.
The facility failed to label opened medications in the nurse's cart for the 100 and 200 halls, including insulin, inhalers, and nasal sprays, with the open date. This oversight was confirmed through staff interviews, revealing a lack of adherence to labeling protocols and insufficient auditing by nursing management.
The facility failed to maintain an infection control program by storing a flu swab specimen in a medication refrigerator instead of the designated specimen refrigerator. This was discovered during an observation with an LVN, who was unaware of the misplacement. Interviews with the ADON and DON revealed expectations for proper storage to prevent cross-contamination, but no recent in-service training had been conducted. The facility's policy requires separate, labeled storage for medications and specimens.
A facility failed to notify a resident, her representative, and the ombudsman in writing about her discharge due to the facility's inability to manage her peritoneal dialysis needs. The resident, who was cognitively intact, was transferred to a hospital without receiving the required written notice detailing the discharge's effective date, reason, location, or appeal rights. This oversight violated the facility's policy and the resident's discharge rights.
A facility failed to provide adequate dialysis care for a resident requiring peritoneal dialysis due to untrained staff. The resident, who was expected to manage her dialysis independently, required assistance that the facility could not provide. Interviews revealed that staff, including CNAs and LVNs, were not trained to assist with the procedure, leading to the resident's discharge to a hospital. The facility's policy required training for staff caring for residents with end-stage renal disease, but this was not implemented.
A facility failed to notify a resident's representative before administering Lorazepam, as required by the resident's medical record instructions. The resident, on hospice care for terminal illnesses, had a representative who requested to be informed before any PRN medication was given. Despite this, an LVN administered the medication without prior notification, leading to dissatisfaction from the representative. Interviews confirmed the oversight, and the DON acknowledged the failure to adhere to the representative's request.
A facility failed to notify a physician of a diabetic resident's significant condition change, leading to hospitalization for diabetic ketoacidosis and severe sepsis. The resident's elevated blood glucose levels were not communicated, and routine monitoring was lacking, resulting in a critical health decline.
A diabetic resident in a LTC facility experienced severe health decline due to neglect in monitoring blood glucose levels. The resident, with multiple health issues, was not properly assessed or monitored after being taken off insulin. Despite elevated glucose levels, the facility lacked a system for routine checks, leading to the resident becoming unresponsive and being diagnosed with diabetic ketoacidosis and severe sepsis. Staff interviews revealed communication and oversight failures, contributing to the resident's condition.
A diabetic resident experienced a severe health decline due to the facility's failure to monitor and manage their condition. Despite a history of diabetes, the resident did not receive routine blood glucose checks or A1C labs, and elevated glucose levels were not communicated to medical professionals. This lack of oversight led to the resident's hospitalization for diabetic ketoacidosis and severe sepsis.
A resident with dementia and Parkinson's disease experienced multiple care deficiencies, including unauthorized medication changes, worsening pressure injuries, and inadequate repositioning. The resident's representative raised numerous grievances about these issues, but the facility failed to document, investigate, or resolve them, leaving the resident's care needs unmet.
Therapeutic Supplement Not Served With Meal
Penalty
Summary
The facility failed to ensure Resident #76 received his ordered therapeutic nutrition supplement during the lunch meal service. Resident #76’s records showed he was a readmitted male with severe cognitive impairment, malnutrition, adult failure to thrive, and cognitive communication deficit, and his MDS reflected recent weight loss. His order summary and nutritional assessment documented an order for Magic Cups twice daily with lunch and dinner, and his care plan addressed unexpected/unintended weight loss related to poor appetite and eating 50% of meals, with an intervention to offer high calorie, nutrient-dense supplements as ordered. On 05/06/26, Resident #76’s lunch meal ticket did not include the Magic Cup. Observation during lunch showed the resident waiting in the dining room and then receiving a tray with grilled cheese sandwiches, chips, ice cream, and tea, but no Magic Cup. The resident’s family member stated the resident had previously lost weight and was supposed to receive a milkshake-like supplement with meals, but it was missing that day. Staff interviews confirmed the supplement was not served because it was not listed on the meal ticket. The DM stated he was handling lunch service that day because the regular DM did not report to the facility, and he said the Magic Cup was normally supposed to be on the meal ticket but was not listed for Resident #76. The Dietitian, ADON, and previous DM all stated the supplement was intended to be included with the resident’s lunch and dinner meals and that the meal ticket system was used to communicate those orders to the kitchen. The previous DM said he was responsible for entering the Dietitian’s orders into the system and was not sure how the order was missed, and he also stated he had not had time to audit whether nutritional supplements were reflected on meal tickets and being received as ordered.
Missing Dialysis Orders and Incomplete Dialysis Communication Forms
Penalty
Summary
The facility failed to ensure dialysis communication forms were completed for a resident who required hemodialysis and failed to ensure there was an order in the chart for dialysis treatment. Resident #85 was admitted with renal insufficiency/renal failure or end-stage renal disease, diabetes mellitus, and severe cognitive impairment, and her record reflected that she received hemodialysis services. Her progress note on admission documented dialysis on Tuesdays, Thursdays, and Saturdays, along with a right chest permacath dressing that was clean, dry, and intact. Review of the resident’s order summary did not show any dialysis orders, and the DON confirmed there was no dialysis order in the electronic record. The ADON stated the dialysis order should include the dialysis days, timing, pickup information, port location, fluid or dietary restrictions, and the dialysis center’s contact information. The facility’s hemodialysis policy also required physician instructions to include the access type and location, dialysis schedule, dialysis facility name and phone number, transportation arrangements, medication instructions, and fluid restriction if requested. The resident’s dialysis pre- and post-assessment forms were also incomplete. For multiple dialysis dates, only the pre-dialysis section was filled out, while the post-dialysis section was blank or missing required information from the dialysis provider. Staff interviews showed the nurse sending the resident to dialysis was expected to complete the pre portion and the receiving nurse was expected to complete the post portion, but the ADON stated the forms were not being completed as expected and there was no monitoring or auditing system in place to ensure completion. The DON stated the purpose of the forms was to monitor the resident after dialysis and to communicate the resident’s condition between the facility and the dialysis center.
Expired Medications Left in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for the 300-hall nurse cart. During observation of the cart with LVN E, surveyors found a bottle of OTC Simethicone 125 mg with an expiration date of 02/26 and a bubble pack of Benzonatate 100 mg prescribed to Resident #29 with an expiration date of 03/26/26 still stored in the cart. Resident #29 was an older female with COPD, chronic respiratory failure without hypoxia, and dementia, and her BIMS score was 8, indicating moderate cognitive impairment. Her care plan included administering medications as ordered, and her order summary showed Benzonatate 100 mg, 2 capsules every 8 hours as needed for cough related to COPD. Record review showed Resident #29 did not receive any as-needed doses of Benzonatate from 03/26/26 through 05/07/26. During interview, LVN E stated the Benzonatate had expired and that nurses were responsible for ensuring there were no expired medications in the carts, while pharmacy also audited the carts. The ADON stated she had completed a cart audit in April 2026 but missed one medication cart, and the expired medications were therefore missed. The DON stated staff responsible for the cart were expected to check expiration dates and that nursing management was responsible for cart audits. The facility's Medication Storage policy stated medications housed on the premises would be stored according to the manufacturer's recommendations.
Inaccurate MAR Documentation for Nutritional Supplement
Penalty
Summary
The facility failed to ensure clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for one resident. RN D documented on the resident’s MAR that the resident received a Magic Cup with lunch, even though the supplement was not actually served. The facility’s documentation policy stated that documentation must be factual, objective, resident centered, accurate, relevant, and complete. Resident #76 was a male with severe cognitive impairment, malnutrition, adult failure to thrive, and cognitive communication deficit. His quarterly MDS reflected recent weight loss, and his care plan included interventions for unexpected unintended weight loss, including offering high calorie/nutrient dense supplements as ordered and recording meal and snack intake in the clinical record. His order summary and nutritional assessment reflected an order for Magic Cups twice daily with lunch and dinner. On the day of the event, the resident was observed in the dining room waiting for lunch because he did not like the meal being served and had requested a grilled cheese sandwich and chips. His lunch tray later included grilled cheese sandwiches, chips, ice cream, and tea. The resident’s family member stated the supplement was missing from the meal. Staff from dietary confirmed the Magic Cup was not on the meal ticket and was not served. RN D stated he did not check the tray, assumed another nurse had checked it, and signed off that the resident received the supplement even though he knew he had not confirmed it. The ADON and DON both stated the resident had not received the Magic Cup and that RN D was responsible for accurately documenting whether it was received.
Missing Hospice Physician Order and Care Coordination
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, and it failed to ensure the resident had a physician order for hospice care. Resident #13 was an elderly female with diagnoses of Alzheimer’s disease and Parkinson’s disease, had a BIMS score of 00 indicating severe cognitive impairment, and was documented as receiving hospice care. Her care plan noted hospice services with an intervention to obtain a physician order and appropriate referral, but the order summary showed no physician order for hospice care services. Record review showed a progress note stating the resident was admitted to hospice and orders were updated on the MAR, but staff interviews confirmed the hospice order was not entered into the physician orders. An LVN stated she normally would place the order but forgot, and an RN stated the resident was on hospice for several months but there was no hospice physician order in the EHR. The DON and ADON both stated a hospice order should be present and that it was important for communication and continuity of care, while the facility’s hospice policy required communication with the hospice medical director, attending physician, and other practitioners, as well as obtaining hospice physician and attending physician orders specific to each resident.
Failure to Ensure Accurate Medication Reconciliation and Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Upon admission, a nurse entered medication orders into the resident's medical record without verifying them against an accurate and current medication list. The records received from the previous facility included another resident's medication administration record (MAR) mixed in with the correct resident's paperwork. As a result, the nurse entered a long list of medications, some of which were not prescribed for the resident, and the facility physician subsequently signed these orders without further verification. The resident, who had multiple diagnoses including Parkinson's disease, vascular dementia, hypothyroidism, bradycardia, hyperlipidemia, anemia, and a cognitive communication deficit, was administered several incorrect medications, including Metformin, Insulin Glargine, Farxiga, Lasix, and Insulin Lispro. These medications were not prescribed for the resident and, in some cases, posed significant clinical risks due to potential drug interactions and the resident's underlying conditions. The care plan did not specify the diagnosis associated with insulin use, and there was evidence of documentation errors, such as another resident's medication action plan being mixed into the records. The error was discovered after the resident was found unresponsive and transferred to the hospital, where he was diagnosed with acute renal failure, aspiration pneumonia, and sepsis. The facility's internal investigation confirmed that the incorrect medications were administered due to the mix-up in records and lack of proper verification during the admission process. Interviews with staff and the physician revealed that the medication reconciliation process was not properly followed, and there was a reliance on nursing staff to accurately enter and verify medication orders without adequate checks.
Removal Plan
- Transfer the resident to the hospital and ensure they no longer reside in the facility.
- The Director of Nursing (DON) or designee conducts a facility-wide review of all residents admitted or readmitted to ensure medication orders are accurately reconciled with hospital discharge instructions and physician orders, including any transfers from other facilities.
- Nursing supervisors verify MAR accuracy, medication availability, and physician clarification as needed. Correct any discrepancies identified immediately.
- The Administrator reviews audit findings and confirms that no additional residents are at risk.
- Terminate the staff member who input the orders.
- All staff are in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members not present are in-serviced prior to working their next shift and before providing resident care. Completion is verified and documented.
- Revise the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse.
- The DON/designee establishes a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified.
- Update the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission.
- The DON/Designee verifies that the admission checklist is completed for all admissions.
- Require DON or designee review of all new admissions and readmissions by next business day.
- The Director of Nursing (DON) or designee provides re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education is provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members not present are in-serviced prior to working their next shift and before providing resident care. Completion is verified and documented.
- Nursing management notifies the Regional Nurse of any significant medication error requiring physician intervention or hospitalization.
- The Regional nurse notifies the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization.
- The Director of Nursing (DON) or designee conducts weekly audits of all new admissions and readmissions for four weeks, then monthly thereafter, to ensure continued compliance with medication reconciliation requirements. Audit results are reviewed by the Administrator and incorporated into the facility's QAPI program. Any identified noncompliance results in immediate corrective action and re-education.
Significant Medication Errors Due to Admission Process Failures
Penalty
Summary
A facility failed to ensure residents were free from significant medication errors, resulting in a resident receiving multiple medications that were not prescribed to him. Upon admission, the admitting nurse entered medications into the resident's medical record without verifying them against an accurate and current medication list. The facility's physician subsequently signed off on these orders without reviewing or verifying the resident's diagnoses with the nurse. The records provided by the transferring facility included another resident's medication administration record (MAR) mixed in with the correct resident's records, leading to the erroneous transcription and administration of medications. The resident, who had a history of Parkinson's disease, vascular dementia, hypothyroidism, bradycardia, hyperlipidemia, anemia, and a cardiac pacemaker, was administered medications including Metformin, Insulin Glargine, Farxiga, Lasix, and Insulin Lispro, none of which were prescribed for him. The MAR and care plan did not accurately reflect the resident's diagnoses or medication needs. The error was discovered after the resident was found unresponsive, with abnormal vital signs and a sudden change in neurological status. The family was notified, and upon review, it was found that the resident had been given medications intended for another patient due to the mixed records. The resident was transferred to the hospital, where he was diagnosed with acute renal failure, aspiration pneumonia, and sepsis. The facility's internal investigation confirmed that the error stemmed from the admission process, where medication reconciliation was not properly performed, and the physician relied on nursing staff for accurate order entry. The incident was determined to be an Immediate Jeopardy situation due to the failure to provide necessary goods and services to avoid physical harm.
Removal Plan
- The resident was transferred to the hospital and no longer resides in the facility.
- The Director of Nursing (DON) or designee conducted a facility-wide review of all residents admitted or readmitted to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders, including any transfers from other facilities.
- Nursing supervisors verified MAR accuracy, medication availability, and physician clarification as needed. Any discrepancies identified were corrected.
- The Administrator reviewed the audit findings and confirmed that no additional residents were at risk.
- The staff member who input the orders was terminated by the DON.
- All staff will be in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members who are not present will be in-serviced prior to working their next shift and before providing resident care. Completion will be verified and documented.
- Revised the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse.
- The DON/designee established a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified.
- Updated the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission.
- The DON/Designee will verify that the admission checklist is completed for all admissions.
- Required DON or designee review of all new admissions and readmissions by next business day.
- The Director of Nursing (DON) or designee will provide re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education will be provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members who are not present will be in-serviced prior to working their next shift and before providing resident care. Completion will be verified and documented.
- Nursing management will notify the Regional Nurse of any significant medication error requiring physician intervention or hospitalization.
- The Regional nurse notified the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization.
- The Director of Nursing (DON) or designee will conduct weekly audits of all new admissions and readmissions to ensure continued compliance with medication reconciliation requirements.
- Audit results will be reviewed by the Administrator and incorporated into the facility's QAPI program.
- Any identified noncompliance will result in immediate corrective action and re-education.
Failure to Resolve and Communicate Grievance Outcomes
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances and did not keep a resident's responsible party (RP) appropriately informed of progress toward resolution. The resident in question was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15, and multiple medical diagnoses including vascular dementia, hypertension, and irritable bowel syndrome. The resident's RP submitted three grievances related to medication administration, unexplained bruising, and the need for a podiatrist appointment. These grievances were submitted on the morning the resident passed away. Record review showed that the facility's Grievance/Concern Report had a blank section for resolution, and there was no documented response or communication of the investigation's findings to the resident's RP. Interviews with facility staff revealed that the DON began investigating the grievances but had to leave for surgery, at which point the investigation was not clearly handed off to the ADON. The ADON did not investigate the concerns or communicate with the RP, and the SW stated she attempted to contact the RP but did not document the attempt or recall if a message was left. As of the time of the survey, the RP had not received any update or resolution regarding the grievances filed. The facility's policy required prompt efforts to resolve grievances and to keep residents or their representatives informed, but this was not followed in this case. The lack of communication and documentation resulted in the RP not being apprised of the findings or resolution of the grievances, despite multiple staff being aware of the concerns and the facility's policy outlining their responsibilities.
Medications Found Unsecured in Resident Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and accessible only to authorized personnel, as required by state and federal regulations. During an observation, two medications prescribed to a resident—Labetalol HCl and Pantoprazole Sodium—were found on the floor, approximately 2-3 inches from the resident's bed. The resident in question was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 2 out of 15, and required partial to maximum assistance with activities of daily living. The medications were discovered by the resident's friend during a visit, who then notified a nurse on duty. Upon being informed, the nurse, who had just started her shift, retrieved the pills from the resident's room and identified them as the resident's morning medications. The nurse checked the medication administration record (MAR) and found that the medications had already been documented as administered, so she did not re-administer them. The nurse also checked the resident's blood pressure and documented the incident in the 24-hour report, as instructed by supervisory staff. However, a subsequent review of the 24-hour report book did not show any documentation of the incident involving the medications found on the floor. Interviews with facility staff, including the ADON and DON, confirmed that the incident was brought to their attention by the resident's friend and that an investigation was initiated to determine how the medications ended up on the floor. The facility's policy on the destruction of unused drugs was reviewed, but there was no evidence that the medications were properly secured or that the incident was fully documented according to policy. The failure to secure medications and ensure proper documentation constituted a deficiency in medication storage and handling.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. For the first resident, a nurse administered a PRN Lorazepam without an active order. The resident, who had Alzheimer's disease, anxiety disorder, and depression, was receiving hospice services. On the day of the incident, the nurse, who was not familiar with the resident, administered the medication based on a colleague's suggestion without verifying the current physician's orders. The nurse realized the error post-administration but did not document it or inform the doctor or the Director of Nursing (DON). The second resident, who had moderate cognitive impairment and non-Alzheimer's dementia, received an incorrect dosage of Lorazepam on two occasions. The nurse administered two tablets instead of one, exceeding the prescribed dosage. The resident's care plan did not reflect the use of PRN Lorazepam, and there was no documentation of the medication administration in the resident's records. The nurse failed to follow the prescribed orders, leading to a medication error. Interviews with the facility's staff, including the DON and Assistant Director of Nursing (ADON), confirmed the medication errors. The staff acknowledged that the nurses involved did not adhere to the facility's medication administration policies, which require verifying the right resident, medication, dosage, time, and method before administration. The errors were considered significant, although no adverse effects were reported for either resident.
Failure to Ensure Resident Privacy Due to Missing Curtains
Penalty
Summary
The facility failed to ensure that resident rooms were equipped to provide full visual privacy for four residents. Observations and interviews revealed that the rooms of these residents lacked privacy curtains, despite the presence of curtain rails and clips on the ceiling. This deficiency was noted during a survey when a resident expressed concern about being seen during personal care, and another resident was found exposed during incontinence care. The absence of privacy curtains was confirmed through multiple observations and interviews with staff, including a CNA who admitted not using the available curtain and a Housekeeping Supervisor who was unaware of the missing curtains. Interviews with the RN, DON, and Maintenance Director revealed a lack of awareness regarding the missing curtains and the process for replacing them. The facility's Dignity policy, which emphasizes maintaining resident privacy, did not specifically address the use of privacy curtains. The deficiency was identified as a failure to maintain resident privacy and dignity, as the absence of curtains left residents exposed during personal care activities.
Failure to Include Antidepressant in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included addressing the use of an antidepressant medication, Sertraline. This deficiency was identified during a review of the resident's records, which showed that although the resident was prescribed Sertraline for depression, her care plan did not reflect this medication. The resident, who had severe cognitive impairment and was diagnosed with unspecified dementia and major depressive disorder, was receiving Sertraline daily without any adverse effects. However, the absence of this information in her care plan meant that staff might not have been fully informed about her care needs and goals. Interviews with facility staff, including an RN, the MDS Coordinator, and the DON, confirmed that the resident's use of Sertraline should have been included in her care plan. The MDS Coordinator acknowledged the importance of having a complete and accurate care plan to ensure that all aspects of the resident's care, including medication management, were addressed. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs, but this was not adhered to in the case of the resident in question.
Failure to Maintain Safe Sharps Disposal Practices
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for four residents by not maintaining sharps containers properly. Observations revealed that the sharps containers in the bathrooms of these residents were filled past the designated fill line, rendering the flaps inoperable. This led to used lancets being placed on top of the flaps, creating a potential safety hazard. The overfilled containers were not addressed over a period of two days, indicating a lack of proper monitoring and maintenance. Interviews with the facility's staff, including an RN, the ADON, and the DON, revealed a lack of clarity regarding who was responsible for changing out the sharps containers. None of the staff members interviewed were aware of a specific policy or designated individual responsible for this task. The facility's Sharps Disposal policy, dated January 2012, stated that designated individuals should replace containers when they are 75-80% full, but this was not adhered to, leading to the potential risk of exposure to bloodborne pathogens for the residents.
Failure to Follow Physician Orders for Enteral Feeding Tube Flushes
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a gastrostomy tube was provided with the appropriate treatment and services to prevent complications. The resident, a female with moderate cognitive impairment, was supposed to have her feeding tube flushed with 55 mL of water every hour as per physician orders. However, observations revealed that the water flush rate was set at 100 mL every 4 hours, contrary to the prescribed orders. This discrepancy was acknowledged by the charge nurse, who admitted to not checking the settings upon her shift commencement, despite being aware of the correct physician orders. Further interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed a lack of oversight and monitoring of the feeding pump settings. The ADON was unaware of the incorrect settings until informed by the charge nurse, and the DON had not conducted audits to ensure compliance with physician orders. The facility's training records indicated that the charge nurse had not attended the relevant competency assessment for enteral tube feeding, which may have contributed to the oversight. The failure to adhere to the physician's orders for water flushes could potentially place the resident at risk for dehydration.
Failure to Administer Correct Medication Dosage
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident, specifically in the administration of a Lidoderm Patch 5% for pain management. The resident, who had a severely impaired cognition and required a scheduled pain medication regimen, was instead administered a Lidocaine 4% patch by a medication aide (MA H) for two days due to the unavailability of the prescribed 5% patch. MA H did not notify the charge nurse about the shortage or obtain a new order for the 4% patch, which was against the facility's medication administration policy. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were unaware of the missing medication until after the error was identified. The ADON acknowledged that there was no schedule for auditing medication carts, which contributed to the oversight. The DON, who was new to the facility, had not conducted prior in-services on medication administration, which may have contributed to the error. The facility's policy requires medications to be administered according to the prescriber's order, and the failure to do so resulted in the resident not receiving the intended therapeutic benefit of the medication.
Failure to Label Opened Medications in Nurse's Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled according to currently accepted professional principles. Specifically, the nurse's medication cart for the 100 and 200 halls contained several opened medications, including a Lantus insulin pen, a Symbicort inhaler, an Azelastine nasal spray, and four boxes of Ipratropium Bromide and albuterol sulfate inhalation solution, none of which were labeled with the open date. This oversight was identified during an observation and was confirmed through interviews with the staff, including LVN A, the ADON, and the DON. Interviews revealed that LVN A acknowledged the responsibility of nurses to label medications with open dates and admitted to not checking the entire cart that morning. The ADON and DON both confirmed the expectation for nurses to check their carts for labeling and expiration every shift, and that it was the responsibility of nursing management to audit the carts. However, a schedule for these audits had not been established due to the newness of the DON. The facility's in-service records indicated that LVN A had not attended the training on labeling and storage, which was conducted to address these issues. The facility's policy required multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer.
Improper Storage of Specimen in Medication Refrigerator
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by improperly storing a flu swab specimen in a medication refrigerator, which was observed during a survey. The specimen, wrapped in plastic paper and dated, was found in the medication room refrigerator for the 100 and 200 halls, instead of being stored in the designated specimen refrigerator located in the 300 and 400 halls. This improper storage practice was identified during an observation with an LVN, who was unaware of the specimen's incorrect placement. The LVN mentioned that she had received in-service training on specimen storage upon hiring, which emphasized the separation of specimens to prevent contamination. Interviews with the ADON and DON revealed that their expectations were for specimens to be stored in the biohazard specimen refrigerator to avoid the risk of cross-contamination with medications. The DON acknowledged awareness of the specimen collection date and the subsequent need to recollect the sample due to its misplacement. However, she was not informed that the specimen was stored in the medication refrigerator and admitted that no in-service training had been conducted for staff regarding proper specimen storage. The facility's policy on the separation of medication and specimen storage mandates that medications and biological specimens must be stored in separate, clearly labeled refrigerators.
Failure to Provide Proper Discharge Notification
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident, her representative, and the ombudsman regarding her transfer or discharge. The resident, who was cognitively intact with a BIMS score of 15, was dependent on renal dialysis and required peritoneal dialysis. The facility initiated the discharge due to their inability to meet the resident's dialysis needs, but did not provide the required written notice detailing the effective date, reason for transfer, location, or appeal rights. Interviews with the resident, her family, and facility staff revealed that the facility was not prepared to assist with the resident's peritoneal dialysis, leading to the decision to discharge her. The family was informed verbally that the facility could not accommodate the resident's needs, and the resident was sent to a hospital without receiving any written discharge notice. The facility's policy required a 30-day advance written notice for planned discharges, which was not adhered to in this case. The facility's administration acknowledged the oversight, with the ADON admitting responsibility for issuing the discharge notice, which was not done. The lack of proper notification could potentially affect all residents transferred or discharged under similar circumstances, as it violates their discharge rights.
Facility Fails to Provide Trained Staff for Peritoneal Dialysis
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident who required peritoneal dialysis, as staff were not trained to assist with the procedure. The resident, a [AGE] year-old female, was admitted to the facility with a diagnosis of dependence on renal dialysis and was expected to manage her peritoneal dialysis independently. However, the facility did not ensure that staff were trained to assist her, leading to inadequate care. Interviews with the resident and her family members revealed that the facility staff were not prepared to assist with the peritoneal dialysis, and the family had to intervene to help the resident. The facility staff, including CNAs and LVNs, confirmed that they were not trained to provide peritoneal dialysis care. The facility's administration acknowledged the lack of training and admitted that they were unable to meet the resident's needs. The facility's policy required staff to be trained in the care of residents with end-stage renal disease, but this was not implemented. The lack of training led to the resident being discharged to an acute care hospital, as the facility could not provide the necessary support for her dialysis needs.
Failure to Notify Resident's Representative Before Administering PRN Medication
Penalty
Summary
The facility failed to extend the right to make decisions on behalf of a resident to the resident's representative. This deficiency was identified when a Licensed Vocational Nurse (LVN A) administered a dose of Lorazepam to a resident without contacting the resident's representative, as was clearly instructed in the resident's electronic medical record. The record explicitly stated in capital letters that the representative should be called before administering any PRN medication. This oversight occurred despite the representative's explicit request to be notified prior to the administration of any PRN medications. The resident involved was an elderly female admitted to the facility on hospice care due to terminal diagnoses, including anxiety, dementia, lung cancer, and bile duct carcinoma. The resident's representative, who was also her emergency contact and power of attorney, had requested to be informed before any PRN medication was given. On the day of the incident, the resident's Medication Administration Record (MAR) showed that Lorazepam was administered without prior notification to the representative, contrary to the documented instructions. Interviews conducted with the resident's representative, hospice nurse, and facility staff confirmed the failure to notify the representative before administering the medication. The Director of Nursing (DON) acknowledged the oversight and noted that the nurse involved was new. The representative expressed dissatisfaction with the lack of communication, emphasizing her right to be informed and involved in the resident's care decisions, as documented in the facility's policies on resident rights.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify the resident's physician of a significant change in the resident's condition, specifically a diabetic resident who experienced elevated blood glucose levels and a decline in willingness to eat. Despite having a blood glucose level of 334, the facility did not inform the physician or conduct further glucose monitoring. This oversight led to the resident becoming unresponsive and being sent to the hospital, where he was diagnosed with diabetic ketoacidosis and severe sepsis, with a blood glucose reading of 1,139 and an A1C of 13. The resident, who had a history of Type 2 Diabetes, was not on any insulin or routine blood glucose monitoring at the facility, despite previous hospitalizations for hyperglycemia. The facility's records showed that blood glucose checks were discontinued, and there was no evidence of routine A1C monitoring as per standard practice. The resident's condition deteriorated over several days, with symptoms such as lethargy, sweating, and vomiting, which were not adequately addressed by the facility staff. Interviews with facility staff revealed a lack of communication and oversight regarding the resident's diabetic management. The Director of Nursing (DON) and other staff members acknowledged that the resident's A1C was not monitored as frequently as it should have been, and there was a breakdown in communication about the resident's condition. The facility's failure to act on the abnormal lab results and the resident's declining condition contributed to the deficiency identified by the surveyors.
Neglect in Monitoring Diabetic Resident Leads to Severe Health Decline
Penalty
Summary
The facility failed to protect a diabetic resident from neglect, resulting in a severe medical condition. The resident, who had multiple health issues including Type 2 Diabetes, was not properly monitored for blood glucose levels after being taken off insulin. Despite having a history of elevated blood glucose levels, the facility did not have a system in place for routine blood glucose monitoring or regular Hemoglobin A1C tests. This lack of monitoring led to the resident experiencing a significant change in condition, including becoming unresponsive and being diagnosed with diabetic ketoacidosis and severe sepsis upon hospital admission. The resident's medical records showed no orders for insulin or routine blood glucose checks for over a year, despite previous hospitalizations for hyperglycemia and sepsis. The facility's staff failed to notify the physician of the resident's elevated blood glucose level of 334, recorded in a lab test, and did not conduct further checks or assessments. The resident's condition deteriorated over several days, with symptoms such as lethargy, refusal to eat, and vomiting, which were not adequately addressed by the facility's staff. Interviews with facility staff revealed a breakdown in communication and oversight regarding the resident's care. The Director of Nursing and other staff members acknowledged that routine blood glucose monitoring and A1C tests were not conducted as required. The facility's failure to implement a proper monitoring system and communicate changes in the resident's condition to the physician contributed to the resident's severe health decline and subsequent hospitalization.
Failure to Monitor and Manage Diabetic Resident's Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for a diabetic resident, leading to a significant decline in the resident's health. The resident, who had a history of Type 2 Diabetes, was not accurately assessed, monitored, or treated for a change in condition after an elevated blood glucose level of 334 was recorded. Over the following weeks, the resident's condition deteriorated, culminating in an unresponsive state and a subsequent hospital admission where a blood glucose level of 1,139 and an A1C of 13 were recorded. The facility's charge nurses did not perform routine blood glucose checks or notify the medical doctor or nurse practitioner of the elevated glucose level, and there was no system in place for regular monitoring of the resident's blood glucose or A1C levels. The resident's care plan, which included monitoring for signs of hypo- and hyperglycemia and notifying the physician if symptoms occurred, was not followed. Despite the resident's history of diabetes and previous hospitalizations for related complications, there were no physician orders for insulin, oral diabetic medication, or routine blood glucose monitoring in the past 12 months. The facility's failure to conduct routine blood glucose checks or A1C labs, as well as the lack of communication with medical professionals regarding the resident's condition, contributed to the resident's severe health decline. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's diabetic management. The Director of Nursing (DON) and other staff members acknowledged that routine blood glucose checks and A1C labs were not conducted as required, and there was a breakdown in communication regarding the resident's change in condition. The facility's failure to implement and monitor effective systems for diabetic care placed the resident at risk for severe complications, as evidenced by the resident's hospitalization for diabetic ketoacidosis and severe sepsis.
Failure to Address Resident Grievances and Care Concerns
Penalty
Summary
The facility failed to promptly address and resolve grievances raised by a resident's representative (RP) regarding the care of a resident with dementia and Parkinson's disease. The resident, who had moderate cognitive impairment and was frequently incontinent, had multiple care concerns that were not documented or investigated by the facility. These concerns included the unauthorized addition of Gabapentin to the resident's medication regimen, worsening and infection of pressure injuries, inadequate repositioning, and improper use of heel boots leading to new wounds. The RP reported that the resident was taken to a doctor's appointment in a soiled state, with urine-soaked clothing and a wheelchair cushion, and returned with crystallized feces on her body. Despite vocal attempts to address these issues with facility staff, including the Director of Nursing (DON) and Administrator, no grievance forms were completed, and no investigations were conducted. The RP also noted that the resident's call light was often out of reach, and there were concerns about the resident's pain management and the application of wound dressings. Interviews with facility staff, including the Administrator, DON, and Corporate Registered Nurse, revealed a lack of documentation and follow-up on the grievances. The Administrator admitted to not completing grievance forms, citing the frequency of complaints from the RP and a judgment call on whether issues warranted formal grievances. The facility's grievance policy was not followed, as grievances were not recorded, investigated, or resolved in a timely manner, leaving the resident's care needs unmet.
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 1,374 citations issued within 25 miles in the last 12 months — including the 53 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 Grapevine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grapevine Medical Lodge | 2.8 mi | ★★★★★ | 0 | 0 |
| Avir At Grapevine | 2.9 mi | ★★★★★ | 11 | 0 |
| Keller Oaks Healthcare Center | 3.5 mi | ★★★★★ | 2 | 0 |
| The Carlyle At Stonebridge Park | 3.9 mi | ★★★★★ | 14 | 1 |
| Discovery Village At Southlake | 4.2 mi | ★★★★★ | 2 | 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.