Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belterra Health & Rehab during CMS and state inspections, most recent first.
Baseline care plans were not developed within 48 hours for four residents, and the plans that were present did not include the minimum information needed to meet immediate needs. The records showed missing care planning for oxygen therapy, feeding tube care, colostomy and catheter care, and multiple diagnoses including DM, HTN, CHF, MI, cellulitis, pain, depression, atrial fibrillation, and urinary retention; staff interviews confirmed the baseline care plans were incomplete and that the expected process was not consistently followed.
A resident with severe cognitive impairment exited the facility unnoticed and was later found at a nearby store after being away for about 20 minutes and falling backward off a decorative rock. In addition, germicidal wipes were left within residents’ reach in two separate areas: on a side table beside a resident receiving IV ABT for discitis and on the floor outside another resident’s room, despite staff stating the wipes should not be left unattended because residents could mistake them for ordinary wipes or be harmed by them.
Medications and topical products were left accessible in resident rooms and on an unattended med cart. Several residents had zinc oxide, pain-relief cream, multivitamins, or a roll-on analgesic on bedside tables or overbed tables, including one resident with dementia and another with Alzheimer’s disease; one resident also had no order for the roll-on product. A container of Biofreeze was also found at the side of an MA’s cart while it was left in the hallway.
Infection control lapses occurred during care for three residents. A CNA placed a catheter bag on a bed, kept the same gloves after touching it, and the blanket that contacted the bag was later used to cover the resident. Another CNA performed incontinent care for a resident with bowel and bladder incontinence and a UTI without changing gloves after touching a trash can and after cleaning the resident’s bottom. A third CNA emptied a catheter bag and checked a brief without wearing a gown for a resident on EBP, despite signage indicating gown use was required.
A resident with lumbar spina bifida, weakness, severe cognitive impairment, and bowel incontinence was observed receiving incontinent care with the door closed but the window blinds left open, leaving his genital area exposed to the parking lot. CNA I said he forgot to close the blinds, and CNA J, the DON, ADON, and Administrator all stated the blinds should have been closed to maintain privacy. Facility policy and in-service materials stated that privacy during care required doors and blinds to be closed.
Missing BiPAP Care Plan: A resident with a solitary pulmonary nodule had a physician order for BiPAP use, but the comprehensive care plan did not include BiPAP interventions or measurable goals. Staff interviews showed the BiPAP should have been care planned when the resident started using it, but the order was not communicated to the MDS Coordinator and the need was not captured in the care plan.
Improper Foley Catheter Positioning During Incontinent Care: A resident with an indwelling Foley catheter and severe cognitive impairment had the catheter bag placed on top of the bed during incontinent care, despite the care plan and facility policy requiring the drainage bag to remain below the bladder. CNA staff acknowledged the bag should have stayed below bladder level to prevent backflow, and leadership confirmed that expectation.
A resident with a BiPAP order for bedtime and PRN use was found with the mask sitting unbagged on her side table instead of being stored in a covered device between uses. The resident said the mask had been left there since the night before, and staff had checked on her several times without addressing it. RN D said she had not noticed the issue, while the DON, ADON, and Administrator stated the mask should be bagged when not in use per policy.
Failure to Separate Esomeprazole From Other Medications and Formula: An LVN administered a resident’s esomeprazole through a PEG tube with the resident’s other morning meds and enteral formula instead of giving it by itself. The resident had dysphagia, GERD, and a feeding tube, and staff later stated the PPI should be given on an empty stomach to support absorption. The facility policy required meds to be given in a safe and timely manner with attention to therapeutic effect and food interactions.
Failure to Post Daily Nurse Staffing Information: The facility did not post the required daily nurse staffing log for one day. An outdated staffing log was observed in the entrance area, and the DON, HR, and ADMIN each acknowledged the posting process was handled by administrative staff and that the updated information was not posted as required. The ADMIN stated the posting was meant to show residents, family, and visitors how the facility was staffed.
The facility failed to ensure expired medication administration supplies were removed from the east side medication room, potentially placing residents at risk. Expired supplies, including syringes, were found during an observation. Staff interviews revealed confusion about responsibility for checking expiration dates, with LVN A unsure due to being in training and Central Supply indicating ADONs were responsible, though one was sick with COVID. The facility's policy stated nursing staff should maintain medication storage areas.
A resident with anxiety and seizure disorders received an incorrect dosage of Clonazepam for 155 days due to a transcription error. The resident was supposed to receive 0.25 mg three times a day, but was given 0.5 mg instead. This error was perpetuated by multiple staff members who followed incorrect instructions on the MAR and medication card. The error was discovered during a review by a medication aide and the ADON.
The facility failed to label and secure medications properly, with eye drops on the 500-hall cart lacking open dates and the 200-hall cart left unlocked and unattended. Staff acknowledged the need for open dates to track medication usability, and the DON confirmed that carts should be locked when not in view. Facility policies require dating multi-dose containers and securing medication carts, which were not followed.
The facility's kitchen failed to meet professional standards for food safety and hygiene. Observations revealed improperly labeled and stored food items, including those past their 'best by' dates, and inadequate hand hygiene practices among staff. These deficiencies could lead to foodborne illness and cross-contamination risks for residents.
A facility failed to maintain proper infection control practices when a nurse entered a COVID-positive resident's room wearing only an N95 mask, without a gown, gloves, or face shield, contrary to facility policy. The resident was on strict contact isolation, and the nurse's actions, including placing a tray from the resident's room in the hallway, were against infection control protocols. Interviews with the ADON and DON confirmed the requirement for full PPE in such situations.
Baseline care plans not completed for immediate resident needs
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents reviewed for baseline care planning. For each of these residents, the baseline care plan did not include the minimum healthcare information needed to provide immediate, person-centered care upon admission, and the plans did not reflect goals or interventions for the residents’ current needs. Resident #56 was admitted with diagnoses including respiratory failure with hypoxia, congestive heart failure, epilepsy, edema, shortness of breath, hypertension, atrial fibrillation, benign prostatic hyperplasia, dementia, anxiety, and depression. The resident’s MDS reflected oxygen therapy and a BIMS score of 15. Record review showed the baseline care plan did not address oxygen use or the resident’s other listed conditions. A physician order directed continuous oxygen at 2 LPM via nasal cannula, and a progress note documented oxygen use. During observation, the resident was sitting in a wheelchair and using oxygen via nasal cannula, and the resident stated he had been using oxygen since admission. Resident #83 was admitted with dysphagia, gastro-esophageal reflux, diabetes mellitus, gastrostomy status, hypertension, myocardial infarction, and constipation. The MDS reflected a BIMS score of 09 and indicated a feeding tube. The baseline care plan only addressed dependency on staff and did not include care for the feeding tube, diabetes mellitus, hypertension, myocardial infarction, or constipation. A physician order directed enteral feeding care, including checking tube placement before formula, medication administration, and flushing. A progress note documented that the resident arrived with a patent and intact G-tube, and during observation the resident was seen with a G-tube in the right upper quadrant of the abdomen. Resident #109 was admitted with cellulitis, injury to the left kidney, pain, hypertension, and heart block. The MDS reflected that the resident was cognitively intact with a BIMS score of 15 and was on oxygen therapy. The baseline care plan only addressed full code status and ADL self-care deficit and did not address oxygen use or the resident’s other diagnoses. A physician order directed continuous oxygen at 2 LPM via nasal cannula, and a progress note documented that the patient was admitted on oxygen therapy at 2 liters via nasal cannula. Resident #120 was admitted with diabetes mellitus, neoplasm of the digestive system, hypertension, depression, atrial fibrillation, neuromuscular dysfunction of the bladder, and urinary retention. The MDS reflected a BIMS score of 13 and indicated an ostomy and indwelling catheter. The baseline care plan did not address the colostomy bag, catheter, hypertension, diabetes mellitus, or neoplasm of the digestive system, and it did not include the resident’s other listed conditions. A physician order directed colostomy care, and a progress note documented that the patient was admitted with a left lower quadrant colostomy.
Failure to Supervise Resident Elopement and Secure Germicidal Wipes
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for three residents. One resident with unspecified dementia, major depressive disorder, and type II diabetes, and with severe cognitive impairment on MDS/BIMS testing, exited the facility without staff knowledge on 04/13/2026 and was later found at Walgreens, approximately 528 yards from the facility, after being away for about 20 minutes. The resident had no elopement risk identified on prior assessments and no care plan areas for wandering or elopement. The incident report stated he had been sitting on a decorative rock at the store, fell backward, and was assisted by store staff before the facility was notified. The incident documentation and interviews showed that staff were unaware the resident had left the building until the store employee called the facility. The DON stated the resident appeared to have followed a group of women out of the front door after an activity, and staff then retrieved him using the facility van. The resident was assessed on return, and the record later reflected he was placed on 1:1 supervision until discharge. The report also noted that the resident had gait imbalance and impaired memory and was ambulating without assistance at the time of the incident. The facility also failed to keep germicidal wipes out of resident areas. In one room, an opened container of germicidal wipes was observed on a resident’s side table beside snacks and ordinary wipes while the resident was receiving IV meropenem for discitis and had a BIMS score of 14. In another area, a container of germicidal wipes was observed on the floor in front of another resident’s room; that resident was cognitively intact with a BIMS score of 14 and was also receiving IV meropenem for acute cystitis with hematuria. Staff interviewed about both observations stated the wipes should not have been left within residents’ reach and could be mistaken for ordinary wipes or cause irritation if used by residents.
Medications and Topical Products Left Accessible in Resident Rooms and on an Unattended Cart
Penalty
Summary
The facility failed to keep drugs and biologicals stored in locked compartments and within proper control of authorized staff when multiple residents had medications or topical products left inside their rooms and one medication cart was left unattended with a topical product accessible. During observations on 04/21/2026, Resident #71, who had spondylosis and radiculopathy and was cognitively intact with a BIMS of 15, was found awake in bed with a tube of pain reliever cream on top of the side table in plain view. The resident stated the cream had always been on the table and that nobody had asked him about it. Resident #102, who had depression and dementia with a BIMS of 09 and no documented assessment for self-administration of medications, was observed awake in bed with a tube of zinc oxide, two sachets of zinc oxide, and a bottle of multivitamins on top of the side table. The resident said staff used the zinc oxide when cleaning and changing her brief, and that the vitamins were hers and staff knew she had them in her room. Resident #63, who had dementia and age-related cognitive decline and no documented assessment for self-administration of medications, was observed with an open sachet of zinc oxide on the side table and said staff gave it to her to apply when her bottom was sore. Resident #79, who had Alzheimer’s disease, transient visual loss, and bowel and bladder incontinence with a BIMS of 07 and no documented assessment for self-administration of medications, was observed with a tube of zinc oxide on the side table in plain view and said staff always left it there for use during care. Resident #107, who had complex regional pain syndrome and benign hypostatic hyperplasia with a BIMS of 14, was observed with a tube of zinc oxide and a roll-on pain reliever on the overbed table; the physician order review showed no order for the roll-on pain relief. In addition, a container of Biofreeze was observed in the bin at the side of MA K’s medication cart while the cart was left unattended in the hallway. MA K and LVN F stated medications should be locked in the cart and not left unattended, and the DON, ADON, and Administrator stated medications and barrier creams should not be inside residents’ rooms or within reach of residents.
Infection Control Lapses During Catheter and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents who were reviewed for infection control concerns. During observation of incontinent care for a resident with a Foley catheter and severe cognitive impairment, CNA J placed the resident’s catheter bag on top of the bed near the resident’s feet, where it remained during care and became entangled with the blanket. CNA J also assisted with fixing the brief without changing gloves after touching the catheter bag. CNA I then used the same blanket that had contacted the catheter bag to cover the resident after care was completed. Both CNAs stated during interview that the catheter bag should not have been placed on the bed and that touching it should have prompted glove changes because it was dirty and could cause infection. For another resident with bowel and bladder incontinence and a diagnosis of urinary tract infection, CNA H performed incontinent care after washing hands and putting on gloves, then touched the trash can, handled the brief, cleaned the resident’s perineal area, rolled the resident, and cleaned the resident’s bottom. After cleaning the bottom, CNA H pulled the brief from the side of the resident and placed it under the resident without changing gloves. During interview, CNA H stated she should have changed her gloves after touching the trash can and after cleaning the resident’s bottom because the gloves were dirty and not changing them could result in infection. For a third resident with an indwelling catheter and a care plan for Foley care each shift, CNA G entered the room, emptied the catheter bag, and did not wear a gown while doing so. She then checked the resident’s brief for wetness while leaning on the catheter tubing and bag. A sign outside the room indicated the resident was on EBP. CNA G stated she should have worn a gown because the resident had a catheter and that the risk was transferring microorganisms from one resident to another. The DON and ADON stated that staff should wear gowns for residents on EBP, change gloves after touching dirty items, and not place the catheter bag on the bed, and the Administrator stated staff were expected to follow hand hygiene, EBP, and infection control policy.
Failure to Maintain Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure Resident #4’s privacy during incontinent care when CNA I and CNA J did not close the window blinds while providing care. Resident #4 was a [AGE]-year-old male admitted with lumbar spina bifida and weakness, and his MDS reflected severe cognitive impairment with a BIMS score of 05 and bowel incontinence. His care plan included assistance during toilet use. During an observation, the resident’s bed was positioned parallel to a window overlooking the parking lot, and there was no curtain. CNA J closed the door, but CNA I did not close the blinds before beginning incontinent care, and the resident’s genital area remained exposed until the care was completed while the blinds stayed open. During interviews, Resident #4 stated staff never closed his blinds when changing him and that he had gotten used to it. CNA I stated he was focused on performing the incontinent care and forgot to close the blinds, and acknowledged they should be closed during such care. CNA J stated the blinds should have been closed to provide privacy, and the DON, ADON, and Administrator all stated that privacy should have been maintained by closing the blinds during care. The facility policy on resident rights stated employees shall treat residents with kindness, respect, and dignity, including privacy, and the in-service on resident rights to privacy stated that during resident care, privacy needed to be maintained at all times and doors and blinds needed to be closed.
Missing BiPAP Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #26 that included measurable objectives and timeframes to meet the resident’s medical, nursing, and psychosocial needs. Resident #26 was an [AGE]-year-old female admitted to the facility with a diagnosis of a solitary pulmonary nodule and was cognitively intact with a BIMS score of 15 on the comprehensive MDS assessment dated 03/31/2026. The resident’s comprehensive care plan dated 04/17/2026 did not include a care plan for her BiPAP, even though a physician order dated 04/16/2026 directed BiPAP IPAP 10, EPAP -6 QHS and PRN/naps at bedtime related to the solitary pulmonary nodule. During observation and interview on 04/21/2026, Resident #26 was in bed awake, and a nasal pillow BiPAP mask was observed on her side table. The resident stated the Respiratory Therapist had brought the BiPAP five days earlier and that she had been using it since then. During later interviews, the MDS Coordinator stated the BiPAP should have been care planned when the resident started using it and that the order had not been communicated to her; the DON stated the BiPAP should have been care planned and communicated to the MDS Coordinator; the ADON stated the MDS Coordinator was doing the care plans and did not know why the BiPAP was not captured. The Administrator stated all residents should have a care plan in line with their needs and that without the care plan, staff would not know the goals and interventions needed by the residents.
Improper Foley Catheter Positioning During Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with an indwelling Foley catheter and a diagnosis of reflux neuropathic bladder. The resident’s MDS reflected severe cognitive impairment with a BIMS score of 05, and the care plan directed staff to position the catheter and tubing below the level of the bladder. During observation of incontinent care, CNA I and CNA J were preparing to provide care when CNA J asked for the resident’s catheter bag and placed it on top of the bed near the resident’s feet. The catheter tubing was observed to contain urine, and the bag remained on top of the bed throughout the incontinent care. During interviews, CNA I stated he knew the catheter bag should always be below the bladder to prevent urine from flowing back into the resident, but he did not anticipate that CNA J would place it on the bed. CNA J stated she did not realize the bag should not be placed on top of the bed and acknowledged it should have been kept below the bladder; she said she placed it there because she was afraid the tubing might be pulled during turning. The DON, ADON, and Administrator all stated the catheter bag should always be below the bladder to prevent backflow of urine, and the facility policy also stated the drainage bag must always be positioned lower than the bladder to prevent urine from flowing back into the bladder.
BiPAP Mask Left Unbagged When Not in Use
Penalty
Summary
Resident #26, a cognitively intact female with a BIMS score of 15 and a diagnosis of a solitary pulmonary nodule, had a physician order for BiPAP use at bedtime and as needed. The resident’s physician orders also directed staff to ensure the CPAP/BiPAP humidification chamber was full and clean, to clean the mask and related equipment with soap and water, and to store the mask in a covered device when not in use. Her comprehensive care plan, dated 04/17/2026, did not include a care plan for her BiPAP. During an observation and interview on 04/21/2026 at 9:10 a.m., the resident was in bed awake and her BiPAP mask was observed on her side table, unbagged. The resident stated the mask had been on the table since the night before and that staff had checked on her several times without addressing it or providing a bag. RN D later stated she had not noticed the mask was not bagged and said she would get a bag, clean the mask, and place it inside the bag. The DON, ADON, and Administrator each stated that the BiPAP mask should be stored in a plastic bag when not in use, and the facility policy also directed that masks be placed and stored in a covered device between uses.
Failure to Separate Esomeprazole From Other Medications and Enteral Formula
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #83 when LVN F administered esomeprazole together with the resident’s other morning medications and enteral formula through the PEG tube. Resident #83 was a [AGE]-year-old male admitted on [DATE] with diagnoses including dysphagia and gastro-esophageal reflux, and his MDS reflected moderate cognitive impairment with a BIMS score of 09 and the presence of a feeding tube and GERD. Resident #83’s physician orders included esomeprazole 40 mg packet via PEG tube daily, mixed with water and given through the G-tube, along with carvedilol, a multivitamin, senna, and bolus enteral nutrition five times daily. The esomeprazole order did not specify administration on an empty stomach. During observation, LVN F prepared five medications, administered them one-by-one through the G-tube with water flushes between each medication, gave esomeprazole last, then flushed the tube again and administered the formula. The medication was not given on an empty stomach. During interview, Resident #83 stated his morning medications were given at the same time and that no medication was given before the others. The DON later stated she had spoken with the pharmacist and was told esomeprazole should be given by itself and on an empty stomach to ensure effectiveness. LVN F stated he changed the schedule so the esomeprazole would be given one hour before the rest of the medications and morning formula, explaining that food or liquid could hamper absorption. The facility policy stated medications are to be administered in a safe and timely manner as prescribed, considering optimal therapeutic effect and preventing potential medication or food interactions.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily, as the required daily staffing document was not posted for 04/20/26. During an observation on 04/21/26 at 5:35 AM, a document labeled Daily Staffing Log dated 04/19/2026 was seen posted in a plastic protector on a desk in the entranceway across from the ADMIN's office. The document listed staff titles including RN, LVN, CNA, and Certified Med Aide, along with the number of staff, hours, total hours worked for each title, total hours worked, and the daily census. Record review showed the facility did not complete and post the nursing staff information for 04/20/26. During interview, the DON stated she knew the required nurse staffing document had to be posted but said she was not responsible for posting it and that an administrative staff member did it daily. HR stated the task had been assigned to administrative staff and acknowledged the updated posting was not done because it had not been replaced in time, describing it as an oversight. The ADMIN stated the posting should include the facility name, census, and nursing breakdown, and said the posting was intended to let residents, family, and visitors see how the facility was staffed.
Expired Medication Supplies Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, specifically in the east side medication room. During an observation, expired medication administration supplies, including boxes of syringes with and without needles, were found stored on the shelves. LVN A, who was present during the observation, indicated that she believed central supply was responsible for checking expiration dates but was unsure due to being in training. The Director of Nursing (DON) stated that Assistant Directors of Nursing (ADONs) were responsible for monitoring medication rooms for expired supplies, with checks scheduled on Mondays and Thursdays. Additionally, a pharmacy consultant was reported to check the medication room monthly, and central supply was supposed to check on Wednesdays. Interviews with staff revealed a lack of clarity and accountability regarding the responsibility for checking expiration dates on supplies. ADON B mentioned that everyone should check expiration dates before using supplies and acknowledged that expired supplies could affect their integrity. Central Supply stated that the ADONs were responsible for checking expiration dates, but one was currently sick with COVID. Central Supply also mentioned that the pharmacy consultant checked some items, but he only checked the dates on over-the-counter medications, not the supplies. The facility's policy indicated that nursing staff were responsible for maintaining medication storage areas and ensuring outdated drugs or biologicals were returned or destroyed.
Medication Error in Clonazepam Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Clonazepam. The resident, a male with anxiety and seizure disorders, was supposed to receive 0.25 mg of Clonazepam three times a day. However, due to a transcription error, the medication was administered as 0.5 mg three times a day for 155 days. This error was perpetuated by 15 different staff members who followed the incorrect dosage instructions on the medication administration record (MAR) and the medication card. The error was discovered when a medication aide (MA) and the Assistant Director of Nursing (ADON) reviewed the medication instructions and realized the discrepancy between the MAR and the physician's order. The Director of Nursing (DON) acknowledged the transcription error and noted that the pharmacy consultant was responsible for monitoring medications monthly. Despite the error, the nurse practitioner (NP) stated that the resident received the intended dose, and there were no concerns with the facility following orders. The facility's policy on administering medications requires adherence to prescriber orders, which was not followed in this case.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards. Specifically, on the 500-hall medication cart, several bottles of eye drops, including timolol, dorzolamide, brimonidine, and latanoprost, were found open without any open dates. This oversight was acknowledged by multiple staff members, including Medication Aides (MAs) and the Assistant Director of Nursing (ADON), who confirmed that open dates are necessary to track the usability of the medications. The Director of Nursing (DON) and the pharmacy consultant provided conflicting information regarding the necessity of open dates, with the DON eventually stating that the manufacturer's expiration date would be used, except for latanoprost, which has a specific post-opening usage period. Additionally, the facility failed to secure medications properly on the 200-hall medication cart. An RN left the cart unlocked and unattended in the hallway with a pill in a medicine cup on top of the cart while attending to a resident in their room. This lapse in protocol was recognized by the RN, who admitted the cart should have been locked or positioned closer to the resident's door. The DON reiterated that medication carts should always be locked when not in direct view of the administering staff to prevent unauthorized access or potential medication misappropriation. The facility's policies on administering and storing medications, revised in April 2019, require that multi-dose containers be dated upon opening and that medication carts remain locked when out of sight. These policies were not adhered to, as evidenced by the observations and interviews conducted during the survey. The lack of adherence to these protocols poses a risk of medication errors and unauthorized access to medications, although no specific incidents of harm were reported in the findings.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their main kitchen. Several food items in both the refrigerator and dry storage room were not labeled or stored according to professional standards. Items such as prune juice, coleslaw salad mix, and various meats and cheeses were either missing discard dates or were past their 'best by' dates. Additionally, some food items were improperly labeled, such as a bag containing a tomato and onion, which lacked clear labeling and discard dates, potentially leading to foodborne illness. The facility also failed to ensure proper hand hygiene among dietary staff. Observations revealed that staff members did not wash their hands or change gloves after touching other surfaces or upon re-entering the kitchen. This included instances where staff handled food and kitchen equipment without washing their hands or changing gloves, increasing the risk of cross-contamination and foodborne illness among residents. Furthermore, the handwashing sink's trash receptacle was not functioning properly, which could hinder proper hand hygiene practices. The facility's Nutrition Services Policy and the U.S. FDA Food Code were not followed, as evidenced by the improper storage, labeling, and handling of food items, as well as inadequate hand hygiene practices. These deficiencies could place residents at risk for foodborne illness and cross-contamination.
Inadequate Infection Control Practices for COVID-Positive Resident
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by improper infection control precautions taken by RN D when entering the room of a resident on droplet precautions due to a positive COVID test. The resident, a [AGE] year-old female with diagnoses including diabetes, morbid obesity, and gangrene, was on strict contact isolation. Despite the presence of a droplet isolation sign and available isolation supplies, RN D entered the resident's room wearing only an N95 mask, without a gown, gloves, or face shield, contrary to the facility's policy and the instructions provided by the ADON and DON. Additionally, RN D exited the resident's room and placed a medicine cup on the medication cart before reentering the room, and later placed a tray from the resident's room on a table in the hallway, actions that were against the facility's infection control protocols. Interviews with the ADON and DON confirmed that all staff should wear full PPE, including an N95 mask, gown, gloves, and face shield, when entering a room with a COVID-positive resident, and that trays should not be removed from isolation rooms. The facility's policy also required all PPE to be discarded and reapplied each time a COVID room was entered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mckinney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Of Mckinney | 3 mi | ★★★★★ | 0 | 0 |
| North Park Health And Rehabilitation Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Mckinney Healthcare And Rehabilitation Center | 4.4 mi | ★★★★★ | 1 | 0 |
| Baybrooke Village Care And Rehab Center | 5.4 mi | ★★★★★ | 20 | 0 |
| The Belmont At Twin Creeks | 6.7 mi | ★★★★★ | 6 | 0 |
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