Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Broadmoor Medical Lodge during CMS and state inspections, most recent first.
A resident with a Foley catheter, type 2 DM, bladder dysfunction, and a stage 4 sacral pressure ulcer, care planned as being at risk for UTI and MDRO acquisition, did not receive care consistent with her catheter care plan and facility policy. During peri care after a bowel movement, a CNA and the ADON changed gloves three times without performing hand hygiene between changes after contact with fecal matter and body fluids, and the urinary drainage bag was placed on the bed at bladder level instead of being maintained below bladder level as required.
A resident with a Foley catheter, stage 4 sacral pressure ulcer, and multiple comorbidities received peri care from a CNA and the ADON who, despite donning PPE and performing hand hygiene before care, failed to perform hand hygiene between three glove changes after contact with fecal matter and body fluids. During the same care episode, the resident’s urinary catheter bag was observed resting on the bed at bladder level instead of being maintained below bladder level as required by the care plan and facility policy. Both staff later acknowledged they should have used hand sanitizer between glove changes and kept the catheter bag below bladder level, and the DON confirmed these expectations and the infection risks associated with noncompliance.
Confidential resident vital signs were left exposed on an unattended nurse cart in a hallway when an LPN left an untitled paper listing eight residents’ names along with BP, pulse, temperature, and O2 saturation visible to passersby. The LPN acknowledged the information was confidential and should have been secured, and the ADON, Administrator, and DON stated the paper should have been turned over, locked away, or otherwise protected from unauthorized viewing.
A resident with legal blindness and cognitive impairment had eyedrops left on an overbed table, another resident had three eyedrops left on an overbed table without an order for them, and a third resident had barrier cream left on a side table while in bed. In addition, an LPN left a vial of breathing treatment medication unattended on top of a cart. Records showed no assessments for self-administration for the residents involved, and the facility policy required drugs and biologicals to be stored in locked compartments.
Kitchen Food Storage and Labeling Deficiency: Surveyors observed multiple dry food items in the kitchen that were not dated, not properly sealed, or exposed to air contaminants, including cereal, rice, sugar, biscuit mix, and graham cracker crumbs. The DC confirmed the findings and stated opened items should be sealed and dated, while the ADM acknowledged the concerns and said expired items should not be served to residents. The facility policy required dry foods to be labeled and dated and opened containers to be sealed or covered during storage.
Staff failed to follow infection control practices during resident care and dining activities. An RN placed barrier cream cups on a resident’s overbed table and then returned them to a cart drawer, a CNA kept gloves in her pocket and used them for incontinent care, and staff did not wear gowns while providing hygiene and dressing care for a resident on EBP with a feeding tube. In the dining area, an RN passed plates without hand hygiene between residents and a CNA assisted feeding two residents without hand hygiene between them.
A resident with dysphagia and a g-tube was observed receiving crushed meds through the tube even though there were no physician orders to flush the tube before and after meds, check placement, or check gastric residuals. RN C performed those steps anyway and said there should have been orders for everything done. The ADON and DON agreed the missing orders were an oversight, and the facility policy required a physician order, tube placement confirmation, GRV check, and flushing.
Improper Storage of Respiratory Equipment: Two residents had respiratory equipment left unbagged when not in use. One resident with cerebral infarction and hospice status had a Yankauer suction tip connected to the suction machine and laying exposed on a table. Another resident with sleep apnea had a nasal cannula hanging on the oxygen concentrator with the prongs near the floor. RN, LVN, ADON, and DON all stated the equipment should be bagged when not in use to prevent cross contamination, and the facility policy required oxygen cannulae and tubing used PRN to be kept in a plastic bag.
Missing Dialysis Assessment Orders for Two Residents: Two residents receiving hemodialysis had no physician orders for dialysis-site monitoring, post-dialysis VS, pressure dressing removal, bruit/thrill checks, or shunt-arm precautions. Staff observed the missing orders in the residents’ profiles and acknowledged that the dialysis-related orders should have been entered in the eMAR/eTAR to guide assessment and care.
A resident with DM, HTN, and severe cognitive impairment was found with two pills left on his overbed table after staff gave him medications and left the room. The resident said he was told to take the pills later, and there was no documented self-administration assessment or competency determination. MA F, RN B, the ADON, the Administrator, and the DON all stated medications should not be left unattended with residents unless they have been assessed to self-administer.
An RN left a container of germicidal wipes on top of an unattended nurse's cart in a hallway while administering meds in a resident room. The wipes were visible as residents passed by, and the RN later stated they should have been stored inside the cart because residents might use them on their face or eyes. The ADON, Administrator, and DON stated the wipes should be secured inside the cart, and the SDS identified the product as an eye irritant and instructed to keep it out of the reach of children.
Three residents did not receive prescribed nutritional supplements or diet modifications, including double protein portions, shakes, and ice cream, as ordered by their physicians. Staff interviews revealed confusion over responsibilities for ensuring correct meal service, and meal tickets reflected the correct orders, but the supplements and portions were not provided during observed meal times.
A resident with severe cognitive impairment and mental health diagnoses did not receive a customized wheelchair within the required timeframe after an IDT meeting recommended it. Miscommunication among staff and confusion over whether to use PASRR or a DME company led to delays, and the facility did not initiate the NFSS as required by policy.
A resident with severe cognitive impairment and multiple diagnoses, who was receiving hospice care, experienced a fall and developed bruises without hospice being notified by facility staff. Documentation and interviews confirmed that required communication with hospice did not occur, resulting in a lack of coordination and documentation of care.
The facility failed to provide adequate pharmaceutical services, resulting in medication errors for four residents. A resident missed 11 doses of alprazolam due to stock issues, another missed a dose of Letrozole, and a third had discrepancies in Tramadol reconciliation. Additionally, a resident received Hydrocodone outside prescribed times. These incidents highlight lapses in medication management, including failure to reorder medications timely, improper documentation, and unauthorized administration.
A resident with cognitive impairments and a history of exit-seeking behaviors was found without her prescribed wander guard bracelet on multiple occasions. Despite facility policies and care plans requiring the use of a wander guard to prevent elopement, staff failed to ensure its placement, as confirmed by observations and interviews with the DON and Administrator.
A facility failed to accurately code a resident's hospice status in the MDS assessment, despite the resident being on hospice as per the care plan and physician orders. The MDS Coordinator admitted the oversight, and both the DON and Administrator stressed the importance of accurate MDS coding for proper care and reimbursement. The Regional Nurse Consultant mentioned the absence of a specific MDS coding policy, relying instead on the CMS RAI manual.
A facility failed to update a resident's care plan after her wound healed, leaving outdated wound care instructions in place. The resident's MDS assessment and order summary showed no current wounds, yet the care plan still included wound care interventions. The MDS Coordinator and DON acknowledged the oversight, emphasizing the importance of accurate care plans for appropriate resident care.
A resident with Parkinson's disease and chronic pain was at risk due to the facility's failure to implement a pharmacist's recommendation to limit acetaminophen dosage to 3,000 mg per day. Despite multiple recommendations, the resident's medication orders lacked this directive, potentially exposing her to liver toxicity. Interviews revealed that the facility's leadership expected pharmacy recommendations to be implemented, but the oversight occurred due to a gap in the facility's policy.
The facility failed to secure medication carts, leaving drugs unattended and accessible. A medication aide left Tramadol unsecured on a cart, and an RN left a cart unlocked while attending to a resident. The DON and Administrator acknowledged the risk of unauthorized access to medications, which could lead to drug diversions or adverse effects.
A facility failed to provide a resident with her prescribed therapeutic diet, specifically her ice cream, on two occasions. The resident, who has dementia and other health conditions, did not receive her ice cream during lunch until a surveyor intervened. Staff interviews revealed that both nurses and aides are responsible for ensuring residents receive the correct diet and supplements, as per facility policy.
A resident with dementia and physical impairments did not receive a physician-ordered plate guard during meals, as required. The care plan and tray card failed to mention the need for the device, and staff were unaware of the requirement. The DON and Administrator acknowledged the oversight, emphasizing the importance of accommodating residents' needs to maintain dignity and nutritional status.
The facility failed to ensure food safety by not enforcing the use of hair restraints in the kitchen. The Dietary Manager was observed in the kitchen without hair and beard restraints, violating the facility's policy and potentially risking food contamination. Interviews confirmed the expectation for all kitchen staff to wear hair restraints to prevent contamination.
The facility failed to coordinate hospice care and maintain necessary documentation for two residents receiving hospice services. Essential documents such as the hospice plan of care, election form, and physician certification were missing, leading to inadequate coordination and communication. Staff interviews revealed a lack of awareness and responsibility for updating hospice records, which could risk inadequate end-of-life care.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and care procedures. A Treatment Nurse did not perform hand hygiene between changing gloves while providing wound care to a resident with a Stage 3 pressure wound. Additionally, a CNA did not change gloves or perform hand hygiene appropriately while providing incontinent care to another resident, using the same gloves to clean different areas and not following the correct wiping technique. Interviews with the DON and Administrator confirmed that staff were expected to perform care and hand hygiene correctly to prevent infection.
The facility failed to maintain a clean and safe environment in the central shower area, as observed with trash and a disposable razor left on the floor. Staff interviews confirmed that CNAs and nurses were responsible for cleaning, and the presence of debris posed fall and injury risks. Facility policies emphasized the need for cleanliness, which was not upheld.
Failure to Maintain Catheter Bag Position and Hand Hygiene During Peri Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate catheter and infection control care for a resident who was incontinent of bladder and had a Foley catheter. The resident was an adult female with a history of stroke, type 2 diabetes, bladder dysfunction, and a stage 4 sacral pressure ulcer, and her care plan identified her as having a Foley catheter, being at risk for UTI, and at increased risk of multidrug-resistant organism acquisition related to the presence of a wound. The care plan included an intervention to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. During an observation of peri care, a CNA and the ADON provided care after the resident had a bowel movement. Both staff donned PPE and performed hand hygiene before entering the room, but neither performed hand hygiene between three glove changes after contact with the resident’s fecal matter and body fluids. The urinary catheter drainage bag was observed resting on the resident’s bed at the same level as the bladder, covered with a privacy bag, instead of being kept below bladder level as required by the resident’s care plan and the facility’s catheter care policy. In interviews, the ADON and DON acknowledged that hand hygiene should have been performed between glove changes and that the catheter bag should always be kept below bladder level to prevent backflow and infection.
Failure to Follow Hand Hygiene and Catheter Positioning Practices During Peri Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during peri care for one resident with significant medical conditions. The resident was an older female with a history of stroke, type 2 diabetes, bladder dysfunction, a Foley catheter, and a stage 4 sacral pressure ulcer. Her care plan identified her as having a Foley catheter with risk for UTI and specified that the catheter bag and tubing should be positioned below bladder level and away from the room entrance. The care plan also documented that she was at increased risk of multidrug-resistant organism acquisition related to the presence of a wound. During an observation of peri care, CNA A and the ADON donned PPE and performed hand hygiene before entering the room. The resident had a bowel movement, and both staff handled fecal matter and body fluids. They changed gloves three times but did not perform hand hygiene between glove changes, contrary to the facility’s hand hygiene policy that requires hand hygiene after contact with blood or bodily fluids and after removing gloves. Additionally, the resident’s urinary catheter bag was observed resting on the bed at the same level as the bladder, rather than being kept below bladder level as required by the facility’s catheter care policy. In subsequent interviews, CNA A and the ADON acknowledged they should have used hand sanitizer between glove changes and that the catheter bag should always be kept below bladder level, and the DON confirmed these expectations and the associated infection risks.
Confidential Resident Vital Signs Left Exposed on Nurse Cart
Penalty
Summary
The facility failed to ensure confidentiality of residents’ personal and medical records for eight residents when LVN E left an untitled paper containing their names and vital signs on top of a nurse’s cart in the hallway. The paper listed Residents #39, #73, #84, #98, #109, #125, #126, and #127 and included blood pressures, pulse rates, temperatures, and oxygen saturations. The cart was unattended and positioned facing the hallway while staff and residents passed by it. Resident records reviewed showed the residents had diagnoses including hypertension, and Resident #98 was diagnosed with localized swelling. During observation and interview, LVN E stated she had left the cart while looking for a resident and acknowledged the paper contained confidential vital signs information. She said she should have secured the paper before leaving the cart. The ADON, Administrator, and DON each stated the information should not have been left exposed and that it should have been turned over, placed under the laptop, locked in a drawer, or otherwise secured so unauthorized individuals could not see it. The facility policy stated protected health information shall not be used or disclosed except as permitted by law and that personnel with access to resident information are responsible for protecting it from unauthorized release or disclosure.
Medications Left in Resident Rooms and Unattended on Cart
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments and allowed medications to be left within resident access or unattended. During observation, a container of eyedrops was found on top of Resident #85’s overbed table while the resident was not in the room. Resident #85 had age-related macular degeneration, legal blindness, and severe cognitive impairment with a BIMS score of 07. Her record included an order for Polyvinyl Alcohol Ophthalmic Solution as needed for teary eyes, but there was no assessment showing she was competent to self-administer medications. A similar issue was observed for Resident #89, who was cognitively intact with a BIMS score of 15 and had diagnoses including lack of coordination and anxiety. Her record did not include an order for eyedrops, and there was no assessment showing she was competent to manage her own medications. Three eyedrops were observed on top of her overbed table while she was not in the room. For Resident #128, who had obesity, muscle wasting, contact dermatitis, moderate cognitive impairment with a BIMS score of 09, and was always incontinent of bowel and bladder, two tubes of barrier cream were observed on top of her side table while she was in bed awake. Her physician order allowed house barrier cream to be applied every shift for prevention, but there was no assessment showing she was competent to self-administer medications. The report also documented that LVN E left a vial of medication for breathing treatment on top of the nurse’s cart unattended while looking for a resident. LVN E stated the medication should have been placed inside the drawer before leaving the cart. Interviews with nursing leadership reflected that medications should not be inside resident rooms or left on carts unattended, and the facility policy stated that drugs and biologicals are to be stored in locked compartments.
Kitchen Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food storage, labeling, and dating. During observation in the kitchen, surveyors found a gallon-size bag of Frosted Flakes with no use-by date, a box of long grain enriched parboiled rice that was not properly sealed and was exposed to air contaminants, a bag of oats cereal with no visible expiration date, a bag of raisin bran with no visible expiration date, a bag of cane sugar with no visible expiration date, an opened bag of biscuit mix that was not properly sealed and was exposed to air contaminants, and a 5 lb. bag of graham cracker crumbs that was opened and not properly sealed and exposed to air contaminants. During interviews, the DC stated he was responsible for ensuring the kitchen met guidelines for food storage and kitchen sanitization and confirmed the surveyor observations. He stated that once items are opened they should be properly sealed and dated, that the listed items were oversights, and that all kitchen staff are responsible for labeling items properly. The ADM stated he oversaw all departments, was aware of the kitchen concerns, and had spoken with the DC. He stated the issues could cause food contamination and that expired items should not be served to residents. The facility’s Food Receiving and Storage Policy required dry foods stored in bins to be removed from original packaging, labeled, and dated, and required opened containers to be dated and sealed or covered during storage.
Infection Control Lapses During Resident Care and Meal Assistance
Penalty
Summary
The facility failed to maintain infection prevention and control practices during multiple resident care and dining activities. Resident #10 was cognitively intact and incontinent of bowels, with a care plan directing staff to clean the perineal area. During an observation, RN B placed barrier cream into two cups, took the cups into Resident #10’s room, and set them on the resident’s overbed table. After the resident said she wanted the cream later, RN B removed the cups from the table and placed them inside the first drawer of her cart. RN B stated the cups had contact with the overbed table and should not have been returned to the cart because they could have been contaminated and transferred to the cart and indirectly to other residents. Resident #18 had severe cognitive impairment and was incontinent of bowel and bladder, with a care plan directing perineal care with each incontinent episode. During incontinent care, CNA H placed gloves inside her pockets and then used a pair taken from her pocket to continue cleaning the resident. CNA H stated she should not have put gloves in her pockets because she was not sure whether the pocket was clean and acknowledged that she would not do so again. The report also described Resident #93, who was cognitively intact, had dysphagia, a feeding tube, and was on enhanced barrier precautions. The care plan directed staff to provide standard precautions during hygiene and dressing. During observation, CNA G shaved Resident #93 without wearing a gown while leaning directly to the resident’s bed, despite a sign outside the room indicating PPE was required for hygiene. Later, CNA G and COTA I changed the resident’s clothing without wearing gowns, and ADON A entered the room and told them they needed to wear gowns. In the dining area, RN C passed plates without performing hand hygiene between plates, and CNA J assisted feeding two residents without hand hygiene between residents. The DON stated staff assisting more than one resident at a time were a risk to residents and that lack of hand hygiene could spread infection from one resident to another. The facility’s EBP orientation tool stated gowns and gloves were used during high-contact care activities such as dressing and providing hygiene, and the hand hygiene policy stated hand hygiene was the primary means to prevent the spread of infections and should be performed before and after assisting a resident with meals.
Missing Orders for G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure a resident with a g-tube received appropriate treatment and services related to enteral feeding and medication administration. Resident #93 was admitted with dysphagia, was cognitively intact with a BIMS score of 13, and had a feeding tube documented on the MDS. The care plan dated 02/08/2026 included interventions to check residual and placement before initiation of formula, medication administration, and flushing the g-tube. On 03/05/2026, record review showed the resident did not have physician orders to check tube placement, check gastric residuals, or flush the g-tube before and after medication administration. During observation on 03/04/2026, RN C administered crushed medication through the g-tube, checked for placement and gastric residual, and flushed the tube before and after giving the medication. He stated he did this to keep the tube patent and to verify placement and absorption, but acknowledged there were no orders for flushing, checking placement, or checking residuals. He said there should have been an order for everything done for the resident. Interviews with the ADON and DON confirmed that there should be orders for flushing, checking placement, and checking residuals, and both identified the absence of those orders as an oversight. The DON stated the placement and residual should be checked to prevent aspiration and that the tube should be flushed before and after medication administration to make sure it was working. The facility policy on administering medications through an enteral tube also required a physician's medication order, confirmation of tube placement, checking gastric residual volume, and flushing the tubing.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents by not properly storing respiratory equipment when it was not in use. Resident #6, a male with cerebral infarction, severe cognitive impairment with a BIMS score of 00, and hospice status, had a care plan for impaired gas exchange with interventions for oxygen as needed and suction as needed. His physician order reflected suction as needed. During observation, a suction machine was seen on top of his drawer with a Yankauer suction tip connected to the tubing and laying on top of the table behind the machine, not bagged. RN B stated the suction tip should be bagged when not in use to prevent cross contamination and removed it, saying she would replace it and place it in a bag. Resident #128, a female with obstructive sleep apnea and moderate cognitive impairment with a BIMS score of 09, had a care plan for altered respiratory status/difficulty breathing related to sleep apnea with oxygen at 2 L/min via nasal cannula at night. Her physician order also reflected oxygen at bedtime. During observation, an oxygen concentrator was at bedside with the nasal cannula connected to it, hanging on top of the concentrator and not bagged, with the prongs almost touching the floor. The resident stated she only used oxygen at night and had taken it off and given it to the nurse. LVN D stated the nasal cannula should have been placed in a plastic bag to prevent cross contamination and discarded it, saying she would get a new one and bag it for the resident's next use. During interviews, the ADON and DON stated that the nasal cannula and Yankauer should be bagged whenever residents were not using them to prevent cross contamination and respiratory infections. The DON said the expectation was for staff to ensure respiratory equipment was properly stored, and the facility policy on oxygen use stated that oxygen cannulae and tubing used PRN should be kept in a plastic bag when not in use.
Missing Dialysis Assessment Orders for Two Residents
Penalty
Summary
The facility failed to ensure that two residents who were receiving dialysis had physician orders in place for ongoing assessment before and after dialysis treatments performed at an outside certified dialysis facility. For Resident #9, record review showed end stage renal disease, cognitive intactness with a BIMS score of 15, and a care plan noting dialysis on Monday, Wednesday, and Friday with daily dressing changes at the access site. However, the physician orders did not include monitoring of the dialysis site, dialysis appointment orders, post-dialysis vital signs, removal of the pressure dressing after dialysis, assessment of bruits and thrills, or instructions to avoid blood pressure or finger sticks in the shunt arm. For Resident #93, record review showed end stage renal disease, cognitive intactness with a BIMS score of 13, and a care plan noting hemodialysis with an intervention to send an approved snack on dialysis days. The physician orders also did not include monitoring of the dialysis site, dialysis appointment orders, post-dialysis vital signs, removal of the pressure dressing after dialysis, assessment of bruits and thrills, or instructions to avoid blood pressure or finger sticks in the shunt arm. During observation, the resident was noted to have a shunt in the right upper arm and stated that the kidneys were no longer functioning and that dialysis had been received for almost two years. During interview, the ADON stated that when residents returned from an outside dialysis clinic, the facility was responsible for assessing the resident, including checking for bleeding, signs and symptoms of infection, and bruits and thrills. She reviewed both residents' profiles and confirmed that the dialysis-related orders were missing, stating that the nurses knew what to do but that orders should be present in the profile and eTAR. RN B and RN C both acknowledged that the dialysis orders were missing and stated that the orders should have been in the residents' profiles to ensure care and assessment were completed. The DON and Administrator also stated that dialysis-related orders were expected to be entered and followed.
Medications Left Unattended With Resident Without Self-Administration Assessment
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for one resident. Resident #126 was an [AGE]-year-old male admitted with diagnoses of diabetes mellitus and hypertension. His MDS assessment dated 03/06/2026 reflected severe cognitive impairment with a BIMS score of 07, and his care plan directed staff to administer medications as ordered for both conditions. Physician orders included Losartan Potassium 50 mg daily for hypertension and Metformin HCl 500 mg twice daily for diabetes. On 03/03/2026, a clinical assessment note review showed no assessment for self-administration of medications or documentation that the resident was competent to manage his own medications. During an observation and interview at 9:17 AM, Resident #126 was found in bed with two dry pills on his overbed table. The resident stated staff had given him the pills and told him to take them after he finished eating candy. He said he knew one medication was for blood pressure but did not remember what the other pill was for, and he was unsure whether the person who gave him the medications was a nurse or a medication aide. During interviews, MA F stated staff should ensure medications are taken before leaving the room and acknowledged she thought the resident had taken the pills. RN B said MA F reported the medications had been left in the room and stated medications should not be left with residents because they might forget them or take them again later. ADON A, the Administrator, and the DON all stated staff should not leave medications unattended with residents and that residents should not take medications by themselves unless assessed for self-administration. The facility policy also stated that only licensed or permitted persons may administer medications and that residents may self-administer only if the decision-making capacity to do so safely had been determined.
Unattended Germicidal Wipes Left on Nurse's Cart
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment when RN C left a container of germicidal wipes on top of an unattended nurse's cart in the hallway. During observation, the cart was parked where residents were passing by, and the wipes remained visible on top of the cart while RN C went into a resident's room to administer medications and closed the door, leaving the cart outside the room. During interview, RN C stated he should have placed the germicidal wipes inside the cart before leaving it unattended because residents might be able to get hold of the wipes and use them to clean their faces and eyes. The ADON, Administrator, and DON all stated the wipes should be stored inside or secured in the cart and not left on top of it when not in use. Record review showed the wipes were germicidal wipes with hazards including eye irritation and a storage instruction to keep them out of the reach of children.
Failure to Provide Prescribed Nutritional Supplements and Diet Modifications
Penalty
Summary
The facility failed to ensure that three residents received the prescribed nutritional supplements and diet modifications as ordered by their physicians. One resident, a male with hemiplegia, dysphagia, and GERD, was observed receiving only a single serving of protein at a meal, despite a physician's order for double protein portions. The meal ticket indicated the correct order, but the tray was not prepared accordingly. The staff member responsible for checking trays before serving acknowledged the mistake and confirmed it was his responsibility to ensure accuracy. Another resident, a female with muscle wasting and a history of unplanned weight loss, did not receive the ordered ice cream and shake with her lunch meal. The dietary note and meal ticket both reflected the need for these supplements, but they were not provided during the observed meal service. Similarly, a third resident, a female with primary progressive multiple sclerosis and a history of poor fluid intake and weight loss, did not receive the ordered shake with her lunch. The meal ticket indicated the need for a shake, but the order summary report did not reflect this, and the supplement was not provided. Interviews with nursing and dietary staff revealed confusion and lack of clarity regarding responsibilities for ensuring residents received the correct diets and supplements. Some staff stated that the nurse should check trays before they are distributed, while others indicated that the cook or dietary staff were responsible for certain components. The DON and Administrator both stated that diet orders should be followed and acknowledged that the observed residents did not receive the prescribed supplements and portions. The facility's policy requires that menus meet residents' nutritional needs and be followed as written.
Failure to Timely Initiate PASARR-Recommended Specialized Services
Penalty
Summary
The facility failed to incorporate recommendations from the PASARR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, after an IDT/PCSP meeting, a customized manual wheelchair was recommended for a resident with major depressive disorder, anxiety, and severe cognitive impairment. The facility did not initiate the request for specialized services (NFSS) within the required 20 business days following the meeting, as outlined in facility policy. Record reviews and staff interviews revealed confusion and miscommunication regarding the process for obtaining the wheelchair. The MDS Coordinator stated that she entered the recommendation into the portal but later claimed it was entered in error, asserting that neither the resident nor the family requested a wheelchair. The DOR and Habilitation Coordinator, however, confirmed that a wheelchair was recommended and that the family initially agreed to pursue it through PASRR, but the facility ultimately sought to obtain it through a DME company and the resident's insurance instead. The Habilitation Coordinator documented multiple follow-ups to remind staff of the need to initiate the request, but the process was not completed within the required timeframe. Interviews with facility leadership, including the DON, Administrator, and Regional Clinical Reimbursement Specialist, indicated a lack of clarity regarding responsibility and timelines for completing the NFSS after the IDT meeting. The facility's own policy required initiation of the request for specialized services within 20 business days, but this was not adhered to, resulting in a delay in the resident receiving the recommended customized wheelchair.
Failure to Notify Hospice of Resident Status Changes
Penalty
Summary
The facility failed to effectively communicate and coordinate with hospice representatives regarding a resident who was receiving hospice services. Specifically, the facility did not notify hospice when the resident experienced a fall and when bruises were identified on her left forearm. Record reviews showed that there was no documentation indicating hospice was informed of these incidents, despite the facility's policy requiring notification of hospice for significant changes in a resident's physical, mental, social, or emotional status. Interviews with facility staff, including the DON and nurses, confirmed that hospice was not notified of these changes, and staff were either unaware or could not recall if notifications had been made. The resident involved was an elderly female with diagnoses including dementia, hypertension, and stroke, and was severely cognitively impaired, requiring extensive assistance with activities of daily living. She was admitted to hospice care and had a care plan addressing her terminal prognosis and associated risks. Despite these needs, the lack of communication and documentation between the facility and hospice resulted in a failure to ensure that hospice could assess and coordinate care in response to changes in the resident's condition.
Medication Management Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in multiple medication errors for four residents. Resident #11 did not receive her prescribed alprazolam for several days due to the medication being out of stock, leading to 11 missed doses. The staff failed to reorder the medication in a timely manner, and there was a lack of communication between the nursing staff and the pharmacy. Despite the resident experiencing symptoms of anxiety, the medication was not administered from the emergency kit, and the issue was not resolved until the pharmacy delivered the medication days later. Resident #50 missed a dose of Letrozole, a hormone treatment for breast cancer, because the medication was unavailable. The nursing staff did not ensure the medication was on hand, and the error was only discovered when a nurse attempted to administer the medication. Similarly, Resident #49's Tramadol, a pain medication, was not accurately reconciled, leading to discrepancies in the narcotic count. The medication was administered without proper documentation, increasing the risk of medication errors and potential drug diversion. Resident #5 received Hydrocodone outside of the prescribed administration times. A medication aide attempted to administer the medication early without a physician's order, which was against the facility's policy. The DON intervened and instructed the aide to waste the medication. These incidents highlight significant lapses in medication management, including failure to reorder medications timely, improper documentation, and unauthorized administration of medications.
Failure to Ensure Wander Guard Placement for At-Risk Resident
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards for a resident who was at risk for elopement due to cognitive impairments. The resident, who had diagnoses including dementia, schizophrenia, and depression, was supposed to have a wander guard bracelet on her left lower leg as per her care plan and physician's orders. However, during observations on two separate days, the resident was found without the wander guard, which was confirmed by both the resident and a CNA. The resident's care plan and physician's orders clearly indicated the need for the wander guard due to her exit-seeking behaviors and risk of elopement. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility staff were responsible for ensuring that residents with orders for wander guards had them in place. The DON acknowledged that the resident was supposed to have the wander guard on and that its absence posed a risk of elopement. The facility's policy on wandering and elopement emphasized the importance of identifying residents at risk and implementing protective measures, yet the failure to ensure the resident had her wander guard on demonstrated a lapse in adherence to this policy.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding hospice services. Resident #14, a male with diagnoses including dementia, seizures, anxiety, and high blood pressure, was not coded as receiving hospice care on the MDS assessment dated 11/08/24, despite being on hospice as indicated in the care plan and physician orders. This discrepancy was identified during a review of the resident's records and interviews with facility staff. The MDS Coordinator acknowledged the error, stating that hospice services were not coded in the MDS assessment, which is crucial for reflecting the resident's care needs and reimbursement. The Director of Nursing (DON) and the Administrator both emphasized the importance of accurate MDS coding to ensure appropriate care. The Regional Nurse Consultant noted that there was no specific policy for MDS coding, and they followed the CMS RAI manual, which requires coding for hospice services. The failure to accurately code the MDS assessment could potentially impact the care and services provided to the resident.
Failure to Update Resident Care Plan Post-Wound Healing
Penalty
Summary
The facility failed to update the care plan for a resident who no longer required wound care, as her wound had healed. Despite the resident's comprehensive care plan indicating a Stage 3 pressure ulcer on the right hip, the care plan was not revised to reflect the healed status of the wound. The resident's quarterly MDS assessment did not indicate any wounds, and the order summary report confirmed there were no current wound care orders. Interviews with the MDS Coordinator and the DON revealed that the care plan should have been updated to reflect the resident's current condition, as the care plan is essential for guiding staff in providing appropriate care. The MDS Coordinator acknowledged the oversight, stating that care plans should be revised whenever there is a change in the resident's condition. The DON emphasized the importance of accurate care plans to ensure residents receive the necessary care. The facility's policy on care plans requires that they be reviewed and updated when there is a significant change in the resident's condition, during readmissions, and at least quarterly. The failure to update the care plan could potentially place residents at risk of not receiving appropriate interventions to meet their current needs.
Failure to Implement Pharmacist's Recommendations for Acetaminophen Dosage
Penalty
Summary
The facility failed to act upon the recommendations of the pharmacist report of irregularities for a resident reviewed for Drug Regimen Review (DRR). The resident, an elderly female with a diagnosis of Parkinson's disease and chronic pain, was receiving medications containing acetaminophen. The pharmacist had recommended that the orders for these medications include a directive not to exceed 3,000 mg per day to prevent the risk of severe liver injury. However, the facility did not implement this recommendation, as evidenced by the resident's medication orders lacking the necessary dosage limit. The resident's comprehensive care plan indicated that she was receiving pain medication therapy, but the orders did not reflect the pharmacist's recommendation to limit acetaminophen intake. The pharmacy consultant had made this recommendation on multiple occasions, emphasizing the importance of adhering to the manufacturer's guidelines to prevent liver toxicity, especially in elderly patients. Despite these recommendations, the facility's order audit report showed that the resident's medication orders did not include the advised dosage limit. Interviews with the pharmacy consultant, the Director of Nursing (DON), and the Administrator revealed that the facility's leadership expected pharmacy recommendations to be addressed and implemented. However, the DON admitted to missing the recommendation for the resident's acetaminophen dosage limit. The facility's policy on the role of the consultant pharmacist did not specifically address the implementation of pharmacy recommendations, which contributed to the oversight in ensuring the resident's medication orders were updated accordingly.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys for two medication carts. Specifically, a medication aide left a controlled narcotic, Tramadol, unsecured on a medication cart while retrieving his computer from the nurse's station, leaving the medication unattended and out of the surveyor's line of sight. Additionally, a registered nurse failed to secure the medication cart on multiple occasions while attending to a resident, leaving the cart unlocked and unattended, which could allow unauthorized access to medications. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's policy required medications and carts to be secured at all times. The DON and Administrator acknowledged the risk of residents accessing unsecured medications, which could lead to drug diversions or adverse effects. The facility's policy, dated April 2019, emphasized the importance of storing drugs and biologicals in a safe, secure, and orderly manner, with specific instructions for maintaining locked compartments and ensuring that medication carts are not left unattended.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that Resident #49 received her prescribed therapeutic diet, specifically her ice cream, as ordered by the attending physician. This deficiency was observed on two separate occasions. On December 2, 2024, during lunch, Resident #49 did not receive her shake or ice cream until a surveyor intervened. CNA R acknowledged that the nurses usually check the trays, but CNAs should also recheck them to ensure residents receive everything on their trays. On December 4, 2024, Resident #49 again did not have her ice cream with her lunch. LVN E admitted to missing the ice cream when checking the tray cards and stated it should have been included with her tray. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's protocol required both nurses and aides to verify that residents received the correct diet and supplements. The DON emphasized the importance of reading meal tickets to ensure residents receive the correct diets, while the Administrator highlighted the necessity of providing the correct diet/supplements to prevent weight loss. The facility's policy on therapeutic diets, dated October 2017, mandates that therapeutic diets be prescribed by the attending physician and regularly reviewed by the dietitian, nursing staff, and physician.
Failure to Provide Physician-Ordered Plate Guard for Resident
Penalty
Summary
The facility failed to provide a physician-ordered plate guard for a resident with dementia, stroke, hemiplegia, and a contracture of the left hand, who required special eating equipment and assistance. The resident's care plan did not mention the use of a plate guard, and the tray card did not reflect the need for it. During observations, the resident was seen eating meals without the plate guard, and staff, including an LVN and the Dietary Manager (DM), were unaware of the requirement. The DM stated that he had not received communication about the need for a plate guard, which should have been included on the tray card. Interviews with the Director of Nursing (DON) and the Administrator revealed that the process for ensuring the resident received the necessary device involved the nurse providing the DM with a copy of the order. The DON expected the plate guard to be in place to allow the resident to feed herself independently. The Administrator acknowledged that not having a plate guard could affect the resident's dignity and nutritional status, emphasizing the importance of getting meal services right. The facility's policy indicated that residents' individual needs, including adaptive devices, should be accommodated and reviewed regularly.
Failure to Use Hair Restraints in Kitchen
Penalty
Summary
The facility failed to ensure that food was prepared and served in a manner that prevented foodborne illness, as observed during a survey. The Dietary Manager entered the kitchen without wearing the required hair and beard restraints, which is a violation of the facility's policy on food preparation and services. This policy mandates that all dietary staff must wear hair restraints to prevent hair from contacting food. During an observation, the Dietary Manager was seen in the freezer and storage area without these restraints, despite having facial and beard hair approximately 1/4 to 1/2 inch long. Interviews conducted with the Dietary Manager, the Director of Nursing (DON), and the Administrator confirmed the expectation that all kitchen staff should wear hair restraints to prevent contamination and ensure infection control. The Dietary Manager admitted to not wearing the restraints and acknowledged the importance of doing so to prevent hair from getting into the food. The DON and Administrator both emphasized the necessity of maintaining a clean kitchen environment and preventing cross-contamination, with the Administrator specifically noting that the Dietary Manager should have adhered to the policy by wearing the appropriate restraints.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for two residents, who were not provided with adequate documentation and coordination of care. The facility did not maintain the hospice binders containing essential information such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. This lack of documentation and communication could potentially place residents at risk of receiving inadequate end-of-life care. For Resident #14, the facility did not have the necessary hospice documentation in the resident's binder, including the physician certification of terminal illness, care plan, medication list, or hospice election form. Interviews revealed that the facility staff were not aware of the frequency of hospice meetings or the responsibility for updating the hospice folders. The hospice administrator confirmed that the binders should contain specific documents and be updated regularly, but this was not being done. The Director of Nursing (DON) acknowledged the lack of communication and monitoring to ensure the hospice documents were brought to the facility. Similarly, for Resident #129, the facility failed to have a hospice plan of care, hospice election form, or physician's certification of terminal illness in the resident's records. The hospice provider's director indicated that these forms were crucial for coordinating care. The DON and other staff members expected the hospice provider to supply all necessary admission paperwork, but this was not consistently happening. The administrator emphasized the importance of having all required documents at the time of admission to ensure proper coordination of care, but the process was not effectively managed.
Infection Control Deficiencies in Hand Hygiene and Care Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving improper hand hygiene and care procedures. In the first incident, a Treatment Nurse did not perform hand hygiene between changing gloves while providing wound care to a resident with a Stage 3 pressure wound. The resident, who was severely cognitively impaired and always incontinent, required specific wound care as per physician orders. The nurse acknowledged forgetting to wash her hands between the dirty and clean phases of the procedure, which could lead to infection. In the second incident, a CNA did not change gloves or perform hand hygiene appropriately while providing incontinent care to another resident. This resident, who was moderately cognitively impaired and always incontinent, required assistance with activities of daily living. The CNA used the same gloves to clean different areas and did not follow the correct wiping technique, which could result in cross-contamination. The CNA admitted to not performing hand hygiene when changing gloves and acknowledged the importance of wiping front to back to prevent infection. Interviews with the Director of Nursing (DON) and the Administrator confirmed that staff were expected to perform peri-care, wound care, and hand hygiene correctly to prevent infection. The facility's policies on hand hygiene, perineal care, and wound care were reviewed, indicating that hand hygiene is considered the primary means to prevent the spread of infection. The DON and Administrator both recognized that failure to adhere to these procedures could lead to infection issues.
Failure to Maintain Cleanliness in Shower Area
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the central shower area, as observed on multiple occasions on 5/24/24. During these observations, a disposable razor and various trash items, including used gloves and popcorn, were found on the floor of the shower room. This failure to maintain cleanliness was noted during three separate observations at different times of the day, indicating a consistent issue with the upkeep of the shower area. Interviews with facility staff, including a CNA, an LVN, and the DON, revealed that the responsibility for cleaning the shower area fell on the CNAs and nurses. The staff acknowledged that leaving razors and trash on the floor posed risks, such as falls and injuries, and emphasized the importance of maintaining a clean environment for infection control purposes. The facility's policies on maintaining a homelike environment and shower procedures were reviewed, highlighting the expectation for a clean and orderly environment, which was not met in this instance.
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 852 citations issued within 25 miles in the last 12 months — including the 15 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 Rockwall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Meadows | 2.4 mi | ★★★★★ | 10 | 0 |
| Rockwall Nursing Care Center | 3.3 mi | ★★★★★ | 27 | 1 |
| Beacon Harbor Healthcare And Rehabilitation | 3.9 mi | ★★★★★ | 9 | 0 |
| Rowlett Health And Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Ridgecrest Healthcare And Rehabilitation Center | 8.9 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.