Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookhaven Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Use PPE During Enhanced Barrier Precautions: An LVN provided wound care and incontinent care to a resident with a stage 4 pressure ulcer and enhanced barrier precautions without wearing a gown. The resident had intact cognition and diagnoses including malnutrition, MS, and HTN. The LVN stated he knew PPE was required but forgot to wear the gown, and the DON stated staff were expected to use appropriate PPE during care.
A resident with quadriplegia and mental health diagnoses did not receive recommended occupational therapy services following an IDT meeting, due to lack of care planning, delays in obtaining physician signatures, and failure to follow facility policy for initiating and documenting PASARR services.
A resident with multiple diagnoses was transferred to a hospital without a completed discharge summary or proper clinical documentation, and the required notice to the Long-Term Care Ombudsman was not provided. Staff interviews revealed that the necessary paperwork and notifications were not completed, and responsibilities for these tasks were unclear among staff.
Multiple residents experienced verbal and physical abuse, including threats with a weapon, from another resident with a history of behavioral disturbances. Despite staff awareness and documentation of repeated aggressive incidents, facility leadership did not implement effective interventions to prevent further abuse, resulting in psychosocial harm and ongoing distress among residents.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A facility failed to complete quarterly MDS assessments within the required timeframe for two residents. One resident had multiple chronic conditions including HTN, anemia, orthostatic hypotension, DM, cerebral palsy, and several psychiatric diagnoses, while another resident had MS, anxiety, depression, psychotic disorder, arthritis, osteoporosis, and muscle weakness. Their quarterly MDS records remained in-progress and were not transmitted to CMS, and staff stated the VP of Reimbursement was handling MDS completion until an MDS coordinator was hired.
Failure to provide needed grooming assistance: A resident with dementia, muscle weakness, and lack of coordination required supervision or touching assistance for personal hygiene, including shaving, but was observed with an excessive amount of thick facial hair on her chin. The resident stated she did not like the hair and wanted it removed, and an LVN said staff were expected to check for facial hair during routine showers and would have expected the chin to have been shaved before it grew that long.
Unlabeled and undated insulin was found in a medication cart on the 200 hall, including two insulin pens for two residents and an opened vial of Novolin 70/30. An LVN said she did not realize the insulin lacked open dates, and the ADON and DON stated that insulin pens and vials should be labeled and dated because opened insulin expires after 28 days.
Baseline care plans were not completed within 48 hours for two newly admitted residents. One resident had dementia, bipolar disorder, and anxiety, and another had a hx of falls. The ADON confirmed the delay, stated there was no specific reason for it, and noted that direct care staff would not have basic information about the new residents when the plans were late.
Blood-Stained Insulin Stored in Medication Cart: An unlabeled vial of insulin lispro with blood stains on the vial and box was found in the top drawer of a hall medication cart with other medications. An LVN, ADON, and DON confirmed the blood stains, stated nursing staff were responsible for keeping medication storage and prep areas clean and sanitary, and noted the blood-stained insulin was later removed and disposed.
Incomplete Admission MDS Assessment: A resident admitted with a history of falls did not have a Comprehensive MDS Assessment completed within the required timeframe. The EMR showed no evidence of an MDS being completed, and the President of Reimbursement confirmed the admission MDS was overdue while the facility lacked a full-time MDS Coordinator and relied on remote coordinators.
A facility failed to ensure a Hospitality Aide had the necessary CNA certification while providing care to residents. The aide was counted as a CNA in staffing numbers and performed various care duties without a license. The ADON and DON were aware of the lack of certification but did not prevent the aide from being included in the schedule. The Administrator could not provide a policy for competent nursing staff.
A resident with severe cognitive impairment and a high risk for wandering eloped from the facility through a door with a faulty alarm. The resident was missing for over 15 hours before being found by police. The care plan indicated the resident was an elopement risk, but inadequate supervision and a malfunctioning alarm system contributed to the incident.
Two residents with cognitive and health issues were found smoking without supervision, violating the facility's smoking policy. Despite being assessed as needing supervision, they kept smoking materials in their possession and smoked outside designated times. Staff were aware of the non-compliance but were unable to enforce the policy effectively.
A resident with dementia and mobility issues was not provided with a functional and comfortable wheelchair, affecting her independence and safety. Despite reporting the issue, the wheelchair remained faulty, with a broken arm pad and difficulty in maneuvering. Facility staff, including the Maintenance Assistant, DON, and Social Worker, were unaware of the ongoing issues, and no specific person was responsible for ensuring the functionality of mobility devices.
A resident's grievance regarding a malfunctioning wheelchair was not resolved in a timely manner, despite being reported to the ADON. The resident, with moderately impaired cognition and several medical conditions, continued to face difficulties in mobility and daily activities. Interviews revealed a lack of awareness and communication among staff about the grievance, and the facility's grievance procedures were not effectively followed.
A resident with severe cognitive impairment and a diagnosis of Major Depressive Disorder was not accurately reflected in the MDS assessment at the facility. Despite being treated with Trazodone and referred for psychiatric services, the MDS did not include this diagnosis. Interviews with staff, including LVN, MDS nurses, DON, and the Administrator, revealed a lack of awareness about the resident's current diagnosis, highlighting a failure to ensure MDS accuracy as per facility policy.
A facility failed to update a PASARR Level 1 screening for a resident diagnosed with Major Depressive Disorder after admission. Despite the new diagnosis, the necessary screening was not submitted, potentially affecting the resident's access to needed services. Interviews with staff revealed a lack of awareness about the requirement to update the screening, and the facility did not provide a related policy when requested.
A facility failed to include a resident's Major Depressive Disorder in their comprehensive care plan, despite it being identified in assessments. The resident exhibited symptoms of depression and was on medication, yet staff were unaware of the diagnosis's omission from the care plan. Interviews with staff, including an LVN, MDS nurses, the DON, and the Administrator, revealed a lack of awareness and responsibility for ensuring care plans matched residents' current needs, leading to potential missed care opportunities.
A resident with diabetes did not receive podiatry services since admission, leading to long, curved toenails and self-managed foot care. Facility staff, including the ADON, DON, and Social Worker, were unaware of the resident's need for podiatry services, resulting in a deficiency in maintaining proper foot health.
A resident with a complex medical history did not receive documented doses of Ipratropium-Albuterol and Robitussin as ordered, due to RN and LVN oversight. The facility staff were unaware of the missed doses, and there was no documentation or physician notification, contrary to facility policy.
A resident with severe cognitive impairment and health issues did not receive necessary dental care due to the facility's failure to complete a dental referral. Despite the resident's desire to see a dentist and a family member's request for services, the care plan lacked dental interventions, and staff were unaware of the resident's needs. Observations noted dental issues, and interviews revealed a lack of communication and coordination among staff.
The facility failed to provide proper catheter care for three residents, leading to potential infection risks. A resident's catheter bag was placed above the bladder during a transfer, causing urine backflow. Another resident's catheter bag was improperly positioned during wound care, and a third resident's catheter bag was found touching the floor. Staff acknowledged the risks of infection due to these actions.
The facility failed to ensure proper handling of damaged medications on a medication cart, as observed with tramadol blister packs having broken seals and taped-over pills. An LVN noticed the issue during a shift change but did not report it due to being busy. The DON emphasized the need for immediate disposal of such medications to prevent drug diversion and infection risks, as per facility policy.
The facility's kitchen failed to meet food safety standards, with issues such as improperly covered and labeled food items, and the use of unclean utensils in bulk food containers. Observations revealed beef patties not covered, a box of diced potatoes without a visible use-by date, and a scoop left in a bulk sugar container, posing risks of food-borne illness and contamination.
Three CNAs in an LTC facility failed to follow proper hand hygiene protocols while providing incontinence care to residents with severe cognitive impairments and various health conditions. The CNAs did not perform hand hygiene after removing soiled gloves and before donning clean gloves, increasing the risk of infection and cross-contamination.
The facility failed to maintain proper nail care for two residents who required assistance with activities of daily living. One resident with severe cognitive impairment and another with moderate impairment were found with long, dirty fingernails, despite the facility's policy requiring regular grooming. Staff interviews revealed that CNAs and LVNs were responsible for nail care, but this was not adequately performed.
The facility failed to ensure that call lights were within reach for two residents, both with a history of falls and severely impaired cognition. Observations and interviews revealed that the call lights were inaccessible, posing a risk to the residents' safety and ability to call for assistance. Staff acknowledged the importance of having call lights within reach, as per facility policy, but failed to ensure compliance, leading to the deficiency.
A resident with a history of stroke and contractures did not receive the prescribed splint treatment on two consecutive days, despite staff signing off as if it had been applied. Observations showed the resident without the splint, and interviews revealed confusion among staff about who was responsible for its application. The facility's policy emphasized the importance of such interventions to prevent further reduction in range of motion.
A resident with paraplegia and chronic respiratory failure, requiring a two-person assist for incontinence care, was inadequately supervised by a CNA who provided care alone. Despite the resident's care plan and MDS assessment indicating the need for two-person assistance, the CNA rolled the resident and pulled him up in bed without help. Interviews revealed that the CNA often worked alone and sometimes called for assistance. The facility's policy prioritized resident safety and supervision, yet this incident placed the resident at risk for accidents and injury.
A facility failed to label and date a hydration bag used for a resident's enteral feeding, which could lead to complications such as incorrect hydration or infection. The resident, dependent on tube feeding due to medical conditions, had a hydration bag with no label indicating its contents or the date it was hung. Interviews with staff confirmed that labeling and dating are standard protocols, which were not followed in this instance.
The facility failed to ensure the resident environment was free of accident hazards by not properly managing contaminated sharps disposal bins. Observations revealed that sharps bins on two medication carts were overfilled, preventing the lids from closing properly and posing a risk to residents and staff. Interviews with staff confirmed the bins should not be filled past the full line and that medications should not be disposed of in the sharps bins.
The facility failed to administer medications timely for two residents due to staff shortages, leading to delays in medication administration. One resident with hypertension and other conditions received her medication over two hours late, while another resident with multiple diagnoses received her morning medications nearly three hours late.
The facility failed to store all drugs and biologicals in locked compartments and permitted unauthorized access to medications on one of the six medication carts reviewed. Eight pills were found stuck between the plastic insert of the sharps container and the lid, preventing the lid from closing properly. Staff acknowledged that medications should not be disposed of in the sharps bin and posed a potential hazard to residents.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident reviewed for infection control. Resident #10 was a female with a BIMS score of 15, indicating intact cognition, and diagnoses that included a stage 4 pressure ulcer of the left buttock, malnutrition, multiple sclerosis, and hypertension. Her care plan, initiated 04/28/26, included a physician order dated 04/15/2026 to implement and maintain enhanced barrier precautions during high-contact care activities related to wound care every shift. During an observation on 05/27/2026 at 10:46 AM, Resident #10’s room had an Enhanced Barrier Precaution sign outside the door and PPE set up on a cart. LVN A prepared the resident’s wound care and incontinent care items, performed hand hygiene, and entered the room, then completed wound care and incontinent care without wearing a gown. During interview, LVN A stated he knew the resident was on enhanced barrier precautions and should have donned PPE before accessing the wound, but forgot to wear the gown. The DON stated that staff were expected to use appropriate PPE while providing care to residents on enhanced barrier precautions and identified infection as the risk.
Failure to Coordinate PASARR Assessments and Initiate Recommended Occupational Therapy
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program as required, resulting in a resident not receiving recommended occupational therapy services. The resident, who was cognitively intact with a history of seizure disorder, quadriplegia, anxiety, and depression, had a PASARR Level 1 Screening indicating mental illness and developmental disability. The interdisciplinary team (IDT) meeting recommended occupational therapy to help the resident regain the ability to feed herself, a goal important to her. However, there was no care plan for PASARR services, and the occupational therapy was not initiated as recommended. Interviews revealed that the MDS Coordinator, who was new to the position, was unaware of the resident's status and did not know why occupational therapy had not started. The Rehabilitation Director stated that an initial request for occupational therapy was denied, and a subsequent request was delayed because the physician was unavailable to sign it. The DON confirmed that the request should have been signed upon the physician's return but was not, and the MDS Coordinator was responsible for sending the request. Facility policy required initiation of specialized services within 20 business days of the IDT meeting and documentation within 3 business days, but these steps were not followed.
Failure to Provide Required Discharge Summary and Notification
Penalty
Summary
The facility failed to complete and provide a discharge summary for a resident who was transferred to a hospital. The discharge summary was required to include a recapitulation of the resident's stay, diagnoses, course of treatment, pertinent laboratory results, a final summary of the resident's status, and a reconciliation of all pre-discharge medications with post-discharge medications. Record review showed that there was no documented discharge summary for the date the resident was sent to the hospital, and staff interviews confirmed that the necessary clinical documents were not prepared or sent to the receiving facility. The resident involved had a history of schizophrenia, anemia, and hypertension, and had exhibited both physical and verbal behavioral symptoms. The transfer to the hospital was ordered for further evaluation and treatment, but the facility did not provide the required clinical discharge summary or documentation to the hospital. Staff interviews revealed confusion about responsibilities, with the nurse on duty stating she did not complete the discharge summary due to a busy day, and the social worker indicating that the former administrator and DON oversaw the transfer. The physician reported giving a verbal report to the hospital but did not prepare a written discharge summary. Additionally, the facility failed to provide the required notice of discharge to the Office of the Long-Term Care Ombudsman. The Ombudsman confirmed that she was contacted for a list of alternative placements but was not provided with the necessary discharge notice or clinical summary. The facility's own policy required notification of the attending physician, the receiving facility, and the resident's representative, as well as preparation of a transfer form and forwarding of the medical record within 24 hours, but these steps were not documented as completed.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from abuse by another resident, resulting in psychosocial harm and threats to safety. One resident, with a history of anxiety, depression, PTSD, and schizophrenia, reported being threatened and verbally abused by another resident who had a diagnosis of non-Alzheimer's dementia and schizophrenia. This resident was observed to have delusions and both physical and verbal behavioral symptoms directed toward others. Multiple incidents occurred, including one where the aggressive resident pushed another resident's wheelchair, leading to a physical altercation, and another where he pulled out a knife and threatened to kill two residents. Staff and other residents reported ongoing verbal abuse, threats, and aggressive behavior from this individual. Despite these repeated incidents, the facility's leadership, including the Administrator and DON, did not take sufficient action to prevent further abuse or to protect the affected residents. Documentation and interviews revealed that staff were aware of the aggressive resident's behaviors, but interventions were limited to redirection and enhanced supervision, which proved inadequate. There was a lack of consistent follow-up with the victims, and some staff and residents expressed that they did not feel safe. The aggressive resident continued to have access to other residents and was able to bring prohibited items, such as a knife and lighter, into common areas. The facility's failure to act promptly and effectively allowed the abusive behavior to continue, resulting in psychosocial harm to at least one resident and ongoing distress among others. Staff interviews indicated that the aggressive resident's behavior was a known issue, and some staff felt that the DON did not adequately address the situation. The Administrator and DON were not fully aware of all incidents, and there was a lack of communication and documentation regarding the threats and abuse. The situation escalated to the point where an Immediate Jeopardy was identified due to the risk of continued abuse and harm.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Late Quarterly MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete quarterly MDS assessments within 90 days for 2 of 19 residents reviewed, including Resident #7 and Resident #48. Resident #7 was a male with diagnoses including hypertension, anemia, orthostatic hypotension, diabetes mellitus, cerebral palsy, anxiety disorder, bipolar disorder, schizophrenia, and autistic disorder. His EHR showed a quarterly MDS assessment that remained in-progress and had not been completed or transmitted to the CMS system, and his most recent completed quarterly assessment was dated 12/14/2024. Resident #48 was a female with diagnoses including multiple sclerosis, anxiety disorder, depression, psychotic disorder, arthritis, osteoporosis, and muscle weakness. Her EHR also showed a quarterly MDS assessment that remained in-progress and had not been completed or transmitted to the CMS system, and her most recent completed quarterly assessment was a prior quarterly assessment. During interviews, the DON, Administrator, and VP of Reimbursement stated the VP of Reimbursement was responsible for completing MDS assessments until an MDS coordinator was hired, and the VP of Reimbursement stated the facility had not completed Resident #31 and Resident #48's quarterly MDS assessments because there was no MDS coordinator.
Failure to Provide Needed Grooming Assistance
Penalty
Summary
The facility failed to ensure Resident #67, a female resident with diagnoses including dementia, muscle weakness, and lack of coordination, received the necessary personal hygiene care to maintain grooming. Her MDS assessment reflected that she required supervision or touching assistance for personal hygiene, including shaving, and her care plan stated that staff were to assist with ADL care as needed so she could remain clean, comfortable, and well groomed. During observation, Resident #67 was sitting in her wheelchair and was noted to have an excessive amount of thick, white facial hair across her chin, approximately 1/3 to 1/2 inches in length. When interviewed, she stated she did not like the hair on her chin and wanted it removed, and she could not recall staff asking whether she wanted her facial hair shaved. An LVN stated direct care staff were expected to check for facial hair during routinely scheduled showers several times per week and said she would have expected the resident’s chin to have been shaved before the hair grew that long.
Unlabeled and Undated Insulin in Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles in one medication cart on the 200 hall. During observation of the cart, Basaglar Kwik pen 100 unit/1 ml for Resident #47, Humulin 70/30 100 units/ml for Resident #11, and an opened vial of Novolin 70/30 were found without open dates, and the Novolin vial also had no label. The report states that opened insulin should be dated because it expires 28 days after opening. Resident #47 was a female with a Quarterly MDS showing a BIMs score of 2 and diagnoses including diabetes mellitus, hypertension, non-Alzheimer's dementia, and renal insufficiency. Her care plan reflected diabetes management with insulin at bedtime, and her physician's order was for Basaglar Kwik pen 100 unit/1 ml, 15 units subcutaneously at bedtime for type 2 diabetes mellitus without complications. Resident #11 was a male with a BIMs score of 15 and diagnoses including diabetes mellitus, hypertension, coronary artery disease, and renal insufficiency. His care plan reflected diabetes management, and his physician's order was for insulin lispro sliding scale before meals and at bedtime. During interview, the LVN stated she did not realize the two insulin pens and the opened vial lacked open dates or proper labeling, and she acknowledged that opened insulin expires after 28 days. The ADON stated that all insulin pens and vials should be labeled and dated, and that it was the responsibility of every nurse to check the open date before administering insulin. The DON stated he was notified of the undated and unlabeled insulin, and that the facility expected charge nurses to check insulin dates before administration. The facility policy stated that drug containers with missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing.
Baseline Care Plans Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care within 48 hours of admission for two residents reviewed. Resident #4 was a female admitted with diagnoses including dementia, bipolar disorder, and anxiety, and her baseline care plan was signed as completed on 05/13/25. Resident #111 was a female admitted with a diagnosis including a history of falling, and her baseline care plan was signed as completed on 07/19/25. During an interview, the ADON stated she completed the baseline care plans for both residents and confirmed that although IDT meetings were held within 48 hours of admission, the baseline care plans were not completed within that required timeframe. She stated there was not a specific reason for the delay and acknowledged that direct care staff members would not have basic information about newly admitted residents when baseline care plans were not completed on time. The facility policy stated that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission.
Blood-Stained Insulin Stored in Medication Cart
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During an observation on 07/22/25 at 1:37 PM, an unlabeled vial of insulin lispro was found in the top drawer of the hall 200 medication cart, stored with other medications, and both the vial and its box had blood stains on them. During interviews, LVN A stated she did not realize the insulin box and vial had blood stains and said nursing staff were responsible for keeping medication storage and preparation areas clean, safe, and sanitary. She stated the blood on the insulin bottle would put residents and staff at risk for blood borne infections and that nurses were supposed to always check and ensure proper infection control. ADON A confirmed the stains were blood and stated nurses were responsible for maintaining infection control and ensuring medication carts were clean and sanitary. The DON later stated he was notified of the blood-stained insulin vial and box, that it was the nurses' responsibility to ensure medications were stored and administered in a clean and sanitary environment, and that the blood-stained insulin was removed and disposed after the notification.
Incomplete Admission MDS Assessment
Penalty
Summary
The facility failed to complete a Comprehensive MDS Assessment within 14 calendar days after admission for Resident #111. Review of the resident’s Face Sheet showed she was an [AGE]-year-old female admitted to the facility with diagnoses including a history of falling. Review of the electronic medical record on 07/22/25 showed no evidence that an MDS Assessment had been completed for the resident. During an interview on 07/22/25 at 12:09 PM, the President of Reimbursement stated the facility did not currently have a full-time MDS Coordinator and had a couple of remote MDS Coordinators assisting until the vacant position could be filled. He confirmed Resident #111’s Comprehensive (Admission) MDS Assessment had not been completed within the required timeframe. Review of the facility’s Electronic Transmission of the MDS policy stated that all MDS assessments, including admission assessments, will be completed and electronically encoded into the facility’s MDS information system and transmitted to CMS’ QIES ASAP system in accordance with current OBRA regulations.
Facility Fails to Ensure Proper Certification for Hospitality Aide
Penalty
Summary
The facility failed to ensure that Hospitality Aide A had the appropriate nurse aide certification while employed and actively providing care for residents. Hospitality Aide A was listed as a CNA on the facility's schedule and counted as a CNA in the staffing numbers for several shifts, despite not having a CNA license. Interviews revealed that Hospitality Aide A performed duties such as making beds, taking out trash, feeding residents, performing incontinence care, and assisting with two-person transfers, even though she had not completed her CNA test. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were aware that Hospitality Aide A did not have a CNA license and stated that she was not supposed to work independently or be counted in the schedule numbers. However, the ADON included her in the numbers, and the DON, despite reviewing the schedule daily, did not notice this discrepancy. The Administrator was unable to provide a facility policy for competent nursing staff before the exit of the surveyors.
Resident Elopement Due to Faulty Door Alarm
Penalty
Summary
The facility failed to ensure a safe environment for a resident who was at risk of elopement. The resident, who had severe cognitive impairment and was identified as a high risk for wandering, managed to leave the facility through a door that did not sound an alarm. This incident occurred despite the resident having a Wander guard and being known to wander aimlessly. The resident was missing for over 15 hours before being found by the police. The resident's care plan indicated that he was an elopement risk and required interventions such as distraction and redirection from exits. However, on the day of the incident, the resident was not adequately supervised, and the door alarm system failed to alert staff when he exited the building. The resident's absence was noticed when he did not appear for dinner, prompting a search by the staff and the involvement of the police. Interviews with staff revealed that the door was usually alarmed, but the alarm did not function as expected on the day of the incident. The facility's administrator confirmed that the alarm system was checked and found to be working after the incident, but the reason for the failure was not determined. The resident was eventually found attempting to enter a school and was returned to the facility by the police.
Failure to Supervise Smoking Residents
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents who were observed smoking without supervision. Resident #55, a male with severe cognitive impairment and multiple health issues including dementia and hemiplegia, was found to be non-compliant with the facility's smoking policy. Despite being assessed as requiring supervision while smoking, he was observed with cigarettes and lighters in his possession and smoking outside the designated smoking times. His care plan indicated that he should not smoke without supervision, yet he was found with smoking materials in his room and was seen smoking unsupervised in the designated smoking area. Resident #12, who has intact cognition but multiple health diagnoses including hypertension and schizoaffective disorder, was also found to be non-compliant with the smoking policy. Although his smoking assessment indicated he required supervision while smoking, he was observed smoking without supervision and admitted to keeping cigarettes and lighters in his room against facility policy. Both residents were aware of the facility's smoking policy but chose to disregard it, keeping smoking materials on their person and smoking outside the scheduled times. Interviews with the ADON, DON, and Administrator confirmed awareness of the residents' non-compliance with the smoking policy. Staff had observed both residents smoking outside the designated times and with smoking materials in their possession. Despite efforts to educate and enforce the policy, the residents continued to violate the rules, posing a risk of fire and injury. The facility's smoking policy clearly outlined the need for supervision and secure storage of smoking materials, which was not adhered to in these cases.
Failure to Provide Operable and Comfortable Mobility Device
Penalty
Summary
The facility failed to provide a resident with a mobility device that was operable and comfortable, which compromised her independence, safety, and psychosocial needs. The resident, who has unspecified dementia, unsteadiness on feet, muscle wasting and atrophy, and unspecified glaucoma, reported that her wheelchair was not in working condition and uncomfortable. Despite filing a grievance and having the Maintenance Assistant attempt repairs, the wheelchair remained faulty, with a broken left arm pad and a narrowing size that made maneuvering difficult. The resident relied on the wheelchair for daily activities and outings with her family, but the unresolved issues made these tasks harder. Interviews with facility staff, including the Maintenance Assistant, DON, Social Worker, and Administrator, revealed a lack of awareness and responsibility regarding the resident's needs. The Maintenance Assistant was not informed of the ongoing issues after his initial repair attempt. The DON and Social Worker were unaware of the resident's discomfort, and the Administrator stated that the resident had not reported any issues. The facility's policy requires ongoing evaluation of residents' needs and preferences, but there was no specific person or department responsible for ensuring the functionality of mobility devices, leading to the oversight in addressing the resident's needs.
Failure to Resolve Resident Grievance in a Timely Manner
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for a resident who relied on a wheelchair for mobility. The resident, who had a moderately impaired cognition and several medical conditions including unspecified dementia and glaucoma, reported that her wheelchair was not in working condition and uncomfortable. Despite filing a grievance with the Assistant Director of Nursing (ADON) months prior, the issue remained unresolved, affecting her ability to perform daily tasks and participate in activities. Interviews with facility staff revealed a lack of awareness and communication regarding the grievance process. The ADON acknowledged receiving the complaint but did not recognize it as a grievance, instead reporting it to the maintenance department. The Maintenance Assistant confirmed working on the wheelchair but was unaware of any ongoing issues. The Director of Nursing (DON) and the Social Worker, who is the designated grievance official, were also unaware of the unresolved grievance, indicating a breakdown in the grievance reporting and resolution process. The facility's grievance procedures were not effectively followed, as evidenced by the absence of the resident's grievance in the grievance logs and the lack of a timely resolution. The Administrator and other staff members did not identify any risks associated with unresolved grievances, and the facility did not provide a grievance policy when requested. This oversight could potentially impact the resident's ability to voice grievances without fear of reprisal and have them resolved promptly.
Inaccurate MDS Assessment for Major Depressive Disorder
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, specifically regarding the diagnosis of Major Depressive Disorder. The resident, a male with severe cognitive impairment, was admitted with active diagnoses including aphasia and hemiplegia. Despite being referred for psychiatric services and being treated with Trazodone for Major Depressive Disorder, the MDS assessment did not reflect this diagnosis. This oversight was identified during a review of the resident's records, which included a psychiatric assessment confirming the diagnosis and active treatment for depression. Interviews with facility staff, including Licensed Vocational Nurse (LVN) I, MDS Nurse G, and MDS Nurse Q, revealed a lack of awareness regarding the resident's current diagnosis of Major Depressive Disorder. LVN I, who had observed the resident's depressive symptoms, was unaware of the active diagnosis and treatment. Both MDS nurses, responsible for ensuring the accuracy of MDS assessments, admitted to not knowing that the resident's MDS did not reflect the current diagnosis. The Director of Nursing (DON) and the Administrator also confirmed their unawareness of the discrepancy in the MDS assessment. The facility's policy and job description for MDS coordinators emphasize the responsibility for ensuring accurate MDS assessments. However, the failure to update the resident's MDS with the correct diagnosis of Major Depressive Disorder indicates a lapse in following these guidelines. This deficiency could potentially lead to missed care and unmet needs for the resident, as the MDS assessment is crucial for planning and delivering appropriate care services.
Failure to Update PASARR Screening for Resident with New Diagnosis
Penalty
Summary
The facility failed to submit an accurate PASARR Level 1 (PL1) screening for a resident diagnosed with Major Depressive Disorder after admission. This oversight was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses including aphasia and hemiplegia following a cerebral infarction, was later diagnosed with Major Depressive Disorder. Despite this new diagnosis, the facility did not update the PASARR Level 1 screening to reflect the presence of a mental illness, which is necessary to determine if a Level II PASARR evaluation is required for accessing needed services. Interviews with facility staff, including MDS nurses and the Director of Nursing (DON), revealed a lack of awareness regarding the need to submit a new PASARR Level 1 screening following the resident's new diagnosis. The MDS nurses were responsible for ensuring the accuracy of PASARR screenings, but they did not submit an updated screening for the resident. The facility also did not provide a policy related to PASARR services or assessments when requested. This failure could result in missed care opportunities for residents who require additional services due to mental illness, intellectual disability, or developmental disability.
Failure to Include Major Depressive Disorder 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 measurable objectives and time frames that addressed the resident's clinical and psychosocial needs. Specifically, the care plan did not include the resident's diagnosis of Major Depressive Disorder, despite it being identified in the comprehensive assessment. This oversight was discovered during a review of the resident's records, which showed active diagnoses of aphasia, hemiplegia following cerebral infarction, and muscle weakness, along with a severe cognitive impairment indicated by a BIMS score of 1. The resident had been referred for psychiatric services due to symptoms of depression, withdrawal, and other related issues, yet these were not reflected in the care plan. Interviews with staff, including an LVN, MDS nurses, the DON, and the Administrator, revealed a lack of awareness regarding the resident's current diagnosis and its absence from the care plan. The LVN was unaware of the resident's treatment for Major Depressive Disorder, despite the resident taking medications for depression. Both MDS nurses acknowledged their responsibility for ensuring care plans were personalized and matched residents' current needs, but they were unaware of the omission. The DON and Administrator also confirmed the oversight and recognized the risk of missed care opportunities due to the lack of a personalized care plan. The facility's policy on comprehensive person-centered care plans, dated December 2016, emphasized the need for care plans to include measurable objectives and timetables to meet residents' needs, which was not adhered to in this case.
Failure to Provide Podiatry Services for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with diabetes, leading to a deficiency in maintaining proper foot health. The resident, a male with a history of diabetes and other health conditions, had not received podiatry services since his admission to the facility. His toenails were observed to be long and curved into his skin, causing him to self-manage a hangnail, which resulted in pain. Despite being assisted with bathing and hygiene, the resident did not receive assistance with toenail clipping, and he did not request help from the staff. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Social Worker, revealed a lack of awareness and communication regarding the resident's need for podiatry services. The ADON and DON acknowledged the importance of regular podiatry visits for residents with diabetes to prevent foot injuries and complications. However, the Social Worker, responsible for making podiatry referrals, was not informed of the resident's condition and had not included him on the referral list for podiatry services. The facility's policies on pharmacy services and activities of daily living (ADLs) emphasize the importance of providing appropriate care and treatment to maintain mobility and foot health. However, the lack of documentation and communication among staff members resulted in the resident not receiving the necessary podiatry care. This oversight could potentially lead to negative outcomes for the resident's foot health, as noted by the staff during interviews.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, resulting in missed medication doses. Specifically, RN B and LVN C did not document the administration of Ipratropium-Albuterol Inhalation Solution and Robitussin Mucus+Chest Congest Oral Liquid as ordered for a resident. This oversight placed the resident at risk of not receiving medications as prescribed by the physician, potentially leading to a worsening of their condition. The resident, a male admitted from an acute care hospital, had a complex medical history including hypertension, pneumonia, septicemia, atrial fibrillation, influenza A, prostate cancer, and muscle weakness. The resident required total assistance with transfers and was on a mechanical soft diet. Despite these needs, the Medication Administration Record (MAR) showed several instances where doses of the prescribed medications were left blank and not signed as administered. Interviews with facility staff, including RN B, LVN E, the ADON, and the DON, revealed a lack of awareness regarding the missed doses. The staff did not document any refusals or reasons for the missed doses in the MAR or progress notes, nor did they notify the physician. The attending physician, upon being informed, stated that the missed doses would not have changed the resident's prognosis or outcome, although the facility's policy required documentation and physician notification for missed doses.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to assist in obtaining routine and emergency dental care for a resident, leading to a deficiency in dental services. The resident, a male with severe cognitive impairment and multiple health issues, expressed a desire to see a dentist but was unaware of whom to contact within the facility. Despite the resident's family member requesting a dental referral, it was not completed, and the resident's care plan did not address his dental needs. Observations revealed the resident had cracked and missing teeth, along with a strong odor from his mouth, indicating potential dental issues. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Social Worker, the Director of Nursing (DON), and the Administrator, revealed a lack of awareness regarding the resident's dental pain and the request for dental services. The Social Worker, responsible for coordinating ancillary services, was not informed of the resident's needs, and the facility's policy on dental services was not followed. The deficiency highlights a breakdown in communication and coordination among staff, resulting in the resident not receiving necessary dental care.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for three residents, leading to potential risks of urinary tract infections. Resident #52, a cognitively intact male with obstructive and reflux uropathy, diabetes, and obesity, was observed during a mechanical lift transfer with his catheter drainage bag placed on his abdomen, above the bladder level. This improper positioning allowed urine to flow back toward the bladder, increasing the risk of infection. Both CNAs involved acknowledged their mistake and the potential for cross-contamination. Resident #70, a cognitively intact female with morbid obesity, chronic heart failure, and a stage 4 pressure ulcer, experienced a similar issue during wound care. RN P placed the catheter bag on the bed, above the bladder level, causing urine to flow back toward the bladder. The RN admitted to knowing the correct procedure and recognized the risk of infection due to the improper placement of the catheter bag. Resident #85, a male with moderate cognitive impairment and a history of hypertension, anxiety, and depression, was found with his catheter bag in contact with the floor while in his wheelchair. Both the CNA and RN responsible for his care acknowledged the increased risk of infection from the catheter bag touching the floor. The resident himself noted that the bag often touched the floor, and he had experienced several urinary infections in the past. The facility's policy clearly stated the importance of keeping the catheter bag below the bladder and off the floor to prevent infections.
Failure to Properly Handle Damaged Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper handling and disposition of damaged medications on one of the medication carts, specifically Nurses Cart Hall 300. During an observation and record review, it was found that the blister packs for tramadol 50 mg tablets, a controlled medication used for pain, for three residents had broken seals with the pills still inside and taped over. This issue was identified during a change of shift count by an LVN, who acknowledged seeing the broken blisters but failed to report it to the Director of Nursing (DON) due to being busy. The DON stated that any medication with a broken seal should be discarded immediately to prevent potential drug diversion and infection control issues. The facility's policy requires discontinued, outdated, or deteriorated drugs to be returned to the pharmacy or destroyed. The responsibility for checking medication blister packs for broken seals during shift changes lies with the nurses and medication aides, and the DON and ADON are expected to check the carts weekly. However, this protocol was not followed, leading to the deficiency.
Deficiencies in Food Storage and Utensil Use in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the refrigerator and freezer were not properly covered or labeled with visible use-by dates. For instance, beef patties in the walk-in freezer were not covered appropriately, and a box of diced potatoes in the refrigerator lacked a visible use-by date. Additionally, a bunch of cilantro was found to be rotten. These lapses in food storage and labeling could potentially lead to food-borne illnesses among residents. Furthermore, the facility did not ensure that staff used clean utensils when accessing bulk foods. A scoop was left inside a bulk sugar container, which could lead to cross-contamination. Interviews with the Dietary Manager and another staff member revealed a lack of awareness and adherence to proper food safety protocols. The Dietary Manager acknowledged the risks associated with these practices, including the potential for freezer burn and food contamination, which could adversely affect the health of residents.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of three Certified Nursing Assistants (CNAs) who did not adhere to proper hand hygiene protocols while providing incontinence care to residents. Specifically, CNA D did not perform hand hygiene after removing soiled gloves and before donning clean gloves while caring for a resident with severe cognitive impairment and multiple health issues, including cerebral infarction and chronic kidney disease. This lapse in protocol occurred during the process of changing the resident's brief and cleaning the resident after a bowel movement. Similarly, CNA F failed to perform hand hygiene after removing gloves and before re-entering a resident's room to continue incontinence care. This resident, who was moderately cognitively impaired and dependent on care for all activities of daily living, was exposed to potential cross-contamination when CNA F did not change gloves after cleaning the resident and before handling clean items. The CNA also did not perform hand hygiene after leaving the room to retrieve supplies, further increasing the risk of infection. CNA L also neglected to perform hand hygiene after removing soiled gloves and before donning clean gloves while providing incontinence care to a resident with severe cognitive impairment and paraplegia. This resident required assistance for all activities of daily living and was always incontinent of urine and bowel. The CNA's failure to adhere to hand hygiene protocols during the care process, including after handling soiled briefs and before placing clean briefs, posed a risk of infection and cross-contamination.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in two residents. Resident #53, a female with severe cognitive impairment due to cerebral infarction and hemiplegia, was found with long, dirty, and chipped fingernails. Despite her condition, which required assistance with personal hygiene, her fingernails were not properly maintained. Similarly, Resident #74, a female with moderate cognitive impairment and physical debility, was found with discolored and dirty fingernails. She required extensive assistance with personal hygiene, yet her nail care was neglected. Interviews with facility staff revealed that both CNAs and LVNs were responsible for nail care, except in cases involving diabetic residents, where only nurses were allowed to perform nail care. The Director of Nursing (DON) stated that nail care should be provided every Sunday or as needed, particularly during shower times. However, the observations indicated a lapse in this routine care, as both residents were not diabetics and should have received regular nail care. The facility's policy on activities of daily living emphasized the need for services to maintain good grooming and hygiene for residents unable to perform these tasks independently, yet this was not adhered to in the cases of Resident #53 and Resident #74.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident #6 and Resident #83, were placed within their reach, which is a violation of their right to reside and receive services with reasonable accommodation of their needs. Resident #6, who has a history of falls, dementia, and severely impaired cognition, was observed in a low bed with the call light hanging off the bed rail, out of reach. Interviews with the resident and staff confirmed that the resident was unable to locate or reach the call light, which is crucial for preventing falls and ensuring assistance is available when needed. Similarly, Resident #83, who also has a history of falls, severely impaired cognition, and is on hospice services, was found with the call light looped and hung on the wall behind the bed, making it inaccessible. The resident was unaware of the call light's location, and staff interviews revealed that the call light should have been placed within reach to allow the resident to call for help if necessary. The staff acknowledged the importance of having the call light within reach to prevent falls and ensure the resident's needs are met. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator confirmed that both residents were at high risk of falls and should always have their call lights within reach. The facility's policy on resident call lights emphasizes the importance of a systems approach to safety, which includes ensuring call lights are accessible to residents to prevent injuries and meet their needs. However, the failure to adhere to this policy resulted in the deficiency observed during the survey.
Failure to Apply Splint as Ordered for Resident
Penalty
Summary
The facility failed to ensure that Resident #44 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the staff did not apply the resident's right hand splint as ordered by the physician on two consecutive days, 06/04/24 and 06/05/24. This oversight was observed during multiple instances where the resident was seen without the splint, despite the treatment administration record (TAR) being signed off as if the splint had been applied. Resident #44, a male with a history of aphasia, right-side hemiplegia, and cerebral vascular accident, was admitted to the facility with a care plan that included the use of a right hand splint to prevent further contractures. The care plan specified that the splint should be worn daily from 8 a.m. to 2 p.m. However, observations on the specified dates showed that the splint was not in place, and interviews with staff revealed a lack of clarity and communication regarding the responsibility for applying the splint. Interviews with various staff members, including CNAs and nurses, highlighted confusion about who was responsible for applying the splint. Some staff members were unaware of the resident's need for a splint, while others mistakenly believed it was not their responsibility. The Director of Nursing (DON) confirmed that nurses were responsible for ensuring the splint was applied and should not have signed off on the TAR if it was not in place. The facility's policy on resident mobility and range of motion emphasized the importance of interventions like splints to prevent a reduction in range of motion, which was not adhered to in this case.
Inadequate Supervision and Assistance for Resident Care
Penalty
Summary
The facility failed to provide adequate supervision and assistance to Resident #51, who required a two-person assist for incontinence care. The resident, a male with paraplegia and chronic respiratory failure, was dependent on staff for all activities of daily living (ADLs) and had severely impaired cognition. During an observation, a certified nursing assistant (CNA) was seen providing incontinence care to the resident without the required assistance, rolling the resident on his side and pulling him up in bed without help. This action was contrary to the resident's care plan and comprehensive MDS assessment, which indicated the need for a two-person assist. Interviews with the CNA and a licensed vocational nurse (LVN) revealed that the CNA often worked alone and would sometimes call for help if someone was available. The Director of Nursing (DON) stated that CNAs were instructed to ask for help with heavy residents and that the MDS should be checked first to determine the level of assistance required. The facility's policy emphasized resident safety and supervision as priorities, yet the failure to adhere to the two-person assist requirement placed the resident at risk for accidents and injury.
Failure to Label and Date Hydration Bag for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received appropriate treatment and services to prevent complications. Specifically, the facility did not label and date the hydration bag used for a resident's tube feeding pump. This oversight was observed during a survey, where it was noted that the hydration bag contained a colorless liquid without any label indicating its contents, the date it was hung, or the resident's name. The resident, who was dependent on tube feeding due to dysphagia and other medical conditions, was unable to provide information about the contents of the bag. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that it was standard protocol to label and date all enteral feeding bags with the contents, the date and time they were hung, and the resident's identifier. The failure to adhere to this protocol could lead to complications such as the use of incorrect hydration or an increased risk of infection. The facility's policy and recommendations from the American Society for Parenteral and Enteral Nutrition emphasize the importance of standardizing labels for all enteral formula containers to ensure safe practices.
Failure to Maintain Safe Sharps Disposal Practices
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible, specifically regarding the management of contaminated sharps disposal bins. During an observation, it was found that the sharps bin attached to the 300 Hall MA Medication Cart was past the full line, preventing the lid from closing completely. Additionally, eight pills were observed stuck between the plastic insert and the insert's lid, further contributing to the lid not closing properly. MA B, who was responsible for the cart, stated she was unaware of the issue and acknowledged that the full bin and medications posed a hazard for residents and staff. Similarly, the sharps bin attached to the 300 Hall Nurse Medication Cart was also found to be past the full line, with RN C acknowledging the potential hazard. Interviews with the ADON and the Administrator confirmed that the sharps bins should never be filled past the full line to prevent possible injury to staff or residents. The ADON and the Administrator both emphasized that medications should not be disposed of in the sharps bin and that the current state of the bins posed a potential risk. The DON confirmed that a staff member had recently been stuck by a needle due to a similar issue, and in-service training had been conducted. The facility's policy on safety and supervision of residents was reviewed, which stated that the environment should be as free from accident hazards as possible. The policy also outlined the responsibilities of staff in identifying and mitigating safety risks. Despite this, the facility failed to adhere to its own policy, resulting in the identified hazards.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for two residents. Resident #15, a female with diagnoses including hypertension, hypothyroidism, and breast cancer, did not receive her Metoprolol ER 50 mg tablet at the scheduled time of 9 am. Instead, the medication was administered at 11:25 am by LVN D, who acknowledged the delay and attributed it to a change in resident assignments after a staff member called off. This delay in medication administration could potentially affect the therapeutic outcomes intended by the physician's order. Similarly, Resident #20, a female with multiple diagnoses including insomnia, Parkinson's disease, and type 1 diabetes mellitus, did not receive her scheduled morning medications on time. MA B administered several medications, including Hydrocodone, Methocarbamol, Topiramate, Levetiracetam, and Trospium Chloride, at 11:54 am instead of the scheduled 9 am. MA B explained that the delay was due to being assigned more residents after another medication aide called off. The Director of Nursing confirmed that medications should be administered within a one-hour window to prevent negative effects and ensure efficacy, and acknowledged that the staff had been in-serviced on medication administration.
Failure to Properly Store and Dispose of Medications
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permitted unauthorized access to medications on one of the six medication carts reviewed. Specifically, eight pills were found stuck between the plastic insert of the sharps container and the lid on the 300 Hall MA Medication Cart, preventing the lid from closing properly. This was observed while residents were self-ambulating through the hall in their wheelchairs. MA B, who was responsible for the cart, stated she did not see the medications and denied disposing of them. She acknowledged that all staff were responsible for ensuring medications were secured and disposed of properly and that medications should not be disposed of in the sharps bin. The ADON and the Administrator confirmed that the medications should not have been on the lid of the sharps bin and posed a potential hazard to residents. The DON stated that the medications should be disposed of properly and not placed in the sharps bin. He changed out the sharps insert and disposed of the pills but was unable to identify what the pills were. He mentioned that staff are trained on how to dispose of medication properly but did not recall when the last training occurred. The facility's policy on the storage of medications indicated that drugs and biologicals should be stored in locked compartments and disposed of properly, but this policy was not followed in this instance.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mustang Park Therapy And Living Center | 1.3 mi | ★★★★★ | 21 | 0 |
| Prestonwood Rehabilitation & Nursing Center Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| Accel At Willow Bend | 3.1 mi | ★★★★★ | 24 | 0 |
| Heritage Gardens Rehabilitation And Healthcare | 4 mi | ★★★★★ | 5 | 0 |
| The Madison On Marsh | 4.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.