Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buckner Westminster Place during CMS and state inspections, most recent first.
Improper Food Storage and Thawing Practices: Surveyors observed sausage and ham thawing in a kitchen sink without being fully submerged or kept under continuous cool running water, cooked chicken in the refrigerator that was not labeled or dated, and buffet lids stored on the floor. The Dietary Mgr, DON, and Administrator all stated these practices were not proper and could lead to foodborne illness.
PRN Psychotropic Order Lacked Required 14-Day End Date: A resident with anxiety, depression, and respiratory failure had a PRN Xanax 0.25 mg order for anxiety, restlessness, and agitation that was entered without a 14-day end date. The DON and Administrator stated PRN psychotropic meds should have a 14-day end date, and no specific policy addressing the deficient practice was provided.
Oxygen tubing and humidifier bottle were not maintained per order for a resident with CHF, acute respiratory failure with hypoxia, and anxiety. Staff observed the nasal cannula tubing on the floor and later uncovered on a recliner, while the humidifier bottle and tubing were dated beyond the weekly change interval. LPNs and leadership stated the tubing should be kept in a bag and off the floor and the oxygen supplies changed weekly.
A resident with a surgical wound to the L hip had wound cleanser left on the bathroom counter during multiple observations, despite orders for twice-daily wound care. The resident said staff usually left the cleanser in the bathroom after use, and the LVN, ADON, DON, and Executive Director all acknowledged that nursing staff were responsible for removing and properly storing the cleanser after treatment.
Failure to Use Gown During Incontinent Care for Resident on EBP: A CNA provided incontinent care to a resident on enhanced barrier precautions without donning a gown first. The resident had urinary incontinence, required moderate ADL assistance, and had a stage 4 wound to the L buttock. Interviews showed staff had differing understanding of when gowns were required for EBP, and the resident reported staff did not wear gowns during changes or wound care.
Three dietary staff members did not have current Food Handler's Certificates as required, with two lacking certificates entirely and one having an expired certificate. Leadership, including the Director of Culinary Services and the Administrator, failed to verify or ensure compliance with food safety training requirements, despite facility policy and state regulations mandating such certification for food service employees.
Two residents did not have their care plans updated to reflect critical physician orders and recommendations, including the need for nectar thickened liquids for a resident with dysphagia and nutritional supplements for a resident with planned weight loss. Staff interviews revealed confusion and delays in updating care plans and entering orders, resulting in incomplete communication of care needs.
A deficiency was identified when the Director of Culinary Services did not complete required training on HIV, restraint reduction, fall prevention, resident rights, behavioral health, or infection prevention and control. Personnel records lacked documentation of these trainings, and interviews revealed confusion over responsibility for ensuring completion. The facility's policy required annual training, but it was not enforced for this staff member.
The facility did not ensure the Director of Culinary Services completed mandatory abuse, neglect, and exploitation prevention training as required by policy. Personnel records lacked documentation of completed training, and interviews revealed both the Director and HR were unaware of the deficiency, with oversight responsibilities unclear between the facility and the contract company.
A resident with a hip fracture experienced a change in condition when her surgical incision dressing became saturated, but the facility failed to notify the physician. Despite documentation by nursing staff of the dressing's condition, no orders were obtained, leading to an infection requiring antibiotics. The facility's policy required physician notification for such changes, but this was not followed.
A facility failed to ensure a resident received appropriate surgical incision care upon admission, leading to an infection. The facility did not clarify or obtain specific care orders for the resident's surgical site, despite hospital discharge instructions indicating the need for infection prevention. Nursing staff documented changes in the wound condition but did not notify the physician or obtain treatment orders until a follow-up appointment revealed an infection.
A resident's room in a LTC facility was found to have a black substance, suspected to be mold, on the air vent and closet, with an open space covered by cardboard allowing bugs to enter. The resident, who was nonverbal and dependent on staff, had chronic obstructive pulmonary disease and pneumonia. Despite previous complaints, the facility's staff were unaware of the issue, highlighting a failure to maintain a safe and clean environment.
The facility failed to store and handle food according to professional standards, with paint and chemicals stored near food, improper use of sanitizer during food preparation, and a staff member with unsecured hair. These practices risked chemical contamination and food-borne illness.
A resident with multiple health conditions, including dementia and parkinsonism, was found without a call light within reach, violating resident rights. Observations showed the call light was placed on a chair two feet away, making it inaccessible. Staff interviews revealed inconsistencies in understanding the importance of call light accessibility, with some staff believing the resident could use it if reachable. The facility lacked a specific call light policy, contributing to the deficiency.
The facility failed to adhere to its infection prevention and control program in one of its laundry rooms, where soiled laundry was found unbagged and improperly handled. Staff interviews revealed non-compliance with the facility's policy requiring soiled laundry to be bagged before leaving a resident's room, posing a risk of cross-contamination and infection.
Two residents in the facility did not receive critical medications due to failures in pharmaceutical services. One resident missed doses of Enoxaparin, a blood thinner, while another missed doses of Bydureon for diabetes. Staff falsified records to indicate medications were administered when they were not available. The facility lacked clear processes for reordering medications, leading to these deficiencies.
Two residents in the facility did not receive their prescribed medications, Enoxaparin and Bydureon, due to significant medication errors. The medications were documented as administered, but pharmacy records showed they were not refilled. Staff, including LVNs and MAs, were involved in falsifying documentation, indicating medications were given when they were not. The facility lacked clear processes for medication management and documentation.
Improper Food Storage and Thawing Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an initial tour, surveyors observed sausage and ham thawing in the kitchen sink without being fully submerged and without water continuously running to agitate the surface of the water, while the sink was draining. Surveyors also observed cooked chicken in a refrigerator container that was not labeled or dated, and buffet lids stored directly on the floor of the kitchen. During interviews, the Dietary Manager stated that foods thawing in the sink should be fully submerged with continuous cool running water agitating the surface and that the sink should not have been draining. She also stated that cooked chicken in the refrigerator should be labeled and dated and that food buffet lids should not be stored on the ground floor. The DON and Administrator both stated that meat should be thawed properly, food should be labeled and dated, and lids should not be stored on the floor. Record review showed facility policies requiring food and supplies to be stored according to current standards of practice and food to be stored, prepared, distributed, and served in accordance with professional standards for food service safety.
PRN Psychotropic Order Lacked Required 14-Day End Date
Penalty
Summary
The facility failed to ensure that Resident #5’s drug regimen was free from a PRN psychotropic medication order that was limited to 14 days. Resident #5 was a [AGE]-year-old female admitted to the facility with diagnoses including anxiety, depression, and respiratory failure with hypoxia. Her significant change in status MDS indicated she understood others and made herself understood, had a BIMS score of 14, and was receiving an anti-anxiety medication. Record review showed a comprehensive care plan addressing altered cardiac function related to atrial fibrillation and noting monitoring for increased anxiety. The physician order for Xanax 0.25 mg by mouth every 4 hours as needed for anxiety, restlessness, and agitation began on 7/11/2026 and had no end date. During interviews, the DON and Administrator stated that PRN psychotropic medications should have a 14-day end date, and the Administrator stated that residents with psychotropic medications should be managed by nursing staff. A requested policy regarding unnecessary medications was not provided because there was no specific policy addressing the deficient practice.
Oxygen tubing and humidifier bottle not maintained per order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #11, a cognitively intact female with diagnoses including chronic systolic congestive heart failure, acute respiratory failure with hypoxia, bradycardia, supraventricular tachycardia, hypertensive heart disease with heart failure, and anxiety disorder. Her record showed she required oxygen therapy, had a care plan for anxiety with oxygen to be administered as needed/ordered, and had physician orders for oxygen at 2-4 liters per minute via nasal cannula as needed and for the oxygen tubing, cannula, and humidifier bottle to be changed and labeled weekly. During observations, Resident #11's nasal cannula tubing was seen on the floor and later hanging uncovered on the back of her recliner while the oxygen concentrator was running with the humidifier bottle and tubing dated beyond the weekly change interval. Staff interviews confirmed that nurses were responsible for keeping the tubing in a bag and off the floor and for changing the humidifier bottle and tubing weekly, and that the items had not been changed for longer than a month. The DON, ADON, and Executive Director all stated that the tubing and humidifier bottles were expected to be changed at least weekly and kept covered to prevent floor contact. The facility policy on oxygen administration stated to inspect equipment and remove expired or defective items from resident use.
Wound Care Cleanser Left Unsecured in Resident Bathroom
Penalty
Summary
The facility failed to store wound care cleanser in a locked compartment for one resident who was reviewed for medication storage. Resident #7 was admitted with diagnoses including aftercare following joint replacement surgery and infection/inflammation reaction due to an internal left hip prosthesis. Her quarterly MDS dated 6/23/26 showed a BIMS score of 13, indicating she was cognitively intact, and her care plan identified ongoing risk related to surgical wound infection and dehiscence of the left hip with wound care orders to be followed as prescribed. Record review showed the resident’s treatment orders included cleansing the surgical wound dehiscence of the left hip with wound cleanser or normal saline twice daily and as needed. During observations on 7/13/26 and 7/14/26, a bottle of wound care cleanser was seen on the resident’s bathroom counter. During interview, the resident stated the cleanser had been left in her bathroom for a while and was usually left on the sink after staff used it. Staff interviews confirmed that nursing staff were responsible for removing and properly storing the wound cleanser after use, and the DON, ADON, and Executive Director all stated medications and wound care cleanser should be properly stored.
Failure to Use Gown During Incontinent Care for Resident on EBP
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one resident who was reviewed for infection control practices. Resident #11 was a [AGE]-year-old female admitted on [DATE] with diagnoses including unspecified urinary incontinence, muscle weakness, urinary tract infections, and need for assistance with personal care. Her MDS assessment dated 6/1/26 reflected that she was understood and understood by others, had a BIMS score of 14, and required moderate assistance with ADLs. Her care plan dated 6/2/26 and order summary reflected that she was on enhanced barrier precautions related to a stage 4 wound to the left buttock, with enhanced barrier precautions ordered continuously on 4/8/26. During an observation on 7/13/26 at 11:37 AM, CNA B performed incontinent care on Resident #11 without donning a gown before providing care, even though the resident was on enhanced barrier precautions. In interviews, CNA B stated she believed staff did not have to wear a gown during peri care or incontinent care for residents on enhanced barrier precautions and said she had been told by the ADON that a gown was not needed for Resident #11. Resident #11 stated staff did not wear gowns when changing her or when changing her wound dressing. Later interviews showed differing understanding among staff: an LVN stated gowns and gloves were expected for peri care, incontinent care, and other high-contact care for residents on enhanced barrier precautions, while the ADON and DON stated staff were expected to wear the appropriate PPE during high-contact care and that nursing staff were responsible for ensuring compliance.
Failure to Ensure Dietary Staff Hold Current Food Handler's Certificates
Penalty
Summary
The facility failed to employ sufficient dietary staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service, as required by regulations. Specifically, three out of twenty kitchen staff members did not possess a current and valid Food Handler's Certificate. Two staff members hired in April did not have any Food Handler's Certificate on file, and a third staff member's certificate had expired in March. This was confirmed through record review and interviews with facility leadership and dietary staff. Interviews revealed that the Director of Culinary Services was responsible for ensuring all dietary staff had current Food Handler's Certificates but had not verified the status of these certificates upon assuming the role. The Director relied on a binder provided at the time of hire, which he did not review, and assumed all certificates were up to date. The Administrator and other leadership staff were aware of the missing certificates but had not taken steps to verify or ensure compliance. The Executive Chef and HR Director both confirmed that the responsibility for maintaining current Food Handler's Certificates rested with the Director of Culinary Services. The facility's own Food Safety Policy and the Texas Food Establishment Rules require that food service employees complete accredited food handler training within 30 days of hire. The lack of current Food Handler's Certificates among dietary staff was acknowledged by multiple staff members, including the Director of Culinary Services, the Administrator, and the Executive Chef, all of whom recognized the importance of this training for safe food handling and compliance with regulatory requirements.
Failure to Update and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to care planning and communication of critical care needs. For one resident with severe cognitive impairment and dysphagia, the care plan did not address the physician's order for nectar thickened liquids, despite documentation in the medical record and staff interviews confirming the need for this intervention. Staff interviews revealed that the omission of thickened liquids from the care plan could result in staff not being aware of the dietary requirement, increasing the risk of inappropriate food or liquid consistency being provided. In the case of another resident with a planned weight loss, the facility did not update the care plan to reflect the physician's and dietitian's recommendations for a multivitamin with minerals and supplemental protein drinks. Although the resident experienced significant weight loss over a short period, the care plan did not include the new interventions, and there was a delay in entering the orders into the electronic medical record. Interviews with nursing staff and administration indicated confusion regarding the process for updating care plans and implementing recommendations, with some staff considering dietitian recommendations as optional until reviewed by a physician. The report documents that the facility's interdisciplinary team did not consistently update care plans to reflect changes in residents' needs or physician orders. Staff interviews confirmed that care plans were not always revised in a timely manner, and there was a lack of clarity regarding responsibility for updating care plans and entering orders. The RAI Manual and federal regulations require that care plans include measurable objectives and timeframes to address all identified needs, but this was not consistently done for the residents reviewed.
Failure to Ensure Required Staff Training for Director of Culinary Services
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, including those under contract and volunteers, as evidenced by the lack of required training for the Director of Culinary Services. Personnel records showed that the Director of Culinary Services, hired on 01/13/25, did not have documentation of completed training on HIV, restraint reduction, fall prevention, resident rights, behavioral health, or infection prevention and control. Interviews revealed that the Director of Culinary Services was unaware that these trainings were incomplete and admitted to not knowing about the required topics. The HR Director stated that managers were responsible for completing their own trainings after receiving email notifications, but confirmed that the Director of Culinary Services had not completed any required trainings. Further interviews indicated a lack of clarity and oversight regarding responsibility for ensuring completion of mandatory trainings, with the Administrator and the Regional Director of the contract food company each suggesting the other party shared responsibility. The facility's staff development policy required all employees to complete specific training courses annually, with non-compliance potentially resulting in corrective action. However, the policy was not effectively enforced in this case, resulting in the Director of Culinary Services not receiving essential training as required by facility policy and regulatory guidelines.
Failure to Provide Required Abuse Prevention Training to Director of Culinary Services
Penalty
Summary
The facility failed to provide required training on abuse, neglect, exploitation, and misappropriation of resident property to the Director of Culinary Services. Review of personnel records showed that the Director of Culinary Services, hired on 01/13/25, did not have documentation of completing any abuse prevention training. Interviews with the HR Director revealed that the Director was responsible for completing his own required trainings, which were communicated via email, but he had not completed any of them. The Director of Culinary Services confirmed he was unaware that the trainings were incomplete and admitted he may not know what constitutes abuse or how to prevent it. The Administrator stated that the Director was expected to complete the required training and that oversight was shared with the contract company, but the trainings were not completed due to a breakdown in responsibility. Further interviews with the Regional Director of the contract food company indicated a lack of awareness regarding the training timelines and shared oversight responsibilities between the facility and the contract company. Review of the facility's abuse policy and staff development policy confirmed that all associates are required to complete abuse prevention training before resident contact and annually thereafter, with non-compliance potentially resulting in corrective action. The absence of completed training for the Director of Culinary Services represents a failure to follow these policies.
Failure to Notify Physician of Surgical Dressing Saturation
Penalty
Summary
The facility failed to consult with the physician when a resident experienced a change in condition, specifically regarding the surgical incision dressing saturation. The resident, a female with a history of a hip fracture, muscle weakness, cirrhosis of the liver, insomnia, and gait abnormalities, had a surgical incision on her left hip. On two occasions, the dressing on the surgical site was found to be saturated, yet the physician was not notified. This lack of communication resulted in the resident developing an infection, which was identified during a post-operative visit and required antibiotic treatment. The nursing staff, including RN D and LVN C, documented the condition of the surgical site, noting serosanguineous drainage and the absence of infection signs initially. However, there was no documentation indicating that the physician was notified to obtain treatment orders. The facility's policy required that changes in a resident's condition, such as dressing saturation, be reported to the physician, but this was not adhered to in this case. Interviews with the nursing staff and the Director of Nursing (DON) revealed that there was an expectation for the physician to be contacted for surgical wound care orders, but this did not occur. The physician confirmed that he would have wanted to be notified of the dressing saturation and that orders should have been sent from the hospital. The facility's failure to notify the physician and obtain appropriate orders for wound care led to the resident's surgical incision becoming infected. The deficiency was identified as past non-compliance, with the facility having corrected the issue before the investigation began.
Failure to Obtain and Clarify Surgical Incision Care Orders
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care in accordance with professional standards of practice for a surgical incision. Upon admission, the facility did not clarify and obtain surgical incision care orders for the resident, who had been discharged from the hospital with a closed displaced fracture of the neck of the left femur. The hospital discharge instructions included general guidelines for preventing infection but did not provide specific orders for surgical incision care. The facility's nursing staff did not obtain or clarify these orders upon the resident's admission. The resident's surgical incision site on the left hip was not properly assessed or monitored for changes in condition. On the day following admission, the resident's surgical dressing was noted to be saturated, but there was no documentation of physician notification or orders for treatment. Over the subsequent days, the nursing staff documented observations of the surgical site, including drainage and the condition of the wound edges, but failed to obtain specific treatment orders or notify the physician of the changes. It was not until a follow-up appointment with the surgeon that an infection was identified, and appropriate antibiotic treatment was initiated. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for obtaining and documenting surgical incision care orders. The Director of Nursing (DON) and other staff members acknowledged that the hospital did not provide specific orders and that the physician should have been contacted upon admission to obtain necessary wound care orders. The facility's failure to ensure proper communication and documentation of surgical incision care orders resulted in the resident developing an infection, highlighting a deficiency in the facility's care practices.
Facility Fails to Maintain Safe and Clean Environment for Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as observed by surveyors. The resident's room had an air vent and closet contaminated with a black substance, suspected to be mold, which was not addressed by the facility's maintenance team. The closet also had an open space covered with cardboard and tape, which was a makeshift repair for a previously removed air conditioning unit. This inadequate repair allowed bugs and flies to enter the resident's room, further compromising the environment. The resident involved was a female with chronic obstructive pulmonary disease and pneumonia, who was admitted to hospice care and was dependent on staff for all activities of daily living. The resident was nonverbal and had impaired communication, making it difficult for her to express discomfort or needs. The black substance in her room was noted by a family member and a CNA, who both expressed concerns about potential respiratory infections due to the environmental conditions. Interviews with facility staff, including the Administrator, Director of Facility Management, and the DON, revealed a lack of awareness and action regarding the resident's room condition. Despite the family member's previous complaint to maintenance, the issue remained unresolved. The facility's policy on resident rights emphasizes the importance of a safe and clean environment, yet the conditions in the resident's room were not aligned with these standards.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Paint, primer, WD-40, and Goo Gone were improperly stored near dry food storage, posing a risk of chemical contamination. Despite being informed, the utility cart containing these items remained in the dry storage area. Additionally, cleaning chemicals were stored under containers labeled as cornmeal, sugar, flour, and rice, which is not compliant with safe food storage practices. During food preparation, a kitchen staff member did not allow the sanitizer to air dry before placing a cutting board on the surface, potentially leading to cross-contamination. The staff member admitted to placing a cutting board on a wet surface sprayed with Sani-Quad sanitizer and then preparing food on it. This practice could have transferred the chemical to the food, posing a risk of chemical ingestion to residents. Furthermore, a kitchen staff member was observed with improperly secured hair, wearing a bandana instead of a hairnet, which could lead to contamination of food. Interviews with staff and the Director of Nursing confirmed that hair should be completely covered while in the kitchen, and cleaning supplies should not be stored near food preparation areas. The facility's documents and safety data sheets emphasize the importance of safe food handling and storage, which were not followed in these instances.
Resident Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident had a call light within reach, which is a violation of resident rights. The resident, a female with multiple diagnoses including dementia, chronic obstructive pulmonary disease, pneumonia, and parkinsonism, was observed on multiple occasions with the call light placed on the back of a chair about two feet away from her bed. This placement made it inaccessible for the resident, who was nonverbal and dependent on staff for all activities of daily living. Despite the resident's inability to verbally communicate, staff interviews revealed that she could potentially use the call light if it were within reach. Interviews with facility staff, including a CNA, LVN, DON, and the Administrator, highlighted a lack of consistent understanding and adherence to the policy that call lights should be accessible to residents. The CNA mentioned that the call light was intentionally placed out of reach due to the resident's Parkinson's disease, while the LVN and DON acknowledged that the call light should be accessible. The Administrator confirmed that the call light should be attached to the resident's bed, emphasizing the resident's right to have it within reach. The facility did not have a specific policy for call lights, which contributed to the inconsistency in ensuring the resident's needs were reasonably accommodated.
Inadequate Infection Control in Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in one of its three laundry rooms, specifically the [NAME] House laundry room. During an observation, soiled clothing, towels, and washcloths were found sitting in a shower chair and a laundry basket on the floor, rather than being properly bagged. Interviews with staff, including CNAs, a housekeeper, the Director of Facilities, and the DON, revealed that the facility's policy required soiled laundry to be bagged before leaving a resident's room to prevent contamination. However, this procedure was not followed, leading to the risk of cross-contamination and infection. The facility's policy, revised in October 2023, mandates that all used laundry be handled as potentially contaminated, with standard precautions such as gloves and gowns used when rinsing and sorting. The policy also requires dirty linen to be bagged before leaving a resident's room and kept separate from clean laundry. Despite these guidelines, the staff interviews indicated a lack of adherence to these procedures, with soiled laundry being improperly handled and transported, increasing the risk of contamination within the facility.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in missed doses of critical medications. Resident #1 did not receive seven doses of Enoxaparin, a blood thinner, between February 15 and February 21, 2024. This medication was crucial for preventing blood clots following her hip surgery. The documentation falsely indicated that the medication was administered, although it was not available in the facility. Similarly, Resident #2 missed eleven doses of Bydureon, a medication for Type 2 Diabetes, from December 11, 2023, to February 13, 2024. The medication was not refilled, yet records falsely showed it was administered. The deficiency was compounded by staff falsifying documentation, indicating that medications were given when they were not available. Interviews revealed that medication aides were instructed to document injections they did not administer, based on verbal confirmations from nurses. The Director of Nursing (DON) discovered these discrepancies during a chart audit, leading to the termination of several staff members involved in the falsification. The facility's process for reordering medications was unclear, with responsibilities not well-defined, contributing to the oversight in medication administration. Interviews with staff highlighted a lack of communication and accountability in the medication management process. Nurses were responsible for reordering medications, but there was no consistent documentation or follow-up to ensure medications were available. The facility's failure to maintain accurate records and ensure the availability of prescribed medications placed residents at risk of not receiving necessary treatments, as evidenced by the missed doses and falsified records.
Medication Administration Failures and Falsification of Records
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who did not receive their prescribed medications. Resident #1 did not receive seven doses of Enoxaparin, a blood thinner, between February 15 and February 21, 2024. This medication was crucial for preventing blood clots post-surgery. The documentation falsely indicated that the medication was administered, although the pharmacy records showed it was not refilled after the initial supply. The Director of Nursing (DON) discovered this discrepancy during a chart audit, revealing that the medication was not available in the facility during the specified period. Resident #2 did not receive eleven doses of Bydureon, a medication for Type 2 Diabetes, from December 11, 2023, to February 13, 2024. The medication was documented as administered, but the pharmacy records indicated that it was not refilled after November 9, 2023. The resident's family raised concerns about the medication administration, prompting an investigation. The investigation revealed that the medication was not present in the facility during the period it was documented as given. The facility's staff, including LVNs and MAs, were involved in falsifying documentation, indicating that medications were administered when they were not. The DON and other staff interviews revealed a lack of proper medication management and documentation practices. The facility's process for reordering medications was unclear, and there was a reliance on verbal confirmations and assumptions that medications were available and administered as required.
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 223 citations issued within 25 miles in the last 12 months — including the 8 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 Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage At Longview Healthcare Center | 0.5 mi | ★★★★★ | 1 | 0 |
| The Oaks At Longview | 0.5 mi | ★★★★★ | 1 | 0 |
| Avir At Longview | 0.6 mi | ★★★★★ | 9 | 0 |
| Longview Hill Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 12 | 0 |
| Treviso Transitional Care | 2 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 October 2026) and official state health department websites.