Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Castle Hills Rehabilitation And Care Center during CMS and state inspections, most recent first.
RN Coverage Not Maintained: The facility failed to ensure RN services for at least 8 consecutive hours per day, 7 days a week. Time records showed missing RN coverage on multiple days, and the DON and ADM acknowledged that RN staffing hours were absent at times. The facility policy required RN coverage and allowed DON hours to count toward the requirement.
The facility failed to consult the physician when two residents consumed alcohol at a fiesta event without doctor’s orders. The DOR allowed the drinks at his discretion, the DON said staff were unaware alcohol would be served, and the EMR showed no physician contact. One resident had moderate cognitive impairment and the other had intact cognition; both were their own RP, and outside providers confirmed they were not notified.
Pharmacy services were not provided as ordered for three residents. Two residents with DM had sliding-scale insulin orders, but the 06:30 AM blood sugar checks were not documented before insulin administration, and the charted notes stated there was no nurse assigned to the hall. A third resident with a pain order for methadone had three scheduled doses marked as unavailable, with notes showing the medication was pending or awaiting pharmacy delivery. Staff interviews confirmed the missed checks and delayed medication availability.
A facility failed to keep two residents’ care plans aligned with assessed needs and orders. One resident’s plan did not address repeated family involvement in providing hands-on care, even though staff had educated the family not to assist with toileting and cleaning. Another resident’s plan did not reflect that he had been assessed to self-administer meds, despite a prior self-administration evaluation and the resident keeping Permethrin cream in his room.
A resident with factitious disorder, OCD, and need for assistance with personal care was observed keeping a labeled tube of Permethrin 5% cream in a vanity drawer rather than in a locked medication area. Although a prior self-administration evaluation said he could self-administer, the care plan did not reflect this, the order summary did not show self-administration approval, and staff interviews confirmed no resident was known to be cleared to keep meds in possession.
Incomplete documentation for medication self-administration. A resident with intact cognition and diagnoses including factitious disorder had a self-administration evaluation stating he could independently take meds, but the care plan did not reflect this and the order summary did not show an order allowing self-administration. During observation, he had Permethrin cream in his room and said an unidentified nurse had given it to him weeks earlier. The DON was unaware of any self-administration assessment, and the LVN who completed the evaluation said she did not obtain a physician order or update the care plan.
Urinary Catheter Tubing Left Touching the Floor: A resident with an indwelling urinary catheter, diabetes, UTI, respiratory failure, HF, and tracheostomy status was observed sitting in a wheelchair with the catheter tubing touching the floor. The CNA and RN both identified this as an infection control issue, and the DON stated catheter bags and tubing should be kept off the floor to maintain a closed drainage system and prevent infection. The resident’s care plan did not address the urinary catheter.
Surveyors found multiple food safety violations in the kitchen, including clean dishes stored wet and contaminated on a rack next to a handwashing sink where water splashed onto dessert bowls, saucers, and cups that still had food particles and residue. In the walk-in refrigerator, produce such as celery, tomatoes, and red bell peppers was either deteriorated or not dated, and in the walk-in freezer, breadsticks and an open bag of frozen carrots were undated. Bins holding serving utensils contained a ladle and bin surfaces with visible food particles and sticky residue, even though these items were supposed to be clean. The dietary manager acknowledged responsibility for proper food storage and date marking, described required time frames for using prepared, unopened, and frozen foods, and recognized that improper drying and dirty utensils could lead to cross contamination and resident illness, contrary to the facility’s written food safety and date-marking policies.
Surveyors found that staff failed to follow hand hygiene, glove use, and enhanced barrier precautions during peri-care for two residents who required extensive assistance with personal care, including one with ESRD, Type 2 DM, incontinence, and a permcath under EBP. One CNA washed hands and used alcohol-based hand rub for only a few seconds, then continued handling the resident’s body, linens, and room items without changing gloves or performing additional hand hygiene. Another CNA entered a resident’s room without donning PPE despite an EBP order, and after cleaning feces, continued to handle clean washcloths, barrier cream, the resident’s hands, brief, and pillow without changing contaminated gloves or performing hand hygiene. The DON confirmed expectations for 20-second hand hygiene, glove changes between dirty and clean tasks, adherence to EBP for residents with indwelling devices, and acknowledged that required EBP signage was not posted.
Surveyors found two nurse medication carts, one on the south hall and one on the north hall, left unlocked and unattended during a med pass. On the south hall, an RN who worked only as needed left the cart in front of the nurse’s station with drawers facing the hallway and no staff present, later stating she forgot to lock it and acknowledging it was her responsibility to do so. On the north hall, an LPN who regularly worked that shift left her cart unlocked in front of a resident’s room while she went to the nurse’s station around the corner, stating she could see the cart, no residents were nearby, and she was gone only briefly. The DON stated that nurses assigned to carts are responsible for locking them when unattended and that leaving carts unlocked places residents at risk of taking medications not prescribed for them, contrary to the facility’s Medication Storage policy requiring meds to be under direct observation or locked.
A resident admitted with a diagnosis of sacral pressure ulcer and documented stage 2 pressure ulcers on both buttocks was inaccurately coded on the admission MDS as having no unhealed pressure ulcers/injuries. Wound assessments and physician orders confirmed bilateral buttock stage 2 pressure ulcers requiring daily treatment, and the care plan addressed heel deep tissue injuries but not the buttock ulcers. The wound care LVN and a hospital nurse verified the presence of the buttock pressure ulcers, and the DON later acknowledged that Section M of the MDS should have been coded to reflect one or more unhealed pressure ulcers, contrary to facility policy requiring complete and accurate documentation.
A resident admitted with a sacral pressure ulcer had documented stage 2 pressure ulcers on both buttocks and physician orders for daily wound care, but the comprehensive care plan only addressed heel deep tissue injuries and omitted the buttock pressure ulcers entirely. The admission MDS inaccurately indicated no unhealed pressure ulcers, and the DON later acknowledged that no specific care plan was developed for the buttock wounds despite wound care being provided and facility policy requiring comprehensive, measurable care plans for all identified conditions.
A resident with stage 2 pressure ulcers on both buttocks had a physician order for daily application of triad with collagen particles, but the Treatment Administration Record lacked nursing initials on three treatment days. The care plan addressed heel injuries but did not include the buttock pressure ulcers. An LVN and another LVN each stated they provided the ordered wound care on their respective shifts but forgot to document it, while an RN stated she applied the triad with collagen particles but did not document because she did not view cream application as wound care. The DON confirmed that this treatment was wound care and should have been documented per facility policy.
A resident with bacteremia, MRSA, peripheral vascular disease, and septicemia had an order for cefazolin 2 g IV every 8 hours, with the pharmacy label directing infusion of 2 g/50 mL over 30 minutes at 100 mL/hr. During observation, an RN set the IV pump to 75 rather than the labeled 100, based on a misreading of the prescription, while the DON later stated that pharmacy establishes the rate and that it is printed on the IV bag. The MAR reflected the IV antibiotic order and administration, and interviews with the DON and MD confirmed that the medication was given at a slower rate than specified on the pharmacy label.
A resident with cerebral palsy, profound intellectual disabilities, neuromuscular bladder dysfunction, severe cognitive impairment, and an indwelling Foley catheter was observed in bed with the Foley drainage bag hung vertically so that the bottom of the bag was touching the floor. Staff, including a CNA, an RN, and the DON, acknowledged that Foley bags should be kept below the bladder, secured to a non-movable part of the bed, placed in a privacy cover or basin, and not allowed to touch the floor due to contamination and infection control concerns. Despite an existing catheter care policy and staff training, the Foley bag for this resident was not maintained in accordance with infection prevention and control practices.
Surveyors observed that the kitchen was dirty, with dirt, grease build-up, and debris present in multiple areas, and staff including the FSS, dieticians, and DON were unable to explain the lack of cleanliness and sanitation despite facility policy requiring regular inspections.
Multiple overhead ceiling lights in the kitchen, including those over the 3-sink area, cooking table, and pantry, were found to be non-functioning during a food service sanitation inspection. Staff interviews revealed no explanation for the lack of lighting or missing work orders, and the facility's policy requires regular inspections to ensure compliance with sanitation and safety standards.
Two licensed nurses were found to have expired CPR certifications, and the facility did not have a formal competencies policy or checklist to ensure ongoing compliance. The HR and DON were aware of the expired certifications but did not ensure timely renewal, relying instead on reminders and the presence of other CPR-certified staff during shifts. This failure did not align with the facility's policy requiring current CPR certification for all licensed staff.
Surveyors identified multiple deficiencies in kitchen sanitation and food storage, including the presence of dirt, debris, and flying insects in food preparation areas, as well as unlabeled and undated food items in both refrigeration and dry storage. Facility staff were aware of some maintenance issues but not the full extent of cleanliness and labeling lapses.
A facility failed to maintain an effective pest control program, resulting in flying insects being observed in a resident's room and the communal dining area. A resident with end-stage renal disease reported frequent flies in his room and in dining areas, describing the situation as disruptive and unsanitary. During meal service, multiple residents were seen swatting at insects landing on their bodies and food. The administrator was aware of intermittent insect issues, and a pest control invoice documented a significant presence of fungus gnats and recommended environmental repairs.
A resident with severe cognitive impairment and a history of dementia eloped from the facility at night, crossing a busy road before being found at a bus stop by an off-duty CNA. The incident occurred due to multiple failures, including non-functioning door alarms, lack of alarm activation by the receptionist and nurse, and inadequate monitoring during a shift change, despite the resident being identified as a moderate elopement risk.
A resident meal service issue occurred when the kitchen did not follow the posted lunch menu and ran short of the main entree. Residents reported that the facility often ran out of the main meal and they were left with an alternate meal or a sandwich. During lunch prep, staff observed sloppy joes being prepared, but the steam table had only a small amount left before the dining room was served, and the cook had used 10 lbs of meat instead of the 17.5 lbs called for in the recipe. The DM also stated French fries were routinely served instead of herb seasoned red potatoes and the posted menu had not been updated.
Food service staff failed to follow safe hygiene practices in the kitchen. Two cooks with facial hair were observed preparing food without beard restraints, even though the restraints were available and staff stated they were required to keep hair out of food. One cook was also observed handling a frozen fries box, working the fryer, and later retrieving clean plates from the dish room without washing hands or changing gloves before returning to plate prep. The dietary manager and DON stated staff should wash hands and change gloves when changing tasks or touching other items.
A resident with cerebral palsy, severe cognitive impairment, communication deficits, and dependence for ADLs had his soft touch call pad left on the nightstand and out of reach during repeated observations. An LVN said she forgot to return it to the bed after giving G-tube meds, while a CNA said it was kept there because the resident would throw it; the DON stated staff were responsible for keeping the soft sensor pad within the resident’s reach.
Inaccurate MDS Coding for Rejection of Care and Nutritional Status: The facility failed to accurately code two residents’ MDS assessments. One resident with Alzheimer’s, schizophrenia, and other conditions had documented refusals of incontinence care, linen changes, and meds, but the Quarterly MDS did not code rejection of care. Another resident with brain degeneration, GERD, and DM had a Quarterly MDS coded as if parenteral/IV feeding was present, even though the resident was on a regular diet and did not have a feeding tube.
A resident who was a current smoker did not have smoking care planned, even though the social history documented smoking and the DON, SW, and Administrator all acknowledged it should have been included. Another resident with cerebral palsy, severe cognitive impairment, and total care needs had a care plan that referenced a call light, but it did not identify his required soft touch pad; staff observed the pad placed out of reach, and a CNA stated he needed the soft pad because he would throw it and needed it to alert staff.
Failure to provide nail care for a dependent resident with cerebral palsy, severe cognitive impairment, and autistic disorder. Staff observed the resident’s fingernails were long and jagged on multiple occasions, and an LVN and CNA acknowledged the nails needed trimming; the CNA said the resident would not allow it and that she reported it to the nurse. Records reviewed did not show nail care provided during the period reviewed, despite the facility’s policy that nails be kept smooth and routine nail care be provided weekly or as needed.
An LVN left the Hallway 4 medication cart unlocked and unattended while she went into a resident’s room to administer G-tube meds. She later stated the cart should have been secured because others could access the meds and this could lead to misappropriation or misuse. The DON stated the cart needed to be locked when unattended, and facility policy required meds and biologicals to be stored in locked compartments or kept under direct observation during med pass.
A CNA failed to follow infection control practices during incontinent care for two residents. For one resident with frequent bowel and bladder incontinence, the CNA handled soiled and clean items without changing gloves or sanitizing hands between tasks. For another resident on EBP with severe cognitive impairment, the CNA did not don a gown and again delayed glove changes until after care was completed. The DON stated the CNA needed to deglove, sanitize hands, and change gloves between soiled and clean items, and that a gown was required for the resident on EBP.
Failure to Complete Smoking Safety Assessment: A resident identified as a current smoker did not have the required Resident Safe Smoking Assessment completed, despite facility policy requiring further assessment to determine whether supervision was needed or whether the resident was safe to smoke. The DON, SW, and Administrator each described different staff responsibilities for completing smoking evaluations, and review of the EMR confirmed no smoking safety assessment had been done.
Survey Results Not Posted in a Visible Public Area: The facility failed to keep the most recent survey results and notice of their availability in a readily accessible, prominent public area. Survey binders were placed behind the receptionist desk on a shelf and were not visible from the entrance or lobby, and residents stated they did not know where to find the survey results. The Administrator stated the area behind reception was open to residents and families, but the survey results policy was not provided prior to exit.
A resident with cerebral palsy and complex medical needs was identified by the LIDDA as requiring a customized DME wheelchair, but the facility failed to submit the required PASARR specialized services request to the State Agency within the mandated 20 business days. The responsible social worker did not complete the submission due to lack of awareness of the deadline and delays in securing the equipment, and the facility's policy did not address this requirement.
A suspected abuse incident involving a CNA and a male resident with multiple chronic conditions was not reported to the State Survey Agency within the required two-hour timeframe. Although the incident was promptly reported internally and the CNA was suspended, the administrator delayed external reporting until the following afternoon, contrary to facility policy and regulatory requirements.
A newly admitted resident with a Foley catheter and active UTI did not have a baseline care plan developed and implemented within 48 hours that included necessary instructions for catheter care and antibiotic use. Despite clear documentation from the hospital and nursing notes about the resident's catheter and infection, the care plan lacked specificity and failed to address these needs, leading to hospitalization for sepsis. Staff interviews confirmed the care plan was not individualized or comprehensive.
A resident with significant neurological impairment and an indwelling Foley catheter was admitted without proper physician orders or documentation for catheter care, monitoring for infection, or tracking of urinary input/output. Despite care plan references, there was no evidence of routine catheter care or monitoring, and staff interviews revealed confusion about the resident's catheter status. The resident experienced multiple falls, ongoing UTI treatment, and was ultimately hospitalized with sepsis and a distended bladder, with hospital records indicating catheter dysfunction.
The facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for two residents. A resident with sepsis/osteomyelitis and another with multiple sclerosis and chronic kidney disease did not receive their prescribed antibiotics correctly. Medications were found unlabeled in a cart, and a medication aide was improperly instructed to administer them. The facility's policy requiring the person who dispenses the medication to administer it was not followed, leading to a deficiency in pharmaceutical services.
A facility failed to maintain proper infection control practices during incontinent care for a resident requiring enhanced barrier precautions. CNA A did not change gloves or perform hand hygiene after cleaning stool, and both CNA A and CNA B did not wear gowns as required. The resident had multiple health issues, including chronic wounds, necessitating strict adherence to infection control protocols. Despite training, the facility's staff did not follow established procedures, leading to potential infection risks.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their records. A resident's smoking habit was not reflected in their MDS, while two other residents had incorrect medication information recorded, with anticoagulants mistakenly noted. These errors were acknowledged by the MDS nurse, highlighting potential risks for inadequate care.
The facility failed to properly label and date open food items and maintain appropriate storage temperatures in their kitchen. Observations revealed unlabeled food in the reach-in freezer and refrigerator, moldy strawberries in the walk-in cooler, and a reach-in refrigerator temperature of 60 degrees. The Dietary Manager and Dietitian acknowledged these issues, which contravened the facility's policies and the U.S. FDA Food Code.
A resident with multiple diagnoses, including ESRD and MDD, was found with the call light out of reach, contrary to their care plan. The DON confirmed the oversight, highlighting the importance of following person-centered care plans. The facility's policy mandates call light accessibility, which was not adhered to in this instance.
A resident with a history of falls and multiple diagnoses, including ESRD and A-fib, was observed in a low bed without a fall mat, contrary to their care plan. The DON confirmed the absence of the fall mat, highlighting the importance of following care plans to ensure resident safety. The facility's policy stresses the need for a hazard-free environment and consistent implementation of interventions.
A resident with severe cognitive impairment and incontinence issues did not receive proper incontinent care when a CNA failed to return the foreskin to its original position after cleaning. This oversight, observed during a survey, could lead to infection and other complications. The resident's care plan required regular checks and assistance, and the CNA had been trained in proper procedures.
A deficiency was identified in a LTC facility when a CNA failed to reposition a resident's foreskin after providing incontinent care, despite having completed competency training. The resident, who had severe cognitive impairment and other medical conditions, was at risk due to this oversight. The facility's policy required the foreskin to be repositioned, which was not followed by the CNA.
A facility failed to ensure proper pharmaceutical services by allowing expired thickened lemon flavor water to remain on a medication cart. The medication aide was unaware of the expiration, and the DON confirmed the oversight, acknowledging that expired products should be discarded according to facility policy.
A facility failed to secure medications properly, leaving a resident's sterile water unattended in their room. The resident, with severe cognitive impairment, required catheter flushing due to urinary tract infections. Staff interviews confirmed that medications should not be left unattended, highlighting a breach in the facility's medication storage policy.
A resident with severe cognitive impairment and multiple health issues was not provided with a built-up spoon during meal service, as required by their care plan and meal ticket. Despite the facility's policy to provide adaptive devices, the resident was given a regular spoon due to the kitchen staff's inability to locate the correct utensil.
A resident's bed headboard was found to be loose and swinging, posing a potential risk for injury. Despite the resident's discomfort, the issue was not reported to staff. Interviews with an LVN and Medical Record and Equipment staff confirmed the oversight, acknowledging the responsibility to ensure equipment safety. The facility's policy prioritizes accident prevention and resident safety.
A resident with moderate cognitive impairment and a history of elopement managed to leave the facility unsupervised, despite being identified as an elopement risk. The resident was last seen in the smoking courtyard and was later found by police approximately 688 feet away from the facility. The facility's elopement protocol was initiated after the resident was discovered missing, but the incident indicates a failure in supervision and monitoring.
The facility failed to prevent two residents from eloping, one of whom was found by police and the other whose whereabouts remain unknown. The incidents revealed significant lapses in monitoring, security measures, and staff training.
The facility failed to prevent two residents from eloping, leading to one resident being found by police and another still missing. The facility lacked adequate supervision, monitoring, and security measures, placing residents at significant risk.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. Record review of the resident roster dated 05/18/2026 showed a census of 54 residents. Record review of the facility's time detail from April 2026 to May 2026 showed the facility did not have an RN working for a total of 8 hours on 04/11/2026, 04/12/2026, and 05/10/2026. During interview, the DON stated there were days when 8 hours of RN staffing hours were missing and said RN staff were important because they provided a supervisory role to LVNs and CNAs. The ADM also stated it was important to have an RN work 8 hours per day because of the additional training an RN received and said the facility was in the process of hiring more RNs. Record review of the facility's policy, Nursing Services-Registered Nurse (RN), revised 02/2026, reflected the facility would utilize the services of an RN for at least 8 consecutive hours per day, 7 days per week, and that the hours worked by the DON would count toward the requirement.
Failure to Notify Physicians After Residents Consumed Alcohol
Penalty
Summary
The facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 2 of 8 residents reviewed for resident rights. Resident #1 was a male admitted with a diagnosis of cognitive communication deficit and was his own responsible party; his quarterly MDS reflected a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Resident #2 was a female admitted and re-admitted with a diagnosis of need for assistance with personal care and was also her own responsible party; her quarterly MDS reflected a BIMS score of 13 out of 15, indicating intact cognition. Record review showed that on 04/17/26 both residents drank 1 alcoholic drink at a facility fiesta event, and the electronic medical record reflected no change in condition and no contact was made to the physician. Interviews revealed the Activities Director oversaw handing out alcoholic drinks at the event, the DOR allowed residents to have alcoholic drinks using his discretion, and Residents #1 and #2 were the only residents served alcohol without a doctor's order. The DON stated the facility was not aware alcohol would be served and said they would have obtained doctor's orders if they had known. Resident #1's hospice company and Resident #2's physician's group both stated they were not contacted after the residents consumed alcohol, and the facility policy on Notification of Changes required informing the resident and consulting the physician and/or notifying the family or legal representative when there is a change requiring such notification.
Pharmacy Services: Missed Blood Sugar Checks Before Insulin and Delayed Methadone Availability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents by not ensuring ordered blood sugar checks were completed before insulin administration for two residents and by not ensuring methadone was available for another resident as ordered. Resident #3 had type 2 diabetes, intact cognition, and an order for Insulin Lispro before meals and at bedtime based on a sliding scale. Resident #4 also had type 2 diabetes, intact cognition, and an order for Insulin Aspart-szjj before meals and at bedtime based on a sliding scale. For both residents, the MAR showed a chart code of 19=Other-See Progress Note for the 06:30 AM insulin administration on 05/10/26, but no blood sugar was documented by LVN A. The progress notes entered later that day stated, “NO NURSE ASSIGNED TO HALL.” Resident #5 had diagnoses including osteoarthritis of the hip, other muscle spasm, and abnormal gait and mobility, with a care plan focus on potential adverse side effects from opioid medication use. Her order was for Methadone HCl 5 mg by mouth twice daily for pain. The MAR showed chart code 19=Other-See Progress Note for the 07:00 PM dose on 05/09/26, the 07:00 AM dose on 05/10/26, and the 07:00 PM dose on 05/10/26. The related progress notes stated the medication was on order, pending delivery from pharmacy, and awaiting delivery of med. During interviews, Resident #3 stated he did not get medication in a timely manner but did not identify a specific missed insulin dose. Resident #4 stated medication was administered in a timely manner, including blood sugar checks and insulin. LVN A stated she wrote the note about no nurse being assigned to the hallway because she was not made aware that the hallway needed nurse coverage to administer insulin, and she said she was monitoring Residents #3 and #4 and they had no change in condition. Regarding Resident #5, the resident stated she did not have her pain medications for 4 to 5 days last week and was upset that the facility did not have her medication. LVN A stated Resident #5 had no methadone last week and that the facility was waiting for the medication to arrive because it required a triplicate prescription form. RN B stated she was unsure whether the delay was due to the facility or the doctor. The DON stated Resident #5 did not have 3 doses of methadone from 05/09/26 to 05/10/26 and that the facility should be proactively ordering refills.
Care Plans Did Not Reflect Family-Provided Care or Medication Self-Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents in accordance with their assessed needs. For one resident admitted with respiratory failure, morbid/severe obesity, urinary tract infection, tracheostomy status, and an indwelling urinary catheter for neurogenic bladder, the care plan did not include a focus, goal, or intervention addressing that family members had been instructed and educated that resident care was to be provided by facility staff rather than by family members. The resident was observed with family members at the bedside, and the family stated they had been helping the resident to the bathroom and cleaning him because staff were not coming when needed. During interviews, an RN stated he had repeatedly discussed and educated the resident and family members about not providing care and about calling staff for assistance, including after the family requested disposable wipes and explained they were needed to clean the resident. On another observation, a family member was seen leaving the room, obtaining gloves, and stating he needed them because he had assisted the resident to the bathroom and needed to clean him. The DON stated she was aware the family members were providing care, that there were safety concerns because of this, and that staff should document education and add the issue to the care plan when identified. The RN later stated he had not documented the discussions or education and had not placed the information in the care plan. For a second resident with diagnoses including factitious disorder imposed on self, need for assistance with personal care, muscle weakness, and obsessive-compulsive disorder, the comprehensive care plan did not reflect that the resident had been assessed to safely self-administer medications. The resident’s record contained a Self Administration of Medication Evaluation stating he was capable of independent self-administration and that the physician’s orders stated he may self-administer, but the order summary did not include an order allowing self-administration. The resident was observed retrieving Permethrin 5% cream from his drawer, and he stated a nursing staff member had given him the cream weeks earlier and that he had kept it. Staff interviews confirmed that self-administration required an assessment, a physician’s order, and inclusion in the care plan, but the resident’s care plan had not been updated to reflect this.
Unsecured topical medication found in resident vanity drawer
Penalty
Summary
The facility failed to ensure that a tube of Permethrin 5% cream was stored in a locked compartment and kept under authorized control for a resident who was not documented as being able to self-administer medications. During observation, the resident opened a drawer in his vanity and removed the tube of Permethrin 5% cream with the pharmacy label attached and his name on it. The resident stated a nursing staff member had given him the cream about 3 weeks earlier and that he had kept the tube in the drawer. Record review showed the resident was cognitively intact and had diagnoses including factitious disorder imposed on self, obsessive-compulsive disorder, muscle weakness, and need for assistance with personal care. Although a Self Administration of Medication Evaluation dated 7/3/25 stated the resident was capable of independent self-administration and the physician's orders stated he may self-administer, the resident's comprehensive care plan did not reflect that he was able to self-administer medications. The Order Summary Report also did not show an order indicating the resident could self-administer medications. Interviews with the DON, ADON, RN C, LVN D, and the LVN Treatment Nurse reflected that no residents in the facility were known to be cleared to self-administer medications. Staff stated that self-administration required an assessment, a physician's order, and care plan documentation. LVN D stated she completed the self-administration evaluation because the resident wanted to take medications with him on pass, but the resident was hospitalized shortly afterward, so no physician's order was obtained and the care plan was not updated. The facility policy stated medications must be stored in locked compartments and only authorized personnel may have access to the keys.
Incomplete Documentation for Medication Self-Administration
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for Resident #2. Record review showed the resident was cognitively intact for daily decision-making and had diagnoses including factitious disorder imposed on self, need for assistance with personal care, muscle weakness, and obsessive-compulsive disorder. The resident’s comprehensive care plan did not reflect that he was able to self-administer medications, and the Order Summary Report did not show an order indicating he could self-administer medications. A Self Administration of Medication Evaluation with an effective date of 7/3/25, authored by an LVN, stated the resident was capable of independent self-administration of medications and that the physician’s orders stated the resident may self-administer. During observation, the resident was seen with a tube of Permethrin 5% cream in his room and stated a nursing staff member had given it to him weeks earlier and applied it to his hands. The DON stated she was not aware the resident had been assessed to self-administer medications and said there were no residents in the facility who had been assessed to self-administer medications since she began employment. The LVN who completed the evaluation stated she did not obtain a physician’s order or update the care plan, and also stated the resident would probably not be capable of self-administering medications because of his condition.
Urinary Catheter Tubing Left Touching the Floor
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when Resident #1’s indwelling urinary catheter tubing was observed touching the floor. Resident #1 was a [AGE]-year-old male admitted with diagnoses including acute and chronic respiratory failure, diabetes, urinary tract infection, heart failure, and tracheostomy status. His orders included monthly catheter drainage bag changes, catheter care every shift and as needed, positioning the urinary catheter privacy bag and tubing below the level of the bladder, and Enhanced Barrier Precautions related to the indwelling medical device. However, the comprehensive care plan did not address the resident’s use of a urinary indwelling catheter, and the clinical admission document reflected that he utilized a urinary catheter. During observation, the resident was sitting in a wheelchair with the catheter draining by gravity on his left side, and the tubing was touching the floor in front of his feet and between his bedside table. A CNA and an RN both observed the tubing on the floor and stated it should not be touching the floor because it was an infection control issue; the RN also stated it could result in infection. The CNA further stated the tubing could become tangled in the bedside table wheels or be stepped on, which could cause injury. The DON stated that keeping catheter bags and tubing off the floor was an infection control standard of care to maintain a closed drainage system and prevent infection. The facility policy on catheter care stated that residents with indwelling catheters should receive appropriate catheter care and maintain dignity and privacy when catheters are in use.
Improper Food Storage, Dishwashing, and Utensil Sanitation Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with food safety standards related to storage, preparation, and handling of food and dishware in the kitchen. During observation of the kitchen, a rack positioned next to a handwashing sink held trays with stacked dessert bowls, saucers, and cups. When the dietary manager (DM) washed her hands, water splashed onto a tray with dessert bowls and pooled on the tray. Bowls taken from the top of the stack were moist and had food particles inside, saucers from the stack had food particles on the bottom, and cups on the top of the stack had a brown substance on their rims. The DM confirmed the dishes were not dry and had food particles on them and acknowledged that the shelf placement next to the handwashing sink allowed water to splash on clean dishes and that dishes should not be stacked to dry because condensation could remain and mold could grow, which she stated could make residents sick or upset their stomachs. Further observations in the walk-in refrigerator revealed a bag of celery that was brown in color and small plastic bins containing tomatoes and red bell peppers that were not dated. In the walk-in freezer, surveyors found undated breadsticks in a plastic bag and an open, undated bag of frozen carrots. Additional observation of two bins on a shelf with serving utensils showed one bin containing a ladle with food particles on it, and the bottoms of the bins had food particles, were visibly dirty, and sticky. The DM stated she was responsible for ensuring all foods were stored properly and labeled with the opened date, acknowledged she had missed some items, and described the facility’s expectations for dating prepared food, unprepared/unopened items, and frozen foods. She also stated that dirty utensils and dishes could cause cross contamination and make residents sick, and that all staff were responsible for keeping utensils and bins clean. Review of facility policies on Food Safety Requirements and Date Marking for Food Safety showed written requirements for proper storage, labeling, dating, covering, and cleaning/sanitizing of food and equipment, which were not followed in these instances.
Failure to Follow Hand Hygiene, Glove Use, and Enhanced Barrier Precautions During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and glove use during perineal care for two residents. For Resident #5, who was re-admitted with a need for assistance with personal care and had impaired physical functioning related to mobility and self-care impairment, observations on 4/14/26 showed that CNA A washed his hands for only 5 seconds before providing peri-care, contrary to facility policy. After cleaning the resident’s genital area, CNA A removed his gloves and used hand sanitizer for only 2 seconds. He then continued care by cleaning the resident’s buttocks, disposing of trash and dirty linen, replacing pillows and blankets, positioning the bed, and handing the remote to the resident without changing gloves or performing additional hand hygiene. During interviews, Resident #5 stated he was not sure about infection control but knew staff washed their hands. CNA A reported that he usually sang the birthday song when washing his hands, estimating this to be about 10 seconds, and stated he did not know the recommended duration for handwashing. He also believed that when using hand sanitizer, hands should be rubbed together until dry, which he estimated at about 5 seconds, and was not aware he had only washed his hands for 5 seconds. CNA A acknowledged he had not realized he failed to remove his gloves or perform hand hygiene after cleaning the resident’s buttocks and stated that proper hand hygiene was important to avoid cross contamination. The DON later stated that staff were expected to wash their hands for at least 20 seconds to help prevent the spread of infections and that it was her responsibility, as infection preventionist, to ensure staff performed hand hygiene as recommended. For Resident #3, who was re-admitted with ESRD, Type 2 diabetes, dependence on renal dialysis, need for assistance with personal care, and was incontinent of bowel and bladder with self-care and mobility impairments, the record showed an order for enhanced barrier precautions (EBP) related to a permcath. On 4/14/26, observation of peri-care revealed CNA B did not don PPE before entering the room, and there was no EBP sign posted outside the door, although PPE was available outside the room. While providing care, CNA B cleaned feces, then retrieved a clean washcloth to dry the resident’s buttocks, obtained barrier cream from the side table and applied it, held the resident’s hands to assist with turning, fastened the brief, and removed a pillow from behind the resident’s head without removing soiled gloves or performing hand hygiene. Resident #3 reported that staff did not follow infection control practices all the time and recalled only one instance of someone wearing a gown the previous week. CNA B stated she kept the same gloves on until she was done with everything in the room, did not know the specific expectations beyond not going from room to room or resident to resident with the same gloves, and believed Resident #3 was not on EBP. The DON stated staff were expected to change gloves when moving from dirty to clean areas, assume gloves were dirty during care, avoid touching items like pillows, remotes, or linen with contaminated gloves, and confirmed that Resident #3 was on EBP but the sign was not on the door. Facility policies required hand hygiene with alcohol-based rub or soap and water for about or at least 20 seconds and glove changes during perineal care after cleansing the buttocks and anus.
Unlocked and Unattended Medication Carts on Two Halls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments on two medication carts observed during survey. On the south hall, surveyors observed a nurse cart at 8:28 AM positioned in front of the nurse’s station with the drawers facing the hallway, unlocked and unattended, with no staff present at the nurse’s station. RN A, who reported she was not regular staff and only worked when needed, stated in interview that she had been passing medications to a resident and forgot to lock the cart when she walked away. RN A acknowledged that carts needed to be locked when staff walked away to prevent residents from taking medications that did not belong to them and stated it was the nurse’s responsibility to ensure carts were locked when they leave them. On the north hall, surveyors observed another nurse cart at 8:42 AM in front of a resident’s room with drawers facing the doorway, also unlocked and unattended, while the nurse was at the north hall nurse’s station around the corner from the cart. LPN B, who regularly worked the 6:00 AM to 2:30 PM shift on the north hall, stated she could see her cart, no residents were around when she walked away, and she had only gone to the nurse’s station for a few seconds. When asked how leaving the cart unlocked could have affected residents, she responded that it could not affect them since it was within her sight and then pushed the cart away from the surveyor and did not answer further questions. The DON stated that staff assigned to nurse or medication carts were responsible for ensuring they were locked before leaving them unattended, that both nurses were experienced and should not have left their carts unlocked, and that leaving a cart unlocked placed residents at risk of taking medications not prescribed for them, which could cause adverse effects including illness or hospitalization. Facility policy on Medication Storage required that during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.
Inaccurate MDS Coding for Resident With Documented Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate admission MDS assessment for a resident with documented pressure ulcers. The resident, a 65-year-old female admitted with a diagnosis of sacral pressure ulcer, had an admission MDS dated 02/03/2026 that coded Section M (Skin conditions) as indicating no unhealed pressure ulcers/injuries. However, the resident’s face sheet listed a diagnosis of pressure ulcer of the sacral region, and a wound care assessment dated 02/02/2026 documented stage 2 pressure ulcers on the left and right buttock. A physician order dated 02/04/2026 directed daily wound care to the left and right buttock stage 2 pressure ulcers using triad with collagen particles. Further record review showed the comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to both heels with interventions such as a pressure-reducing mattress, skin care, treatment, and turning/repositioning, but did not include a care plan for the resident’s buttock pressure ulcers. During interviews, a hospital nurse and the facility’s wound care LVN confirmed the presence of stage 2 pressure ulcers on both buttocks at admission and that wound care was being provided. The DON acknowledged that the admission MDS was inaccurate regarding pressure ulcers and stated that Section M should have been coded to reflect one or more unhealed pressure ulcers/injuries. The facility’s policy on documentation required each resident’s medical record to contain a complete and accurate representation of the resident’s status and progress.
Failure to Care Plan for Resident’s Buttock Pressure Ulcers
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with documented pressure ulcers. The resident, a 65-year-old female admitted with a diagnosis of a sacral pressure ulcer, had an admission MDS that incorrectly indicated she did not have any unhealed pressure ulcers or injuries. Her comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to the right and left heels, with interventions such as a pressure-reducing mattress, skin care, treatment, and a turning and repositioning schedule, but it did not include any care plan problem, goals, or interventions for pressure ulcers to the right and left buttock areas. Further record review showed that a wound care assessment on 02/02/2026 documented stage 2 pressure ulcers on the resident’s left and right buttocks, and a physician’s order dated 02/04/2026 directed daily wound care to those areas using triad with collagen particles. Interviews with the hospital nurse confirmed the presence of stage 2 pressure ulcers to the buttocks, and the facility’s wound care LVN stated that the resident had unhealed stage 2 pressure ulcers to the left and right buttocks upon admission and that wound care was provided as ordered. The DON acknowledged that there was no specific care plan for the stage 2 buttock pressure ulcers and attributed this to an inaccurate MDS assessment, despite the facility’s policy requiring a comprehensive care plan with measurable objectives and timeframes for all needs identified in the comprehensive assessment.
Incomplete Documentation of Ordered Wound Care on Treatment Administration Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with professional standards for one resident receiving wound care. A 65-year-old female resident was admitted with pressure-related skin issues, including deep tissue injuries to both heels and, per a wound care assessment dated 02/02/2026, stage 2 pressure ulcers on the left and right buttocks. The comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to the heels but did not include a care plan for the resident’s stage 2 pressure ulcers on the buttocks. A physician’s order dated 02/04/2026 directed daily application of triad with collagen particles to the stage 2 pressure ulcers on the left and right buttocks. Review of the Treatment Administration Record (TAR) for 02/01/2026 through 02/28/2026 showed that the ordered wound care was not initialed as given on 02/01/2026, 02/07/2026, and 02/08/2026. LVN-B reported working on 02/01/2026 and providing the ordered wound care but stated she forgot to document it on the TAR. LVN-A reported working on 02/07/2026, providing the ordered triad with collagen particles once daily and leaving the area open to air, but also forgot to document on the TAR. RN-C reported working on 02/08/2026, providing the triad with collagen particles to the buttock pressure ulcers, but did not document because she did not consider applying cream with collagen particles to be wound care. The DON confirmed that applying triad with collagen particles to the stage 2 buttock ulcers was considered wound care and that nurses should have documented these treatments on the TAR, consistent with the facility’s documentation policy requiring licensed staff to document all services at the time of service or by the end of the shift.
Incorrect IV Antibiotic Infusion Rate Due to Nurse Misinterpretation of Pharmacy Label
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration of an IV antibiotic in accordance with pharmacy directions for one resident. The resident was an elderly male with diagnoses including bacteremia, MRSA infection, peripheral vascular disease, multidrug-resistant organism, and septicemia. His admission and annual MDS assessments showed a decline from cognitively intact (BIMS 15) at admission to severely cognitively impaired (BIMS 0) at the time of the annual assessment. He had active orders for cefazolin sodium 2 g IV every 8 hours for MSSA to both lower extremities, with the pharmacy label specifying CEFAZOLIN 2G/50 ML-DEXTROSE to be activated, mixed, and infused intravenously over 30 minutes at a rate of 100 mL/hr every 8 hours. The MAR reflected this IV antibiotic order and documented administration by RN A. During surveyor observation, the resident was noted to have a PICC line in the left upper arm and reported no issues with IV medication administration. Later observation showed RN A administering the cefazolin IV and setting the infusion pump rate at 75 (mg/hr), despite the IV bag label indicating administration at 100 (mL/hr). In interviews, the DON acknowledged that administering at 75 versus 100 would result in a slower rate and stated she expected nurses to check the rate, noting that the rate was printed on the IV bag and set by the pharmacy because hospital discharge orders did not include a rate. RN A stated the medication was to be titrated over one hour and reported misinterpreting the prescription, believing 100 referred to volume and 75 to the rate. MD B stated that administering the medication at 75 instead of 100 was medically acceptable and would only prolong the administration time. No facility policy on medication administration was requested for review.
Improper Foley Catheter Bag Positioning and Infection Control Lapse
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program by not ensuring proper positioning of an indwelling Foley catheter drainage bag for one resident. The resident was an adult male with cerebral palsy, profound intellectual disabilities, neuromuscular dysfunction of the bladder, severe cognitive impairment (BIMS score of 0/00), range of motion impairment in all extremities, wheelchair use, and dependence for self-care and mobility. He had an indwelling catheter in place for a neurogenic bladder, with an active order for the catheter and a care plan addressing the indwelling catheter. During observations, the resident was seen in bed with his Foley catheter bag hung vertically with the bottom of the bag touching the floor. Staff interviews confirmed that the observed Foley bag position was inconsistent with facility expectations and training. A CNA who normally worked on the resident’s hall stated that Foley bags were supposed to be set up under the bed on the side, vertical, in a privacy bag, and not touching the floor, and acknowledged that a bag touching the floor would be considered contaminated. An RN stated that nurses were responsible for ensuring Foley bags did not touch the floor, that the bag should be lower than the resident, hung on a non-movable part of the bed, and not touching the floor due to contamination risk. The DON stated that nurses and CNAs were responsible for ensuring Foley bags were appropriately placed or in a basin so they did not touch the floor, and that it would be an infection control concern if the bag touched the floor, although she later stated she did not believe the bag touching the floor would have impacted this resident because the bag was enclosed. The facility’s catheter care policy stated it was the policy to ensure residents with indwelling catheters receive appropriate catheter care, but the observed practice did not align with this standard.
Failure to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by observations of a dirty kitchen. During an inspection, surveyors observed dirt, grease build-up, and debris under the juice table, pantry floor, steam table, and cooking table. Multiple staff interviews, including with the Food Service Supervisor (FSS), two dieticians, and the Director of Nursing (DON), revealed that none could provide an explanation for the lack of cleanliness and sanitation in the kitchen. The FSS stated he had attempted to clean the kitchen the previous night without assistance, while both dieticians acknowledged the need for cleanliness and sanitation but could not explain the deficiency. Record review showed that the facility's policy required regular sanitation inspections to ensure food service areas were clean, sanitary, and compliant with regulations. Despite this policy, the kitchen was found to be in an unsanitary condition during the survey, and staff were unable to account for the failure to maintain proper standards of cleanliness and sanitation in the food service area.
Failure to Maintain Safe Operating Condition of Kitchen Equipment Due to Inadequate Lighting
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the kitchen, as evidenced by multiple non-functioning overhead ceiling lights. During an observation, it was noted that three ceiling lights were not working over the 3-sink area, two lights were out over the cooking table, and two additional lights were not functioning in the pantry. This lack of adequate lighting was observed during a food service sanitation and safety inspection. Interviews with the Food Service Supervisor (FSS), two dieticians, and the Director of Nursing (DON) revealed that none could provide an explanation for the non-functioning lights or why work orders had not been submitted for their replacement. The FSS confirmed there was no work order in place, and the DON stated that the FSS had been educated on the need to submit work orders when necessary. Review of the facility's Sanitation Inspection policy indicated that regular inspections are required to ensure compliance with sanitation and safety regulations.
Failure to Ensure Current CPR Certification for Licensed Nursing Staff
Penalty
Summary
The facility failed to ensure that all licensed nursing staff possessed current Basic Life Support (CPR and AED) certifications, as required by facility policy and national standards. Specifically, two nurses, an RN and an LPN, were found to have expired CPR certifications at the time of review. The HR was responsible for checking certifications during onboarding and sent monthly reminders to staff with expired certifications, escalating to the DON after multiple reminders. Despite being aware of the expired certifications, both the HR and DON did not ensure that the certifications were renewed in a timely manner. The DON stated that competencies were reviewed upon hire and annually, but there was no formal competencies policy or checklist in place. Interviews with the DON, HR, and the affected RN revealed that the facility relied on documentation of certification to verify competency, and there was no evidence that either nurse worked shifts without another CPR-certified nurse present. The facility's policy required that CPR-certified staff be available at all times and maintain current certification through an approved provider. However, the lack of current certification for these two nurses represented a failure to comply with the facility's own policy and procedures regarding staff competencies and resident safety.
Deficient Food Storage, Labeling, and Sanitation in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, preparation, and cleanliness. The kitchen and refrigeration areas were found to have dirt and debris, including a layer of white and brown debris on the floor, trash behind the refrigerator, broken tiles exposing damaged drywall, and a wet, black substance around the dishwashing area plumbing and on ceiling tiles. Additional dirt and debris were noted along the edges of the floors and underneath storage racks in the walk-in refrigerator. The plumbing of the handwashing sink had an open, exposed pipe, and the wall trim beneath was peeling, exposing stained and damaged drywall. Multiple flying insects were present in the food preparation and distribution areas. Food storage practices were also deficient. In the walk-in refrigerator, trays of beverages portioned into single-serve cups were not labeled or dated, and in the dry storage area, several bags of bread buns and rolls were not labeled or dated. Interviews with the Dietary Services Manager (DSM) and the Administrator revealed awareness of some ongoing maintenance issues, such as plumbing and broken tiles, but a lack of awareness regarding the extent of dirt, debris, and current insect presence. The DSM acknowledged that labeling and dating of prepared foods and bread items were not consistently performed according to facility policy.
Failure to Maintain Effective Pest Control in Resident Room and Dining Area
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flying insects in both a resident's room and the communal dining area. Observations confirmed that flying insects were present in a male resident's room, who had end-stage renal disease and intact cognition, and the resident reported that flies were consistently present in his room as well as in the kitchen and dining areas. The resident described the situation as disgusting. During meal service in the communal dining area, multiple flying insects were observed, causing residents to swat at them as they landed on their bodies and food. The same resident confirmed that flies were always present during meals, which he found disruptive and dirty. The facility administrator acknowledged awareness of intermittent insect issues in the facility, including in residents' rooms, but was unaware of the specific incident in the dining area. Review of the most recent pest control invoice documented the discovery of a significant number of fungus gnats and included recommendations for prevention, such as removing standing water, repairing damaged floors and walls, and fixing faulty plumbing. Despite a request, the facility's pest control policy was not provided prior to the survey exit.
Failure to Prevent Elopement Due to Lapses in Supervision and Door Alarm Protocols
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia, Alzheimer's disease, and hypertension eloped from the facility at night. The resident was ambulatory and had been assessed as a moderate risk for elopement, with a care plan in place that included frequent rounding and monitoring. On the evening of the incident, the resident was observed wandering throughout the facility and was last seen following staff members down the hall. The resident subsequently exited the building, crossed a busy five-lane road, and was found at a bus stop by an off-duty CNA. The investigation revealed multiple failures in the facility's supervision and safety protocols. The inside door to the front lobby had a charm and keypad, but the wandering alert system and electronic magnetic lock were not functioning. The front door was secured only by a deadbolt and lacked an alarm or delay system. The receptionist, whose desk was adjacent to the front door, left her post to purchase dinner and did not activate the foyer alarm as required by protocol. Additionally, the nurse responsible for setting the keypad at 8:00 PM did not do so, and this lapse was not verified by another staff member as required. Staff interviews confirmed that the alarm was not set, and the resident was able to leave the facility undetected during a shift change. Documentation and staff statements indicated that the facility had an elopement protocol and policies requiring monitoring of residents at risk for wandering, regular checks of door alarms, and verification of alarm activation. However, these protocols were not followed on the night of the incident. The receptionist did not arm the foyer door, the nurse did not verify or set the alarm, and there was no effective monitoring of the resident during the critical period. The facility's own root cause analysis identified the failure to set the foyer alarm and the absence of the receptionist at the front desk as the primary causes of the elopement.
Menu Not Followed and Posted Meal Substitution Not Updated
Penalty
Summary
The facility failed to ensure the posted menu was followed and updated for the lunch meal service in 1 of 1 kitchen. During a resident group meeting, residents stated the facility often ran out of the main meal and they were left with the alternate meal or a sandwich, which they described as happening frequently. Residents said the alternate was usually chicken tenders and reported frustration with the situation. During observation of lunch preparation, the kitchen was preparing sloppy joes with French fries and green beans, while the posted dining room menu listed sloppy joes, herb seasoned red potatoes, and green beans. At 12:57 p.m., the steam table had only about one-quarter pan of sloppy joe mixture remaining, and the main dining room had not yet been served while room trays had already gone out. A staff member stated there was not another pan of sloppy joe mix in the oven and only the one pan was available on the steam table. The Dietary Manager later stated the cook had used only 10 pounds of meat when the recipe called for 17.5 pounds, and additional meat had to be prepared using hamburger patties and sloppy joe sauce to finish the meal. The Dietary Manager also stated French fries were usually served instead of the red potatoes because they felt fries went better with sloppy joes, and the posted menu had not been updated. The Administrator stated menu accuracy was important so residents could be informed and make a choice. A CNA stated the kitchen ran out of the main entree about one day per week when certain cooks were present and that residents became upset when this happened.
Food Service Staff Failed to Use Beard Restraints and Maintain Hand Hygiene
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. During observation, two cooks were seen preparing food without beard restraints despite having facial hair. One cook had a mustache and goatee, and the other had a mustache and goatee as well. They were observed working in food preparation areas, including preparing beverage carts, pureed food, and packaging cookies, while not wearing the facial hair restraints that were available in the kitchen. During interview, both cooks stated beard restraints were used to keep hair from getting into food and were required for sanitary reasons. One cook stated the restraints were available and kept in the boss office, and the other stated staff with facial hair should wear them so hair would not contaminate food or cause choking. The dietary manager and administrator also stated beard restraints should be worn by staff with facial hair and were available in the kitchen. The facility also failed to ensure proper hand hygiene and glove changes when staff changed tasks. One cook was observed handling a box of frozen French fries, dumping fries into a fryer basket, and then returning to plate preparation without washing hands or changing gloves. The same cook was later observed leaving the steam table, going to the dish room to retrieve washed plates, and returning to plate preparation without washing hands or changing gloves. During interview, he stated he should have washed his hands and changed gloves after touching other items and when switching duties, and the dietary manager and administrator stated staff should wash hands when leaving the serving area and returning and when changing tasks.
Call Pad Left Out of Reach for Resident With Severe Cognitive and Physical Impairments
Penalty
Summary
The facility failed to provide reasonable accommodation of Resident #23’s needs and preferences when his soft touch call pad was not kept within reach for 2 days. Resident #23 was a [AGE]-year-old male with spastic diplegic cerebral palsy, convulsions, depression, autistic disorder, anxiety, and insomnia. His quarterly MDS reflected that he sometimes understood and was sometimes understood, he was not a candidate for a BIMS because his cognition was severely impaired, he had behavioral symptoms not directed toward others, received enteral feedings, and was dependent for ADLs and incontinent of bowel and bladder. His care plan identified communication deficits and fall/injury risk, with interventions including having the call light within reach and encouraging him to call for assistance. On 09/09/2025 at 10:30 a.m., Resident #23 was observed lying on a low bed with his soft touch call pad on the nightstand out of reach. On 09/10/2025 at 07:00 a.m., he was again observed with the soft touch call pad on the nightstand out of reach. During interview, LVN A stated the call light needed to be within reach so the resident could use it to call staff if he was in trouble, and she said she had placed it on the nightstand while giving G-tube medications and forgot to put it back on the bed. CNA B stated the pad was on the nightstand because the resident would throw it, but also stated he needed to be able to touch the soft pad to let staff know he needed something. The DON stated the resident needed a soft sensor pad as a call light and staff were responsible for keeping it within his reach.
Inaccurate MDS Coding for Rejection of Care and Nutritional Status
Penalty
Summary
The facility failed to ensure Resident #25’s Quarterly MDS accurately reflected rejection of care. Resident #25 had diagnoses including Alzheimer’s disease, secondary Parkinsonism, schizophrenia, anxiety disorder, and mood disorder due to a known physiological condition. Progress notes documented that on 07/26/2025 the resident refused incontinence care, a bed linen change, and medication despite encouragement and multiple attempts, and on 07/30/2025 the physician was notified of medication refusals. However, the 08/01/2025 Quarterly MDS coded Section E0800 as behavior not exhibited for rejection of care, even though the resident’s care plan identified the resident as resistive to care related to Alzheimer’s and schizophrenia. During interview, the SW stated the resident refused care most of the time and acknowledged the MDS coding was a mistake; the DON also stated the resident refused care daily and should have been coded on the MDS. The facility also failed to accurately code Resident #33’s nutritional status on the Quarterly MDS. Resident #33 had diagnoses including senile degeneration of the brain, GERD, and type 2 diabetes mellitus, and the physician order summary showed a regular diet with regular texture and thin consistency. The 08/27/2025 Quarterly MDS coded Section K0520 Nutritional Approaches as if the resident had parenteral/IV feeding, even though the resident did not have a feeding tube. The care plan identified a potential nutritional problem related to therapeutic diet, risk for malnutrition, DM, impaired cognition, and GERD.
Care plans did not reflect smoking status and adaptive call device needs
Penalty
Summary
Facility staff failed to develop a comprehensive person-centered care plan for Resident #2 that reflected his status as a current smoker. The resident’s face sheet showed diagnoses including essential hypertension, malignant neoplasm of colon, and hypotension, and his quarterly MDS assessment showed a BIMS score of 15, indicating intact/borderline cognition. His social history documented that he was a current smoker, but his revised care plan did not include smoking-related interventions or supervision needs. During interviews, the DON stated Resident #2’s smoking should have been care planned and that staff would not have known whether he was a supervised smoker or needed a vest without that information. The SW also stated smoking should be care planned and, after reviewing the care plan, did not see any smoking-related plan. The Administrator stated the MDS nurse and IDT were responsible for care plans and that smoking was care planned for resident safety. The facility’s Resident Smoking policy stated that all safe smoking measures would be documented on each resident’s care plan and communicated to staff responsible for supervision. Facility staff also failed to reflect Resident #23’s need for a soft touch pad in his comprehensive care plan. His record showed diagnoses including spastic diplegic cerebral palsy, convulsions, depression, autistic disorder, anxiety, and insomnia. His quarterly MDS indicated severe cognitive impairment, dependence for ADLs, enteral feedings, and bowel and bladder incontinence. His care plan addressed fall and injury risk and included a call light within reach and encouragement to call for assistance, but it did not identify the soft touch pad that was being used instead of a standard call light. Observations showed the soft touch pad placed out of reach on his nightstand, and staff stated he needed the soft pad because he would throw it and needed to be able to touch it to alert staff.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to ensure Resident #23 received nail care as part of assistance with activities of daily living. Resident #23 was a male with diagnoses including spastic diplegic cerebral palsy, convulsions, depression, autistic disorder, anxiety, and insomnia. His quarterly MDS reflected that he sometimes understood and was sometimes understood, was not a candidate for a BIMS due to severely impaired cognition, had behavioral symptoms, received enteral feedings, was dependent for ADLs, and was incontinent of bowel and bladder. His care plan identified a risk for self-harm related to poor coping mechanisms and emotional distress secondary to autistic disorder, including scratching at his arms and face, and also noted potential complications related to cerebral palsy, cognitive impairments, and communication deficits with interventions to assist with ADLs as needed. During observations, the resident was seen lying in bed and later sitting up in bed with long, ragged fingernails. An LVN stated the nails appeared to need trimming and said they should be trimmed during his Sunday bath, noting that if left long and sharp he could scratch himself and get hurt. A CNA stated she noticed the long nails, but the resident would not let staff trim them, and that she reported the issue to the nurse. The CNA shower review for the resident’s recent bath did not mention long fingernails, and point-of-care charting showed no history of nail care provided during the reviewed period. The DON stated staff were responsible for trimming ragged or long nails during bathing for safety and dignity reasons, and that nail care was completed weekly or as needed.
Unsecured Medication Cart During Medication Pass
Penalty
Summary
The facility failed to ensure that 1 medication cart, the Hallway 4 medication cart, was left locked and attended during medication administration. During observation of a medication pass, LVN A left the medication cart unsecured in Hallway 4 when she went into a resident’s room to administer G-tube medications and closed the door behind her. During an interview shortly afterward, LVN A stated she should have secured the cart because others could have access to the medications and this could result in misappropriation or misuse leading to harm. The DON later stated that LVN A needed to secure the medication cart when she left it so others could not access medications and other biological substances, and she stated she was accountable for facility nursing care. Facility policy required all drugs and biologicals to be stored in locked compartments, with access limited to authorized personnel, and during medication pass medications to be under direct observation or locked in the medication storage area/cart.
Infection Control Lapses During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 3 residents reviewed for incontinent care. Resident #69 was a female admitted with diagnoses including cerebral infarction due to embolism of the right middle cerebral artery, type 2 diabetes mellitus, hemiplegia, and multiple fractures. Her MDS reflected moderately impaired cognition, moderate assistance with ADLs, dependence for dressing and showering, and frequent bowel and bladder incontinence. Her care plan directed staff to provide proper peri-care. During observation of incontinent care for Resident #69, CNA C washed her hands and put on gloves, removed the soiled brief, and wiped the resident’s perineal area, labia, buttocks, and anal area. CNA C then placed a clean brief on the resident without removing the soiled gloves, sanitizing hands, or putting on clean gloves before handling the clean brief and bedding. CNA C later stated she did not know she was supposed to change her gloves between dirty and clean items, and acknowledged that changing gloves was important because of cross contamination. Resident #23 was a male with diagnoses including spastic diplegic cerebral palsy, convulsions, depression, autistic disorder, anxiety, and insomnia. His MDS reflected severely impaired cognition, dependence for ADLs, enteral feedings, and bowel and bladder incontinence. His care plan included enhanced barrier precautions related to his G-tube and directed staff to don gown and gloves during high-contact personal care. During observation, CNA C entered the room with EBP signage and PPE available outside, washed her hands, and put on clean gloves but did not don a gown. She performed incontinent care, handled soiled and clean items, and changed her gloves only after completing care. CNA C stated she was confused about when to change gloves and did not remember to put on a gown for direct care. The DON stated CNA C needed to deglove, sanitize hands, and put on clean gloves between soiled and clean items for both residents, and needed to wear a gown for Resident #23.
Failure to Complete Smoking Safety Assessment
Penalty
Summary
The facility failed to follow its established smoking policy for 1 of 1 resident reviewed for smoking because a Resident Safe Smoking Assessment was not completed for a resident identified as a current smoker. Record review showed the resident was admitted with diagnoses including essential hypertension, malignant neoplasm of colon, and hypotension. The resident’s Quarterly MDS assessment dated 08/07/2025 showed a BIMS score of 15, indicating intact/borderline cognition, and the Social History dated 08/08/2025 identified the resident as a current smoker. Review of the EMR showed the resident had not been assessed for smoking safety. During interviews, the DON stated activities and social services were responsible for completing smoking evaluations and said she was not aware the resident was on the smokers list. The DON stated that without an assessment, staff would not know whether the resident was a supervised smoker. The SW stated the resident was a smoker and that smoking assessments were used to determine capacity to smoke, whether protective equipment was needed, or whether the resident could properly dispose of ashes, but after reviewing the EMR confirmed no assessment had been completed. The Administrator stated the MDS nurse would be responsible for completing smoking assessments, with the charge nurse second, and noted the social worker had been responsible in the past. The facility’s smoking policy stated residents who smoke would be further assessed using the Resident Safe Smoking Assessment to determine whether supervision was required or whether the resident was safe to smoke at all.
Survey Results Not Posted in a Visible Public Area
Penalty
Summary
The facility failed to post the most recent survey results in a place readily accessible to residents, family members, legal representatives, and visitors, and failed to post notice of the availability of those reports in areas prominent and accessible to the public for 4 days. During the survey period, the survey results were kept behind the receptionist's desk on a shelf, and the sign identifying the survey results was not viewable from the entrance or small lobby area. Observations on multiple days showed the survey results and related signage were not located at the front entrance or in a visible public area. In a resident group meeting, residents stated they were not aware they could read the facility's survey results and did not know where to find them, though they said they were interested in reading them. On observation, two binders labeled survey results were seen approximately 7 feet behind the receptionist desk on a built-in bookshelf, and no signage indicating their location was observed. Later, the Administrator stated the area behind the reception desk was open to residents and families, and the survey binders and sign were moved to a more visible shelf in view of anyone entering the front door. The facility survey results policy was requested from the Administrator but was not received prior to exit.
Failure to Timely Submit PASARR Specialized Services Request for Resident Needing Custom Wheelchair
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program as required, specifically by not submitting a request for Nursing Facility Specialized Services (NFSS) for a resident within the mandated 20 business day timeframe. The resident, who had cerebral palsy and was assessed as medically complex with intact cognition, was identified by the Local Intellectual and Developmental Disability Authority (LIDDA) as needing a customized DME wheelchair. Despite this recommendation being made during an interdisciplinary team (IDT) meeting, the facility did not submit the required NFSS request to the State Agency in a timely manner. Record reviews and interviews revealed that the social worker, responsible for submitting NFSS recommendations into the Texas Medicaid & Healthcare Partnership (TMHP) SimpleCFS website, did not complete the submission within the required period because the Director of Rehabilitation (DOR) had not secured the custom wheelchair from the vendor. The social worker was unaware of the 20-day submission requirement. Additionally, the facility's policy did not address the need to submit NFSS requests within this timeframe, as confirmed by the administrator. As a result, the resident did not receive the benefits of the LIDDA's recommendations in a timely manner.
Failure to Timely Report Suspected Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported within the required timeframes. Specifically, an incident was observed in which a certified nursing assistant (CNA) was seen kissing a male resident with chronic systolic heart failure, epilepsy, and chronic obstructive pulmonary disease. The incident occurred late in the evening and was immediately reported by another CNA to the Director of Nursing (DON), who then notified the administrator. Despite this, the administrator did not report the suspected abuse to the State Survey Agency (HHSC) within the mandated two-hour window. Instead, the report was made the following afternoon, well beyond the required timeframe. Interviews and record reviews confirmed that the administrator, who is responsible for reporting suspected abuse or neglect, was informed of the incident on the same night it occurred. The administrator stated that after ensuring the resident felt safe, he waited until the next day to begin the investigation and subsequently reported the incident to HHSC in the afternoon. Facility policy and staff training both required immediate reporting of such incidents, but this protocol was not followed in this case.
Failure to Develop and Implement Baseline Care Plan for New Admission with Foley Catheter and UTI
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan within 48 hours of admission that included all necessary instructions for effective, person-centered care for a newly admitted resident. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, and Wernicke's encephalopathy, was admitted with a Foley catheter and an active urinary tract infection (UTI) requiring antibiotics. Despite hospital discharge records and multiple nursing notes indicating the presence of a Foley catheter and ongoing antibiotic treatment, the facility's care plan did not specifically address the resident's catheter care or current UTI and antibiotic use. The medical record review revealed inconsistencies and omissions regarding the resident's catheter status and care. The Minimum Data Set (MDS) did not reflect the presence of an indwelling catheter, and there were no physician orders for catheter care or monitoring. Nursing documentation failed to consistently record skilled assessments or urine output measurements related to the Foley catheter. Although some care plan interventions referenced catheter care if a catheter was in place, the plan lacked specificity and did not incorporate the hospital's discharge instructions or the resident's current infection and antibiotic regimen. Interviews with facility staff, including nurses, the administrator, and the DON, confirmed that the care plan was not individualized to the resident's needs and did not include essential information from the hospital discharge summary. Staff acknowledged that the lack of a resident-centered care plan and failure to document and implement catheter care could result in unmet care needs. The resident was ultimately hospitalized with a diagnosis of sepsis, and the facility's failure to provide a comprehensive, individualized care plan within the required timeframe was identified as the root cause of the deficiency.
Failure to Provide Appropriate Catheter Care and Monitoring
Penalty
Summary
A deficiency occurred when a male resident with a history of hemiplegia, hemiparesis, cerebral infarction, and Wernicke's encephalopathy was admitted to the facility with an indwelling Foley catheter. Despite clear documentation from the hospital regarding the presence of the catheter and the need to prevent infection, the facility failed to obtain or document physician orders for catheter care, monitoring for signs and symptoms of infection, or monitoring of urinary input and output. The resident's care plan referenced catheter care interventions, but these were not supported by corresponding orders or consistent documentation in the medical record. Throughout the resident's stay, there was a lack of skilled nursing notes regarding catheter assessments or urine output measurements. Multiple progress notes and assessments referenced the presence of a Foley catheter, but there was no evidence of routine monitoring or documentation of catheter care. Interviews with staff revealed confusion and lack of recall regarding the resident's catheter status, and several staff members indicated that if catheter care was not documented, it likely was not performed. The absence of catheter care orders in the electronic medical record meant that necessary care tasks were not prompted or completed. The resident experienced multiple falls, confusion, and ongoing antibiotic treatment for a urinary tract infection. Ultimately, the resident was hospitalized and diagnosed with sepsis, with hospital records noting a distended bladder and recommendations to assess for catheter dysfunction. Interviews with facility staff and the resident's family confirmed that catheter care was not adequately managed, and the lack of orders and monitoring contributed to the resident's decline and hospitalization.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to medication administration errors. Resident #1, who was cognitively intact and had a diagnosis of sepsis/osteomyelitis, was prescribed doxycycline to be administered twice daily. However, the medication was documented as administered at an incorrect time by LVN B. Similarly, Resident #2, also cognitively intact and diagnosed with multiple sclerosis and chronic kidney disease, was prescribed sulfamethoxazole-trimethoprim for a urinary tract infection. This medication was also documented as administered at an incorrect time by LVN B. Observations revealed that medication cups containing antibiotics for both residents were found unlabeled in a medication cart, and MA A, a medication aide, was instructed by LVN B to administer these medications, which she did not do. MA A stated she was trained to only administer medications she dispensed herself, and LVN B admitted to asking MA A to administer the antibiotics, which was against the facility's policy. Interviews with the residents indicated confusion about the administration of their medications, with Resident #1 recalling receiving medications from MA A and Resident #2 unsure about receiving her antibiotics. The Director of Nursing (DON) confirmed that the facility's policy required the person who dispenses the medication to administer it, emphasizing the importance of adhering to the 5 rights of medication administration. The facility policy also stated that medications should be administered within one hour of their prescribed time. The failure to follow these procedures resulted in a deficiency in pharmaceutical services, as the medications were not administered as prescribed, potentially placing residents at risk of medication errors.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during the provision of incontinent care to a resident. CNA A did not change her gloves after cleaning the resident's stool and proceeded to reposition the resident without changing gloves or performing hand hygiene. This lapse in protocol was acknowledged by CNA A, who admitted to not following the proper procedures despite having received training in infection control and incontinent care. Additionally, the facility did not ensure that CNA A and CNA B wore gowns during the provision of incontinent care to the same resident, who was identified as requiring enhanced barrier precautions (EBP) due to chronic wounds. Despite the presence of a sign indicating the need for gowns and gloves, and the availability of PPE outside the resident's room, both CNAs performed care without wearing gowns. They stated that they were instructed by the ADON to hurry and not wear gowns, although the ADON later denied giving such instructions. The resident involved had multiple diagnoses, including metabolic encephalopathy, pressure ulcers, and end-stage renal disease, and required maximum assistance for toileting and perineal care. The facility's policies on hand hygiene and EBP were not adhered to, as evidenced by the failure to use hand hygiene between glove changes and the omission of gown use during high-contact care activities. These deficiencies were observed despite the facility's training programs and policies designed to prevent the spread of infections.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) records. Resident #8, who was a smoker, had an annual MDS that inaccurately indicated no tobacco use. Despite having a comprehensive care plan and smoking assessment confirming the resident's smoking habits, the MDS nurse acknowledged the error, admitting that the question regarding tobacco use should have been answered affirmatively. Resident #14's MDS inaccurately recorded the use of anticoagulants, while the resident was actually taking Plavix, an antiplatelet medication, for cerebral infarction. The physician orders confirmed the absence of anticoagulant prescriptions, and the MDS nurse recognized the mistake, noting that the MDS should have reflected the correct medication class. Similarly, Resident #26's MDS inaccurately indicated the use of anticoagulants, despite no such medication being prescribed according to the physician orders. The MDS nurse admitted the error, acknowledging the responsibility for ensuring the accuracy of the MDS. These inaccuracies in the MDS assessments could potentially lead to inadequate care and services for the residents involved.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in their kitchen. Specifically, the facility did not label or date open food items stored in the reach-in freezer, refrigerator, and dry storage. Additionally, strawberries stored in the walk-in cooler were found to have mold, and the temperature of the reach-in refrigerator was recorded at 60 degrees, which is above the acceptable range. These issues were identified during an observation of the kitchen, where four bags of open food were found unlabeled and undated, along with trays of dry cereal and cups with liquids that were also not labeled. The Dietary Manager acknowledged the responsibility of ensuring that all open food items are labeled and dated and that food items are not spoiled or moldy. The facility's temperature logs indicated that the reach-in refrigerator's temperature was recorded at 32 degrees during the AM shift, but the thermometer read 60 degrees during a later observation. The Dietitian confirmed that the temperature should be 41 degrees or lower and that the food in the refrigerator would be discarded due to the uncertainty of how long it had been over temperature. The facility's policy on refrigerator and freezer temperatures and food labeling was not followed, as evidenced by the lack of labeling and the improper storage temperatures. The U.S. FDA Food Code requires that refrigerated, ready-to-eat, time/temperature control for safety food be clearly marked with a date or day for consumption, sale, or disposal, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, Resident #22 was found in bed with the call light on the floor at the foot of the bed, out of reach. This was observed during a survey, and it was noted that the resident had a care plan intervention for the call light to be within reach to prevent falls. The resident, who had diagnoses including End Stage Renal Disease, Major Depression Disorder, and Atrial Fibrillation, was asleep and easily aroused, indicating she was tired from dialysis. The Director of Nursing (DON) confirmed the call light was out of reach and emphasized the importance of following the care plan, which is person-centered, to ensure residents receive proper care. The facility's policy on answering call lights also stated that call lights should be accessible to residents when in bed. The administrator acknowledged that the call light should be within reach to allow residents to alert staff when they need assistance, which could be critical in emergent situations.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding fall prevention measures. During an observation, it was noted that the resident, who had a history of falls and was care planned for fall prevention, was in a low bed without a fall mat next to it. This was contrary to the resident's care plan, which specified the use of a fall mat as an intervention to prevent falls. The resident, who had been diagnosed with End Stage Renal Disease, Major Depression Disorder, and chronic Atrial Fibrillation, was observed asleep in bed after returning from dialysis. The Director of Nursing confirmed the absence of the fall mat and acknowledged the importance of adhering to the care plan to provide proper care. The facility's policy emphasized the importance of making the environment free from accident hazards and ensuring interventions are implemented correctly and consistently.
Inadequate Incontinent Care for Uncircumcised Resident
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in preventing urinary tract infections and ensuring proper care for uncircumcised males. During an observation, CNA A did not return the foreskin of a resident to its original position after cleaning, which could lead to complications such as infection and paraphimosis. The resident, who has severe cognitive impairment and is frequently incontinent of bladder and always incontinent of bowel, was dependent on staff for most activities of daily living. The resident's care plan required checking every two hours and assisting with toileting as needed, including providing perineal care after each incontinence episode. Despite being trained and having completed a competency checklist for incontinent care, CNA A failed to follow the facility's policy and procedure for perineal care, which includes repositioning the foreskin of uncircumcised males. The Director of Nursing acknowledged the importance of this step to prevent potential complications.
Deficiency in Nursing Staff Competency During Incontinent Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care, as evidenced by an incident involving CNA A during incontinent care for a resident. During the care, CNA A retracted the resident's foreskin to clean the penis but did not return it to its original position, which could lead to potential complications such as irritation, swelling, and infection. This incident was observed by surveyors and highlighted a deficiency in the competency of the nursing staff. The resident involved had a history of severe cognitive impairment, cerebral infarction, dysphagia, hemiplegia, hemiparesis, and dementia, and was dependent on staff for most activities of daily living. The facility's policy and procedure for perineal care required the repositioning of the foreskin after cleaning, which CNA A failed to do. Despite having completed a competency checklist for incontinent care, CNA A admitted to being nervous and not following the proper procedure, indicating a lapse in the application of her training.
Expired Thickened Water Found on Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper monitoring of expiration dates on medication carts. Specifically, the South unit medication aide cart contained a bottle of thickened lemon flavor water with high vitamin C that was expired. This expired product was observed on the cart, and the medication aide acknowledged its presence, stating that it had not been opened because no resident required it at the time. However, the aide kept it on the cart for potential future use with new residents, indicating a lack of awareness or oversight regarding the expiration status of the product. The Director of Nursing (DON) confirmed the presence of the expired thickened water on the medication cart and acknowledged that any expired medication or food product should be discarded. The facility's policy on the storage of medications requires that outdated or deteriorated drugs or biologicals be returned to the pharmacy or destroyed. The DON is responsible for ensuring that nursing staff check expiration dates, but this oversight was not effectively implemented, leading to the potential risk of residents consuming expired products.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel. During an observation, it was noted that a medication cart on the South unit was not properly secured, and a resident's 0.9% sodium chloride irrigation sterile water was left unattended on a nightstand in the resident's room. This oversight was confirmed through interviews with staff, including an LVN who acknowledged that medications should not be left in resident rooms unattended. Resident #3, who was involved in this incident, had a history of severe cognitive impairment and was totally dependent on others for activities of daily living. The resident's medical records indicated a need for regular catheter flushing with sterile water due to a history of urinary tract infections. Despite this, the sterile water was found unsecured in the resident's room, contrary to the facility's policy that requires all medications to be stored in locked compartments.
Failure to Provide Required Eating Utensils
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them during meal service. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including intracranial injury, protein-calorie malnutrition, type 2 diabetes mellitus, dysphagia, and intellectual disabilities, was not provided with a built-up spoon as indicated on their meal ticket. The resident's care plan, initiated in November 2022, specified the need for a divided plate with a built-up spoon due to potential nutritional issues related to swallowing problems. However, during an observation on August 20, 2024, the resident was given a regular spoon instead of the required built-up spoon. Interviews with facility staff revealed that the nutrition service director acknowledged the resident was supposed to receive a built-up spoon to prevent potential swallowing problems. The kitchen staff could not find a built-up spoon for lunch, although one was provided for breakfast. An LVN confirmed that the meal ticket indicated the need for a built-up spoon, but the kitchen staff set up the lunch with a regular spoon due to the unavailability of the correct utensil. The facility's policy on assistance with meals, revised in March 2022, stated that adaptive devices should be provided for residents who need or request them, but this was not adhered to in this instance.
Failure to Maintain Safe and Functional Equipment
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, specifically for one resident. The deficiency was identified when it was observed that the headboard of the resident's bed was loose and swinging up and down. This issue was noted during an observation on August 20, 2024, at 2:21 PM, when the resident was lying on the bed. The resident, who has a history of schizoaffective disorder, hypothyroidism, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and nicotine dependence, reported feeling a little uncomfortable due to the loose headboard but did not inform the staff, as he thought he was fine and was unaware of how long the headboard had been loose. Interviews conducted on August 21, 2024, with an LVN and a representative from Medical Record and Equipment confirmed the headboard's condition. The LVN acknowledged that the loose headboard could potentially cause the resident to fall. The Medical Record and Equipment representative admitted that it was their responsibility to ensure all medical equipment was safe and that no one had reported the issue with the resident's bed headboard to them. The facility's policy, revised in July 2017, emphasizes the importance of maintaining a safe environment free from accident hazards, highlighting that resident safety and supervision are facility-wide priorities.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as an elopement risk. The resident, who had a history of elopement and was assessed with moderate cognitive impairment, managed to leave the facility unsupervised. The resident was last seen in the smoking courtyard and was later found approximately 688 feet away from the facility at an intersection. The resident's care plan identified him as an elopement risk and included interventions such as monitoring for elopement-seeking behavior and redirecting him to other activities. Despite these measures, the resident was able to elope, indicating a failure in supervision and monitoring. The incident occurred when the resident was focused on obtaining another cigarette after his last allotted smoke break for the day, and staff attempted to redirect him to other activities. The facility's elopement protocol was initiated after the resident was discovered missing, involving an all-facility search and notification of the local police department. The resident was eventually found by the police and returned to the facility without injuries. The deficiency highlights a lapse in the facility's ability to monitor and supervise residents at risk of elopement effectively.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, and exploitation, leading to two residents eloping from the facility without staff knowledge. Resident #2, a male with severe disabilities and a history of behavioral issues, was able to exit the building and wheel himself to a bus stop on a city sidewalk. Staff were unaware of his exit-seeking behavior, which was documented in his admission paperwork. He was eventually brought back by police, but the incident highlighted a significant lapse in monitoring and security measures within the facility. Resident #1, a female with a history of drug abuse and homelessness, also managed to leave the facility without staff noticing. She was last seen walking towards the smoking courtyard but was later found to be missing during a medication round. Despite the facility's efforts to locate her, including contacting local hospitals and the police, her whereabouts remained unknown. This incident further underscored the facility's failure to adequately monitor and secure residents, particularly those with known risk factors for elopement. Interviews with staff and record reviews revealed that the facility did not have adequate alarm systems or monitoring protocols in place to prevent such incidents. The doors did not alarm or chime upon opening, and there were no cameras to monitor exits. Staff were also not adequately trained to recognize and respond to elopement risks, as evidenced by the lack of immediate action when residents were found to be missing. These deficiencies placed residents at significant risk of harm, highlighting the need for improved security measures and staff training to ensure resident safety.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that residents were free from abuse, neglect, and exploitation, leading to two residents eloping from the facility without staff knowledge. Resident #2, a male with severe disabilities and a history of behavioral issues, was able to exit the building and wheel himself to a bus stop on a city sidewalk. Staff were unaware of his exit-seeking behavior, which was documented in his admission paperwork. He was eventually brought back by police, but the incident highlighted a significant lapse in supervision and monitoring by the facility staff. Resident #1, a female with a history of drug abuse and homelessness, also managed to exit the building without staff knowledge. She was last seen walking towards the smoking courtyard and was later found to be missing during the evening medication round. Despite the facility's efforts to locate her, including contacting local hospitals and the police, her whereabouts remained unknown. This incident further underscored the facility's failure to adequately supervise and monitor residents, particularly those with known behavioral issues. Interviews with staff and record reviews revealed that the facility did not have adequate measures in place to prevent such elopements. The doors did not alarm or chime upon opening, and there were no cameras to monitor exits. Additionally, the facility's policy on wandering and elopement was not effectively implemented, as evidenced by the lack of proper risk assessments and monitoring for residents with exit-seeking behaviors. These deficiencies placed residents at significant risk of harm, injury, or death.
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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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadway Nursing & Rehabilitation | 2.9 mi | ★★★★★ | 33 | 1 |
| Sage Park San Antonio | 3.3 mi | ★★★★★ | 15 | 0 |
| The Lev At San Antonio | 3.3 mi | ★★★★★ | 30 | 0 |
| The Heights At Medical Center | 3.5 mi | ★★★★★ | 13 | 0 |
| Golden Estates Rehabilitation Center | 4 mi | ★★★★★ | 12 | 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.