Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Ridge Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Three cognitively impaired, functionally dependent residents with fall risk care-plan interventions requiring call lights to be within reach were observed with their call lights inaccessible: one resident in bed had the call light tucked at the foot of the bed, another sitting by the sink had the call light positioned behind the bed’s headboard and reported difficulty reaching and pulling it, and a third resident in bed had the call light lying on the floor while housekeeping was preparing to clean the room, contrary to facility policy and staff expectations that call lights remain accessible.
Activities Program Not Directed by a Qualified Professional: The facility failed to ensure its activities program was directed by a qualified professional for all residents. Record review showed the Activity Director was not certified, and the documents provided included CEUs and an old letter stating she met prior guidelines. The AD stated she had used the letter as her certification, had not completed an accredited activity director course, and did not have certification from a recognized accrediting body or OT/OTA licensure. The Administrator stated he believed she met the criteria based on her experience and longevity.
A facility failed to keep several medications and topical products secured, as zinc oxide, topical antibiotic ointment, topical pain relief gel, and eyedrops were found in resident rooms and visible from the hallway. Residents with cognitive impairment, incontinence, blindness, or self-administration status had these items left on tables or sinks, and staff stated the products should not be accessible to other residents because they could be used inappropriately.
Food storage and sanitation deficiencies were identified in the kitchen when surveyors found multiple food items that were undated, past use-by dates, or not properly sealed, along with a main ice machine with a brownish and blackish substance on the ice bin. The DM confirmed the observations and stated he was responsible for kitchen labeling, dating, and sanitization, while the ADM acknowledged the concerns and confirmed that food items needed to be dated, sealed, and discarded when expired.
A facility failed to maintain infection control during wound care, medication administration, and incontinent care. An ADON’s aide did not perform hand hygiene before assisting with wound care for a resident with a surgical skin graft, an MA reused a BP cuff between two residents with HTN without sanitizing it and wore it on her wrist, and a CNA did not perform hand hygiene or change gloves while providing pericare to a resident with hemiplegia and frequent incontinence. Facility policy required hand hygiene before and after glove use and cleaning resident care equipment between uses.
Improper Wound Care Technique During Dressing Change: An interim ADON performed wound care on a resident with a skin graft and used the same gauze to cleanse the surrounding skin and then the wound bed. The ADON and Corporate Nurse stated the gauze should have been discarded after cleaning the surrounding skin, and the Administrator acknowledged improper wound care could lead to infection.
An LVN left a container of germicidal wipes unattended on top of her cart while administering meds in a resident room, and another container was later observed on the nurse's station ledge near a resident. The ADON and Corporate Nurse stated the wipes should be stored inside the cart or medication room and not left where residents could access them; the facility policy also required disinfectant wipes to be secured or kept under direct staff supervision.
Improper Perineal Care During Incontinent Care: A resident with hemiplegia, moderate cognitive impairment, and frequent bladder and bowel incontinence received incontinent care from a CNA who cleaned the shaft of the penis and then used the same wipes to clean the head of the penis and the opening. The CNA, ADON, and Corporate Nurse all stated that the head of the penis should be cleaned with clean wipes, and the facility policy directed staff to wash the perineal area starting with the urethra and working outward.
Two residents with hypothyroidism and severe cognitive impairment missed scheduled morning levothyroxine doses when an LPN left prepared medications inside the med cart instead of administering them. The cups were later found labeled with the residents' names, and there was no documentation explaining the missed doses. The ADON stated medications should not be left in the cart, and the Corporate Nurse said one resident was sleeping and the other refused, but the doses were not later given.
A resident with COPD and moderately impaired cognition had her oxygen tubing and nebulizer mouthpiece left unbagged and exposed on her bed and bedside table when not in use. Staff interviews revealed inconsistent practices and understanding regarding the proper storage of respiratory equipment, and the resident's care plan and facility policy were not consistently followed, resulting in a failure to meet infection control standards.
A resident with multiple chronic conditions and severe cognitive impairment developed a left heel wound, but the care plan was not updated to include this new issue or the physician-ordered wound care interventions. Staff interviews confirmed that care plans should be revised to reflect changes in condition, but this did not occur, resulting in a lack of documented guidance for the resident's wound care needs.
A resident with muscle weakness, lack of coordination, and dizziness experienced a fall, but the care plan was not updated to address fall risk. Despite documentation of the incident and staff acknowledgment of the need for fall-related interventions, the care plan did not include measurable objectives or actions for fall prevention, contrary to facility policy.
The facility failed to ensure call lights were accessible to three residents, preventing them from obtaining assistance when needed. A resident with severe cognitive impairment had her call light on the floor, another had his stuck between the bed and wall, and a third found his unreachable on the wall after being moved to a new room. Staff acknowledged the importance of call lights but did not consistently ensure they were within reach.
The facility failed to implement comprehensive care plans for three residents with indwelling catheters, each lacking appropriate interventions. One resident had a catheter for a sacral wound but only had an intervention to check for kinks. Another resident with urinary retention had a care plan limited to monitoring for infection signs. The third resident, with a prostate history, had a care plan that only monitored discomfort. These deficiencies were noted despite physician orders for regular catheter care.
The facility failed to properly store respiratory equipment for four residents, leading to potential risks of infection. A resident's nebulizer mask was found unbagged and in contact with a sanitizer bottle, while another resident's nasal cannula tubing was on the floor. Similar issues were observed with two other residents' equipment. Staff interviews confirmed the need for proper storage to prevent contamination, but the facility's policy was not provided.
The facility failed to maintain a clean and homelike environment for residents, with observations revealing dirty air conditioning vents and unclean conditions in six rooms. Staff acknowledged the difficulty in cleaning the vents and recognized potential health risks. The facility's policy emphasizes a clean and orderly environment, which was not upheld.
A facility failed to ensure residents were free from unauthorized physical restraints. Four residents with severe cognitive impairments and total dependence on assistance were found with scoop or bolster mattresses on their beds without physician orders or assessments. The facility's policy requires physician authorization for such restraints, which was not obtained, leading to a deficiency in providing a restraint-free environment.
The facility's kitchen failed to meet food safety standards, with staff not wearing appropriate hair and beard coverings, and food items improperly labeled and stored. Sanitation issues were noted, including dirty ice scoop holders and bins. Food transported to resident areas was uncovered, risking contamination. The Dietary Manager acknowledged these deficiencies.
The facility failed to maintain effective infection control during incontinent care for two residents. CNAs did not change gloves or perform hand hygiene after touching contaminated surfaces and before handling clean items. One CNA also failed to wash hands after leaving and re-entering a resident's room. These actions were inconsistent with the facility's infection control policies.
A resident with impaired cognition was found with pointed scissors in their room, posing a risk of injury. The resident used the scissors for cutting paper and briefs, but staff were unaware of the latter use. The facility lacked a policy on sharp objects, contributing to the deficiency in maintaining a safe environment.
A facility failed to secure confidential medical records for two residents, leading to a breach of privacy. An RN left her laptop open during medication administration and wound care, displaying sensitive information visible from the hallway. The RN acknowledged the oversight, and interviews with the ADON, DON, and Administrator confirmed the expectation to protect residents' information.
A wound care cart was left unlocked and unattended by an RN, allowing potential resident access to medical supplies. The cart contained items such as dressings and ointments, which could be misused if accessed. Interviews with facility staff confirmed the expectation that carts should be locked when not in use to prevent resident access.
A facility failed to maintain an effective Infection Prevention and Control Program when a CNA did not perform hand hygiene before donning gloves and failed to change gloves after touching contaminated surfaces during incontinent care for a resident with chronic kidney disease. Despite receiving training, the CNA did not adhere to protocols, leading to potential cross-contamination. Interviews with facility leadership confirmed the importance of hand hygiene and glove changes as per policy.
Failure to Maintain Accessible Call Lights for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that call lights were accessible to residents as required by their care plans and facility policy. For one male resident with a history of cerebral infarction, muscle weakness, severe cognitive impairment (BIMS score 00), and dependence for transfers, hygiene, showering, and dressing, the comprehensive care plan identified fall risk and included an intervention to keep the call light within reach. During an observation, this resident was found awake in bed with the call light tucked at the foot side of the bed, and when asked where his call light was, he only shrugged his shoulders, indicating he did not know its location. A female resident with chronic pain, anxiety, lack of coordination, severe cognitive impairment (BIMS score 00), and dependence for hygiene, dressing, transfer, and bed mobility also had a care plan indicating she was at risk for falls and that her call light should be within reach. During observation, she was sitting by her sink while her call light was located behind the headboard of her bed. When asked if she could reach it, she stated it would be difficult for her to reach and pull the cord, and although she could ambulate, she was unable to pull the call light in that position. Another female resident with muscle weakness, chest pain, shortness of breath, severe cognitive impairment (BIMS score 00), and need for assistance with hygiene, dressing, and transfer had a care plan intervention to maintain the call light within reach due to fall risk. During observation, she was in bed with eyes closed and her call light was on the floor as housekeeping staff prepared to clean the room. The facility’s own policy, “Answering the Call Light,” revised September 2022, states that staff must ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. Staff interviews confirmed that call lights are used by residents to call staff when they need something or are in distress, and that call lights should always be within residents’ reach.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to provide an activities program directed by a qualified professional for 85 of 85 residents. During record review, the facility’s Administrative and other licensed professional staff licensure audit showed the current Activity Director was not certified. The documents provided for the Activity Director included training certificates showing completion of 3.5 hours of CEUs through Lifetime Wellness that were pre-approved by NCCAP for Activity Directors and 7 hours of CEUs through the employer on dementia training over the prior 12 months. The record also included a typed letter dated February 1, 2012, signed by ADM H, stating that the Activity Director met DADS NFR/LMC 19.702 guidelines for a qualified activities professional and had worked in the facility’s social and recreational program since January 2006, with full-time management of the activity program beginning in February 2011. In interview, the Activity Director stated she had always used the letter as her certification, had not completed an accredited Activity Director course, did not have certification from a recognized accrediting body, and did not have licensure as an OT or OTA. The Administrator stated he believed the Activity Director met the criteria based on her experience and longevity and had accepted that current staff met criteria when the company stated they did.
Medications Left Accessible in Resident Rooms
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments and to limit access to authorized personnel for several residents. During observations, a tube of zinc oxide was found on top of Resident #1’s side table while the resident was not in the room. Resident #1 had paraplegia, moderate cognitive impairment with a BIMS score of 08, and was incontinent of bladder and bowel. His care plan included incontinent care as needed and application of barrier cream. Resident #8, who had cerebral infarction, moderate cognitive impairment with a BIMS score of 10, and bowel incontinence, was observed in bed while a tube of zinc oxide, a cup with white cream, and an open tube of topical antibiotic ointment were on top of the sink and side table inside the room. The resident stated staff used the cream every time he was changed and said he did not know what the topical antibiotic ointment was for because he did not have any skin infection. The record review showed no physician order for the topical antibiotic ointment and no assessment that the resident was competent to self-administer medications. Resident #18, who had anxiety, dementia, severe cognitive impairment with a BIMS score of 07, and bladder and bowel incontinence, was not in the room when a tube of zinc oxide was observed on top of the sink. Resident #66, who had legal blindness and dementia with severe cognitive impairment and received scheduled pain medication, was in his wheelchair when a tube of topical pain relief gel was observed on top of a table near the room entrance and visible from the hallway. The resident said it was his pain medication and that he kept it on the table so he would know where to get it if needed; the record showed no order for the topical pain relief gel and no assessment for self-administration competency. Resident #41, who was cognitively intact with a BIMS score of 15 and had impaired eyes, was observed not in the room while a box of eyedrops and several eyedrops in a plastic cup were on top of the overbed table and visible from the hallway. The resident had a physician order for cyclosporine emulsion eye drops and a self-administration safety screen indicating he may self-administer medication unsupervised. Staff interviews stated that zinc oxide barrier creams, topical antibiotic ointment, topical analgesic, and eye drops should not be left accessible in resident rooms because other residents might use them inappropriately or be harmed by them.
Food Storage, Labeling, and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food storage, labeling, and dating. During observation in the kitchen, surveyors found multiple food items that were either undated, past their use-by dates, or not properly sealed, including marshmallows, crispy fried onions, graham crumbs, cake mix, beans, egg noodles, cornbread mix, noodles, spaghetti noodles, potatoes, cooked beef patties, cut potatoes, premade salad, vegetable soup, and assorted sandwiches. Several items were observed with no visible expiration date, while others had use-by dates that had already passed. Some food items were stored in bins or bags that were not properly sealed and were exposed to air contaminants. The main ice machine in the interior portion also had a brownish and blackish substance on the top portion of the ice bin. During interviews, the DM stated he was responsible for ensuring the kitchen met guidelines for food storage and sanitization and confirmed the surveyor observations. He stated that once items were opened, they should be properly sealed and dated, and that he and the kitchen aide were responsible for labeling and making sure items were labeled properly. The ADM stated he oversaw all departments, was aware of the kitchen concerns, and confirmed that food items needed to be dated, sealed, and discarded when expired.
Infection Control Lapses During Wound Care, Medication Administration, and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for four residents reviewed for infection control. During wound care preparation for a resident with a surgical skin graft to the left heel and a history of moderate cognitive impairment, CNA F assisted the ADON while wearing a gown and gloves but did not wash or sanitize her hands before beginning the care. The resident had orders for wound cleansing, collagen application, and dressing changes to the left heel wound. For two residents receiving antihypertensive medications, MA D obtained a blood pressure cuff from the medication cart, placed it on her wrist, used it to take one resident’s blood pressure, returned it to the cart without sanitizing it, and then used the same cuff on the second resident in the same manner. Both residents had hypertension and medication orders that required blood pressure checks before administration. MA D stated she should have sanitized the cuff between residents and should not have worn it on her wrist. During incontinent care for a resident with hemiplegia and frequent bladder and bowel incontinence, CNA E entered the room, put on gloves without performing hand hygiene, and then touched the trash can, cleaned the resident’s perineal area and bottom, handled the soiled brief and draw sheet, and then handled a clean brief without changing gloves. The resident’s care plan directed staff to provide pericare after each incontinent episode. The facility’s policies reviewed in the record stated that hand hygiene should be performed before and after glove use, that resident care equipment should be cleaned between uses, and that perineal care includes washing hands and applying gloves.
Improper Wound Care Technique During Dressing Change
Penalty
Summary
The facility failed to ensure that wound care for Resident #5 was provided in a manner consistent with professional standards of practice. Resident #5 was a male admitted to the facility with a diagnosis of skin transplant status, had a BIMS score of 12 indicating moderate cognitive impairment, and had a care plan addressing a surgical skin graft to the left lower leg/foot with an intervention to keep the incision clean and dry. A physician order directed staff to cleanse the skin graft/surgical wound to the left heel with wound cleanser, pat dry, apply collagen to the wound bed, and cover and secure the dressing. During observation of wound care, the interim ADON removed the old dressing, sanitized her hands, and began cleansing the wound. She used gauze to clean the surrounding skin of the wound and then used the same gauze to clean inside the wound, repeating this twice. In interview, the ADON stated the gauze used on the surrounding skin should not have been used inside the wound because germs could transfer and cause infection, and she acknowledged she should have discarded it and used a new gauze. The Corporate Nurse stated the gauze should be changed after every stroke and discarded, and the Administrator stated improper wound care could lead to infection.
Unattended Germicidal Wipes Left Accessible to Residents
Penalty
Summary
The facility failed to ensure the resident environment remained free of hazards when LVN C left a container of germicidal wipes unattended on top of her cart while she went into a resident's room to administer medications. During the observation, she closed the door and left the wipes on the cart until she finished the medication pass. LVN C later stated she forgot to place the wipes inside the cart before entering the room and acknowledged residents might be able to get hold of the wipes and use them to clean their faces and eyes, which could result in irritation. The facility also failed to ensure there were no germicidal wipes left unattended on the ledge of the nurse's station. At the time of observation, the nurse's station was unattended and a resident was sitting nearby. LVN C said she moved the wipes from the cart to the medication room after noticing them on the nurse's station ledge. The ADON and Corporate Nurse stated the wipes should be stored inside the cart or medication room and not left where residents could access them, and the facility policy required disinfectant wipes not be left unattended and to be stored in secured compartments or maintained under direct staff supervision.
Improper Perineal Care During Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a male resident who had hemiplegia, moderate cognitive impairment with a BIMS score of 10, and was frequently incontinent of bladder and bowel. His care plan directed staff to provide pericare after each incontinent episode. During an observation, a CNA put on gloves and cleaned the sides and top of the resident’s perineal area, then pulled the skin of the shaft of the penis and cleaned the shaft downward. Using the same wipes, he then cleaned the head of the penis and touched the opening of the penis, repeating this twice. During interview, the CNA stated he should not have used the wipes from the shaft to clean the head of the penis because germs from the shaft could enter the opening of the penis and may cause UTI. The ADON and Corporate Nurse both stated that wipes used on the shaft should not be used on the head of the penis because microorganisms from the shaft might enter the opening of the penis, and that the head should be cleaned with clean wipes. The facility policy for perineal care stated that for a male resident, the perineal area should be washed starting with the urethra and working outward.
Missed Morning Levothyroxine Doses Left in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for two residents. Resident #33, a female with hypothyroidism and severe cognitive impairment, had a physician order for levothyroxine 12.5 mcg by mouth every morning. Resident #46, a male with hypothyroidism and severe cognitive impairment, had a physician order for levothyroxine 88 mcg by mouth every morning. For both residents, the eMAR and progress notes showed the medication was not administered, and there was no documentation explaining why the doses were missed. During observation on 03/31/2026, MA D was preparing medications and opened the first drawer of the medication cart, where two small cups containing one pill each were found inside the drawer. The cups were labeled with Resident #33 and Resident #46's names. During interview, MA D stated the medications had been left by the night nurse and that she did not know why they were left inside the cart. She took the cups and said she would show them to the DON. During interview, the ADON stated there should be no medications already prepared inside the cart. She said the night nurse should have told the medication aide if she was unable to give the medications, should have discarded medications if residents refused, and should have revisited residents who were still sleeping so they would not miss medications. The Corporate Nurse stated one resident was still sleeping and the other refused, so she placed the medications inside the cart and planned to return to administer them but forgot. The facility policy stated missed residents are followed up after completion of the medication pass and refused, withheld, or rescheduled medications are documented appropriately on the MAR.
Failure to Properly Store Respiratory Equipment for Resident with COPD
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received such care in accordance with professional standards, the resident's care plan, and the resident's preferences. Specifically, the resident, who had a history of COPD and hypertension and was assessed as having moderately impaired cognition, was observed to have her oxygen tubing left unbagged on her bed and her nebulizer mouthpiece left unbagged on her bedside table when not in use. The resident reported that she removed her oxygen tubing and placed it on her bed when leaving for smoke breaks and typically placed the nebulizer mouthpiece on the bedside table after use. Staff interviews confirmed that the charge nurse was responsible for bagging the mouthpiece after medication administration, and that the resident often left respiratory items exposed after use. Record review showed that the resident's care plan included interventions for continuous oxygen via nasal cannula and noted a risk for infection due to non-compliance with nasal cannula use, with instructions for nursing to monitor and replace the cannula if found on the floor. Facility policy required nebulizer equipment to be stored in a plastic bag with the resident's name and date, but the policy on oxygen tubing storage was unclear. Staff interviews indicated inconsistent understanding and implementation of proper storage procedures for respiratory equipment, resulting in the resident's respiratory items being left exposed and not stored in accordance with infection control standards.
Failure to Update Care Plan for New Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan was not updated to include a left heel wound that was identified by a physician order. The resident, an older adult male with chronic kidney disease stage 3, heart failure, and pneumonia, had severe cognitive impairment as indicated by a BIMS score of 06. Despite the physician's order to apply xeroform and a bordered gauze dressing to the left heel, the care plan dated after the wound was identified did not reflect this new condition or the required interventions. Interviews with facility staff, including the Administrator, Wound Care Nurse, MDS Coordinator, and DON, confirmed that it was their responsibility to update care plans to reflect changes in residents' conditions. Staff acknowledged the importance of including all resident needs in the care plan to ensure appropriate and consistent care. The facility's own policy required ongoing assessment and timely revision of care plans as residents' conditions changed, but this was not followed in the case of the resident with the left heel wound.
Failure to Care Plan for Resident's Fall Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of falls. Record review showed that the resident, an elderly female with diagnoses including muscle weakness, lack of coordination, and dizziness, had an unwitnessed fall that was documented in the facility's incident report and progress notes. Despite this incident and the resident's high risk for falls, her quarterly care plan did not include any interventions or objectives related to fall prevention. The resident's MDS assessment indicated moderate cognitive impairment and a need for extensive assistance with activities of daily living. Interviews with facility staff, including the ADON and MDS nurse, confirmed that the resident should have been care planned for falls following the incident, but this was not done. Both staff members acknowledged their responsibility, along with the DON, for ensuring care plans were updated to reflect the resident's fall risk. The facility's policy requires an interdisciplinary approach to care planning based on MDS triggers and care area assessments, but this process was not followed in this case.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents, which could prevent them from obtaining assistance when needed. Resident #29, a female with severe cognitive impairment and dependent on staff for activities of daily living (ADLs), was observed with her call light on the floor at the foot of her bed. Despite being awake, she did not respond when asked about how she called for staff assistance. Resident #73, a male with severe cognitive impairment and requiring maximal assistance for ADLs, was found with his call light stuck between the bed and the wall. When questioned about the call light, he merely shrugged his shoulders, indicating a lack of awareness or ability to address the issue himself. A Certified Nursing Assistant (CNA) later repositioned the call light to be within reach. Resident #82, a male with moderate cognitive impairment, was transferred to a new room and found his call light coiled and unreachable on the wall. He expressed that he had to leave his room to seek assistance. The Director of Nursing (DON) and other staff acknowledged the importance of call lights and the expectation that they should be within reach of residents at all times, but this was not consistently ensured during staff rounds.
Inadequate Care Plans for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, each with an indwelling catheter, which did not include appropriate interventions. Resident #36, a female with a surgical site infection on the sacrum, had a care plan that only included checking for kinks in the catheter each shift, despite having a physician's order for Foley Catheter Care every shift and as needed. The resident experienced abdominal pain, leading to the removal of the catheter, which was initially placed to aid in the healing of her wound. Resident #68, a male diagnosed with urinary retention, had a care plan that only included monitoring for signs and symptoms of urinary tract infection. This was insufficient given the physician's order for Foley Catheter Care every shift and as needed. During an interview, the resident confirmed the presence of the catheter due to bladder issues, and the MDS Coordinator acknowledged the lack of comprehensive interventions in the care plan. Resident #79, a male with a history of malignant neoplasm of the prostate, had a care plan that only included monitoring for signs and symptoms of discomfort on urination and frequency. The care plan did not align with the physician's order for Foley Catheter Care every shift and as needed. Observations revealed the resident had a catheter leg bag secured to his right leg, and staff noted the need to replace the catheter with a leg strap due to the resident's tendency to drag it. The MDS Nurse recognized the need to update the care plan to include more interventions.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for four residents, leading to potential risks of respiratory infection and unmet respiratory needs. Resident #16's nebulizer mask was found unbagged and in contact with a bottle of sanitizer, which could lead to cross-contamination. The Licensed Vocational Nurse (LVN) was unaware of the mask's ownership and acknowledged the need for it to be bagged when not in use. Resident #28's nasal cannula tubing was observed on the floor, unbagged, and connected to an oxygen concentrator, which was not in use at the time. Similarly, Resident #40's oxygen tubing was found unbagged in a drawer, and Resident #38's nebulizer mask was left on top of the nebulizer without proper storage. These observations indicate a lack of adherence to infection control practices regarding respiratory equipment. Interviews with staff, including LVNs, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), confirmed that respiratory items should be stored in bags when not in use to prevent contamination. Despite this understanding, the facility's policy for bagging nasal cannulas and breathing masks was not provided, highlighting a gap in policy implementation and staff compliance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in six of the ten rooms reviewed. Observations revealed that the air conditioning units in these rooms had vents filled with black and brown dirt-like debris. Additionally, one room had a bedside table with red stains, and another room's mini fridge contained personal items such as hairbrushes, a towel, and sandwiches wrapped in napkins. These conditions were noted during a survey conducted on January 14, 2025. Interviews with facility staff, including the Administrator, a housekeeper, and the Housekeeping Supervisor, confirmed that housekeeping was responsible for cleaning the air conditioning units. The staff acknowledged the difficulty in removing dirt particles from the vents and recognized the potential health risks to residents due to the unclean conditions. The facility's policy on maintaining a homelike environment emphasizes the importance of a clean, sanitary, and orderly setting, which was not upheld in this instance.
Unauthorized Use of Restraints in Facility
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment. Specifically, four residents were found to have scoop or bolster mattresses on their beds without the necessary physician orders or assessments. These mattresses were intended to assist in fall prevention but were used without proper authorization, potentially restricting the residents' movement in bed. The facility's policy requires that any physical restraint must be ordered by a physician and used only when necessary to treat a medical condition, which was not adhered to in these cases. The residents involved had severe cognitive impairments and were totally dependent on assistance for activities of daily living. Despite their conditions, there were no physician orders for the use of scoop or bolster mattresses for these residents, as confirmed by the Director of Nursing (DON) after checking the records. The facility's failure to obtain the required physician orders and assessments for the use of these mattresses constitutes a deficiency in providing a restraint-free environment as mandated by their policy.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. Staff were not wearing appropriate hair and beard coverings, which could lead to hair contamination in food. Specifically, the Dietary Manager was seen preparing food without a beard guard, and another staff member was observed without a head covering while plating food. These lapses in protocol were acknowledged by the Dietary Manager, who admitted that such coverings are necessary to prevent hair from falling into the food. Food storage practices were also found to be inadequate. Items in the refrigerator and freezer, such as packages of bologna, ham, and raw celery, were not labeled with the date they were received from the vendor. Additionally, several items in the freezer, including bags of okra, waffles, and cookie dough, were improperly sealed, exposing them to airborne contaminants. The dry storage area also contained unlabeled packages of hamburger buns and tortillas. The facility's policy requires all stored food to be covered, labeled, and dated, but these standards were not met. Sanitation issues were evident in the kitchen, with the ice scoop holder showing brownish and white stains, and sugar and flour bins having dark dirt-like stains. Furthermore, food transported to resident rooms and the memory care unit was not properly covered, posing a risk of contamination. During a dining observation, uncovered desserts and green beans were seen on a food cart, and residents were observed standing over the trays. The Dietary Manager acknowledged these issues, noting that the ice scoop holder should be cleaned after every shift and that food should be covered during transport to prevent contamination.
Inadequate Infection Control During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs during incontinent care for two residents. For one resident, CNA A and CNA B did not change their gloves or perform hand hygiene after touching potentially contaminated surfaces and before handling clean items. Specifically, CNA A did not change gloves after placing a plastic bag in the trash can and before cleaning the resident's perineal area, nor after cleaning the resident's bottom and before touching a new brief. CNA B also failed to change gloves after handling a soiled brief and before assisting with a clean brief. In another instance, CNA B did not perform hand hygiene after leaving and re-entering a resident's room to retrieve wipes. Although she initially washed her hands upon entering the room, she failed to do so again after touching door knobs and other surfaces outside the room, which could have led to contamination. This oversight occurred during the provision of incontinent care for a resident diagnosed with cerebral infarction and incontinence. Interviews with the CNAs revealed a lack of awareness regarding the importance of changing gloves and performing hand hygiene to prevent cross-contamination and infection. The Director of Nursing and other staff acknowledged the importance of hand hygiene and glove changes in preventing infections, but the observed practices did not align with the facility's policies on hand hygiene and perineal care.
Failure to Maintain a Safe Environment Due to Presence of Scissors
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards, as evidenced by the presence of pointed scissors in the room of a resident with impaired cognition. The resident, who had a history of cerebrovascular disease and a cognitive communication deficit, was found to have a pair of large scissors with non-rounded ends stored in his wheelchair. The resident stated he used the scissors to cut the sides of a soiled brief, which posed a risk of injury to himself and others. The Director of Nursing (DON) was notified of the scissors, and it was acknowledged that the presence of such an item in the resident's room was unsafe. Interviews with staff revealed that the resident used the scissors for cutting paper, and there was no awareness among staff that the resident used them to cut briefs. The facility lacked a policy regarding residents or family members bringing sharp objects like scissors into rooms, and the DON admitted that such items posed a danger. The facility did not provide a policy about environmental hazards, and the DON emphasized the importance of staff being diligent about safety awareness. The absence of a policy and the lack of staff awareness contributed to the deficiency in maintaining a safe environment for the resident.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to secure confidential and personal medical records for two residents, leading to a breach of privacy and confidentiality. During medication administration to a resident diagnosed with neurocognitive disorder with Lewy bodies and hypertension, RN A left her laptop open, displaying sensitive information such as the resident's name, status, location, gender, date of birth, age, physician's name, latest vital signs, allergies, code status, emergency instructions, and medications. This information was visible from the hallway, exposing it to unauthorized individuals. RN A acknowledged the oversight, stating that she usually locks or minimizes the screen but forgot on this occasion. Similarly, while providing wound care to another resident diagnosed with dementia, RN A again left her laptop open, displaying the resident's personal and medical information, including the order for wound care. This information was also visible from the hallway. RN A admitted to repeating the mistake and recognized the importance of protecting residents' health information as per HIPAA regulations. Interviews with the ADON, DON, and Administrator confirmed the expectation that staff should ensure residents' information is not exposed, emphasizing the confidentiality and privacy of residents' medical records.
Failure to Secure Wound Care Cart
Penalty
Summary
The facility failed to ensure that a wound care cart was kept locked or under direct observation of authorized staff, which was accessible to residents. On the specified date, RN A was observed preparing to perform wound care and left the wound care cart unlocked in the hallway, with its drawers facing outward. The cart contained various medical supplies, including dressings, wound cleansers, ointments, and other items that could potentially be misused if accessed by residents. Interviews with RN A, the ADON, the DON, and the Administrator confirmed the expectation that carts should be locked when unattended to prevent residents from accessing potentially harmful items. RN A acknowledged forgetting to lock the cart and recognized the risk of residents accessing the contents. The ADON, DON, and Administrator all emphasized the importance of securing carts to prevent accidental ingestion or misuse of the items contained within.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA B during the provision of incontinent care to Resident #3. Resident #3, a female with chronic kidney disease and moderate cognitive impairment, was frequently incontinent for bowel and bladder. During the care process, CNA B did not perform hand hygiene before donning gloves, and failed to change gloves after touching potentially contaminated surfaces, such as the trash can and the resident's soiled bottom, before handling a clean brief. CNA B's actions were observed during an interview and care session, where she admitted to not washing her hands before starting the care and not changing gloves at appropriate times. She acknowledged that her gloves were soiled when she touched the new brief, which could lead to cross-contamination. Despite having received in-service training on incontinent care and hand hygiene, CNA B did not adhere to the expected protocols. Interviews with the ADON, DON, and Administrator confirmed that the facility's policy required hand hygiene before and after incontinent care and glove changes when transitioning from dirty to clean tasks. The facility's policies on hand hygiene and perineal care were reviewed, highlighting the importance of these practices in preventing infections and ensuring resident comfort.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 235 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pilot Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Pilot Point | 1.3 mi | ★★★★★ | 2 | 0 |
| Settlers Ridge Care Center | 11.3 mi | ★★★★★ | 1 | 0 |
| Whitesboro Health And Rehabilitation Center | 16.6 mi | ★★★★★ | 5 | 1 |
| Cottonwood Nursing And Rehabilitation | 16.7 mi | ★★★★★ | 17 | 0 |
| Denton Village By Purehealth | 16.8 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.