Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Manor Advanced Rehab & Healthcare during CMS and state inspections, most recent first.
Failure to Maintain Required RN Coverage: The facility failed to document 8 consecutive hours of RN coverage on 2 Sundays reviewed. The March nursing schedule showed no RN scheduled, and the Administrator and DON said they were responsible for ensuring daily RN coverage but could not provide prior timesheets after a software change. The facility policy required an RN to provide services at least 8 hours every 24 hours, 7 days a week.
Improper Food Storage and Refrigerator Monitoring in Nourishment Rooms: The facility failed to properly complete refrigerator temperature logs, and a nourishment room refrigerator contained unlabeled and undated food items, a staff lunch box, and an opened item that had been stored beyond 72 hours. The ADONs and DON stated the refrigerators were for resident items only, that food should be labeled and dated, and that opened items should be discarded after 3 days.
A facility failed to maintain infection control for residents on contact isolation and EBP. A CNA entered an isolation room without PPE, and a caregiver for a resident with ESBL, MRSA, conjunctivitis, and a feeding tube touched the resident without PPE and said she had not been trained on PPE. Two other residents with ESBL, C. diff-related precautions, feeding tubes, Foley catheter use, and severe cognitive or functional impairment also lacked proper isolation signage and timely care plan alignment with ordered precautions.
Care plans were not reviewed and revised to reflect isolation precautions for three residents with infectious concerns. One resident with ESBL, MRSA, a feeding tube, and severe cognitive impairment had a care plan that did not include contact isolation or EBP until after the resident was already being kept in a private room for active infection, and a caregiver was observed providing care without PPE and said she had not been trained. A second resident with diarrhea, C. diff testing, and ESBL precautions had no isolation signage in the room and the care plan did not reflect the precautions until later. A third resident with dementia, ESBL history, a feeding tube, and a Foley catheter had care plan issues related to isolation/EBP documentation despite ongoing infection-related orders and notes.
A resident with a feeding tube and significant neurologic conditions was observed receiving meds via mic-key-tube while the window blinds facing the parking lot were fully open, leaving the resident visible from outside. An LVN said the blinds were forgotten, and the DON confirmed staff were trained to secure full visual privacy, including closing doors, curtains, and blinds before medication administration or other personal care.
Baseline care plan missing contact precautions: A resident with dementia, psychosis, and ESBL in urine had an order for contact precautions on admission, but the baseline care plan did not include this information within 48 hours. During observation, a CNA entered the resident’s isolation room without PPE, and the RN and DON acknowledged the baseline care plan should have addressed the contact precautions.
Soft Helmet Order Not Followed: A resident with severe cognitive impairment, stroke-related paralysis, dementia, and self-injurious behaviors had a physician order and care plan requiring a soft helmet to be on at all times except bathing. During observation, he was in bed without the helmet, scratching his head, and staff could not locate the helmet in his room or therapy area. The PTA said she believed it was only needed when out of bed and had not reviewed the order, while the DON stated staff were responsible for following orders.
Unattended Lancet Left on Bedside Table: A resident with DM and ordered blood sugar monitoring had a diabetic lancet observed sitting on top of her bedside table unattended. An LVN stated it should have been secured in the med cart or discarded in the sharps container, and the DON confirmed it should be kept in the med cart until use and then thrown away in the sharps container per facility policy.
A resident with acute respiratory failure with hypoxia had nebulizer mask tubing left on the nightstand with the tubing touching the floor instead of being stored in a zip top bag when not in use. The CNA, assigned LVN, and DON all stated the equipment should be kept in a bag at bedside, and the facility policy required nebulizer and mask storage in a separate labeled plastic bag.
A resident with severe cognitive impairment and diagnoses including type 2 DM and right-hand contracture had a Tramadol 50 mg PRN order. The Tramadol blister pack showed 13 tablets remaining, but the controlled substance record showed 14 on hand. An LVN said she administered the dose but forgot to sign the controlled substance record, and the DON stated nurses should sign the controlled substance sheet when the medication is popped from the blister pack and sign the MAR after administration.
Two residents with dysphagia, severe cognitive impairment, and weight loss were not weighed weekly as ordered. One resident had cancer-related decreased intake and the other had protein-calorie malnutrition and poor oral intake. Staff stated weekly weights were taken by an RA and entered into PCC by the DON, but the record lacked documented weights for specific weeks for both residents, and the DON said the missing weights prevented accurate calculation of weight loss percentages.
A saline flush was observed sitting on top of an unattended medication cart in the 400 hall instead of being stored inside the locked cart. An LVN stated it should have been locked away and could have been taken by a resident, other residents, or visitors, while the DON stated no medication or saline flush should have been left on top of the cart. The facility policy required medications to be stored with proper sanitation, temperature, moisture control, segregation, and security.
A resident with a g-tube and severe cognitive impairment was on enhanced barrier precautions, with care plan directions to wear a gown and gloves during high-contact care. During incontinent care, two CNAs performed hand hygiene for only 15 seconds and did not wear PPE. Both CNAs stated they knew the resident required EBP and that a gown should have been worn, and the DON confirmed staff were required to perform hand hygiene before and after care and follow EBP for residents with feeding tubes.
A resident with chronic pulmonary edema, acute respiratory failure with hypoxia, and pleural effusion had a physician order for continuous O2 at 3 L/min via nasal cannula. During observation, the O2 concentrator was found set at 2.5 L/min, and an LVN adjusted it to the ordered 3 L/min. The resident had moderate cognitive impairment and a care plan noting behaviors of removing the nasal cannula and chewing on O2 tubing. Nursing leadership reported performing routine rounds to check O2 settings, and facility policy required treatments to be administered as ordered, but at the time of observation the O2 flow rate did not match the physician’s order.
A resident with hemiplegia, severe cognitive impairment, and dependence for most ADLs slid from bed onto a floor mat and activated the call light while on the floor. Video evidence showed the call light blinking shortly after the resident reached the floor and remaining unanswered for approximately 1 hour and 45 minutes until a CNA and an LVN entered and assisted the resident. Staff interviews revealed that the room had been noted as pending rounds, some staff saw or believed they saw the call light on but did not enter, and the unit was short-staffed due to call-ins and a no-call/no-show, resulting in a prolonged delay in responding to the resident’s call light despite care plan interventions requiring timely assistance and use of the call light.
Two residents with cognitive and behavioral impairments engaged in a physical altercation in a hallway, with one resident striking the other multiple times before staff intervened. Both had documented histories of aggression and required assistance with daily activities, but the facility did not prevent the unsupervised encounter, resulting in a failure to protect residents from abuse.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The report highlights insufficient environmental safety measures and lack of proper supervision, but does not specify further details about the hazards or individuals involved.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A facility failed to maintain an effective infection control program when a CNA did not follow the protocol of using one wipe per swipe during incontinent care for a resident with severe cognitive impairment. Despite recent in-service training, the CNA used a single wipe multiple times, risking cross-contamination. Interviews with staff confirmed awareness of the correct procedure, highlighting a gap in adherence to the facility's infection control policy.
Two residents in a LTC facility had incomplete documentation of insulin administration in their MARs. Despite receiving their insulin, the responsible LVN failed to transfer the documentation from her personal journal to the electronic MAR. The DON confirmed the documentation lapses, noting that the facility's policy was not followed.
A CNA at a long-term care facility failed to wear gloves while delivering a meal tray to a COVID-19 positive resident under droplet isolation, despite facility policies requiring full PPE. The CNA misunderstood the necessity of gloves, influenced by practices at other facilities, and had not reviewed the specific PPE policy. The facility's DON confirmed the requirement for gloves, gowns, goggles/face shields, and an N95 mask to prevent infection spread.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of an RN for at least 8 consecutive hours a day, 7 days a week on 2 days reviewed, 03/01/2026 and 03/15/2026. Record review of the March 2026 nursing schedule showed no RNs scheduled on those two Sundays, and the facility’s staffing records for the months reviewed reflected that RN coverage was not documented on those days. The deficiency was identified during review of RN hours for the period January 1, 2026 through March 31, 2026. During interviews on 06/24/2026 and 06/25/2026, the Administrator and DON stated it was their responsibility to ensure the facility had 8 consecutive hours of RN coverage every day. The Administrator said the facility had recently changed software and no longer had access to timesheets from the prior system, and she was unable to provide proof of RN coverage for the two dates. She stated that resident assessments completed by an RN on those days showed 2.44 hours of RN work on 03/01/2026 and 0.20 minutes on 03/15/2026. The facility’s policy stated that an RN provides services at least 8 hours every 24 hours, 7 days a week.
Improper Food Storage and Refrigerator Monitoring in Nourishment Rooms
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in two nourishment rooms. In one nourishment room, the refrigerator temperature log was being completed on the section intended for vaccine monitoring with a digital thermometer, while the section intended for use with an analog thermometer was left blank. Observation of the nourishment room refrigerator also found multiple food items that were not labeled or dated, including two sandwich bags of green substance, two 32-ounce cups containing a light brown substance, and nine small water bottles wrapped in plastic. A blue bowl with a clear lid was labeled with a name and room number but had no date. The same refrigerator contained a staff member’s zippered pouch lunch box, even though the ADON stated the refrigerator was for resident use only and staff personal items were to be stored in the staff refrigerator. A black bowl wrapped in clear plastic was labeled and dated 6/16/2026, indicating it had been stored longer than 72 hours after opening. During interviews, the ADONs stated that refrigerator temperatures were their responsibility, that resident food items should be labeled and dated, that personal items should not be stored in the resident refrigerator, and that opened items should be discarded after 3 days. The DON and Administrator also stated that the ADONs were responsible for maintaining the nourishment room refrigerators and ensuring proper labeling, dating, cleaning, and temperature monitoring.
Failure to Follow PPE and Isolation Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program for residents on transmission-based precautions and enhanced barrier precautions. During observation, a CNA entered a resident’s room on contact isolation without wearing PPE, despite PPE being available outside the room. The CNA stated she entered quickly only to place a yellow bag in the isolation bin and said she did not know it was not allowed to enter without PPE. Resident #106 had diagnoses including dementia, Parkinson’s, Alzheimer’s, MRSA, ESBL, diabetes, malnutrition, and a feeding tube. Physician orders required contact isolation for ESBL in the urine, and the resident also had conjunctivitis treated with erythromycin ophthalmic ointment. The resident was dependent for all ADLs and incontinent of bladder and bowel. On observation, the resident’s caregiver was touching the resident and standing close to the bed without PPE. The caregiver stated she had not been trained on PPE, did not know how to put it on or remove it, and did not understand why therapy staff wore gowns and gloves in the room. Resident #92 had diagnoses including Alzheimer’s, dementia, malnutrition, anxiety, depression, and was dependent for toileting, bathing, dressing, hygiene, positioning, and transfers, with bowel and bladder incontinence. Physician orders reflected C. diff precautions and contact isolation for ESBL in the urine, and the resident had a feeding tube. The room was observed without signage for C. diff isolation precautions or contact precautions on the door or in the room. Resident #12 had dementia, depression, ESBL resistance, malnutrition, kidney disease, a feeding tube, a Foley catheter, and a stage 4 sacral pressure ulcer. The resident’s care plan included enhanced barrier precautions for the feeding tube, Foley catheter, and pressure ulcer, but the report also noted contact isolation for stool testing and recurrent wound infection related to ESBL.
Care Plans Not Updated for Isolation Precautions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents whose records were reviewed. The deficiency involved care plans that did not reflect isolation precautions for known contagious diseases or, in one case, did not include those precautions until after the relevant events had already occurred. The facility policy stated that the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Resident #106 had diagnoses including malnutrition, diabetes, dementia, depression, lung disease, Parkinson’s, Alzheimer’s, MRSA, ESBL, and feeding tube placement. The resident’s MDS showed severe cognitive impairment, total dependence for ADLs, incontinence of bowel and bladder, and need for a feeding tube. Physician orders indicated transmission-based precautions with contact isolation due to ESBL in the urine, and the resident was kept in a private room with meals, activities, rehab, and other services provided in the room. The care plan dated 04/20/26 was not updated to include contact isolation precautions or EBP for contagious infections and a feeding tube until 06/24/26. Observation and interview on 06/23/26 showed the caregiver touching the resident without PPE and standing close enough that clothing rubbed against the bed rails and covers; the caregiver stated she had not been trained on PPE and did not know how to use it. Resident #92 had diagnoses including Alzheimer’s, malnutrition, anxiety, dementia, high blood pressure, abdominal distention, and depression. The resident’s quarterly MDS showed no cognitive impairment, dependence for toileting, bathing, dressing, hygiene, positioning, and transfers, and incontinence of bowel and bladder. Physician orders reflected C. diff precautions and contact isolation due to ESBL in the urine, with the resident in a private room because of active infection. The care plan did not reflect the isolation precautions until 06/24/26, despite progress notes on 06/20/26 and 06/21/26 documenting multiple episodes of diarrhea, orders for blood work and C. diff testing, and initiation of contact precautions pending results. Observation on 06/23/26 found no signage for C-diff or contact precautions on the resident’s door or in the room. Resident #12 had diagnoses including dementia, depression, ESBL resistance, malnutrition, and kidney disease. The resident’s quarterly MDS showed severe cognitive impairment, dependence for ADLs, moderate assistance with oral hygiene and eating, maximal assistance with upper-body dressing, and incontinence of bowel and bladder. Physician orders included enteral feeding, enteral tube site care, and catheter care every shift. The care plan dated 03/21/26 included a feeding tube focus without EBP interventions at that time, while another focus for EBP related to a stage 4 sacral wound, Foley catheter, and feeding tube had been revised on 06/04/26. Progress notes documented recurrent wound infection secondary to ESBL, multiple episodes of diarrhea, contact isolation pending stool results, and a Foley leaking. Interviews with CNAs and the DON reflected that staff understood isolation and EBP as different precautions and stated that signs should indicate the type of precautions, while the DON stated that isolation precautions should be in care plans.
Privacy Not Maintained During Tube-Feed Medication Administration
Penalty
Summary
The facility failed to ensure a resident’s right to personal privacy during medication administration via feeding tube. Resident #19 had diagnoses including unspecified nontraumatic intracerebral hemorrhage and spastic quadriplegic cerebral palsy, and the record showed she was on a feeding tube, NPO, and at nutritional and dehydration risk related to tube feeding due to dysphagia, cerebrovascular accident, anoxic brain damage, and related conditions. Physician orders included medications to be administered via mic-key-tube, including Aspirin, Levetiracetam solution, and Acetaminophen-Codeine suspension. During observation, LVN A was performing a medication pass in the resident’s room while the window blinds facing the parking lot were completely open, leaving Resident #19 visible from outside during medication administration via the mic-key-tube. In interview, LVN A stated the blinds were forgotten and acknowledged that closing them was important to provide privacy during personal treatments. The DON confirmed staff were trained to secure full visual privacy, including closing doors, privacy curtains, and window blinds before medication administration or physical treatment, and the facility policy titled Activities of Daily Living stated to screen and drape the resident for maximum privacy.
Baseline Care Plan Missing Contact Precautions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #122 that included the instructions needed to provide effective and person-centered care. Resident #122 was admitted with diagnoses including dementia, unspecified psychosis, and ESBL in urine, and her entry MDS assessment showed a BIMS score of 5, indicating severe cognitive impairment. Her admission record showed an order for transmission-based precautions, including contact precautions, due to ESBL in urine, but the baseline care plan initiated on 06/21/2026 did not address contact precautions. During observation, Resident #122 was on contact isolation precautions, with PPE available outside her room, but CNA H entered the room without PPE. CNA H stated staff needed to put on gloves and a gown before entering an isolation room and said she entered quickly to place a yellow bag in the isolation bin. RN D stated the contact precautions order had been effective since admission and that the baseline care plan should have included this information. The DON stated the admitting nurse was responsible for completing baseline care plans and acknowledged that Resident #122's plan should have included contact precautions within the 48-hour timeframe, but had not.
Soft Helmet Order Not Followed
Penalty
Summary
The facility failed to ensure Resident #8 received care in accordance with the physician’s order for a soft helmet to be on at all times, with removal allowed only for bathing. Resident #8 was a male with stroke-related left non-dominant paralysis, diabetes, mood disorder, major depressive disorder, anxiety, cancer, hypertension, obstructive uropathy, and dementia. His quarterly MDS showed a BIMS score of 00, indicating severe cognitive impairment, and he was dependent on staff for all ADLs, required mechanical lifting for transfers, had a feeding tube, and was on pleasure feeds. His care plan identified behaviors including attempts to self-transfer, yelling, hallucinations, and hitting, punching, and scratching himself while in bed, with an intervention that the soft helmet be on at all times. Record review showed the physician’s order also stated the soft helmet was to be on at all times. However, when observed, Resident #8 was lying in bed scratching his head and intermittently yelling, and he was not wearing the helmet; none was visible in the room. The PTA stated he only had to wear the helmet when out of bed and had not actually looked at the order. She later could not locate the helmet in the room or therapy department and provided a new one. The family member stated he did not wear the helmet all the time and that she had not taken it home. The DON stated staff were responsible for following orders and that not following the helmet order was noncompliance.
Unattended Lancet Left on Resident Bedside Table
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for Resident #121 when a diabetic lancet was found sitting unattended on top of the resident’s bedside table. Resident #121 was a female admitted with a diagnosis of diabetes mellitus due to underlying condition with hyperglycemia, and her baseline care plan identified that she had diabetes and was at risk for unstable blood sugars and abnormal results, with blood sugar monitoring ordered by the physician. During observation, the lancet was seen on the bedside table at 11:08 a.m. An LVN stated the lancet should have been secured in the medication cart or discarded in the sharps container and that leaving it there could allow someone to grab it. The DON later stated the lancet should be kept in the medication cart until use and then thrown away in the sharps container, and that leaving it unattended was a safety issue because anyone could grab it. The facility policy for obtaining a fingerstick glucose level states to discard the lancet into the sharps container.
Improper Storage of Nebulizer Equipment
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with acute respiratory failure with hypoxia. The resident’s care plan identified impaired respiratory status and directed staff to provide nebulizer therapy as ordered. During an observation, the resident was in bed and his nebulizer mask tubing was lying on the nightstand with the tubing touching the floor. During interviews, a CNA stated the nurse was responsible for placing the nebulizer mask and tubing in a zip top bag when not in use and said the tubing should not touch the floor because it could cause contamination and infection. The assigned LVN stated the mask and tubing should be inside the zip top bag when not in use and acknowledged they could become contaminated. The DON also stated nebulizer masks and oxygen tubing should be stored in a zip top bag at bedside when not in use. The facility policy required nebulizer and mouthpiece or mask storage in a separate labeled plastic bag.
Controlled Substance Record Did Not Match Tramadol Count
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to maintain an accurate system for documenting the disposition of controlled drugs. For Resident #25, the Individual Resident's Controlled Substance Record for Tramadol did not match the medication count on hand. During observation, the Tramadol 50 mg blister pack contained 13 tablets remaining, while the controlled substance record showed 14 tablets on hand. Resident #25 was admitted with diagnoses including type 2 diabetes mellitus without complications and contracture to the right hand. Her quarterly MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment. The physician's order for Tramadol was 50 mg, 1 tablet by mouth every 6 hours as needed for pain. During interview, an LVN stated she had administered Tramadol but forgot to sign the controlled substance record because she was pulled away, and said the record had to be signed right after the resident took the medication. The DON stated nurses should sign the controlled substance sheet when they popped the medication out from the blister pack and sign the MAR after administering the medication.
Missed Weekly Weights for Two Residents With Weight Loss
Penalty
Summary
The facility failed to ensure that two residents with physician-ordered weekly weights were weighed as ordered. Resident #1 was a female with diagnoses including left patella fracture, muscle wasting and atrophy, dysphagia, cognitive communication deficit, rheumatoid arthritis, dementia, and cancers of the breast and lung. Her MDS reflected severe cognitive impairment, weight loss, and dependence for eating. Her care plan identified her as at risk for malnutrition and noted unplanned weight loss related to decreased oral intake and cancer. A physician order required weekly weights beginning 02/18/26, but the weight record showed weekly weights only through 03/26/26, with no weight documented for the week of 03/30/26. Resident #2 was a male with diagnoses including cerebral palsy, dementia, cognitive communication deficit, dysphagia, and protein-calorie malnutrition. His MDS also reflected severe cognitive impairment, weight loss, and the need for substantial to maximal assistance with eating. His care plan identified him as at risk for malnutrition and noted unplanned weight loss related to poor oral intake. A physician order required weekly weights beginning 04/28/26, but the weight record showed weights on 05/01/26, 05/12/26, and 05/27/26, with no weight documented for the weeks of 05/04/26 or 05/18/26. During interviews, the ADONs and DON stated that residents with weight loss were supposed to be weighed weekly and that the weights were taken by an RA and then entered into PCC by the DON. The DON stated she reviewed a binder and did not find weights for the missing weeks for either resident. The DON also stated the facility could not accurately calculate percentages of weight loss without the weekly weights being done or documented appropriately. The facility's Weight Management policy stated that all admission, readmission, weekly, and monthly weights are to be entered into PCC.
Unsecured saline flush left on medication cart
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and accessible only to authorized personnel for 1 of 2 medication carts reviewed, the 400 hallway cart. During an observation on 05/12/2026 at 3:45 p.m., a saline flush was found sitting on top of the unattended 400 hall medication cart. During an interview at 3:50 p.m., LVN A stated the normal saline flush should have been inside the medication cart and locked, and said a resident, other residents, or visitors could take it and that it could become contaminated or cause an allergic reaction. During an interview on 05/14/2026 at 4:45 p.m., the DON stated no medication or saline flush should have been left on top of the medication cart and that another resident or any resident or visitor could take it and have an adverse reaction. The facility policy titled Medication Storage stated medications must be stored, dated, and labeled according to manufacturer recommendations and with proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Failure to Use EBP and Proper Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain its Infection Prevention and Control Program for Resident #1, a severely cognitively impaired female with dysphagia, a history of cerebral infarction, and a feeding tube. Her care plan identified enhanced barrier precautions due to the g-tube, with interventions to wear a gown and gloves during high-contact resident care activities. During observation of incontinent care on 05/13/26, CNA B and CNA C performed hand hygiene for 15 seconds and did not have personal protective equipment on while providing care to the resident. During interviews, CNA B and CNA C each stated that residents with a tube were required to be on enhanced barrier precautions and that they should have worn a gown but forgot when entering the room. CNA B stated she was aware handwashing should be for at least 20 seconds and that the negative outcome could be the spread of contamination. CNA C also stated she was aware handwashing should be for at least 20 seconds. The DON stated that any resident with a feeding tube was placed on enhanced barrier precautions and that staff were always required to perform hand hygiene before and after care. The facility policy required gown and gloves for high-contact care activities and required hand hygiene with soap and water for at least 20 seconds.
Failure to Administer Oxygen at Prescribed Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered oxygen therapy was administered at the prescribed setting for a resident requiring continuous oxygen. The resident, an older female with chronic pulmonary edema, acute respiratory failure with hypoxia, and pleural effusion, had an active physician order dated 3/17/2026 for continuous oxygen at 3 liters per minute via nasal cannula every shift. The resident’s MDS assessment indicated moderate cognitive impairment and documented oxygen therapy as a treatment performed on admission and while a resident. The care plan identified a behavioral problem in which the resident removed the nasal cannula and chewed on the oxygen tubing, with an intervention to administer medications as ordered. On 3/19/2026 at 10:56 a.m., surveyors observed the resident in bed with oxygen being delivered via nasal cannula from a concentrator set at 2.5 liters per minute instead of the ordered 3 liters. LVN A was observed checking and then adjusting the concentrator setting to 3 liters per minute in response to this finding. Earlier that morning, LVN A reported having checked the oxygen setting and stated it was at 3 liters, with an oxygen saturation of 98% at 9:30 a.m. The ADONs reported that they conducted rounds each morning, including checking oxygen settings, and that managers made Quality of Life rounds to address issues such as oxygen settings. The facility’s policy on Medication-Treatment Administration and Documentation Guidelines required medications to be administered according to the physician’s order, which was not followed at the time the oxygen concentrator was found set below the prescribed rate.
Failure to Timely Respond to Call Light for Dependent Resident on Floor Mat
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with the resident’s person-centered care plan and professional standards of practice by not responding to a call light for an extended period. The resident involved was an older female with hemiplegia and hemiparesis affecting the left non-dominant side, contracture of the left hand, lack of coordination, schizoaffective disorder, and epilepsy. A quarterly MDS showed severe cognitive impairment with a BIMS score of 4, and Section GG documented that she was dependent or required substantial/maximal assistance for nearly all self-care and mobility tasks, including transfers and toileting. Her care plans identified ADL self-care performance deficits and risk for unmet needs, fall risk related to reduced mobility and hemiplegia with a history of falls, and behavior issues including throwing herself on the floor and sliding down to the mat. Interventions included keeping the bed in the lowest position, placing a floor mat next to the bed, ensuring the call light was within reach, and encouraging the resident to use the call light for assistance. On the date of the incident, surveillance video from the resident’s room showed that at 4:37 a.m. she was lying in bed with her feet dangling off the side. At 4:43 a.m., she was observed sliding down from the left side of the bed into a sitting position on the floor mat and pressing the call light within eight seconds of reaching the floor. The wall-mounted call light was seen turned on and blinking. At 4:44 a.m., the resident was seen waving the call light in the air and placing it on top of the bed, and by 4:45 a.m. she had positioned herself lying on the floor. No video footage was available between 4:45 a.m. and 6:36 a.m. A second video segment with a timestamp of 6:36 a.m. showed a CNA entering the room, removing a blanket from the resident’s legs while she remained on the floor, and an LVN entering within about 10 seconds to check the resident. The family member’s own video, viewed by surveyors, similarly showed the resident sliding off the bed onto the mat, pressing the call light, and staff not entering the room until approximately two hours later. Interviews with the resident and staff further described the delay in response to the call light. The resident reported that staff sometimes took a long time to answer her call light and that on this occasion she slid off the bed, sat on the mat, became dizzy, and remained on the floor for about an hour before staff helped her back to bed, though she stated she had no injuries. A family member stated that no one entered the room after the call light was pressed and that the camera in the room only recorded when there was movement, with video showing the resident sliding to the floor and pressing the call light, and a later clip showing staff entering the room roughly two hours afterward. Multiple staff interviews revealed that the call light system required staff to physically enter the room to turn off the light and that there was no electronic log of call light duration. Staff accounts indicated that the resident’s room had been noted as “pending to be seen,” that some staff saw or believed they saw the call light on but did not enter the room, and that staffing on the unit was reduced due to call-ins and a no-call/no-show on the overnight shift. Collectively, these observations and statements show that the resident’s call light remained unanswered for approximately 1 hour and 45 minutes while she was on the floor, contrary to her care plan interventions and the facility’s call light response policy.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to ensure the right of each resident to be free from abuse, as evidenced by a physical altercation between two residents in the hallway. Both residents involved had significant cognitive impairments and histories of behavioral issues, including aggression and resistance to care. On the day of the incident, one resident was wheeling himself towards the nurse's station when the other resident grabbed his shirt and struck him multiple times on the left shoulder. The altercation escalated, with both residents striking each other before being separated by staff. Video surveillance confirmed that one resident was the initial aggressor, and both residents were assessed by nursing staff immediately after the incident, with no visible injuries or complaints of pain noted at that time. Record reviews revealed that both residents had documented behavioral problems and required varying levels of assistance with activities of daily living due to cognitive and physical limitations. One resident had a history of aggression with staff and was noted to be resistant to care, while the other had a diagnosis of dementia, psychosis, and delusional disorder, with a care plan indicating a risk for aggressive behavior and a need for close monitoring. Despite these known risks, the facility did not prevent the altercation from occurring as the residents encountered each other unsupervised in the hallway. Interviews with staff indicated that they were aware of the residents' behavioral histories and the potential for aggression. Staff described previous incidents of aggression and confusion, as well as the need for interventions to prevent abuse. However, the incident in question demonstrated a failure to implement effective supervision and preventive measures, resulting in a physical altercation between the two residents. The facility's policies and procedures required protections against abuse, but these were not adequately followed to prevent the event.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific nature of the hazards, the supervision lapses, or the condition of any residents involved are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency is based on the observation that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting procedures were not followed as mandated. The report specifically notes the lack of timely communication and documentation to the appropriate authorities regarding both the suspicion and the outcome of the internal investigation.
Infection Control Deficiency in Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during incontinent care for a resident. The resident, a female with severe cognitive impairment and total dependence on assistance for personal hygiene, was observed receiving care where CNA A did not adhere to the protocol of using one wipe per swipe. Instead, CNA A used a single wipe multiple times on the resident's buttock area, which could lead to cross-contamination. This practice was contrary to the facility's policy, which mandates the use of one wipe per swipe to prevent infection and cross-contamination. Interviews with CNA A, CNA B, the ADON, and the DON revealed that the staff were aware of the correct procedure and had been in-serviced on incontinent care recently. However, CNA A was unsure of the correct number of times a wipe could be used, indicating a gap in adherence to the training. The facility's policy, last revised in November 2024, clearly outlines the requirement for using a wipe once per swipe, and the failure to follow this protocol was identified as a deficiency in the infection prevention and control program.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the documentation of medication administration for two residents. Resident #2, a cognitively intact female with a history of type 2 diabetes mellitus with hyperglycemia, had incomplete documentation in her Medication Administration Record (MAR) for insulin administration on June 3, 2024. The MAR showed three unsigned sections for insulin orders, despite the resident reporting that she received all her insulin and blood sugar checks as ordered. Similarly, Resident #3, also cognitively intact and diagnosed with diabetes mellitus due to an underlying condition with hyperglycemia, had an incomplete MAR for the same date. The MAR had one unsigned section for insulin administration, although the resident confirmed receiving her insulin and blood sugar checks. Licensed Vocational Nurse (LVN) A, who was responsible for administering and documenting the insulin, admitted to documenting the administration in her personal journal but failing to transfer this information to the electronic MAR. Interviews with LVN A and the Director of Nursing (DON) revealed that LVN A was new to the station and unfamiliar with the separate insulin MAR. Despite having been trained on documentation procedures, LVN A did not follow the facility's policy to document medication administration immediately on the MAR. The DON confirmed the documentation lapses and acknowledged that the facility's policy was not followed, as the MAR was left incomplete, which could lead to potential errors in care and treatment.
Inadequate PPE Usage in COVID-19 Isolation Room
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA C, who did not adhere to the required personal protective equipment (PPE) protocols when entering the room of a resident diagnosed with COVID-19. The resident, a cognitively intact female with multiple health conditions including COVID-19, was under droplet/contact precautions. Despite the clear signage and existing orders for transmission-based precautions, CNA C entered the resident's room wearing an N95 mask, eye protection, and a gown, but failed to wear gloves, which are part of the required PPE. CNA C admitted to not wearing gloves during the delivery of a meal tray, under the mistaken belief that gloves were unnecessary if there was no direct contact with the resident. This misunderstanding stemmed from practices observed at other facilities, rather than the specific policies of the current facility. CNA C acknowledged the importance of wearing gloves to prevent infection and cross-contamination, especially in the context of a COVID-positive resident on droplet isolation. The facility had provided training on PPE usage, which CNA C had attended, but he had not reviewed the facility's specific policy on PPE requirements for droplet isolation rooms. The Director of Nursing (DON), who also served as the Infection Control Practitioner (ICP), confirmed that the facility's policy required the use of gloves, gowns, goggles/face shields, and an N95 mask when entering rooms of residents with confirmed COVID-19. The DON emphasized the importance of adhering to these protocols to prevent outbreaks and protect both residents and staff. The facility's policy and training materials clearly outlined the necessary PPE for such situations, but the failure to comply with these protocols by CNA C highlighted a gap in adherence to the infection control measures in place.
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 231 citations issued within 25 miles in the last 12 months — including the 5 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 Pharr
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edinburg Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 17 | 1 |
| Hidalgo Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 11 | 0 |
| Mcallen Nursing Center | 2.8 mi | ★★★★★ | 12 | 0 |
| Windsor Nursing And Rehabilitation Center Of Edinb | 3.5 mi | ★★★★★ | 4 | 0 |
| Grand Terrace Rehabilitation And Healthcare | 4 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.