Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Colonial Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Provide and Document Ordered Nutritional Supplements: A resident with cerebral palsy, profound ID, and anorexia was observed not eating and did not receive an ordered Health Shake, while records showed significant wt loss and an unimplemented RD recommendation to switch to Med Pass. Two other residents with dementia and other chronic conditions also had significant wt loss, but their Med Pass 2.0 orders did not specify the amount, were not placed on the MAR, and had no documentation of administration.
Incomplete documentation of nutritional supplement orders and administration: The facility failed to accurately transcribe and document supplement orders and administration for several residents with weight loss and swallowing or cognitive impairments. A dietitian recommendation for Med Pass 2.0 was not entered on the MAR/TAR for one resident, physician orders for Med Pass lacked the specific amount for two residents, and a Health Shake order for another resident was not reflected on the MAR. Staff interviews confirmed there was no documentation showing the supplements were administered or consumed.
Residents Were Exposed to Staff Eating Lunch Before Their Meal Was Served: Two CNAs ate their personal lunch in a secure unit dining area while several residents, including two residents with dementia-related diagnoses and elopement risk status, were sitting and waiting for lunch. The residents said they were hungry and described the behavior as rude, and both CNAs acknowledged the residents should not have been watching staff eat when they had nothing to eat.
Inaccurate MDS Coding for Dehydration: A resident's annual MDS coded dehydration based on hospital fluids and fever, but the hospital records, PCP follow-up, and facility documentation did not show a dehydration diagnosis, treatment, intake/output records, clinical signs, or lab values supporting that code. The MDS Coordinator said she believed the evidence was sufficient, although the MDS RAI Manual requires two or more indicators before coding dehydration.
A facility failed to electronically transmit admission MDS assessments to CMS within the required timeframe for 5 residents. Record review showed the MDSs were incomplete or never added to a batch, and the MDS Nurse stated she did not realize they had not been transmitted even though it was her responsibility. The DON said she was unaware the assessments had not been completed and transmitted.
A medication cart was found to contain 15 expired tablets of APAP/Codeine 300-30mg that had not been removed from use, despite facility policy and staff training requiring regular checks and removal of expired medications. The expired medication was discovered during an observation and interview with an RN, and the DON confirmed that such medications should not be present in storage areas.
The facility failed to maintain RN coverage for 8 consecutive hours, 7 days a week, on multiple dates in December 2024 and January 2025. Interviews with staff confirmed the absence of a full-time RN, which is required by the facility's policy. This deficiency left residents without access to staff with advanced care skills, potentially affecting their care needs.
The facility failed to appoint a full-time Director of Nursing (DON) since early November 2024, as confirmed by interviews and record reviews. The absence of a DON was acknowledged by both the administrator and the Assistant Director of Nursing (ADON), who started their roles after the last recorded day of DON coverage. This lack of a designated DON could risk residents due to insufficient nursing oversight.
The facility's kitchen operations were found deficient in maintaining sanitary conditions, with improperly sealed food items and incorrect use of test strips for dish sanitization. The dish machine log was pre-filled with inaccurate data, and several thickened liquid products were not labeled with opening dates. These issues could place residents at risk of foodborne illness.
The facility failed to accurately assess three residents' PASRR status, leading to incorrect MDS coding. A resident with bipolar disorder and another with psychotic disorder were both inaccurately coded as not having a serious mental illness, despite positive PASRR screenings. The MDS Coordinator misunderstood the coding requirements, resulting in these inaccuracies.
A facility failed to ensure proper medication administration for a resident with a G-Tube. The resident's medications were crushed and administered together without the required water flushes, contrary to facility policy. This action led to a blockage in the G-Tube, and the LVN did not follow the correct procedure, potentially risking tube damage and complications.
The facility failed to properly administer medications to two residents, leading to potential risks. A resident with a gastrostomy tube received improperly crushed medications without required water flushes, while another resident with severe cognitive impairment did not receive the prescribed Vitamin B12 dose due to unavailability, leading to unauthorized dose calculations by a Medication Aide. These actions violated facility policies and physician orders, highlighting deficiencies in medication administration practices.
A facility reported a medication error rate of 7% due to improper administration of medications via a gastrostomy tube. An LVN crushed a delayed-release medication, Protonix, and administered it with other medications, contrary to physician orders and facility policy. The resident involved had a gastrostomy tube and intact cognition. The LVN admitted to the error, and the ADON confirmed non-compliance with medication administration policies.
A facility failed to accurately document a resident's code status, leading to a discrepancy between the resident's wishes and the facility's records. The resident, with severe cognitive impairment and multiple health issues, had a signed OOHDNR document, but staff believed she was Full Code due to lack of communication and documentation errors. This oversight could have led to resuscitation actions against the resident's wishes.
A facility failed to maintain an effective infection prevention and control program when an LVN did not adhere to Enhanced Barrier Precautions while administering medications through a gastrostomy tube to a resident. Despite the requirement to wear gloves and a gown for high-contact activities, the LVN only donned gloves, contrary to the facility's policy and CDC guidelines. Interviews confirmed the necessity of these precautions for residents with indwelling medical devices to prevent infection spread.
A facility failed to protect residents from abuse and neglect, with incidents involving both staff and resident aggression. A resident reported being assaulted by an MA, but the facility did not investigate or report the incident. Another resident was left unsupervised for hours, resulting in a fall. Additionally, a resident with a history of aggression was involved in multiple incidents of abuse towards other residents, which the facility failed to adequately address.
The facility failed to implement its abuse and neglect policies, resulting in multiple incidents involving residents. A resident reported being assaulted by a staff member, but the facility did not investigate or suspend the alleged perpetrator. Another resident was left unattended for hours, resulting in a fall. Additionally, the facility did not protect residents from abuse by other residents, with incidents of inappropriate touching and physical aggression not properly addressed.
A resident with severe cognitive impairment and paralysis fell during a mechanical lift transfer conducted by a CNA working alone, despite the care plan requiring two staff members. The incident occurred due to a strap coming off the Hoyer lift, which had smaller hook holders. The CNA admitted to not asking for assistance and was terminated for not following protocol.
A resident with multiple medical conditions, including double amputation and cognitive impairment, slid out of a manual wheelchair during transportation due to improper securement by the driver. The driver, who was not a CNA, did not call emergency services and continued to transport the resident on the floor of the van. Upon arrival at the facility, staff assessed the resident and called EMS for hospital evaluation. The incident highlighted a failure to follow the facility's transportation policy and inadequate care planning for the resident's needs.
A resident's Hydrocodone medication was delivered to the facility but was not accounted for, leading to a deficiency in pharmaceutical services. The medication, prescribed for pain management following surgical amputation, was signed for by an LVN but could not be located afterward. The facility's policies on medication storage and destruction were not followed, resulting in a lack of proper documentation and control over the medication.
Failure to Provide and Document Ordered Nutritional Supplements
Penalty
Summary
The facility failed to ensure adequate nutritional support and failed to carry out ordered liquid supplements for three residents with documented weight loss. Resident #9, who had spastic quadriplegic cerebral palsy, profound intellectual disability, and anorexia, was observed at lunch not attempting to feed herself and turning away from spoon-fed food. Her tray did not include the ordered Health Shake. Record review showed she had lost 6.5% of her body weight from 01/02/2026 to 02/10/2026, and the quarterly MDS coded her for significant weight loss and need for one-person supervision and assistance with eating. For Resident #9, the record showed an order for Health Shake twice daily and a dietary supplement list indicating Health Shake at lunch daily, but the February and March clinical records did not show documentation that the supplement was provided or refused. A Nutrition/Dietary Note dated 02/21/2026 recommended discontinuing Health Shakes and starting Med Pass 90 ml twice daily, but the February and March physician orders, MARs, and TARs did not reflect that recommendation. During interviews, the RD stated the prior RD had recommended Med Pass because it provided more calories and protein, while the ADON stated she was responsible for following up on RD recommendations but had not seen the recommendation in the progress notes and had transcribed the Health Shake order into the record without assigning it to the MAR. Resident #25 and Resident #31 also had significant weight loss and orders for Med Pass 2.0 that were incomplete. Resident #25, who had dementia, dysphagia, vitamin D deficiency, and debility, weighed 117 lbs. and then 108 lbs., a 7.5% loss. A progress note documented a new order for 90 ml of Med Pass 2.0 daily with morning medications, but the physician order did not specify the amount and did not identify who was responsible for giving it, and the MAR contained no instructions or documentation that it was given. Resident #31, who had dementia, schizoaffective disorder, bipolar disorder, and chronic kidney disease, weighed 119 lbs. and then 110 lbs., also a 7.5% loss. Her progress note likewise documented an order for 90 ml of Med Pass 2.0 daily with morning medications, but the physician order did not specify the amount, the MAR did not include the supplement, and there was no documentation that it was administered. The ADON stated she was responsible for transcribing dietary recommendations into physician orders and selecting the appropriate EHR, and she acknowledged that the amount of Med Pass 2.0 was not specified for Residents #25 and #31 and that the order was not assigned to the MAR.
Incomplete documentation of nutritional supplement orders and administration
Penalty
Summary
Medical records were not completed and accurately documented for four residents reviewed for record accuracy. The facility failed to document administration of nutritional supplements for Residents #55, #9, #25, and #31, and failed to ensure physician orders for liquid nutritional supplements included complete instructions. The report states these failures could place residents at risk for incomplete clinical records. Resident #55 was a female with diagnoses including cerebral infarction, dementia, and dysphagia, and her MDS showed a BIMS score of 4, indicating severely impaired cognition. A dietitian recommended Med Pass 2.0 in the morning because of weight decrease, with instructions to provide 90 ml with breakfast. The recommendation was not transcribed to the February and March MAR or TAR, and the physician order dated 03/16/2026 did not specify the amount to be given. Staff interviews confirmed there was no MAR or TAR documentation showing the supplement was administered, and the ADON, Dietary Manager, and DON all acknowledged they could not confirm whether the resident consumed the supplement. Resident #9 had diagnoses including spastic quadriplegic cerebral palsy, profound intellectual disability, and anorexia, and her quarterly MDS noted significant weight loss and that she was rarely or never understood. Her care plan directed staff to assist with all meals and serve diet and supplements as ordered. The physician order dated 11/18/2025 directed a Health Shake twice a day, and the Dietary Supplement List showed a Health Shake at lunch daily, but the March 2026 MAR contained no physician orders or instructions to give the supplement and no documentation that it was received. Resident #25 and Resident #31 both had dementia and significant weight loss documented in their records, and both had progress notes showing a new order for 90 ml of Med Pass 2.0 daily with morning medications after weight loss was identified. For both residents, the physician orders dated 02/19/2026 did not specify the amount of Med Pass to be given, the orders were not placed on the MARs, and there was no documentation that either resident received the supplement. During interview, the ADON stated she was responsible for transcribing dietary recommendations into physician orders and assigning them to the MAR and TAR, and she acknowledged the amount of Med Pass 2.0 was not specified for Residents #25 and #31 and that the orders should have been assigned to the MAR for administration.
Residents Were Exposed to Staff Eating Lunch Before Their Meal Was Served
Penalty
Summary
The facility failed to protect and promote the rights of residents to dignity and respect for 6 of 11 residents reviewed for dignity and respect, including Resident #14 and Resident #35. Resident #14 was a female with diagnoses including Alzheimer's dementia and major depressive disorder, had an elopement risk assessment indicating she was an elopement risk, and was assigned to the secured unit. Her annual MDS noted a BIMS score of 4, indicating severely compromised cognition, and that she was independently ambulatory and able to feed herself. Resident #35 was a female with diagnoses including dementia, depression, and anxiety, had an elopement risk assessment indicating she was an elopement risk, and was assigned to the secured unit. Her annual MDS noted a BIMS score of 14, indicating intact cognition, and that she was independently ambulatory and able to feed herself. During an observation, six residents, including Resident #14 and Resident #35, were sitting in the secure unit dining room area waiting for lunch to be served while CNA-A and CNA-B were eating their personal lunch in the area that opened to the dining room and was visible to the residents. When told lunch was about to be served, Resident #14 said, "Good, I'm hungry," and Resident #35 waved toward the CNAs and said, "Me too, they're not." In interviews, both residents said it was rude for staff to eat in front of residents who had not eaten. CNA-B said she ate there so she could keep an eye on residents, acknowledged that the residents should not have to watch staff eat when they had nothing to eat, and said she did not consider how it may have looked to the residents. CNA-A said the residents should be treated with courtesy, consideration, and respect and that she and CNA-B should not have been eating lunch in front of residents who had not eaten and were hungry. The DON stated staff were expected to be courteous and respectful and that aides in the secured unit should not have been eating in view of residents when the residents had not eaten and had nothing to eat.
Inaccurate MDS Coding for Dehydration
Penalty
Summary
The facility failed to ensure an accurate MDS was completed for Resident #35, whose annual MDS with an ARD of 02/09/2026 coded dehydration during the 7-day look-back period. Resident #35 was a female who re-admitted to the facility after hospitalization for Influenza A, bilateral pneumonia, and sepsis. The MDS Coordinator stated she coded dehydration because Resident #35 received fluids in the hospital and had a fever, and she believed that was sufficient evidence for dehydration. Record review showed the hospital emergency department notes, discharge summary, and the PCP's follow-up note did not include dehydration as a diagnosis or treatment. The hospital and facility records also did not reveal documentation of intake and output, clinical signs of dehydration, or elevated laboratory values indicative of dehydration. The MDS RAI 3.0 Manual stated that dehydration should be checked only if the resident presents with two or more indicators such as low fluid intake, clinical signs of dehydration, or fluid loss exceeding intake.
Failure to Timely Transmit Admission MDS Assessments
Penalty
Summary
The facility failed to ensure that admission MDS assessments were electronically transmitted to the CMS system within 14 days after completion for 5 of 24 residents reviewed for assessments: Residents #15, #20, #41, #42, and #62. Record review showed each of these residents had an admission MDS dated 03/18/2026, and the MDS status for Residents #20, #41, #42, and #62 reflected incomplete with the assessment never added to a batch, meaning it had not been electronically transmitted to CMS. The records also showed that Residents #15, #20, #41, #42, and #62 had been discharged, and their MDS records were over 120 days old. During interview, the MDS Nurse stated she was responsible for completing and transmitting the MDS and acknowledged that the admission MDS should have been completed and transmitted by the 14th day. She stated the MDSs for Residents #15, #20, #41, #42, and #62 had not been completed and transmitted because she did not realize they had not been transmitted, although it was her responsibility to transmit all MDSs to CMS. The DON stated she was not aware these residents' MDSs had not been completed and transmitted and said the MDS Nurse was responsible for completing and transmitting them, with the DON indirectly responsible for ensuring they were transmitted in a timely manner.
Expired Medication Not Removed from Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with regulatory requirements, specifically by not removing expired medication from a medication cart. During an observation and interview, it was found that a medication cart on A Hall contained an individual medication card with 15 tablets of APAP/Codeine 300-30mg that had expired 10 days prior. The medication was stored in a locked compartment, but had not been removed from use. The responsible RN confirmed the medication was expired and stated she had not administered any of the expired tablets. She also indicated she was trained to check for expired medications and maintain the cart free of such items. The DON stated that expired medications should not be present in medication carts or rooms and that nurses are expected to check for and remove expired medications during each shift. Review of the facility’s control drug record showed the medication was last administered prior to its expiration, and pharmacy monthly reviews did not identify the expired medication for removal. Facility policy requires that outdated drugs be returned to the pharmacy or destroyed, but this process was not followed in this instance.
Failure to Maintain RN Coverage in Facility
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for 8 consecutive hours, 7 days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage on multiple dates in December 2024 and January 2025. Specifically, the facility lacked RN coverage from December 2 to December 9, December 13 to December 18, December 20 to December 22, December 25, and from December 28 to January 6, 2025. The absence of an RN during these periods meant that residents did not have access to staff with advanced care skills, which could potentially affect their care needs. Interviews with facility staff, including the Administrator and the Business Office Manager (BOM), confirmed the lack of a full-time RN. The Administrator acknowledged the potential negative outcomes of not having an RN on duty, such as staff being unprepared to handle emergencies. The BOM also noted the absence of an RN as a lack of an additional set of eyes for resident care but was unaware of the reasons behind the staffing shortfall. The facility's Departmental Supervision policy, dated April 2006, mandates that nursing services be supervised by an RN or LPN/LVN at all times, with an RN employed as the Director of Nursing Services (DNS) during the day shift, Monday through Friday. However, this policy was not adhered to during the specified dates.
Failure to Designate a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis since November 3, 2024. This deficiency was identified through interviews and record reviews, which revealed that the last day of DON coverage was on November 3, 2024. The facility's administrator, who began employment on November 25, 2024, confirmed that there was no DON at the time of her hiring. Additionally, the Assistant Director of Nursing (ADON), who started on November 11, 2024, also confirmed the absence of a DON. Further investigation showed that the facility's policy requires the Nursing Services department to be managed by a full-time DON, who is a licensed RN with experience in nursing administration, rehabilitation, and geriatric nursing. Despite this requirement, the facility has been unable to employ a DON, as confirmed by the current administrator, who started his role on January 7, 2025. The absence of a DON could place residents at risk due to a lack of nursing oversight and a higher level of care.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, which could potentially place residents at risk of foodborne illness. During an inspection, it was observed that a 16 oz. bag of tortilla chips was opened and not properly resealed. Additionally, in the walk-in cooler, several thickened liquid products, including nectar thick iced teas, nectar thick orange juice, and honey thick water with lemon, were opened but not labeled with the date they were opened, contrary to the packaging instructions that specified a limited shelf life after opening. The dishwashing process was also found to be deficient. The dietary aide (DA A) was using quaternary ammonia test strips instead of the correct chlorine test strips to check the sanitizing solution in the dish machine. This error was due to the incorrect test strips being left by the dish machine vendor, and DA A was unaware of the mistake. Furthermore, the dish machine log was pre-filled with results for a meal that had not yet occurred, and there were missing entries for sanitizing conditions on several dates. The dietary manager (DM) was unaware of these issues and did not regularly check the sanitizing logbook. The facility's policies on dishwashing and food storage were not adhered to, as evidenced by the incorrect use of test strips and the lack of proper labeling and storage of food items. The DM did not ensure that the dishwashing machine was checked for proper sanitizer concentrations regularly, and the facility's Refrigerators and Freezers policy was not followed, as expired or improperly labeled food items were found in storage. These lapses in protocol could compromise the safety and quality of food served to residents.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents regarding their Preadmission Screening and Resident Review (PASRR) status. Resident #16, a male with bipolar disorder and depressive disorder, was inaccurately coded in the Minimum Data Set (MDS) as not having a serious mental illness, despite having a PASRR Level 1 screening indicating a primary diagnosis of dementia. Similarly, Resident #52, diagnosed with psychotic disorder and dementia, was also inaccurately coded in the MDS as not having a serious mental illness, even though his PASRR Level 1 screening was positive for mental illness. Resident #53, with psychotic disorder and major depressive disorder, was incorrectly coded in the MDS as not having a serious mental illness, despite his PASRR Level 1 screening indicating a primary diagnosis of dementia. The MDS Coordinator, during an interview, revealed a misunderstanding of the coding requirements for Section A1500 of the MDS, which led to these inaccuracies. She believed that if residents did not qualify for specialized services under PASRR, they should be coded as negative for mental illness, intellectual disability, or developmental disability, even if they had a positive PASRR screening. This misunderstanding resulted in the incorrect coding of the residents' mental health status, potentially affecting their care and services.
Failure to Follow G-Tube Medication Administration Policy
Penalty
Summary
The facility failed to ensure that a resident with an enteral device received appropriate treatment and services to prevent complications. The resident, a female with intact cognition, had a gastrostomy tube (G-Tube) due to conditions including pharyngeal dysphagia and erosive esophagitis. The care plan indicated she was on a pureed diet with liquid feedings via the G-Tube as needed, but it lacked specific instructions for administering medications through the G-Tube. During an observation, LVN D prepared the resident's morning medications by crushing them together, contrary to the facility's policy, which required medications to be administered separately with water flushes before, between, and after each medication. LVN D used a syringe plunger to push the medication mixture into the G-Tube, which led to a blockage. He attempted to resolve the blockage by dislodging the medication and re-crushing it, but he did not flush the G-Tube with water before or after administering the medications. Interviews with LVN D and the MDS Nurse Coordinator revealed that the facility's policy was not followed. LVN D admitted to not following the correct procedure due to concerns about the resident's tolerance for extra water flushes and acknowledged the risk of tube occlusion and damage. The facility's policy outlined specific steps for safe medication administration through an enteral tube, which were not adhered to, potentially placing the resident at risk for complications.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the accurate administration of medications for two residents, leading to potential risks. Resident #34, who had a gastrostomy tube due to pharyngeal dysphagia, received medications that were improperly crushed and administered together without the required water flushes before and after each medication. The Licensed Vocational Nurse (LVN) responsible for administering the medications did not follow the physician's orders or the facility's policy, which required medications to be given separately with water flushes in between. The LVN admitted to crushing all medications together due to concerns about the resident's tolerance for extra water flushes, despite knowing that Protonix should not be crushed and required specific administration instructions. Resident #50, who had severe cognitive impairment and a diagnosis of Alzheimer's Disease, did not receive the prescribed Cyanocobalamin (Vitamin B12) 2500 mcg tablet due to its unavailability. Instead, a Medication Aide (MA) performed unauthorized mathematical calculations to substitute the dose with available Vitamin B12 tablets of different strengths. The MA administered two 1000 mcg tablets and one 500 mcg tablet to meet the prescribed dose but documented it as a single 2500 mcg tablet. The Assistant Director of Nursing (ADON) acknowledged that the physician's order should have been updated to reflect the available medication strengths and that medication aides were not permitted to perform dose calculations. The facility's policies on administering medications through an enteral tube and general medication administration were not adhered to, resulting in potential risks for non-therapeutic responses and incorrect dosing. The deficiencies in medication administration practices were identified through observations, interviews, and record reviews, highlighting the need for accurate physician orders and adherence to established protocols to ensure resident safety.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7% due to two errors out of 26 opportunities. The deficiency involved a resident who was administered medications via a gastrostomy tube. The Licensed Vocational Nurse (LVN) responsible for the administration crushed a delayed-release medication, Protonix, which is not intended to be crushed, and mixed it with other medications before administering them together. This action was contrary to the physician's orders and the facility's policy, which required the use of Protonix granules and separate administration of medications with flushing in between. The resident involved was an elderly female with intact cognition, who had a gastrostomy tube due to conditions including pharyngeal dysphagia and erosive esophagitis. The LVN admitted to substituting the prescribed Protonix granules with a tablet form due to unavailability in the medication cart and acknowledged the error of crushing the tablet. The Assistant Director of Nursing (ADON) confirmed that the LVN did not adhere to the facility's medication administration policies, which prohibit crushing delayed-release medications and require separate administration through enteral tubes.
Failure to Accurately Document Resident's Code Status
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented, specifically regarding the resident's code status. The resident, an elderly female with Alzheimer's Disease, depression, coronary atherosclerosis, communication deficit, and a history of colon cancer, was admitted with a Full Code status. However, a signed and notarized Out Of Hospital Do Not Resuscitate (OOHDNR) document was found in her chart, indicating a discrepancy between her documented code status and her actual wishes. Interviews with facility staff revealed confusion and lack of communication regarding the resident's code status. A Licensed Vocational Nurse (LVN) and an unidentified Registered Nurse (RN) both believed the resident was Full Code based on the face sheet and physician orders. The Admission Coordinator also confirmed the Full Code status but acknowledged that the resident's family had been indecisive about the code status. The facility's Administrator noted that the hospice service had not communicated the change in code status to the facility, leading to the OOHDNR document being filed without proper notification or updates to the resident's medical records. The facility's policy on advance directives requires that changes be submitted in writing to the Administrator and communicated to the Care Plan team. However, the OOHDNR document was faxed to the facility and placed in a tray for scanning without anyone being made aware of the change. This oversight could have resulted in the resident receiving resuscitation against her wishes, as staff would have attempted to resuscitate her based on the incorrect Full Code status documented in the facility's records.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN D, who did not adhere to the required Enhanced Barrier Precautions (EBP) when administering medications through a gastrostomy tube to a resident. The resident, a female with multiple medical conditions including pharyngeal dysphagia, necrotizing fasciitis of the neck, and a gastrostomy tube, was observed to have a sign on her room indicating the need for EBP, which includes wearing gloves and a gown for high-contact activities. Despite this, LVN D only donned gloves and failed to wear a gown, which is a breach of the facility's policy and CDC guidelines aimed at preventing the spread of infections. Interviews with the ADON and the MDS Coordinator, who also serves as the Infection Preventionist, confirmed that the facility's policy requires the use of gloves and gowns for residents with indwelling medical devices, such as feeding tubes, to reduce infection risks. LVN D admitted to not wearing a gown, mistakenly believing it was unnecessary since the resident no longer had an active infection or pressure ulcer. This oversight in following the established infection control protocols could potentially expose residents to communicable diseases and infections.
Facility Fails to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect several residents from abuse and neglect, as evidenced by multiple incidents involving both staff and other residents. One incident involved a resident who reported being physically assaulted by a medication aide (MA). The resident, who was cognitively intact, claimed that the MA grabbed her arm and refused to let go, resulting in bruising. Despite the resident's report and a subsequent hospital evaluation confirming the assault, the facility did not properly investigate or report the incident, nor did they suspend the alleged perpetrator. Another deficiency involved a resident who was left unsupervised for several hours during the night, resulting in her falling out of bed and remaining on the floor for approximately 4.5 hours. The certified nursing assistant (CNA) responsible for checking on the resident falsely reported having completed rounds, leading to the resident's prolonged neglect. The family, who had cameras in the resident's room, was aware of the incident, and the CNA was later terminated for neglect. Additionally, the facility failed to prevent abuse between residents. One resident, with a history of aggressive behavior, was involved in multiple incidents of physical aggression towards other residents, including pushing, choking, and inappropriate sexual behavior. Despite these repeated incidents, the facility did not adequately address the resident's behavior or implement effective interventions to prevent further occurrences. This lack of action resulted in continued abuse and potential harm to other residents.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse policy, resulting in multiple incidents of abuse and neglect involving several residents. One resident reported being physically assaulted by a staff member, but the facility did not investigate the allegation or suspend the alleged perpetrator. The resident was cognitively intact and had a history of confrontational behavior related to smoking. Despite the resident's report of bruising consistent with her account of the incident, the facility did not take appropriate action to protect her or report the incident to the state agency until prompted by surveyor intervention. Another resident was left unattended for several hours during the night, resulting in her rolling out of bed and remaining on the floor for an extended period. The CNA responsible for her care falsely reported having checked on the resident, and the incident was only discovered due to the presence of cameras in the resident's room. This neglect was confirmed, and the CNA was terminated, but the facility's failure to ensure adequate supervision and care for the resident was a significant deficiency. Additionally, the facility failed to protect residents from abuse by other residents. One resident was found inappropriately touching another resident, and there were multiple incidents of physical aggression involving the same resident. These incidents were not properly investigated, and the facility did not implement measures to prevent further occurrences. The lack of appropriate interventions and reporting of these incidents highlights the facility's failure to maintain a safe environment for its residents.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices during a mechanical lift transfer for a resident, leading to an accident. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs), fell during a transfer conducted by a CNA who was working alone. The resident's care plan required the use of a mechanical lift with two staff members for transfers due to his condition, which included paralysis on the left side from a stroke and generalized muscle weakness. On the day of the incident, the CNA attempted to transfer the resident alone using a Hoyer lift, contrary to the facility's protocol that mandates two staff members for such transfers. During the transfer, a strap from the Hoyer lift came off, causing the resident to fall to the floor and sustain a laceration and bruising to the right eye area. The CNA admitted to not asking for assistance and acknowledged that she had previously transferred the resident unassisted without incident. Interviews with facility staff revealed that the Hoyer lift used was relatively new and had smaller hook holders, which were deemed inappropriate after the incident. The Maintenance Supervisor and Therapy Director confirmed that the lift was removed from use following the accident. The facility did not have a schedule for checking the Hoyer lifts, and the CNA involved was terminated for failing to meet performance expectations by not adhering to the two-person transfer protocol.
Failure to Secure Resident During Transportation
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, leading to an accident. The resident, a female with multiple medical conditions including double lower extremity amputation and cognitive impairment, was being transported from the hospital in a manual wheelchair. The transportation driver did not secure the wheelchair properly, resulting in the resident sliding out of the wheelchair onto the floor of the van. The incident occurred as the van was nearing the facility, and the resident was found on the floor with a pillow under her head, experiencing pain in her hips. The transportation driver, who was not a CNA, was not trained on how to handle such incidents and did not call emergency services immediately. Instead, she attempted to secure the resident on the floor of the van and continued the journey back to the facility. Upon arrival, facility staff assessed the resident and called emergency medical services, who transported the resident to the hospital for further evaluation. The driver had previously received training on proper wheelchair securement and transportation procedures but failed to apply this knowledge during the incident. Interviews with facility staff revealed that the resident typically used a power wheelchair but was in a manual wheelchair on the day of the incident. The Director of Nursing and Assistant Administrator acknowledged that the resident's care plan should have addressed the risk of sliding out of the wheelchair, and additional personnel should have been present during transportation. The facility's transportation policy required immediate reporting of incidents, but this protocol was not followed by the transportation driver.
Failure to Account for Controlled Medication
Penalty
Summary
The facility failed to maintain accurate records and control of a resident's controlled medication, Hydrocodone, which was prescribed for pain management. The resident, a female with a history of orthopedic aftercare following surgical amputation and peripheral vascular disorder, was readmitted to the facility with a prescription for Hydrocodone. The medication was delivered to the facility, but the staff could not account for it, leading to a deficiency in pharmaceutical services. Interviews and record reviews revealed that the Hydrocodone was delivered on a specific date, signed for by an LVN, and placed in the medication cart. However, the medication was not located afterward, and there was no record of its administration or destruction. The facility's Director of Nursing (DON) and other staff members were unaware of the missing medication until it was brought to their attention during the survey. The lack of proper documentation and control over the medication could have resulted in the resident not receiving the intended therapeutic dose for pain management. The facility's policies on medication storage and destruction were not followed, as evidenced by the missing Hydrocodone and the absence of a control drug record. The DON acknowledged that missing medication is a reportable incident and expressed an intention to in-service staff on narcotic delivery procedures. Despite the facility's policy requiring secure storage and restricted access to controlled substances, the medication was not accounted for, highlighting a significant lapse in the facility's pharmaceutical services.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lindale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Lindale | 0.7 mi | ★★★★★ | 14 | 0 |
| Mineola Gardens Wellness & Rehabilitation | 11.4 mi | ★★★★★ | 6 | 0 |
| Greenbrier Nursing & Rehabilitation Center Of Tyle | 11.6 mi | ★★★★★ | 22 | 0 |
| Avir At Mineola | 12.5 mi | ★★★★★ | 22 | 1 |
| Watkins-logan-garrison Texas State Veteran's Home | 12.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.