Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Copperfield Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, multiple myeloma, moderate cognitive impairment (BIMS 8), and hospice/DNR status, who was dependent on staff for ADLs and incontinent care, was not treated with dignity during a nighttime interaction with a CNA. Video from authorized electronic monitoring showed the CNA questioning the resident about whether he needed to be changed, responding to his answer with statements such as, “You will? What that mean? You will or you do right now. When I’m leaving, I’m gone,” and, “Don’t talk in riddles, I’m not well in riddles… either you need it now or you don’t.” The resident later indicated the CNA made him feel very small and as if she wanted nothing to do with him. This conduct conflicted with the resident’s care plan interventions for incontinence and psychosocial well-being and with facility resident rights policies requiring respectful, dignified treatment.
A facility failed to assess residents for bed rail safety, review risks and benefits, obtain informed consent, or document proper orders and care planning before using grab assist rails on multiple residents’ beds. One resident with severe cognitive impairment and multiple medical diagnoses was found entrapped between the mobility bar and the head of the bed, while other residents stated the rails were already in place on admission and that they had not been assessed, trained, or asked for consent.
A resident experienced slurred speech and altered mental status, which was reported by a family member to nursing staff. The nurse assessed the resident but failed to document the concerns, notify the provider, or communicate the event to the next shift. The following day, after further family concern, the resident was sent to the hospital and diagnosed with an acute ischemic stroke. The delay in notification and documentation led to a delay in treatment.
A resident exhibited signs of stroke, including slurred speech and altered mental status, which were reported by a family member to nursing staff. The nurse on duty did not document the complaint, notify the provider, or communicate the change to other staff, resulting in a delay of over 24 hours before the resident was assessed and transferred to the hospital, where an acute ischemic infarct was diagnosed. Additionally, the facility failed to obtain a timely physician order to discontinue a mid-line catheter for another resident after IV therapy was completed.
A resident with severe cognitive impairment, a stage 4 sacral pressure ulcer, and multiple chronic conditions had a mid-line inserted for IV antibiotics. Although the IV antibiotic course ended, staff did not obtain an order to discontinue the line, and the LVN, NP, DON, and Infection Control Preventionist each described gaps in communication and follow-through regarding the line’s removal. The resident was later observed still having the mid-line in place, and the Infection Control Preventionist stated the line should have been discontinued after IV therapy was completed.
A resident with diabetes received rapid-acting insulin too far in advance of meals on multiple occasions, with staff and the DON acknowledging the insulin should be given within a limited pre-meal window. In a separate event, an LPN applied a Lidocaine patch to another resident’s knee without an order after mixing up medications with a roommate; the resident had severe cognitive impairment, total ADL dependence, and a feeding tube, and the only pain order on record was PRN Tylenol.
A facility failed to maintain a safe and functional environment when a resident room door had a keyed lock that prevented staff and a family member from entering for 15 to 20 minutes, while another resident had cabinet drawers that swung open on their own and a bathroom door that closed too quickly and struck her wheelchair. A third resident also reported a self-closing bathroom door, and the Maintenance Director acknowledged some room doors were self-closing and that the keyed lock had remained after an office was converted back to a resident room.
Incomplete person-centered care plans for resident needs and devices: The facility did not include key needs and devices in the care plans for three residents. One resident with stroke, dementia, and neurogenic bladder was not care-planned for incontinence related to the bladder condition, another resident with a mid-line had no care plan for the IV access device despite active orders and observed placement, and a third resident had mobility bars on the bed without a corresponding care plan. Staff interviews confirmed the omissions were oversights and that the care plans were intended to reflect individualized interventions and measurable goals.
A CNA and an LVN failed to provide privacy during personal care for two residents. One resident received incontinent care without the privacy curtain being closed while another person was in the room, and another resident received tracheostomy care with the door and privacy curtain left open while the roommate was present. The residents had significant medical needs, including one with intact cognition and one with severe cognitive impairment, and both were care planned for the services being provided.
Failure to complete and submit a discharge MDS: A resident with pneumonia, ulcerative colitis, CHF, malnutrition, legal blindness, and muscle weakness was discharged without a completed or accepted discharge MDS in the EMR. The MDS A stated she did not know why it was not done and noted the facility would audit for other missed discharge MDS assessments.
Disinfectant Wipes Left at Bedside: A resident with severely impaired cognition and diagnoses including CVA, aphasia, DM2, and cancer had a container of Super Sani-Cloth germicidal disposable wipes left on the bedside nightstand. Staff stated the wipes were not supposed to be stored in the room because the resident could open the container, staff could mistake them for disposable wipes, and the chemicals could harm the resident. The DON stated such wipes were never to be left at the bedside, and the resident’s ambassador did not recall seeing them there during rounds.
A resident with a G-tube, severe cognitive impairment, stroke-related paralysis, and dementia had an ordered bowel rest period, but the feeding pump was observed still running when it should have been off. The DON confirmed the pump was on, an LVN said she had turned it off but it turned back on, and the pump was not fully stopped until later. Staff interviews showed confusion about the bowel rest order and how the pump should have been disconnected.
Tracheostomy Care Provided With Oxygen Turned Off An LVN turned off a resident’s oxygen for about 2 minutes while providing trach care to a resident with chronic respiratory failure, a trach, and severe cognitive impairment. During the procedure, the resident’s O2 saturation fluctuated between 91% and 93%, and the LVN later said she made a mistake and should not have turned the oxygen off because it could cause desaturation and hypoxia. The DON and RT both stated oxygen should not be turned off during trach care, and the RT later assessed the resident with O2 saturation at 93% to 94% on 5 liters.
An LPN left an opened insulin pen for a resident with DM on top of a locked med cart while stepping away to care for another resident. The cart was unattended with no staff or residents nearby, and facility policy required meds to remain locked and not be kept on top of the cart.
An RN failed to perform hand hygiene after glove removal while assisting one resident and after taking vital signs for another resident, and also failed to sanitize a BP device after use. In addition, two wash basins in another resident’s bathroom were not both labeled or bagged. The RN said he had been in-serviced on hand hygiene and equipment sanitizing but got in a hurry and forgot; the DON said resident personal care items were supposed to be labeled and bagged.
A resident with a stage III sacral pressure ulcer did not receive timely assessment or treatment upon admission to the facility. The facility failed to notify the physician or obtain wound care orders for several days, leaving the wound uncovered and untreated. Staff interviews revealed a lack of communication and adherence to protocols, with the Wound Care Nurse not adequately trained and failing to perform necessary assessments.
A LTC facility reported a 12% medication error rate, involving three residents. Errors included incorrect dosing of Trintellix for depression, wrong multivitamin for eye health, and incorrect Lidocaine patch for pain management. These errors were due to pharmacy mistakes, staff oversight, and misunderstanding of physician orders.
A facility failed to maintain accurate clinical records for two residents regarding the administration of controlled substances. The MARs were incomplete, and staff did not sign the correct narcotic count sheets, potentially affecting residents' care. Interviews revealed that nurses signed out medications on incorrect count sheets, and there was a lack of proper reconciliation of narcotic records.
A resident with multiple diagnoses, including pneumonia, was admitted to an LTC facility, but the baseline care plan was incomplete, lacking focus, goals, and interventions for pneumonia. Interviews with staff revealed the omission, with the RN admitting to documenting antibiotic treatment for sepsis instead of pneumonia. The facility's policy requires a comprehensive care plan within 48 hours of admission, which was not met in this case.
Failure to Treat a Resident With Dignity During Incontinent Care Interaction
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with dignity and respect during an interaction about incontinent care. The resident was a 77-year-old man with Parkinson’s disease, difficulty walking, lack of coordination, muscle wasting and atrophy, and multiple myeloma without remission. He was on hospice services, had a DNR order, and his MDS showed moderate cognitive impairment with a BIMS score of 8. He required substantial to maximal assistance for toileting, hygiene, bathing, and transfers, and his care plan identified dependence on staff for activities, cognitive stimulation, social interactions, and incontinence of bowel and bladder, with interventions including checking for incontinence as required and allowing time for him to answer questions and verbalize feelings. The resident’s care plan was updated to include his right to health, safety, and dignity in connection with authorized electronic monitoring in his room, which had been requested and signed for by a family member. On the night in question, video footage from the resident’s room showed CNA A asking the resident if he needed to be changed. When the resident responded, “I will,” CNA A replied, “You will? What that mean? You will or you do right now. When I’m leaving, I’m gone.” After the resident responded inaudibly, CNA A continued, “Well I’m asking, don’t talk in riddles, I’m not well in riddles… either you need it now or you don’t,” before the footage cut off. This exchange was reported by the resident’s family member, who viewed it on the electronic monitoring system and provided the video to the surveyor. In a subsequent interview, the resident stated he could not remember the specific exchange but recalled seeing CNA A later that night and indicated she made him feel “this big,” using his fingers to show something small, and that she made him feel like she wanted nothing to do with him. CNA A reported that she did not remember the exchange, stated she was probably “playing,” and acknowledged she sometimes just said things even though she was not familiar with the resident. She also stated she was aware of the camera in the room and believed the issue might have been related to telling the resident he had feces on his hands. Facility leadership, including the DON and ADM, described the family’s report that CNA A was disrespectful and unprofessional, and the ADM characterized CNA A’s “talking in riddles” comment as inappropriate. The facility’s written policy on Resident Rights and Responsibilities stated that residents are to be informed of their rights and that resident rights information is to be made available and posted, but the observed interaction showed the resident was not treated in a manner that promoted dignity and respect as required.
Bed Rails Used Without Assessment, Consent, or Proper Review
Penalty
Summary
The facility failed to ensure appropriate alternatives were attempted before installing bed rails or mobility bars and failed to ensure correct installation, use, and maintenance of those devices, including assessing residents for entrapment risk, reviewing risks and benefits with the resident or representative, and obtaining informed consent before use. The deficiency involved 11 of 11 residents reviewed for mobility bars/bedrails, including newly admitted residents who already had grab assist rails in place on admission and had no documented assessment, consent, or care plan focus for the devices. Resident #84 was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, chronic kidney disease, syncope and collapse, cognitive deficit, falls, cerebral infarction, hypertension, and muscle wasting and atrophy. The resident had severely impaired cognition with a BIMS score of 0. Records did not show a mobility bar assessment, physician order, consent, or documentation that the resident or representative was educated on risks and benefits. During observation, the resident was found entrapped between the mobility bar and the head of the bed, with sheets and bedspread wrapped around the lower torso and legs, and the resident was unable to untangle herself without assistance. Other residents reviewed, including residents with intact cognition and residents with moderately impaired cognition, were observed in beds with grab assist rails on both sides of the bed. Several stated the rails were present on admission, that they had not been assessed for use of the rails, had not been trained on them, and had not given consent. One resident reported the rails were wobbly and did not feel safe using them. The facility’s policy stated that alternatives should be attempted before installing side rails or bed rails, that the interdisciplinary team should assess for entrapment risk after alternatives fail, and that informed consent should be obtained prior to installation or use.
Failure to Immediately Notify Provider and Representative of Resident Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative when a significant change in the resident's condition was reported. A family member contacted the facility after noticing the resident had slurred speech and altered mental status. The nurse on duty assessed the resident but did not document the family’s concerns or her assessment, nor did she notify the provider or communicate the event to the next shift. There was no documentation of any changes in the resident’s condition in the 24-hour report or progress notes for that day. The following day, the family member followed up and again expressed concern. The nurse practitioner was then notified, assessed the resident, and, after discussion with the family, arranged for the resident to be sent to the hospital for evaluation. Upon hospital admission, the resident was diagnosed with an acute ischemic stroke. Prior to this event, the resident had a history of metabolic encephalopathy, difficulty walking, and high blood pressure, but was able to ambulate with supervision and had only moderate cognitive impairment. Interviews with facility staff revealed that the nurse on duty at the time of the initial report did not follow facility policy regarding documentation and notification of changes in condition. The nurse practitioner and DON confirmed that immediate notification of the provider and documentation are required when a change in condition is reported, regardless of the day of the week. The delay in notification and lack of documentation resulted in a delay in the identification and treatment of the resident’s stroke.
Delayed Response to Stroke Symptoms and Failure to Discontinue Mid-Line Catheter
Penalty
Summary
A facility failed to provide timely assessment and intervention for a resident who exhibited signs and symptoms of a stroke, including slurred speech, altered mental status, and fatigue. The resident's family member reported these symptoms to nursing staff on a Sunday, but the nurse on duty did not document the complaint, did not notify the provider or facility administration, and did not communicate the events to the night shift nurse. The nurse attributed the symptoms to possible early dementia and suggested a psychiatric consultation for the following day, without performing or documenting a thorough assessment or following the facility's change in condition protocol. The following day, another nurse was notified of the family’s concerns and performed an assessment, noting decreased cognition and slower speech. The nurse then notified the nurse practitioner, who ordered laboratory tests and, after discussion with the family, arranged for the resident to be transferred to the hospital for further evaluation. Upon hospital admission, the resident was diagnosed with an acute ischemic infarct (stroke) and experienced a significant decline in activities of daily living, requiring substantial assistance for mobility and care. Interviews with facility staff and review of records confirmed that the initial report of stroke symptoms was not acted upon for over 24 hours, and required notifications and documentation were not completed as per facility policy. Additionally, the facility failed to obtain a timely physician order to discontinue a mid-line catheter for another resident after completion of IV antibiotic therapy, resulting in the device remaining in place for an extended period without medical necessity. These failures were identified through observation, interviews, and record review, and were found to be inconsistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Failure to Discontinue Mid-Line After IV Antibiotics Ended
Penalty
Summary
The facility failed to administer parenteral fluids consistent with professional standards of practice and physician orders for one resident with a mid-line catheter. Resident #12 had multiple diagnoses including chronic respiratory failure, type 2 diabetes mellitus, cerebral infarction, stage 4 sacral pressure ulcer, dysphagia, Parkinson’s disease, hypertension, cognitive communication deficit, tracheostomy, colostomy, and gastrostomy. Her quarterly MDS showed a BIMS score of 3, indicating severely impaired cognition. Her physician orders included insertion of a mid-line on 08/05/25, IV cefepime for 7 days, and IV meropenem for 2 weeks, with meropenem discontinued on 08/28/25. Record review showed the facility followed the IV medication orders and mid-line care orders, but the resident’s comprehensive care plan did not reflect a care plan for the mid-line insertion. On 09/10/25, the resident was observed with a mid-line in the right upper arm. The LVN stated that when IV antibiotic therapy is completed, the physician or NP is normally called to obtain an order to discontinue the IV, and that she had not contacted the physician or NP about discontinuing the resident’s mid-line. The NP stated that antibiotic therapy had stopped on 08/28/25 and that the facility had not notified her that the resident still had the mid-line. The DON stated the Infection Control Preventionist monitored IV lines and antibiotic stop dates, and that the line should be discontinued after IV antibiotic therapy was completed. The Infection Control Preventionist stated she monitored IV lines weekly and believed the resident’s IV antibiotic had ended on 08/28/25 or 08/29/25, but she did not call the physician or NP to have the mid-line discontinued. The mid-line was removed later that day using sterile technique, and the tip remained intact with no redness, drainage, swelling, or foul odor at the site.
Medication Administration Errors Involving Insulin Timing and Unordered Lidocaine Patch
Penalty
Summary
The facility failed to ensure a resident with type 2 diabetes received pre-prandial HumaLOG insulin safely for 25 occasions between 08/01/25 and 09/11/25. Resident #2 had diagnoses including kidney failure, enlarged prostate, irregular heartbeat, and type 2 diabetes, and had moderately impaired cognition with a BIMS score of 12 out of 15. The resident’s HumaLOG order was for administration before meals, and the facility dining schedule listed breakfast from 07:45 AM to 08:15 AM, lunch from 11:45 AM to 12:15 PM, and supper from 05:00 PM to 05:30 PM. Record review showed multiple instances when HumaLOG was given more than 15 minutes before the scheduled meal time, including doses given well before breakfast, lunch, and supper. Observation and interview on 09/11/25 showed LVN M preparing insulin for Resident #2 at 11:30 AM after checking a blood sugar of 181, and the resident was not yet at lunch; a CNA did not bring the resident to the dining area until 11:35 AM, and lunch had not been served by 12:30 PM. The DON stated pre-prandial insulin should be administered within 30 minutes of meals and said the facility had not had snacks in place before breakfast or lunch to prevent hypoglycemia when meals were delayed. NP A stated pre-prandial insulin should be given in a 30-minute window and that giving it too early could place residents at risk for low blood sugars. Resident #2 stated he had not experienced symptoms of hypoglycemia. The facility also failed to ensure medication was administered as ordered for another resident when LVN K applied a Lidocaine 4% patch to Resident #109’s right knee without an order. Resident #109 had diagnoses including stroke due to a blood clot, type 2 diabetes, paralysis of the right dominant side, and gastrostomy status, and had severely impaired cognitive skills for daily decision making with total dependence for ADLs. During observation, LVN K retrieved the patch, performed hand hygiene, put on gloves, and applied it to the resident’s knee, then stated she had mixed up the medication for Resident #109 and her roommate and that Resident #109 did not have an order for the patch. The resident’s order summary listed only Tylenol 325 mg, 2 tablets by mouth every 6 hours as needed for pain, with no other pain medication orders.
Unsafe room access and environmental hazards
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 8 residents reviewed for environmental concerns. One issue involved Resident #38, a female admitted for orthopedic aftercare with diagnoses including a fall, lower leg fracture, and ankle fracture. She had intact cognition with a BIMS score of 15/15 and was totally dependent for several functional abilities, including transfers and bed mobility. During observation, staff and a family member were unable to open her room door for 15 to 20 minutes because the door had an interior push lock that required a key from the outside. The resident was in bed with her call light within reach and had her right ankle fixed in place with a metal pin/rod through the ankle. The family member stated he had not locked the door, and the resident said she could not have opened it herself because of her leg condition. A second issue involved Resident #25, a female admitted for orthopedic aftercare with diagnoses including difficulty walking and hip fracture. She had intact cognition with a BIMS score of 15/15 and required staff assistance with transfers, incontinent care, repositioning, bathing, and showering. During observation, her built-in cabinet drawers were open and were observed to slide open on their own after being pushed closed. The resident stated the drawers did not stay closed and she was concerned they could hit her in the head, so she left them open. The contents of the drawer occupied less than half of the space, and the tracks were clear of debris or clutter. The resident also stated her bathroom door closed by itself, hit the back of her wheelchair when she went to the restroom, and closed too quickly for her to get through without being struck. A third issue involved Resident #104, a female admitted for orthopedic aftercare with diagnoses including difficulty walking and fracture of the top of the left shin bone. She had moderately impaired cognition with a BIMS score of 9/15 and required staff participation with transfers and repositioning. She stated her bathroom door was self-closing and that she had been told by the Maintenance Director that nothing could be done because of fire and safety regulations. The Maintenance Director stated some resident rooms had self-closing doors to prevent levered door handles from getting stuck together, and he also stated that Resident #38's room had previously been used as an office and still had a keyed lock after being converted back to a resident room. The Administrator and Maintenance Director both stated that resident room doors should not have keyed locks and that drawers should not swing open on their own.
Incomplete person-centered care plans for resident needs and devices
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents whose needs were identified in their assessments and orders. The report states that Resident #80, Resident #12, and Resident #84 were reviewed for comprehensive care plans and each had a condition or device that was not reflected in the resident’s care plan. Resident #80 had diagnoses including stroke with left-sided paralysis, dementia, and neurogenic bladder, and her quarterly MDS showed a BIMS score of 03 with severe cognitive impairment. She was totally dependent on staff for ADLs, transfers, and toileting. Her care plan addressed bowel and bladder incontinence related to stroke, impaired mobility, and neurogenic bladder, and a later care plan addressed risk for urinary retention with monitoring for UTI signs and therapy evaluation for pelvic floor exercise. However, the record review and staff interviews identified that she was not care-planned for incontinence related to the neurogenic bladder diagnosis, and staff acknowledged this was an oversight. Resident #12 had diagnoses including chronic respiratory failure, diabetes, cerebral infarction, stage 4 sacral pressure ulcer, dysphagia, Parkinson’s disease, tracheostomy, colostomy, and gastrostomy, and her quarterly MDS showed a BIMS score of 3 indicating severe cognitive impairment. Her physician orders included insertion and ongoing care of a mid-line, including monitoring for infection or infiltrate, flushing before and after medication administration, and dressing changes as needed or every 7 days when visible for assessment. The MAR and TAR reflected the facility followed these orders, and observation confirmed a mid-line in the right upper arm, but her comprehensive care plan did not include the mid-line insertion. Resident #84 had diagnoses including hemiplegia, hemiparesis, dysphagia, chronic kidney disease, syncope and collapse, cognitive deficit, falls, cerebral infarction, hypertension, and muscle wasting and atrophy, and her admissions MDS coded cognition as severely impaired with a BIMS score of 0. Observation showed mobility bars on her bed, but the physician order summary did not reflect an order for mobility bars and her comprehensive care plan did not include them. Interviews with the DON, Administrator, MDS nurse, and MDS Coordinator confirmed that care plans were intended to include individualized interventions and that the omission of these items from the care plans was an oversight.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to provide personal privacy during incontinent care for one resident and during tracheostomy care for another resident. One resident was an [AGE]-year-old female with diagnoses including hypothyroidism, type 2 diabetes mellitus, protein-calorie malnutrition, hypertension, pressure ulcer of the left heel, chronic kidney disease, and a gastrostomy tube; her MDS reflected a BIMS score of 15, indicating intact cognition. She was care planned to require incontinent care assistance. During observation, a CNA provided incontinent care without pulling the resident's privacy curtain, while a hospice CNA was present in the room and passing by the resident's bed to enter the bathroom. The second resident was an [AGE]-year-old female with chronic respiratory failure, type 2 diabetes mellitus, cerebral infarction, stage 4 sacral pressure ulcer, dysphagia, Parkinson's disease, hypertension, cognitive communication deficit, tracheostomy, colostomy, and gastrostomy. Her quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment, and her care plan identified her as dependent for tracheostomy care. During observation, an LVN performed tracheostomy care without closing the door or pulling the privacy curtain while the roommate was resting in the room. The CNA and LVN both stated they were supposed to close the door and pull the privacy curtain to promote resident dignity, and the DON stated staff should provide privacy during resident care.
Failure to Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to ensure MDS data was transmitted within 14 days of completion for 1 of 5 closed record reviews, CR #62, because the resident’s discharge MDS assessment was not completed and submitted to CMS. Record review showed CR #62 was a [AGE]-year-old female who was admitted on [DATE] and discharged on [DATE]. Her diagnoses included pneumonia, ulcerative colitis, moderate protein-calorie malnutrition, legal blindness, congestive heart failure, and muscle weakness. Review of the resident’s EMR on 09/17/2025 showed the history and status of all MDS assessments completed and submitted, and no discharge MDS assessment was completed or accepted for the resident’s 05/09/2025 discharge from the facility. The record listed several other assessments, including Medicare 5-day, admission, entry, discharge return not anticipated, and modification of entry assessments. In interview on 09/17/25 at 12:46 PM, the MDS A stated she did not know why the discharge MDS was not completed or submitted and said the facility would audit to determine whether other discharge MDS assessments were not completed.
Disinfectant Wipes Left at Resident Bedside
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards for one resident with severe cognitive impairment. Resident #11 was a [AGE]-year-old male admitted with diagnoses including cerebral infarction, aphasia, type 2 diabetes mellitus, and malignant neoplasm. His quarterly MDS reflected a BIMS score of 2, indicating severely impaired cognition. On 09/09/25, the resident was observed awake in bed resting quietly, and a purple-top container labeled Super Sani-Cloth Germicidal Disposable Wipes was on the nightstand at the right side of his bed. The container stated that it disinfects in 2 minutes, is not a skin or baby wipe, should be kept out of the reach of children, and is not to be disposed of in the commode. On 09/11/25, the same disinfectant wipe container was still on the resident’s nightstand. During interview, CNA E stated the wipes were not supposed to be stored at the bedside because the resident could try to open the container or staff could mistake the wipes for disposable wipes; CNA E also stated the wipes should be stored outside the room on the nurse medication cart. LVN M stated sani-wipes should not be in a resident room because the chemicals could harm the resident and staff could mistakenly use them for incontinent care. The DON stated disinfectant sani-wipes were never to be left in a resident room at the bedside because residents with dementia could try to open the container and the wipes would be toxic to the resident. The Dietary Supervisor, identified as the resident’s ambassador, stated she made rounds on the resident’s room in the morning but did not recall seeing the wipes on the nightstand.
Enteral Feeding Pump Left Running During Ordered Bowel Rest
Penalty
Summary
The facility failed to ensure a resident who received nutrition through a gastrostomy tube was provided appropriate enteral feeding care when the resident's ordered bowel rest was not maintained. Resident #72 was an older male with diagnoses including paralysis following stroke affecting the left non-dominant side, type 2 diabetes mellitus, cognitive communication deficit, gastrostomy status, and dementia. His MDS reflected severe cognitive impairment, that he was rarely or never understood, and that he was totally dependent on staff for all ADLs, including eating and personal care. Resident #72's September 2025 MAR showed an order for bowel rest from 9:00 AM to 11:00 AM, with feeding resumed at 11:00 AM. On 09/11/2025 at 10:00 AM, the resident was observed asleep in bed with the feeding pump still on. The DON was notified and confirmed the pump was still running. LVN H stated she had turned the pump off, but it turned back on, and then turned it off at 10:10 AM. LVN H said she had shaved the resident and then turned the pump on, assuming it would run for one hour, and she called the physician, who said the bowel rest period would be adjusted going forward. Record review and interviews showed staff were uncertain about what occurred with the pump and how the bowel rest order was being followed. ADON A stated there was no excuse for the pump to be on when it should have been off and said the event was being treated as though there had been no pause in feeding because it was unclear whether the machine had turned back on. The RD and DON both described bowel rest as time off the feeding for activities or rest, and the facility record showed the gastrostomy tube policy required licensed nurses to start, stop, or disconnect the tube and to follow physician orders for bowel rest. The facility's gastrostomy tube policy did not address intermittent feeding.
Tracheostomy Care Provided With Oxygen Turned Off
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with a tracheostomy when LVN M turned off the resident’s oxygen for about 2 minutes during tracheostomy care. Resident #12 was a severely cognitively impaired female with diagnoses including chronic respiratory failure, tracheostomy, dysphagia, Parkinson’s disease, cerebral infarction, diabetes, hypertension, a stage 4 sacral pressure ulcer, colostomy, and gastrostomy. Her physician orders included tracheostomy aerosol via trach collar at 5-8 liters of oxygen to keep oxygen saturation above 90%, tracheostomy care every shift, and oxygen saturation checks every shift while suctioning and as needed for respiratory distress. During observation of tracheostomy care, Resident #12 was resting in bed with oxygen connected to a trach collar at 5 liters with humidification. Her oxygen saturation fluctuated between 91% and 93% while LVN M performed care. LVN M removed the old dressing, cleaned around the tracheostomy site, and applied a new sterile dressing. At 10:16 AM, LVN M stated she would turn the oxygen back on, indicating it had been off during the procedure. LVN M later stated she made a mistake and said she was not supposed to turn off the resident’s oxygen because it could cause desaturation and hypoxia. The DON stated that oxygen should not be turned off at any time during tracheostomy care because it could cause the resident’s oxygen level to drop and lead to respiratory distress. The Respiratory Therapist stated he observed LVN M providing trach care and knew better than to turn off the resident’s oxygen. He also assessed the resident afterward and found oxygen saturation between 93% and 94% on 5 liters. The facility’s tracheostomy policy, revised May 2007, did not reflect turning off the resident’s oxygen.
Unsecured insulin pen left on top of medication cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to medication keys for 1 of 3 medication carts, the 200 Hall Nurse Cart, and for 1 of 8 residents reviewed, Resident #52. During observation on 09/11/25 at 08:36 AM, an opened and in-use insulin pen for Resident #52 was found on top of the locked 200 Hall nursing cart at the end of the hall with no residents or staff around the cart. LVN K stated that medications were expected to be locked when not under direct supervision of nursing staff and acknowledged that she forgot to lock the insulin pen when she went to provide care to another resident. Resident #52 was a [AGE]-year-old female with diagnoses including lack of coordination, high blood pressure, high cholesterol, dementia, and type 2 diabetes. Her order summary showed Tresiba FlexTouch (Insulin Degludec) 22 units subcutaneously daily for type 2 diabetes, and the location of administration report showed the insulin was administered at 08:04 AM on 09/11/25. Facility policy stated that compartments containing drugs and biologicals shall be locked when not in use and that trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others; another policy stated that no medications are kept on top of the cart and the cart must remain closed and locked when out of sight of the medication nurse.
Infection Control Lapses With Hand Hygiene, Equipment Cleaning, and Resident Personal Care Items
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. During observation, RN E was seen taking Resident #3’s vital signs while wearing gloves, then removing the gloves and leaving the room without washing or sanitizing his hands. He also placed the blood pressure machine on the cart without sanitizing the equipment before continuing to work at the cart. RN E was later observed entering Resident #84’s room and donning gloves to assist the resident to a wheelchair. Resident #84’s brief was soiled with feces, and the resident had placed the brief on the floor. After assisting the resident and placing the soiled brief in the trash can, RN E removed his gloves and left the room without washing his hands or sanitizing before returning to work at the hallway cart. RN E stated he had received in-service on fall prevention, infection control, hand washing, and sanitizing resident care equipment, and acknowledged that he had not practiced infection control because he had gotten in a hurry and forgot. In another observation, two gray wash basins were seen in Resident #12’s bathroom on top of the commode chair, with one basin unlabeled and the other labeled with the resident’s name. The wash pans were not inside plastic bags. CNA V stated resident personal care items should be labeled and bagged to prevent cross contamination and infections. LVN M stated wash pans should be labeled and bagged separately, and the DON stated resident personal care items were supposed to be labeled and bagged, although the facility had not yet designated the task to anyone.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a sacral pressure ulcer, consistent with professional standards of practice. The resident, who was admitted with a stage III pressure ulcer, did not have the wound properly assessed or treated in a timely manner. The facility did not notify the physician or obtain wound care orders from 1/24/25 to 1/27/25, and there was no documentation of the wound's size until 1/27/25. This lack of timely intervention and documentation could have placed the resident at risk for worsening wounds, infection, and hospitalization. Upon admission, the resident was identified as high risk for pressure ulcers due to her medical conditions, including severe protein-calorie malnutrition, COPD, and dementia. Despite this, the facility's staff failed to follow the protocol for assessing and documenting the resident's skin condition. The Wound Care Nurse did not perform a skin assessment until three days after admission, and the initial nurse did not inform the physician about the wound during the admission process. Additionally, there was a lack of communication and coordination among the staff, leading to the wound being left uncovered and untreated for several days. Interviews with staff revealed a breakdown in communication and adherence to protocols. The Wound Care Nurse was not adequately trained and did not know to call the Wound Care MD for orders. The DON acknowledged that the Wound Care Nurse did not complete a head-to-toe assessment and failed to cover the wound. The facility's policy required that any changes in the resident's skin condition be communicated to the physician, but this was not done in a timely manner, contributing to the deficiency.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 12% due to three errors out of 25 opportunities. The errors involved three residents who did not receive their medications as prescribed. One resident was given an incorrect dose of Trintellix, a medication for major depressive disorder, due to a pharmacy error and oversight by the medication aide. The aide administered a 5mg dose instead of the prescribed 10mg, and the discrepancy was not reported immediately to the charge nurse. Another resident was given a standard multivitamin instead of the prescribed Occuvite Eye + Multivitamin with Minerals, which is intended to support eye health. The medication aide misunderstood the physician's order and was unaware of the specific purpose of the medication, leading to the administration of the incorrect supplement. This resident had a history of macular degeneration, making the correct administration of the prescribed supplement crucial. The third resident received a Lidocaine 5% patch instead of the ordered Aspercreme 4% Lidocaine for pain management. The RN administering the medication did not verify the current physician's order, resulting in the application of an incorrect medication. This resident had a history of osteoarthritis and required accurate pain management to maintain her quality of life. The facility's failure to ensure proper medication administration procedures contributed to these errors, potentially impacting the residents' therapeutic outcomes.
Deficient Documentation of Controlled Substances
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically regarding the administration and documentation of controlled substances for two residents. For one resident, the Medication Administration Record (MAR) for June 2024 was incomplete, as RN M did not document or sign off on the administration of Oxycodone with Acetaminophen, a controlled substance prescribed for pain. Similarly, for another resident, the MAR for April 2024 was incomplete, with RN M failing to document or sign off on the administration of Hydrocodone with Acetaminophen, also a controlled substance for pain relief. Additionally, the facility staff failed to sign the correct narcotic count sheets for both residents' medications. The narcotic count sheet for the first resident's Oxycodone with Acetaminophen was not signed correctly, and the same issue was observed with the second resident's Acetaminophen/Codeine. This discrepancy in documentation could potentially affect the residents' care and treatment, as accurate records are crucial for ensuring proper medication administration. Interviews with staff, including the Director of Nursing (DON) and RN A, revealed that the nurses were signing out medications on incorrect count sheets, and there was a lack of proper reconciliation of narcotic records. The DON acknowledged the importance of accurate documentation to prevent drug diversion and ensure the safety of residents. The facility's policies and procedures for medication administration and controlled drugs emphasize the need for accurate record-keeping, which was not adhered to in these instances.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered admission baseline care plan within 48 hours of admission for a resident diagnosed with pneumonia. The resident, a male with severe cognitive impairments, was admitted with multiple diagnoses including pneumonia, type 2 diabetes mellitus, epilepsy, chronic diastolic heart failure, obstructive hydrocephalus, and hyperlipidemia. Despite these conditions, the baseline care plan for the resident was incomplete, lacking focus, goals, and interventions, particularly for pneumonia. Interviews with facility staff revealed that the resident's pneumonia diagnosis was not included in the care plan, which was acknowledged as an oversight. The RN responsible for the care plan admitted to mistakenly documenting the antibiotic treatment for sepsis instead of pneumonia. The MDS Nurse and ADON also confirmed the omission, emphasizing the importance of including pneumonia in the care plan to monitor respiratory interventions and track the infection's progression. The facility's policy requires the development and implementation of a baseline care plan within 48 hours of admission, including necessary healthcare information and instructions for effective, person-centered care. However, this policy was not adhered to in the case of the resident, as the care plan did not address the pneumonia diagnosis, potentially impacting the resident's care and treatment outcomes.
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.
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What surveyors actually found near you
We read the 549 citations issued within 25 miles in the last 12 months — including the 46 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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Pointe Health & Wellness | 2.5 mi | ★★★★★ | 12 | 0 |
| Eagle Crest Rapid Recovery | 2.8 mi | ★★★★★ | 26 | 3 |
| Cypress Creek Rehabilitation And Healthcare Center | 4.9 mi | ★★★★★ | 4 | 0 |
| Fallbrook Rehabilitation And Care Center | 5.7 mi | ★★★★★ | 17 | 4 |
| Park Manor Of Cyfair | 5.7 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.