Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Cornerstone Retirement Community during CMS and state inspections, most recent first.
A resident with dementia, parkinsonism, and anxiety had an incomplete care plan that did not reflect current transfer status, behaviors, or needed devices. Video showed a CNA providing ADL care and transfers without explaining care, continuing after the resident said quit, and using unsafe handling techniques instead of following individualized care guidance. The DON and MDS Coordinator stated the care plan and Kardex should have shown the resident’s current transfer needs and how staff should respond to resistance.
A resident with Parkinsonism, dementia, and severe cognitive impairment was transferred from bed to wheelchair by a CNA in an unsafe manner. Video showed the CNA pulling the resident up by the neck, lifting under her arms and by her pants, and continuing despite the resident saying to quit and not assisting with the transfer. The CNA, RP, LVNs, DON, and ADM all stated the transfer was improper and that a gait belt and/or additional help should have been used.
A resident with severe cognitive impairment and dementia was provided ADL care by a CNA who did not explain the care, continued despite the resident saying quit and stop, and used physical force to reposition and transfer her. The resident’s care plan called for staff to converse during care, explain procedures, allow time, and stop if she became resistive. The DON and ADM stated staff should have stopped, made the resident safe, and notified the charge nurse when the resident resisted care.
Unlabeled and Improperly Stored Food Items in Kitchen and Pantry: Surveyors observed multiple unlabeled food items in Freezer #1, Freezer #2, and the pantry, including several bags and packages with no labels. A pantry breadcrumbs bin was left open, and one freezer bag was open to air. The Dietary Manager and Administrator stated that food items should be labeled and bins closed after use, and facility policy required food to be covered, labeled, dated, and stored to prevent contamination.
A resident with a stage 4 pressure ulcer and total assist needs for toileting hygiene did not have EBP signage or PPE supplies in the room, and CNAs and an RN provided high-contact incontinent care, wound care, and turning/repositioning without wearing gowns. Staff interviews showed conflicting understanding of when EBP applied, while the facility policy and CDC guidance reviewed stated EBP applies to residents with wounds or indwelling devices during high-contact care.
A resident with stroke-related hemiplegia/hemiparesis and fall risk had a care plan and order for a fall mat at the bedside when in bed, but observations showed the mat folded up and leaning against the wardrobe while she was lying in bed. Staff interviews confirmed the mat should have been in place, that it was sometimes moved during meals, and that it was not replaced afterward. The MAR showed the intervention was signed off each shift, but the mat was not actually positioned as ordered.
A resident with Lewy body neurocognitive disorder, dementia, and dependence for most ADLs was shown in a video being handled roughly by a CNA during care. The CNA shoved the resident's legs, used a harsh tone, and made disrespectful comments while the resident was combative. The family member reported the incident, and staff interviews acknowledged the behavior was inappropriate and abusive, although no injuries were found on assessment.
A resident with a central venous line developed a localized infection due to the facility's failure to change the dressing according to protocol. The resident's medical records lacked documentation of dressing changes, and staff interviews revealed that the admitting nurse did not input an order for dressing changes. The site was observed to be red and warm, leading to the resident being sent to the hospital for catheter replacement.
The facility's kitchen failed to meet food safety standards by not discarding expired food items, leaving a scoop in a flour container, and having an unlabeled bag of whipped cream. The Dietary Manager and Administrator acknowledged these oversights, which could lead to foodborne illness and cross-contamination.
The facility failed to implement comprehensive care plans for three residents, leading to unmet needs and potential risks. A resident with severe cognitive impairment was not weighed as required, and interventions for fall prevention and skin protection were not followed. Another resident's care plan for daily weights was not adhered to, and a third resident's interventions for fall prevention and dining were not implemented. Staff interviews confirmed the expectation to follow care plans, but these were not effectively executed.
The facility failed to ensure proper behavior monitoring and appropriate diagnoses for psychotropic drug use in four residents, leading to unnecessary medication regimens. Residents were prescribed antidepressants, antipsychotics, and antianxiety medications without adequate monitoring or specific diagnoses, contrary to facility policy. Interviews with staff confirmed these expectations were not met.
The facility failed to obtain necessary lab tests for two residents, leading to deficiencies in care. One resident did not receive a prealbumin and HgbA1c test as ordered, while another missed monthly CBC, BMP, HgbA1c, and TSH tests for three months. These oversights were due to staff failing to process lab orders and audit results, potentially delaying treatment.
The facility failed to maintain an effective infection control program, as evidenced by the lack of proper signage and PPE use for a resident on contact isolation due to CRE. Staff confusion and miscommunication led to inappropriate PPE usage, increasing the risk of infection spread. Additionally, the facility's laundry practices were inadequate, with linen carts in disrepair and improper storage of clean linens, further compromising infection control efforts.
The facility failed to respect residents' rights to privacy and dignity by not ensuring staff knocked on doors before entering. Two residents with dementia experienced this breach, with one resident's family member expressing concern over the lack of privacy. The CNA involved admitted to not consistently knocking, despite recent training. The administration emphasized the importance of knocking as a sign of respect.
A resident with COPD and severe cognitive impairment had their nasal cannula improperly stored multiple times, touching the floor or bed instead of being placed in a designated bag. Staff interviews confirmed the storage policy was not followed, posing an infection risk.
A resident with moderate cognitive impairment was found with Blue-emu cream and Thera Tears eye drops at her bedside without a physician's order or self-medication assessment. Facility staff acknowledged the lack of necessary assessments and orders, posing a potential risk of improper medication use or access by other residents.
Incomplete Care Plan and Unsafe Transfer Care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one resident to meet medical, nursing, mental, and psychosocial needs. The resident had diagnoses including parkinsonism, dementia, hypertension, and an anxiety disorder. The quarterly MDS indicated severe cognitive impairment with a BIMS of 00, fluctuating inattention and disorganized thinking, use of a wheelchair for mobility, and substantial to maximal assistance needed for several ADLs and transfers. The resident’s undated care plan included interventions for emotional, intellectual, physical, and social needs, risk for physical aggressiveness during ADL care, impaired cognitive and communication function, restorative nursing care, and pain related to transfers. The care plan also referenced mechanical lift transfers for pain-related complaints, but the DON and MDS Coordinator stated the resident’s transfer status and required assistance should have been reflected in the care plan and Kardex. They also stated the care plan should include behaviors during transfers and any devices needed, and that the resident’s current transfer status had not been updated. Video footage showed a CNA providing care without explaining what she was doing and continuing care after the resident said “quit.” During bed care, the CNA pulled the resident’s pants up while using the resident’s body and clothing to reposition and lift her. During transfer to the wheelchair, the CNA grabbed the resident under the knees, placed a hand behind the resident’s neck, lifted her into a sitting position, and continued despite the resident saying “Oh, Oh, quit.” The CNA did not stop care when the resident resisted, and the resident was moved into the wheelchair while appearing to be handled roughly. The CNA later stated she should have talked to the resident, stopped when the resident said quit, and used a gait belt instead of the resident’s pants. She also stated she was not familiar with a care plan and had not seen anything describing the care the resident needed.
Unsafe Resident Transfer and Improper Use of Assistance Devices
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and failed to ensure adequate supervision and assistance devices were used to prevent accidents for one resident. The resident had diagnoses including Parkinsonism, dementia, hypertension, and anxiety disorder. Her quarterly MDS indicated severe cognitive impairment with a BIMS of 00, fluctuating inattention and disorganized thinking, use of a wheelchair for mobility, and substantial to maximal assistance needs for lower-body dressing, bed mobility, sit-to-stand, and chair/bed-to-chair transfers. Her care plan included safe bed, wheelchair, and shower transfers and noted potential pain-related complaints with mechanical lifts for transfers per relative use. Video footage showed a CNA rolling the resident side to side to pull up her pants, then moving the wheelchair to the bedside and attempting to transfer her. The CNA pulled the resident’s legs off the bed, placed a hand behind the resident’s neck to bring her to sitting, and continued despite the resident saying, “Oh, Oh, quit.” The CNA then lifted the resident from under her arms and by the back of her pants while turning her toward the wheelchair. The resident did not attempt to stand or assist, and when the CNA slipped, the resident sat back on the bed before being lifted again and placed hard into the wheelchair. During the transfer, the resident hollered and said, “you hit me,” and the resident’s RP stated the resident’s head hit him while he was holding the wheelchair. Interviews confirmed the transfer was not performed safely. The resident’s RP stated the CNA was rough and almost dropped the resident, and he had not seen staff use gait belts. The CNA stated she should not have pulled the resident up by the neck, should have used a gait belt, and should have gotten help. LVNs, the DOR, the DON, and the ADM all stated the transfer was improper, that staff should not pull a resident up by the neck or lift under the arms and by the pants, and that a gait belt and/or additional help should have been used when the resident was resistant or not assisting. The facility’s CNA competency checklist showed the CNA had demonstrated transfer skills and gait belt use, and the facility policy required safe resident handling, use of individualized care plans, proper assistive devices, and requesting assistance when needed.
Failure to Provide Appropriate Dementia Care During ADL Assistance
Penalty
Summary
The facility failed to ensure a resident with dementia received appropriate treatment and services to maintain her highest practicable well-being. Resident #1 had diagnoses including parkinsonism, dementia, hypertension, and anxiety disorder. Her quarterly MDS indicated severe cognitive impairment with a BIMS of 00, fluctuating inattention, and disorganized thinking. She used a wheelchair for mobility and required substantial to maximal assistance with several ADLs, including lower-body dressing and transfers. The resident’s care plan identified that she was dependent on staff for emotional, intellectual, physical, and social needs, and that staff should converse with her during care, explain procedures, not rush, and allow time for questions. The care plan also noted she was at risk for physical aggressiveness during ADL care without apparent cause and directed staff to determine her mood before contact and stop care if she was resistive. The facility’s dementia policy also stated staff should use calm, respectful communication, simple instructions, adequate response time, and reassurance and validation. Video footage showed CNA A providing care to the resident without verbal explanation of what she was doing. While pulling up the resident’s pants and repositioning her, CNA A used physical force to turn and move the resident despite the resident saying “quit” and “stop” multiple times. CNA A continued care without stopping or communicating with the resident. The video also showed CNA A pulling the resident by the legs, placing a hand behind her neck to bring her to sitting, and lifting and turning her toward the wheelchair while the resident continued to vocalize distress. During interviews, CNA A stated she should have talked to the resident and stopped when the resident said quit, and the DON and ADM stated staff should explain care, stop when a resident with dementia resists, make the resident safe, and notify the charge nurse.
Unlabeled and Improperly Stored Food Items in Kitchen and Pantry
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. During observation, multiple food items in Freezer #1 were found with no labels, including 6 bags of beige food slices, 3 bags of a light brown cylinder-shaped food item, 8 bags of orange stick-shaped food item, 4 bags of light brown stick-shaped food item, and 6 bags of a round green breaded food item; one of the bags was open to air. In the pantry, a storage bin labeled breadcrumbs had its lid open exposing the contents to air, and 11 packages of a light beige, flat, round food item were on a shelf with no label. In Freezer #2 inside the pantry, surveyors observed two packages of a large brown food item with no label, 3 packages of a long brown food item that smelled like garlic with no label, and 1 package of a brown, round food item with no label. The Dietary Manager stated that all food items should be labeled and that food bins should be closed as soon as staff were finished with them, and the Administrator stated that the person who unloaded food was responsible for dating and labeling it and that food bins should be closed after use. Facility policy stated that all food, non-food items, and supplies used in food preparation shall be stored to prevent contamination, and that unused portions and open packages should be covered, labeled, and dated.
Failure to Use Enhanced Barrier Precautions for Resident With Open Wound
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 diseases and infections for one resident reviewed for infection control practices. Resident #7 was a female admitted with acute on chronic diastolic heart failure. Her quarterly MDS reflected a BIMS score of 15, clear speech, and that she usually required total staff assistance with toileting hygiene. The care plan documented that she required assistance with ADLs or transfers and had a stage 4 pressure ulcer to the sacrum, with enhanced barrier precautions listed as an intervention. On 02/03/2026, CNA C and CNA D provided incontinent care to Resident #7 while she was lying in bed. The resident had a wound dressing on her sacrum, and there was no signage on the door indicating enhanced barrier precautions were required. There were also no PPE supplies readily available inside the room. CNA C and CNA D did not wear an isolation gown while providing the high-contact incontinent care. Later that day, RN F performed wound care and CNA G assisted with turning and repositioning. Resident #7 smiled and talked with staff during the care activity and had no signs of distress. Her wound was open with depth unable to be measured related to tunneling, the surrounding skin was pale with no redness, and the wound had no obvious signs of infection. There was again no signage on the door and no PPE supplies readily available inside the room, and RN F and CNA G did not wear an isolation gown while providing the high-contact wound care. During interviews, CNA C stated enhanced barrier precautions included gown and gloves and should have been used for high-contact care such as incontinent care, and she said Resident #7 was not on enhanced barrier precautions because there was no sign or PPE in the room. CNA E stated residents with wounds required enhanced barrier precautions and said Resident #7 was not on them even though she had a wound. RN F stated enhanced barrier precautions were required for some open wounds, but said Resident #7 did not require them because there was no drainage on the dressing and that the Infection Control Preventionist and Treatment Nurse decided they were not needed. The ADON, who was also the infection control preventionist, stated wounds were a gray area and it was at the facility's discretion whether to implement enhanced barrier precautions, and said Resident #7 had initially required them but they were stopped after discussion with NP H. NP H stated she understood enhanced barrier precautions were for wounds with MDROs or significant drainage and was unaware they were required for any open wounds. The facility policy and CDC information reviewed stated enhanced barrier precautions apply to residents with wounds or indwelling medical devices and require gown and gloves for high-contact care activities such as changing briefs, assisting with toileting, and wound care.
Fall Intervention Not Implemented as Care Planned
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #2, a female admitted with hemiplegia and hemiparesis following a stroke affecting her right dominant side. Her quarterly MDS reflected unclear speech, that she was sometimes understood by others, usually able to understand others, and had upper and lower functional range-of-motion limitations that interfered with daily functions and placed her at risk for injury. The comprehensive care plan, dated 09/18/2025, identified her as at risk for falls related to gait and balance problems and included the intervention of a right fall mat at bedside when in bed. Record review showed an order for a fall mat on the right side of the bed due to high fall risk, and the MAR for February 2026 showed the fall mat was signed off every 12-hour shift. However, observations on 02/02/2026, 02/03/2026, and 02/04/2026 showed Resident #2 lying in bed while her grey fall mat was folded up and leaning against the wardrobe. During these observations, she was in bed and no distress was noted, but the fall mat was not in place as identified in the care plan and order. Interviews with CNA staff, RN, ADON, DON, and the Administrator confirmed that fall mats should be in place when the resident was lying in bed and that mats were sometimes moved during mealtimes and should be replaced afterward. Staff stated the fall interventions were listed in the charting system and that nursing staff, CNAs, and nursing management were responsible for monitoring that the interventions remained in place. The facility policy on fall risk management stated staff would implement a resident-centered fall prevention plan and monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure the right to be free from abuse was provided for one resident. Resident #35 was admitted with diagnoses including neurocognitive disorder with Lewy bodies, diabetes, dementia, and anxiety disorder. The resident had unclear speech, was rarely to never understood, and was dependent on staff for most ADLs. The care plan indicated the resident was dependent on staff for emotional, intellectual, physical, and social needs and required extensive assistance with one staff member. An undated video showed CNA A providing care to the resident while he was in bed and combative. After the resident grabbed the CNA's wrist, CNA A shoved the resident's legs over in an aggressive manner, walked to the closet, and made comments in a harsh tone, including asking why he insisted on fighting folks and telling him he did not have to be mean. The CNA continued to roughly dress the resident while appearing frustrated. The resident's family member reported that the video showed CNA A being rough with the resident and stated that the resident could not explain what happened because of dementia. The family member sent the video to the Social Worker, who notified the Administrator and DON. The DON completed a head-to-toe assessment and documented no injuries. The Social Worker later documented no change from baseline and no distress. Interviews with the family member, CNA A, the LVN, the Social Worker, the DON, and the Administrator reflected that staff viewed the behavior as disrespectful and abusive, but the Administrator stated the allegation was unconfirmed because no physical or emotional harm was identified. The investigation report indicated CNA A was suspended and later terminated for misconduct, and the facility's abuse prevention policy stated residents have the right to be free from verbal, mental, sexual, or physical abuse.
Failure to Maintain Central Venous Line Leads to Infection
Penalty
Summary
The facility failed to maintain a central venous line site according to professional standards for a resident, leading to a missed dressing change. The resident, a male with a history of urinary tract infection, pneumonia, and a carrier of carbapenem-resistant Enterobacterales, was observed with a midline catheter dressing that had not been changed since the date of insertion. This oversight resulted in the resident developing a localized infection at the site, which was confirmed by a Nurse Practitioner. The resident's medical records did not show documentation of a central venous line dressing change or site assessment for several days. During observations, the dressing was noted to be dated from the time of hospital discharge, and the site was red and warm to the touch. The resident was subsequently sent to the hospital for the replacement of the midline catheter due to the infection. Interviews with facility staff revealed that the admitting nurse failed to input an order for dressing changes, which contributed to the oversight. The Director of Nursing and other staff acknowledged that the dressing should have been changed every seven days and documented accordingly. The lack of a physician's order for central venous line care and the failure to follow the facility's protocol for dressing changes were identified as key factors leading to the deficiency.
Food Safety Lapses in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not dispose of expired food items stored in the walk-in refrigerator, including a pan of pasta, a bowl of cornbread mix, a pan of cake, and two types of cheese. Additionally, a zippered bag containing a white creamy substance, identified as whipped cream, was found unlabeled and undated. Furthermore, a scoop was improperly left in a flour container, which is against the facility's food safety policy. Interviews with the Dietary Manager and the Administrator revealed that the facility's procedures were not followed, as the walk-in refrigerator was not checked for expired foods over the weekend. The Dietary Manager acknowledged the oversight and confirmed that expired foods should have been discarded, and all items should have been labeled with expiration dates. The Administrator also confirmed these expectations and recognized the risk of foodborne illness and cross-contamination due to these lapses in food safety practices.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which resulted in unmet individualized needs and potential risks to their well-being. Resident #7, a female with severe cognitive impairment and multiple health conditions, had care plan interventions for daily weights, fall mats, and a heel protector that were not implemented. Observations revealed that the resident was not weighed on numerous occasions, and the fall mats and heel protector were not properly utilized. Resident #15, also with severe cognitive impairment, had a care plan intervention for daily weights that was not followed. The weight log indicated multiple days when the resident was not weighed as ordered. Similarly, Resident #28, with severe cognitive impairment and a history of weight loss, had care plan interventions for fall mats and dining room meals that were not implemented. Observations confirmed the lack of adherence to these interventions. Interviews with facility staff, including an RN, the DON, and the ADM, highlighted the expectation that care plans should be followed by CNAs and nurses. The staff acknowledged that not implementing care plans could lead to resident harm, including falls, disease exacerbation, and weight fluctuation. The facility's policy emphasized the importance of developing and implementing comprehensive care plans to meet residents' needs, but these were not effectively executed for the residents in question.
Failure to Monitor Psychotropic Drug Use
Penalty
Summary
The facility failed to ensure that the drug regimens of several residents were free from unnecessary psychotropic drugs due to inadequate behavior monitoring and lack of appropriate diagnoses. Specifically, four residents were identified as not having orders for behavior monitoring for their psychotropic medications, which included antidepressants, antipsychotics, and antianxiety drugs. This lack of monitoring was noted despite the facility's policy requiring such documentation to support the continued use of these medications. Resident #7, a female with severe cognitive impairment, was taking two antidepressants daily without any recorded behavior monitoring. Similarly, Resident #15, who also had severe cognitive impairment, was on an antidepressant and two antipsychotic medications without behavior monitoring. Additionally, the antipsychotic medications prescribed to Resident #15 lacked a specific, appropriate diagnosis, as dementia was not considered a proper diagnosis for these medications. Resident #14, a male with Parkinson's disease, dementia, and depression, was taking both antipsychotic and antidepressant medications without an order for behavior monitoring. His Seroquel medication was prescribed for a mood disorder without a specific documented condition. Resident #27, a female with Parkinson's disease and dementia, was also taking antianxiety and antidepressant medications without behavior monitoring. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed the expectation for behavior monitoring and specific diagnoses for psychotropic medication use, which were not met in these cases.
Failure to Obtain Necessary Lab Tests for Residents
Penalty
Summary
The facility failed to provide necessary laboratory services for two residents, leading to deficiencies in their care. Resident #7, a female with severe cognitive impairment, diabetes, and heart failure, did not receive a prealbumin and HgbA1c test as ordered by the wound care physician. The oversight was attributed to the wound care nurse, who failed to process the lab orders, although the resident's wound eventually healed without the tests. This lapse in obtaining the required lab tests could have delayed treatment and affected the resident's condition. Similarly, Resident #28, also with severe cognitive impairment, diabetes, and anemia, did not receive monthly lab tests, including CBC, BMP, HgbA1c, and TSH, for three consecutive months. The admitting nurse acknowledged the failure to create lab requisitions due to distractions and did not audit the labs as required. The absence of these tests could have resulted in untreated medical conditions. The facility's policy required staff to process test requisitions and ensure tests were conducted, but this was not followed, leading to the deficiency.
Inadequate Infection Control and Laundry Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved Resident #18, who was supposed to be on contact isolation due to a diagnosis of carpenium-resistant enterobacterales (CRE). However, there was no signage on the door of Resident #18's room indicating the need for contact isolation. This lack of signage led to confusion among the staff, resulting in inappropriate use of personal protective equipment (PPE) by CNAs providing care to the resident. CNA H and CNA G both failed to wear the required gowns while assisting Resident #18, despite the resident's isolation status. Interviews with the staff revealed a lack of awareness and communication regarding the resident's isolation status. CNA H mentioned that she thought the isolation was over because there were no signs on the door, while CNA G admitted to not realizing the seriousness of the situation despite seeing the sign. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the oversight in signage and PPE usage, with the ADON admitting to accidentally removing the contact isolation sign. This miscommunication and failure to adhere to infection control protocols could potentially lead to the spread of infection within the facility. Additionally, the facility's laundry practices were found to be inadequate. The linen carts used for transporting clean and dirty linens were in disrepair, with debris and dirt present, and some carts were not properly covered. The laundry aide and housekeeping supervisor were unaware of the carts' condition, and clean linens were improperly stored on the dirty side of the laundry room. These lapses in maintaining clean and sanitary conditions for linens further compromised the facility's infection control efforts, posing a risk of cross-contamination and infection to the residents.
Failure to Knock on Residents' Doors Violates Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and privacy by not ensuring that staff knocked on residents' doors before entering their rooms. This deficiency was observed in the cases of two residents, both of whom had significant medical conditions including dementia. Resident #7, a female with severe cognitive impairment, was observed to have her room entered twice by a CNA without knocking. Her family member confirmed witnessing this behavior multiple times and expressed concern that the resident, who was known to value privacy before her dementia diagnosis, would be upset by such actions. Similarly, Resident #182, a male with dementia and other health issues, experienced the same lack of privacy when a CNA entered his room without knocking. During an interaction, both the resident and his family member requested that the CNA knock before entering, highlighting the resident's awareness of his rights and his preference for being notified of someone's presence. The CNA acknowledged the importance of knocking and admitted to not consistently doing so, despite recent in-service training on the matter. The facility's administration and DON emphasized the importance of knocking as a sign of respect and a means to maintain a home-like environment for residents.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for a resident with chronic obstructive pulmonary disease (COPD), high blood pressure, and anxiety. The resident, who had severe cognitive impairment, was observed multiple times with a nasal cannula improperly stored. On several occasions, the nasal cannula was found draped over the oxygen concentrator or the bed, touching the floor or the bed frame, instead of being stored in a designated bag when not in use. Interviews with staff, including a registered nurse (RN), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, confirmed that the nasal cannula should have been stored in a bag to prevent infection. The facility's policy on infection prevention for respiratory therapy equipment, dated November 2011, also indicated that oxygen cannulae and tubing should be kept in a plastic bag when not in use. The failure to adhere to these standards posed a risk of infection due to potential contamination from bacteria on the floor.
Failure to Secure Medications at Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required by state and federal laws. Specifically, a resident was found to have Blue-emu cream and Thera Tears eye drops at her bedside without a physician's order or a self-medication administration assessment. The resident, who had moderate cognitive impairment, used these medications herself without assistance from the nursing staff. Observations over several days confirmed that the medications remained at the bedside, even when the resident was not present in the room. Interviews with facility staff, including a registered nurse, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, revealed that the facility's policy required a self-administration evaluation and a physician's order for residents to keep medications at their bedside. The staff acknowledged that the resident did not have the necessary assessments or orders, and there was a potential risk of improper medication use or access by other residents. The facility's policy on medication storage emphasized the need for safe and secure storage of all medications and biologicals.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Texarkana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Cowhorn Creek | 0.9 mi | ★★★★★ | 29 | 2 |
| Reunion Plaza Senior Care And Rehabilitation Cente | 1.8 mi | ★★★★★ | 25 | 2 |
| Avir At Texarkana | 2.5 mi | ★★★★★ | 7 | 3 |
| The Villa At Texarkana | 2.5 mi | ★★★★★ | 9 | 0 |
| Heritage Plaza Nursing Center | 2.7 mi | ★★★★★ | 2 | 0 |
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