Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Cottonwood Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that a large maintenance toolbox was left open and unsecured at the end of one resident hall, exposing tools such as a cordless drill, screwdrivers, wrenches, and a hammer while residents, including a wandering resident, were moving about the hall. The Administrator acknowledged the toolbox was in use for repairs but agreed it should not have been left unsecured due to safety concerns, and the Maintenance Director admitted it should have been secured because it posed a trip hazard and the tools could harm a resident. This situation did not comply with the facility’s Resident Rights policy requiring a safe environment and a physical layout that does not pose a safety risk.
Surveyors found that the facility failed to ensure meals were palatable and served at safe, appetizing temperatures for most residents on regular, mechanical, and pureed diets. A resident council president reported ongoing complaints for months that food at all meals was cold, and test trays observed with the Dietary Manager were lukewarm. The Dietary Manager acknowledged she only intermittently verified that cooks checked food temperatures, was not present when temperatures were taken, and could not produce temperature logs for two meals reviewed. A cook stated he took temperatures when food came off the stove, with no verification or clear instruction on when to check, and temperature logs for the reviewed meals were missing from the facility’s logbook.
A resident with acute respiratory failure and a PRN order for 2–4 L/min O2 via nasal cannula was observed in a wheelchair while the nasal cannula, last used during the prior night, was left unbagged on the bed instead of being stored properly. An LVN, the Regional Nurse, and the ADON each acknowledged that nursing staff were responsible for ensuring the nasal cannula was bagged when not in use to prevent contamination and infection, and that this practice did not follow the facility’s oxygen administration guidelines.
Improper Food Labeling and Storage: Surveyors observed multiple unlabeled, improperly dated, expired, and spoiled food items in the kitchen, refrigerator, freezer, and bread pantry, including sandwiches, cheese, mushrooms, cream cheese, meats, fish, chicken, pie crust, biscuits, and bread with mold or freezer burn. The DM acknowledged the findings and stated she was responsible for kitchen sanitation and proper food storage, while the ADMIN stated items needed to be dated and that failure to follow policy could result in residents getting sick from foodborne illnesses.
Call lights were not kept within reach for three residents with severe cognitive impairment and significant assistance needs. One resident's call light was pinned between the bed and wall, another's was clipped to a curtain at the foot of the bed, and a third resident's call light was on the floor between beds. Staff later moved the call lights beside the residents' hands, and interviews confirmed that staff were expected to ensure call lights remained accessible.
Incomplete and Untimely Care Plans: The facility failed to keep several residents’ comprehensive care plans current and reviewed on a quarterly basis. Record review showed gaps in the care plans for multiple residents, with quarterly updates missing for months at a time. The MDS Coordinator acknowledged the gaps, and the ADON, DON, and Administrator stated that care plans needed to reflect current needs and be updated when conditions changed.
Improper Gauze Use During Wound Care: An LVN cleansed a resident’s scattered left thigh wounds using the same gauze across multiple wounds and again to dry them, rather than changing gauze between wounds. The resident had a non-pressure chronic ulcer of the left thigh, was cognitively intact, and had wound care orders for cleansing with NS and applying Triad Paste. The ADON and DON stated the practice was not proper because it could introduce bacteria and cause cross contamination.
A resident with dysphagia, severe cognitive impairment, and a g-tube had medication administration observed by the ADON. The ADON flushed the tube before, between, and after meds, but the chart did not contain an order for flushing before and after medication administration. The DON and Administrator stated an order should be present for g-tube care and medication administration.
A facility failed to keep medications and biologicals secured when zinc oxide cream was left in the rooms of two residents with severe cognitive impairment, another resident had zinc oxide on a side table, and a breathing treatment solution was left in a resident’s room after use. Staff interviews confirmed the items should not have been left where residents could access them, and the facility policy required the medication cart to be locked and secured after administration.
Infection control failures occurred during care for two residents. For one resident with severe cognitive impairment and total incontinence, two CNAs cleaned the resident and changed the brief without changing gloves after handling soiled material. For another resident with an indwelling catheter, open wound, and EBP, an LVN did not perform hand hygiene before gloving, did not wear a gown during bed mobility, and placed the catheter bag on the bed linen. A CNA later changed linens without hand hygiene before gloving, placed the catheter on the clean linen, and continued handling the linen without changing gloves.
Privacy and confidentiality were not maintained for two residents. An ADON left a laptop open and facing the hallway while preparing g-tube medication, exposing a resident's name, DOB, vital signs, allergies, code status, and orders. In a separate event, an LVN performed ADL care for another resident without closing the door, leaving the resident's privacy unprotected.
Improper Catheter Bag Positioning: A resident with an indwelling Foley catheter and bladder dysfunction had the drainage bag placed on top of the bed at the same level as the bladder during turning and wound care. Urine was observed flowing back into the tubing, and the LPN acknowledged the bag should have been kept below the bladder by pulling the bed or repositioning the resident. The ADON, DON, and Administrator stated the bag should always remain below the bladder to allow drainage by gravity and prevent backflow.
Improper Storage of Oxygen and Nebulizer Equipment: Surveyors observed two residents with COPD and severe cognitive impairment whose respiratory equipment was not stored properly when not in use. One resident’s nasal cannula was found in a trash can with no Oxygen in Use sign outside the room, and another resident’s nebulizer mask was found on the floor instead of being bagged. Staff stated the equipment should have been bagged to prevent cross contamination and respiratory infection.
Nebulizer Medication Left With Resident for Self-Administration: A resident with COPD, moderate cognitive impairment, and generalized weakness had an order for Ipratropium-Albuterol nebulizer treatments, but no assessment showed he was competent to self-administer medications. Surveyors observed a nebulizer machine and four unopened solution vials left at the resident’s bedside, and the resident said nurses left several vials with him so he could give himself treatments. An LVN, ADON, DON, and Administrator all stated medications should not be left in the room for unsupervised self-administration.
A facility failed to maintain an effective infection control program when two CNAs did not adhere to proper hand hygiene during incontinent care for a resident. The resident required a two-person assist and was always incontinent. CNA A and CNA B did not wash or sanitize their hands appropriately between glove changes, leading to a breach in infection control practices. Interviews with staff revealed awareness of the importance of hand hygiene, but protocols were not followed during the observed care.
The facility's kitchen failed to meet professional standards for food safety, with issues in labeling and dating food items, and inadequate cleaning of the ice machine and other equipment. Interviews revealed a lack of awareness and adherence to protocols, posing a risk of food contamination.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and smoking habits, and another receiving hospice care and tube feeding. The absence of care plans addressing these needs was observed, highlighting a lack of communication and awareness among staff regarding care plan responsibilities.
A facility failed to provide adequate respiratory care for three residents. One resident on oxygen therapy lacked an 'Oxygen In Use' sign outside his room, posing a fire hazard. Another resident's oxygen mask was improperly stored, increasing the risk of respiratory issues. A third resident's CPAP mask was left exposed, risking contamination and infection. The facility lacked a specific policy for bagging masks, contributing to these deficiencies.
A facility failed to maintain an effective Infection Prevention and Control Program, leading to potential cross-contamination risks. A CNA did not change gloves or sanitize hands during incontinent care, and an LVN did not sanitize a blood pressure cuff between residents. These actions were contrary to the facility's infection control policies, which emphasize hand hygiene and equipment sanitation.
A facility failed to obtain physician's orders and assess a resident for a scoop mattress before its installation, contrary to professional standards and facility policy. The resident, with severe cognitive impairment and a history of falls, was placed on the mattress without prior assessment, which was later acknowledged as an oversight by the DON.
Two residents in the facility were found unable to access their call lights, which were on the floor and out of reach. One resident, a female with hemiparesis, and another, a male with cerebral infarction, both required assistance for personal care and had moderate cognitive impairments. Staff interviews revealed a failure to adhere to the facility's policy of ensuring call lights are accessible, compromising the residents' ability to communicate their needs.
A resident with a gastrostomy tube did not receive proper care as LVN B failed to check the tube's placement and gastric residual before administering medication, contrary to physician's orders. This oversight was confirmed by interviews with LVN B, the DON, and the ADON, highlighting a deficiency in the facility's adherence to its own policies and procedures for enteral feeding.
Unsecured Maintenance Toolbox Left Accessible on Resident Hall
Penalty
Summary
Surveyors identified a deficiency related to accident hazards on one of four resident halls (Hall 3). During observation, a large maintenance toolbox was found open and unsecured at the end of Hall 3. The open toolbox contained multiple tools, including a cordless drill, screwdrivers, wrenches, and a hammer. At the same time, residents were observed entering and exiting their rooms, and one resident was noted wandering in the hall near the unsecured toolbox. The facility’s written policy on Resident Rights states that residents have the right to a safe, clean, comfortable, and homelike environment, and that the facility must ensure residents can receive care and services safely and that the physical layout does not pose a safety risk. When the Administrator was shown the unsecured toolbox, she acknowledged that maintenance was using it to make repairs and stated that it should not have been left unsecured because it was a safety concern for residents. In a subsequent interview, the Maintenance Director was informed that his toolbox had been left on the hall unsecured. He confirmed that the Administrator had spoken with him about this and acknowledged that the toolbox needed to be secured because it could be a trip hazard and the tools inside could harm a resident. These observations and interviews demonstrated that the Maintenance Director failed to ensure his toolbox was closed and secure from resident access on Hall 3, resulting in an environment that was not as free from accident hazards as possible, contrary to facility policy.
Failure to Ensure Meals Served at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that residents’ food and drink were palatable, attractive, and served at safe and appetizing temperatures for 37 of 39 residents on regular, mechanical, or pureed diets. The Resident Council President reported that for the past six months, she and other residents had been complaining during council meetings that the food served at all meals was always cold, and she stated she had communicated these concerns to the Dietary Manager. During an observation with the Dietary Manager, test trays for regular, mechanical, and pureed diets were found to be lukewarm. The Dietary Manager stated she only sometimes checked to ensure the cook was checking food temperatures during preparation, did not do so regularly, and was not present when temperatures were taken. She also stated she received temperature logs from cooks at the end of the day but could not provide temperature logs for the breakfast and lunch meals served on the day of the survey. A cook reported that he had been at the facility for four months and usually took food temperatures when removing items from the stove, with readings well over 165 degrees, but that no one verified his temperature checks and he was never instructed on when to check food temperatures. He stated he simply turned in the temperature information at the end of his shift. Record review of the facility’s temperature logbook showed no temperature logs for the breakfast and lunch meals served to residents on the survey date. The facility’s undated Resident Rights policy stated that residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
Improper Storage of Nasal Cannula for Resident on PRN Oxygen
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the resident’s care plan by not properly storing a nasal cannula when not in use. Record review showed that the resident was an adult male with acute respiratory failure with hypoxia and an active diagnosis of respiratory failure, admitted with a physician’s order for oxygen at 2–4 L/min via nasal cannula as needed for acute respiratory failure. The resident’s MDS reflected intact cognition. During an observation in the morning, the resident was seen in his wheelchair in the hallway while his nasal cannula, which he reported using only at night and not since getting out of bed that morning, was found lying unbagged on top of his bed. When the LVN was shown the unbagged nasal cannula, she stated that the night nurse should have bagged it to avoid contamination and confirmed that the resident used oxygen at night and sometimes during the day. She further stated it was the nurse’s responsibility to ensure the nasal cannula was bagged when not in use. The Regional Nurse, when informed of the situation, stated the nasal cannula should have been bagged when not in use and that not bagging it could result in the resident getting an infection, reiterating that it was the nurse’s responsibility. The ADON also stated that the nasal cannula needed to be bagged when not in use to prevent infection and that it was the nurse’s responsibility to ensure this occurred. The facility’s Oxygen Administration policy, dated 10/2010, outlined guidelines for safe oxygen administration, including verifying a physician’s order and reviewing the resident’s care plan, but the observed practice did not align with these standards.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its kitchen. During observation of the kitchen, surveyors found two sandwiches wrapped in plastic in the refrigerator with no label or expiration date, a gallon-size bag of cheddar cheese dated 07/31/25 with a use-by date of 08/07/25, and a plastic bin of unpackaged sliced cheese dated 07/24 with a use-by date of 07/30/25. A flat of mushrooms was stored in a cardboard box on a refrigerator shelf, labeled 07/10/25 but not labeled with a use-by date, and the mushrooms had a dried-out appearance. A block of cream cheese in the refrigerator had a manufacturer use-by date of 07/18/2025 but was marked in sharpie 07/24/25. Surveyors also observed multiple frozen and pantry items that were expired or showed signs of spoilage. In the freezer, there was a large freezer bag containing three separate smoked sandwich meats with visible freezer burn, two 2-lb smoked turkey breasts with visible freezer burn, a gallon-size freezer bag with four fish fillets with visible freezer burn, a freezer bag labeled chix pieces dated 07/18/25 with a use-by date of 07/22/25, and three 2-gallon freezer bags of chicken thighs with visible freezer burn. There was also a clear bag containing a pie crust dated 07/17/25 with a use-by date of 07/22/25. In the bread pantry, surveyors found a gallon-size bag containing five individual biscuits dated 08/01/25 with a use-by date of 08/08/25, one loaf of bread with visible green/black mold, four loaves of bread dated 07/31/25 with a use-by date of 08/08/25, three loaves of bread dated 07/17/25 with a use-by date of 07/30/25, and one loaf of bread dated 07/03/25 with a use-by date of 07/18/25. The DM stated she was responsible for kitchen sanitation and proper storage of food products and acknowledged the observations, stating the concerns were oversights. The ADMIN stated everything needed to be dated and that if opened it needed an open date and expiration date; she also stated the risk of not following policy was that residents could get sick from foodborne illnesses.
Call Lights Not Kept Within Reach of Residents
Penalty
Summary
The facility failed to ensure that the call light system in the rooms of three residents was positioned within reach and accessible to them. Resident #5, a female with muscle weakness, lack of coordination, and severe cognitive impairment with a BIMS score of 03, had a care plan intervention for a reachable call light. During observation, she was in bed awake, and her call light was pinned between the bed and the wall and could not be pulled. When asked what she used to call staff, she did not answer. Resident #9, a female with muscle weakness, lack of coordination, and severe cognitive impairment with a BIMS score of 00, also had a care plan intervention to keep the call light within reach. During observation, she was in bed awake, and her call light was clipped on the curtain at the foot of the bed. When asked about her call light, she did not reply. A CNA later observed the call light clipped to the curtain, unclipped it, and placed it near the resident's hand, stating she had not noticed it was clipped there and that she was responsible for making sure call lights were with the residents on her hall. Resident #40, a male with muscle weakness, lack of coordination, and severe cognitive impairment with a BIMS score of 00, had a care plan intervention to keep the call light within reach. During observation, he was in bed with his eyes closed, and his call light was on the floor between his bed and his roommate's. The RCN removed it from the floor and placed it beside his hand, stating staff should make sure call lights were with residents before leaving the room. Interviews with the ADON, Administrator, and DON reflected that staff were expected to ensure call lights were with residents at all times and within reach when in the room.
Incomplete and Untimely Care Plans
Penalty
Summary
The facility failed to ensure that each resident’s person-centered comprehensive care plan was completed within 7 days of the comprehensive assessment and reviewed and revised by an interdisciplinary team. Based on interviews and record reviews, six of eight residents reviewed for care plan revision did not have timely quarterly care plans: Residents #2, #9, #10, #12, #29, and #44. The record review showed that each of these residents had a gap in quarterly care plan documentation, with the next care plan entered months after the prior one, rather than at the expected quarterly interval. For Resident #2, the quarterly care plan completed after 12/11/2024 was dated 06/15/2025, when a care plan dated 03/2025 should have been present. For Resident #9, the quarterly care plan completed after 11/26/2024 was dated 06/15/2025, when a care plan dated 02/2025 should have been present. For Resident #10, the quarterly care plan completed after 11/26/2024 was dated 06/10/2025, when a care plan dated 02/2025 should have been present. For Resident #12, the quarterly care plan completed after 11/26/2024 was dated 06/15/2025, when a care plan dated 02/2025 should have been present. For Resident #29, the quarterly care plan completed after 12/11/2024 was dated 06/15/2025, when a care plan dated 03/2025 should have been present. For Resident #44, the quarterly care plan completed after 01/23/2024 was dated 06/15/2025, when a care plan dated 04/2025 should have been present. The MDS Coordinator stated it was her responsibility to update care plans and acknowledged that the residents’ care plans had gaps and missing quarterly updates. The ADON and DON stated that care plans should be updated for changes in condition and reviewed quarterly, and the Administrator stated the MDS Nurse, nurse managers, and leadership were responsible for ensuring care plans were current.
Improper Gauze Use During Wound Care
Penalty
Summary
The facility failed to ensure that wound care was provided in accordance with professional standards of practice for one resident with a non-pressure chronic ulcer of the left thigh with fat layer exposed. The resident was cognitively intact with a BIMS score of 15 and had two lymphedemic wounds to the left posterior thigh. The care plan directed wound care as ordered, and the physician order required cleansing the left posterior thigh with normal saline, patting dry, and applying Triad Paste daily and as needed, with an adhesive dressing only when the resident was in a wheelchair. During observation of wound care, an LVN cleansed the resident’s scattered wounds on the left thigh using gauze soaked with normal saline and used the same gauze to clean multiple wounds without changing it between wounds. The same gauze was then used to dry the wounds as well. In interview, the LVN stated she should have discarded the gauze after cleaning one wound and used a new one for the next wound. The ADON and DON stated that using the same gauze across wounds was not proper procedure because it could introduce bacteria from one wound to another and cause cross contamination.
Missing g-tube flushing order during medication administration
Penalty
Summary
Resident #40, a [AGE] year-old male admitted with dysphagia and severe cognitive impairment with a BIMS score of 00, had a feeding tube documented on the quarterly MDS assessment. His care plan reflected that he required tube feeding and that medications were to be administered as ordered. Physician orders included flushing the tube with at least 5 mL of water between each medication and holding Dilantin Infatabs for one hour before and one hour after administration, but the record on 08/13/2025 did not contain an order for flushing the g-tube before and after medication administration. During observation on 08/13/2025, the ADON administered medications via the g-tube, flushing with 30 mL of water before the medications, 5 mL between medications, and 30 mL after the medications. In interview, the ADON stated g-tubes should be flushed before and after medication administration and acknowledged there was no order for that flushing. The Administrator and DON later stated there should be an order for everything done for residents and that the g-tube should be flushed before and after medication administration to prevent clogging and ensure delivery of medications, but the order was not present in the resident’s chart at the time of the observation.
Medications Left Accessible in Resident Rooms
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments and permitted access to medications left inside resident rooms for four residents. The deficiency involved zinc oxide cream left in the rooms of two residents with severe cognitive impairment and incontinence-related skin care needs, and breathing treatment solution left in another resident’s room. Surveyors observed the items in resident-accessible areas during the survey, and interviews with nursing staff confirmed the medications should not have been left where residents could access them. Resident #2 was a female with dementia and severe cognitive impairment, with a BIMS score of 03, and her care plan and physician order directed barrier cream use for incontinence and skin protection. Resident #11 was a female with Alzheimer’s disease and severe cognitive impairment, also with a BIMS score of 03, and her care plan and physician order directed barrier cream use for pressure ulcer prevention related to incontinence. On observation, two tubes of zinc oxide were found inside the room shared by Resident #2 and Resident #11, beside the sink, and the tubes were still there on the following day when the ADON was notified and removed them. Resident #42 was a male with dementia and severe cognitive impairment, with a BIMS score of 04, and his care plan and physician order also directed barrier cream use as needed every shift. Surveyors observed a tube of zinc oxide on top of his side table while he was in bed with his eyes closed. Resident #30 was a male with COPD, moderate cognitive impairment, and generalized weakness, with an order for ipratropium-albuterol solution by nebulizer every 4 hours while awake for shortness of breath or wheezing. The LVN stated she had administered the morning treatment but forgot to remove the solution from the room, and staff interviews and the facility policy indicated medications were expected to be stored in a locked medication cart or secured medication area.
Infection Control Lapses During Incontinent Care, Turning, and Linen Changes
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents reviewed for infection control. Resident #6 had chronic kidney disease, severe cognitive impairment with a BIMS score of 02, and was always incontinent of bladder and bowel. Her care plan directed staff to provide pericare after each incontinent episode. During observation of incontinent care, two CNAs washed their hands and put on gloves, then cleaned the resident’s perineal area and bottom, removed the soiled brief, and applied a new brief without changing gloves after cleaning the bottom or after handling the soiled brief and new brief. Both CNAs acknowledged they should have changed gloves because their gloves were dirty and could cause cross contamination and infection. Resident #44 had neuromuscular dysfunction of the bladder, obesity, an indwelling catheter, an open wound, and was on enhanced barrier precautions. Her care plan required gloves and gowns during bed mobility. During an observed turning episode, an LVN put on gloves but did not perform hand hygiene before donning them and did not wear a gown while turning the resident. The LVN also placed the catheter bag on top of the bed linen near the area where the resident’s wound would be when rolled back. The LVN stated she should have worn a gown, performed hand hygiene before care, and not placed the catheter bag on the bed because it was dirty. Later, after wound care, a CNA changed Resident #44’s bed linens. The CNA put on gloves and a gown but did not perform hand hygiene before donning gloves. While changing the linens, she unhooked the catheter and placed it on top of the new linen, then reattached it to the bed railings. She did not change gloves after touching the catheter and continued handling the clean linen. The CNA stated the catheter bag was dirty and should not have been placed on the new linen, and that she should have changed gloves after touching it. The DON, ADON, and Administrator all stated that hand hygiene, glove changes, catheter handling, and gown use were required to prevent cross contamination and infection.
Privacy and Confidentiality Failures During Medication Prep and ADL Care
Penalty
Summary
The facility failed to ensure the resident's right to personal privacy and confidentiality of personal and medical records for Resident #40. On 08/13/2025 at 8:57 AM, the ADON was preparing to administer medication via the resident's g-tube and went into the resident's room to sanitize the overbed table. She left her laptop open on top of her cart, with the screen facing the hallway. The monitor displayed the resident's name, status, location, gender, date of birth, age, physician name, latest vital signs, allergies, code status, that the resident was on g-tube, the NP's name, and several physician orders. Resident #40's record reflected diagnoses including dysphagia and severe cognitive impairment with a BIMS score of 00, and the resident had multiple tube-feeding-related medication orders. The facility also failed to ensure privacy for Resident #44 during ADL care. Resident #44's record reflected the resident was cognitively intact with a BIMS score of 15 and needed assistance rolling left and right. On 08/12/2025, LVN A performed ADL care for the resident without closing the door. The report states this failure could place the residents at risk of not having their personal privacy maintained during ADLs and their medical information exposed to unauthorized individuals.
Improper Catheter Bag Positioning
Penalty
Summary
The facility failed to ensure appropriate catheter care for Resident #44, a cognitively intact female with neuromuscular dysfunction of the bladder and an indwelling Foley catheter. Her care plan directed staff to position the catheter bag and tubing below the level of the bladder. During observation, LVN A turned the resident for bowel movement and wound care, but first unhooked the catheter and placed the bag on top of the resident’s bed at the same level as the bladder, with urine observed traveling back into the tubing. The bag remained on the bed during the continued care, and urine was still observed in the tubing. During interview, LVN A stated she placed the catheter bag on top of the bed so it would not be pulled and cause injury, and acknowledged she should have pulled the bed or hung the catheter on the other side to prevent backflow of urine. Resident #44 stated some staff would pull her bed to transfer the catheter when she needed to be turned, but some staff would place the bag on top of the bed. The ADON, Administrator, and DON each stated the catheter bag should always be below the bladder to allow drainage by gravity and prevent backflow, and the DON confirmed the bed should have been pulled or the resident turned to keep the catheter bag below the bladder. The facility policy also stated to keep the drainage bag below the level of the bladder when cleaning the urethral area.
Improper Storage of Oxygen and Nebulizer Equipment
Penalty
Summary
The facility failed to ensure Resident #29, a male with COPD and severe cognitive impairment who was ordered oxygen 2-4 LPM as needed to keep oxygen saturation above 92%, had his nasal cannula stored properly when not in use. On 08/13/2025, the resident was not in his room, and surveyors observed an oxygen concentrator at the bedside with the nasal cannula connected to it, but the cannula was inside the trash can and not bagged. At the same time, there was no Oxygen in Use sign outside the resident’s room. During interview, LVN C stated the nasal cannula should be inside a bag to prevent cross contamination and respiratory infection. She observed the cannula in the trash can, removed it, and replaced it with a new nasal cannula and plastic bag. She stated the resident needed assistance during transfer and that whoever transferred the resident should have ensured the cannula was stored properly or notified her so it could be changed. She also stated she would get signage for oxygen use so staff and visitors would know oxygen was being used. The facility also failed to ensure Resident #31, a female with COPD and severe cognitive impairment who had an order for Ipratropium-Albuterol solution every 6 hours as needed for shortness of breath, had her breathing mask stored properly when not in use. On 08/12/2025, surveyors observed the nebulization machine on the resident’s side table with a breathing mask connected to it, but the mask was not bagged and was on the floor. The resident stated nurses would give it to her and come back to take it off. The RCN stated the mask should be inside a clean plastic bag when not in use, observed it on the floor, and said it should have been bagged properly or replaced with a new one if needed.
Nebulizer Medication Left With Resident for Self-Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for one resident with COPD. Resident #30’s record showed a diagnosis of chronic obstructive pulmonary disease, a BIMS score of 11 indicating moderate cognitive impairment, generalized weakness, and a care plan intervention to administer medications as ordered. The physician ordered Ipratropium-Albuterol solution, 1 vial via nebulizer every 4 hours while awake for shortness of breath or wheezing, and the resident’s assessment notes did not show an assessment for self-administration of medications, clear instructions for self-administration, or that the resident was competent to manage his own medications. During observation, the resident was awake in his wheelchair with a nebulizer machine on his side table and four unopened plastic vials of breathing treatment solution beside it. The resident stated he was administering his own breathing treatment and that nurses would leave several vials with him so he could do it if needed, and he did not tell staff when he used a treatment. An LVN stated she was administering the breathing treatment but was unaware the resident was doing it himself, and she acknowledged the solutions should not have been left in the room because they were medications. The ADON, Administrator, and DON each stated medications should not be left with a resident to administer unsupervised, and the DON stated staff should never leave the solutions at the bedside for the resident to administer unsupervised.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care to a resident. The resident, a cognitively intact female with a BIMS score of 15, was always incontinent for both bowel and bladder and required a two-person assist during care. During the observed care, CNA A and CNA B did not adhere to proper hand hygiene protocols, which are critical to preventing cross-contamination and infection. CNA A was observed cleaning the resident's perineal area without changing gloves before handling a new brief. CNA B entered the room, donned gloves without washing her hands, and assisted in turning the resident. After cleaning the resident's bottom, CNA B changed her gloves but failed to sanitize her hands before putting on a new pair. Both CNAs continued to handle clean items without proper glove changes or hand sanitization, which is a breach of infection control practices. Interviews with the CNAs, ADON, DON, and Administrator revealed an awareness of the importance of hand hygiene and the facility's policies requiring hand washing and sanitization before and after care, as well as between glove changes. However, the CNAs did not follow these protocols during the observed care, leading to a deficiency in the facility's infection prevention and control program.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. The deficiencies included improper labeling and dating of food items in both the refrigerator and freezer, with several items such as miniature pizzas, a whole ham, a pork butt, and various vegetables either lacking labels or missing expiration dates. Additionally, the facility's ice machine and ice scoop holder were not thoroughly cleaned, with dust, dirt, and rust observed on and inside the machine. The milk dispenser and drink stirrer holder in the dining area were also found to be dusty and dirty. Interviews with the Dietary Manager (DM), Dietician, and Maintenance Director revealed a lack of awareness and adherence to proper food storage and equipment cleaning protocols. The DM and Dietician acknowledged the issues and mentioned that food items were being dated without the year due to vendor practices. The Maintenance Director admitted to cleaning the ice machine only once a month and was unaware of the rust issue. The Administrator expressed expectations for the kitchen to meet required standards and noted improvements with the new DM, but acknowledged the risk of food contamination if the concerns were not addressed.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which is a deficiency in meeting the residents' needs. Resident #16, a female with severe cognitive impairment and a history of smoking, did not have a care plan addressing her smoking habits. Despite being observed independently going to the designated smoking area, her care plan lacked any mention of smoking, which is crucial for ensuring her safety and health needs are met. Similarly, Resident #20, a female with cognitive communication deficit and dysphagia, was receiving hospice care and tube feeding but did not have a care plan addressing these critical aspects of her care. Observations revealed that she was connected to a feeding formula, yet her care plan did not reflect the necessary interventions for tube feeding or hospice care. This oversight could lead to inadequate care and services for her specific medical needs. Interviews with facility staff, including the Senior MDS Case Manager, DON, ADON, and the Social Worker, highlighted a lack of awareness and communication regarding the responsibility for creating and maintaining comprehensive care plans. The staff acknowledged the importance of care plans in guiding resident care and admitted to oversights in ensuring that all residents had complete and detailed care plans tailored to their current conditions.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in their care. Resident #26, a male with chronic obstructive pulmonary disease and acute respiratory failure, was observed to be on oxygen therapy without an 'Oxygen In Use' sign outside his room. This oversight was acknowledged by LVN B, who stated that the sign is necessary to remind staff and visitors of the potential fire hazard posed by oxygen use. Resident #30, a male with COPD and obstructive sleep disorder, had an oxygen mask that was not properly stored. The mask was found exposed on a stand instead of being placed in a sealed bag, as required. RN M confirmed the improper storage and noted that the failure to bag the mask could lead to respiratory concerns. The responsibility for ensuring proper storage was attributed to the CNAs and nurses. Resident #189, a male with obstructive sleep apnea, had a CPAP mask that was not bagged when not in use. The mask was left exposed on top of the CPAP machine, which could lead to contamination and infection. LVN B and the DON both acknowledged the need for the mask to be bagged to prevent cross-contamination and respiratory infections. The facility lacked a specific policy for bagging masks, which contributed to the oversight.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in potential cross-contamination and infection risks for several residents. During an observation, CNA A did not change gloves or perform hand hygiene while providing incontinent care to a resident. Despite initially washing hands and donning PPE, CNA A touched the trash can and handled a new brief without changing gloves or sanitizing hands, which could lead to cross-contamination. Additionally, LVN B did not sanitize the blood pressure cuff between its use on multiple residents. The blood pressure cuff was used on several residents without being cleaned, increasing the risk of transferring infections between residents. LVN B acknowledged forgetting to sanitize the cuff and recognized the potential for infection transfer due to this oversight. Interviews with the DON, ADON, and Administrator confirmed the expectation for staff to sanitize equipment and perform hand hygiene to prevent infections. The facility's policies on perineal care and infection control emphasize the importance of hand hygiene and equipment sanitation, which were not adhered to in these instances.
Failure to Obtain Physician Orders for Scoop Mattress
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not obtain physician's orders or assess a resident for a scoop mattress before its installation. This oversight was identified during an observation and interview with RN M, who confirmed that the physician's orders for the scoop mattress were only submitted after the concern was raised. The resident in question was an elderly female with severe cognitive impairment, requiring moderate assistance for activities of daily living, and had a history of dementia, lack of coordination, and repeated falls. The Director of Nursing (DON) acknowledged that the scoop mattress was installed without prior physician assessment or orders, which was an oversight. The facility's policy on physician orders, dated August 2007, mandates that no resident should be placed in physical restraints for convenience or discipline, and that restraints should only be used to treat medical symptoms after assessing for the least restrictive measures. The failure to adhere to this policy could potentially result in physical harm to the resident.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were accessible, which is a deficiency in accommodating the needs and preferences of residents. Resident #23, a female with a history of cerebrovascular accident and hemiparesis, was found unable to reach her call light, which was on the floor under her bed. This resident, who has moderate cognitive impairment and is dependent on staff for personal care, expressed difficulty in moving and the need for assistance, highlighting the importance of having the call light within reach. Similarly, Resident #26, a male with cerebral infarction and anxiety disorder, was also unable to access his call light, which was observed on the floor. This resident, who requires maximal assistance for personal care and has moderate cognitive impairment, emphasized the necessity of having the call light near his functioning hand due to his dependency on staff for most activities. Both residents were at risk for falls, and their care plans specifically included ensuring the call light was within reach as an intervention. Interviews with staff, including a CNA, LVN, DON, ADON, and the Administrator, revealed a lack of adherence to the facility's policy of ensuring call lights are accessible to residents. Staff acknowledged the importance of call lights for communication and assistance, yet failed to consistently ensure they were within reach, as evidenced by the observations. The facility's policy emphasizes the right of residents to a dignified existence and access to necessary services, which was not upheld in these instances.
Failure in Gastrostomy Tube Management
Penalty
Summary
The facility failed to ensure proper management of a gastrostomy tube for a resident, leading to a deficiency in care. Specifically, LVN B did not check the placement of the gastrostomy tube before administering medication to Resident #20, nor did they check the gastric residual. This oversight occurred despite the physician's orders requiring these checks every shift before feeding and medication administration. Resident #20, a 77-year-old female with a diagnosis of cognitive communication deficit and dysphagia, was observed in bed with a feeding formula hanging from an IV pole, which was not connected to her. LVN B prepared and administered medications via the gastrostomy tube without verifying the tube's placement or checking the residual, which are critical steps to ensure the tube is correctly positioned and the stomach is emptying properly. Interviews with LVN B, the DON, and the ADON confirmed the importance of these checks to prevent potential complications such as aspiration pneumonia. The facility's policy also outlined the necessity of checking tube placement and gastric residuals as part of the procedure for enteral feeding. However, these steps were not followed, resulting in a failure to provide appropriate care for the resident with a feeding tube.
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 369 citations issued within 25 miles in the last 12 months — including the 9 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 Denton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Denton Village By Purehealth | 0.5 mi | ★★★★★ | 15 | 1 |
| Vintage Health Care Center | 1.9 mi | ★★★★★ | 24 | 0 |
| University Rehabilitation Center | 4.1 mi | ★★★★★ | 7 | 1 |
| Lake Forest Village By Purehealth | 5.3 mi | ★★★★★ | 13 | 0 |
| Denton Rehabilitation And Nursing Center | 6.7 mi | ★★★★★ | 4 | 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.