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 Crimson Heights Health & Wellness during CMS and state inspections, most recent first.
The facility failed to answer call lights in a timely manner for multiple dependent residents whose care plans required call lights to be kept within reach due to risks such as seizures, falls, diabetes, and immobility. One resident reported repeated waits of 30 minutes or more while needing incontinence care, worsening her feelings of helplessness and depression. Another resident on hospice with diabetes stated that her evening call light requests for a prescribed snack often took 45 minutes or more to be answered, or were not answered at all, leaving her nauseated. A third resident, who required extensive ADL assistance, activated her call light and waited 20 minutes while an RN entered the room, ignored the illuminated call light, and left without addressing her needs; she reported prior waits of more than 30 minutes when she was extremely ill and expressed fear that staff would not respond in an emergency. Other residents, the resident council secretary, and the Ombudsman described ongoing long call light response times, especially on night shift, while staff interviews and the written call light policy confirmed that such delays were inconsistent with expectations that call lights be answered promptly.
A resident with multiple chronic conditions and total dependence for ADLs had an order for Nucynta ER (tapentadol) 150 mg daily for pain. A narcotic pill was found in a cup on the resident’s side table after a night shift, contrary to facility policy requiring staff to remain with residents while medications are swallowed and never leave medications in rooms without an order. A CNA observed the pill and notified an RN, who later took possession of it and learned from an LVN that a PRN narcotic had been signed out and documented as wasted because it was reportedly not taken. The LVN, another LVN who trained a CMA, and the CMA gave conflicting accounts about who administered or handled the medication, while the narcotic record showed the LVN documented one tablet as given and then marked as wasted, demonstrating improper administration, disposal, and documentation of a controlled drug.
A resident with multiple chronic conditions, including COPD, schizophrenia, seizure disorder, and paraplegia, who was totally dependent for ADLs and on a daily order for Nucynta ER (tapentadol) 150 mg, was found with a blue pill in a cup on the bedside table. The resident reported that a nurse had placed the narcotic pill there while she was asleep. A CNA observed the pill during morning care and later noted it was still in the resident’s possession. An RN stated he eventually took the pill and that the night LVN reported a PRN narcotic had been signed out and documented as wasted. The LVN indicated a new MA had signed out the pill and left it on the table, despite facility policy requiring staff to remain with residents until medications are swallowed and never leave medications in rooms without an order. The narcotic log showed one Nucynta ER tablet documented as given and wasted by the LVN.
A resident's personal refrigerator contained undated, leaking ice cream and an old beverage, indicating improper food storage and handling. Staff interviews revealed inconsistent monitoring of refrigerator temperatures and removal of expired foods, with some staff unaware of correct procedures. The facility's policy required labeling and proper storage of perishable foods, but these practices were not consistently followed.
A deficiency was cited for not ensuring a resident's right to a safe, clean, comfortable, and homelike environment, including the safe provision of treatment and daily living supports.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A deficiency was cited when a nursing home area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment did not meet safety standards, and there was insufficient oversight of residents in the area.
A resident with moderate cognitive impairment and a history of stroke did not have a functioning toilet for an extended period. Despite informing staff, the issue was not addressed, leading the resident to use a urinal and bedpan and dispose of waste in a trash can. Staff and maintenance were inconsistently aware of the problem, and the maintenance log did not reflect the issue until it was observed by surveyors.
A resident with a stage 2 pressure ulcer on the right buttock was found without a dressing, contrary to physician's orders and facility protocol. The hospice aide removed the dressing during a bed bath but failed to notify the nursing staff, leading to a lapse in care. The resident had severely impaired cognition and was at risk for infection due to incontinence and other health issues.
Two residents in an LTC facility experienced deficiencies in care related to activities of daily living (ADLs) and call light response. One resident, with severe cognitive impairment, was left without necessary assistance during meals, risking poor nutrition. Another resident waited 50 minutes for a call light response while in a soiled brief, leading to feelings of neglect. These incidents highlight failures in adhering to care plans and facility policies.
The facility failed to provide sufficient staff for food and nutrition services, leading to delayed meal service in the dining room. Residents experienced increased hunger and frustration due to waiting times of up to an hour or more for meals. The delays were caused by the late arrival of nursing staff required to check meal tickets and trays before serving, despite attempts to address the issue with scheduling and paging systems.
The facility failed to ensure that call lights were within reach for several residents, including those with severe cognitive impairments and fall risks. Observations revealed that call lights were either out of reach or improperly placed, contrary to the facility's policy. This deficiency could lead to delays in care and increased risk of falls.
A facility failed to accurately document a resident's dialysis services in the MDS assessment, despite the resident having end-stage renal disease and attending dialysis thrice weekly. Interviews revealed that the DON and MDS nurses were unaware of the omission, which could impact the care plan. The facility's policy requires comprehensive assessments, but this oversight was identified during a survey.
A facility failed to update a resident's care plan after discontinuing her IV medication. The resident, with a history of acute kidney failure and Alzheimer's, had a care plan that inaccurately reflected the need for IV medication. Staff interviews revealed a lack of awareness and reliance on physician orders over care plans, despite facility policy requiring timely updates.
A crash cart in a facility was found unattended and unlocked in a busy hallway, containing medical supplies including sharps. Staff interviews revealed confusion about who was responsible for ensuring the cart was locked, with the DON confirming it should be secured when not in use. The ADM also expected all carts to be secured per policy.
A resident with Alzheimer's and Parkinson's was not provided with the physician-ordered cream soup at meals, as confirmed by the dietary manager. Despite the facility's policy to ensure accuracy in therapeutic diets, the resident's nutritional needs were unmet, risking malnutrition and weight fluctuations.
A facility failed to accurately document a resident's mealtimes and food intake, leading to inconsistencies in medical records. The resident, with multiple health conditions, had meal entries recorded at incorrect times, which could affect her care. The DON confirmed that staff made entries to meet documentation requirements, not reflecting actual intake, contrary to the facility's policy.
A resident with dementia and a history of wandering eloped from the facility and was missing for seven hours before being found by EMS. The facility lacked specific protocols for monitoring residents at risk of elopement, leading to inadequate supervision. Staff interviews revealed inconsistencies in monitoring practices and documentation, contributing to the delay in recognizing the resident's absence.
A resident with quadriplegia repeatedly requested cough assistance to expel mucus, but staff were uncomfortable performing the procedure without a formal order. This led to the resident calling 911 for help. Despite the need being documented by healthcare providers, the facility failed to obtain a formal order until much later, resulting in a deficiency in care.
A resident's grievance requesting that a specific staff member not be involved in his care was not respected, leading to continued contact and care by the staff member despite the resident's explicit requests. The facility's grievance process was not properly followed, resulting in a failure to maintain the resident's dignity and respect.
The facility failed to update the care plan for a resident with quadriplegia to include necessary cough assistance, leading to an emergency situation where the resident had to call 911 for help. Staff interviews revealed confusion and discomfort in providing the needed care due to the lack of documentation in the care plan.
Failure to Answer Call Lights Timely, Affecting Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to treat residents with respect and dignity by not answering call lights in a timely manner, despite care plan directives and facility policy. One resident, an older female with COPD, hypothyroidism, hyperlipidemia, schizophrenia, hypertension, type 2 diabetes with hyperglycemia, and paraplegia, was totally dependent on staff for all ADLs. Her care plan required that the call light be kept within reach at all times due to risks related to seizures and falls. She reported that it took staff at least 30 minutes or more to answer call lights on multiple occasions when she needed to be changed, leaving her sitting in a soiled brief. She stated that this created a feeling of helplessness, worsened her depression, and that the call light issue was ongoing and had been raised in resident council as a grievance. Another resident, an older female on hospice with COPD exacerbation, immunodeficiency, type 2 diabetes with polyneuropathy, upper respiratory infection, anxiety disorder, and hypertensive heart disease with heart failure, had a baseline MDS showing moderate cognitive impairment and required supervision or touching assistance for all ADLs. Her care plan required that the call light be kept within reach at all times and that she receive diabetic snacks between meals and at bedtime. She reported that when she pushed her call light for her evening snack, it took approximately 45 minutes or more to be answered, and sometimes it was not answered at all, resulting in her not receiving the snack and feeling nauseated and sick to her stomach. A third resident, an older female with multiple diabetes-related diagnoses, diverticulitis, moderate cognitive impairment, and extensive ADL assistance needs, had care plan approaches including keeping the call light in reach at all times due to fall risk and monitoring for dehydration and pressure injury. During an observation, this third resident activated her call light while sitting on the side of her bed. Twenty minutes later, an RN entered the room, walked past her, looked behind the curtain of the absent roommate, and then left the room without addressing the activated call light. In a subsequent interview, the resident stated she very seldom used the call light but recalled being extremely sick on one occasion when it took more than 30 minutes for staff to respond, and she expressed fear that if she were dying she might be dead before staff responded. Additional residents reported that call lights routinely took 30 minutes to 1.5 hours to be answered, and the resident council secretary confirmed that long wait times for call lights were an ongoing issue documented in council minutes. The Ombudsman reported multiple complaints about unacceptable call light response times, particularly on night shift. Staff interviews showed awareness that answering call lights after 30 minutes was not acceptable and that all staff could and should answer call lights, while the ADON characterized the issue as a perception problem. The RN observed failing to respond to the call light acknowledged he did not address the resident’s needs despite the light being on and stated this could have resulted in the resident being in distress. The facility’s call light policy required staff to respond to call lights and requests for assistance as quickly as practicable and to respond to emergency lights immediately, which was not followed in these instances.
Improper Handling and Documentation of Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and follow procedures for accurate administration and documentation of a controlled medication for one resident. The resident was an older female with multiple diagnoses including COPD, hypothyroidism, hyperlipidemia, schizophrenia, hypertension, type 2 diabetes with hyperglycemia, and paraplegia, and was totally dependent on staff for ADLs with care plan directions to keep the call light within reach. She had a physician’s order for Nucynta ER (tapentadol) 150 mg once daily for pain. The facility’s medication management program required that authorized staff remain with the resident while medication is swallowed and never leave medication in a resident’s room without an order to do so. The resident reported that over a weekend a nurse put a narcotic pill in a cup and placed it on her side table while she was asleep. The next morning, a CNA providing care around 6:00 a.m. observed a blue pill in a cup on the resident’s side table and questioned the resident, who stated she did not know how the pill got there and believed the nurse had left it the previous night. The resident stated she informed an RN and showed him the pill, and the CNA later returned and found the pill still in the resident’s possession. In a subsequent interview, the RN confirmed that the resident showed him the pill, that he then took the pill into his possession, and that he spoke with the night nurse, who told him she had given a PRN narcotic and signed it as wasted in the narcotic book because the resident did not take it. The night LVN stated she worked that weekend, was informed by the CNA about the narcotic pill in the resident’s room, and acknowledged that medications are to be observed while the resident takes them. She stated that a medication aide had signed out the pill and left it on the resident’s table, and that the pill was already signed out as wasted when she looked at the narcotic record. Another LVN, who trained the medication aide, stated she was familiar with the resident’s medications, had observed the aide administer scheduled narcotics in the morning, and denied that she or the aide would place a pill in a cup and leave it by a resident’s desk, reiterating that aides are trained to observe residents taking medications. The medication aide reported she only administered scheduled medications that morning, observed the resident take them, did not administer in the evening, and stated that the tapentadol in question was a PRN medication that only nurses could administer. Review of the controlled drug receipt/record/disposition form showed that on the evening in question, the night LVN documented giving one tablet of Nucynta, with an amount left of ten, and signed it as “wasted (missed dose),” indicating improper documentation and handling of the controlled drug.
Unsecured Narcotic Tablet Left in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that controlled medications were properly secured and not left unattended in a resident’s room. A female resident with multiple diagnoses, including COPD, hypothyroidism, hyperlipidemia, schizophrenia, hypertension, type 2 diabetes with hyperglycemia, paraplegia, seizure disorder, and fall risk, was totally dependent on staff for all ADLs and required supervision with eating and for safety. Her care plan required that the call light be kept within reach at all times. Physician orders included Nucynta ER (tapentadol) 150 mg, a Schedule II narcotic, to be given once daily for pain. The resident reported that over a weekend, a nurse put a narcotic pill in a cup and placed it on her side table while she was asleep. The next morning, a CNA entered the room around 6:00 a.m. to provide care and observed a blue pill in a cup on the resident’s side table. The resident told the CNA she did not know how the pill got there and stated that the nurse must have placed it there the previous night. The resident also stated she informed an RN about the pill and showed it to him. The CNA later returned to the room and found that the resident still had the pill in her possession. The RN confirmed that the resident showed him the pill and that he then took it into his possession. He stated that the night nurse, an LVN, told him she had given the resident a PRN narcotic and signed it as wasted in the narcotic book because the resident did not take it, and he acknowledged the pill should never have been left. The LVN stated that a medication aide (MA) had signed out the pill and left it on the resident’s table, and that all medications were supposed to be observed as taken by the resident. Another LVN, who trained the MA, stated that at no time would she or her trainee place a pill in a cup and leave it by a resident’s desk, and that MAs are trained to administer medications and observe ingestion. The DON stated that the pill found in the resident’s room was not appropriate. Facility policy on medication management required that authorized staff remain with the resident while medication is swallowed and to never leave medication in a resident’s room without an order to do so. The narcotic record showed that on the relevant evening, one Nucynta ER 150 mg tablet was documented as given and wasted by the LVN.
Failure to Enforce Safe Storage and Handling of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to implement and enforce a policy regarding the use and storage of foods brought in by family and visitors for residents, resulting in improper storage and handling of perishable items. During an observation, a personal refrigerator in a resident's room was found to contain two undated containers of ice cream that had liquefied and leaked, as well as a cup of red liquid dated several weeks prior. Staff interviews revealed inconsistent practices regarding the monitoring and documentation of refrigerator temperatures and the removal of expired or spoiled food items. Some staff were unaware of the correct procedures for temperature logging or the safe temperature range for food storage, and there was confusion about whether all temperatures should be recorded or only those above a certain threshold. The resident involved had a history of dementia, polyneuropathy, immunodeficiency, and type 2 diabetes, and required assistance with activities of daily living, including supervision with eating. The resident's care plan indicated a need for support with these tasks, and the resident's cognitive impairment may have limited her ability to manage food safety independently. Despite daily checks being part of the facility's protocol, expired and improperly stored food was still present in the resident's refrigerator, and staff responsible for these checks did not consistently identify or remove the items. Review of facility policy confirmed that perishable foods brought by family or visitors should be labeled with the resident's name, item, and use-by date, and stored in resealable containers with tightly fitting lids. However, the observed practice did not align with this policy, as undated and leaking food items were found, and staff interviews indicated gaps in training and understanding of the procedures. The lack of consistent implementation of the policy and inadequate staff knowledge contributed to the deficiency.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided report excerpt, nor are there direct observations or events described beyond the general statement of noncompliance with the requirement.
Failure to Follow Approved Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or observed events are provided in the report.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pest infestations within the facility. No additional details regarding specific residents, staff, or observed pests were provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring within the facility. Specific actions or inactions leading to this deficiency include the lack of proper hazard mitigation and insufficient oversight of residents in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Functioning Toilet for Resident
Penalty
Summary
The facility failed to ensure that all patient care equipment was in safe operating condition, specifically by not providing a functioning toilet for one resident. The resident, a male with moderate cognitive impairment, a history of stroke, cellulitis, and pain disorder, required assistance with toileting and was always continent. Despite this, his toilet was not operational for an extended period, as confirmed by both the resident and his family member. The resident reported using a urinal and bedpan, disposing of waste in his trash can, and stated he had informed both the Receptionist and Maintenance Director about the issue. Multiple staff interviews revealed inconsistent awareness of the problem, with some staff noting the toilet sometimes worked and others unaware of the malfunction. Observations by the surveyor and staff confirmed the toilet would not flush, and maintenance staff were not aware of the issue until the day of the survey. The maintenance log did not reflect any prior reports of the problem, and the facility's policies required routine checks to ensure toilets were functioning. The lack of timely response and communication resulted in the resident being without a functioning toilet, leading to unsanitary conditions in his room.
Failure to Maintain Dressing on Resident's Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident's stage 2 pressure ulcer on the right buttock was properly covered with a dressing, as observed on a specific date. The resident, an elderly female with severely impaired cognition and multiple health issues, including muscle weakness and incontinence, was found without a dressing on her wound during a wound care session. The wound care nurse noted that the dressing might have been removed by a hospice aide during a bed bath, but the aide did not report this to the nurse, as required by the facility's protocol. Interviews with the wound care nurse and a licensed vocational nurse revealed that the hospice aide failed to notify them about the missing dressing, which was against the physician's orders for daily and as-needed dressing changes. The assistant director of nursing confirmed that the hospice aide should have informed the floor nurse or wound care nurse immediately to prevent potential infection. The facility's wound care policy emphasized the importance of dressing changes to protect against infection, but this protocol was not followed in this instance.
Deficiencies in ADL Assistance and Call Light Response
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to significant deficiencies in care. Resident #98, a male with severe cognitive impairment and limited mobility, required supervision or touching assistance while eating. Despite this requirement, observations revealed that the resident was left unattended during meal times, with his food tray inadequately set up and no staff returning to assist him. This lack of assistance was corroborated by interviews with the resident and staff, indicating a failure to adhere to the care plan and facility policies, which placed the resident at risk of poor nutrition and dehydration. Resident #50, also with severe cognitive impairment and dependent on assistance for toileting and transferring, experienced a significant delay in response to his call light. The resident was left in a soiled brief for 50 minutes despite repeated verbal requests for help. Interviews with staff and the resident confirmed that such a delay was unacceptable and not in line with good resident care practices. The facility's policy on responding to call lights was not followed, leading to the resident feeling neglected and isolated. The report highlights systemic issues in the facility's adherence to care plans and policies regarding ADLs and call light responses. Both residents were at risk due to the facility's failure to provide timely and appropriate assistance, as evidenced by the observations and interviews conducted during the survey. The deficiencies in care for these residents underscore the need for improved staff training and adherence to established protocols to ensure resident safety and well-being.
Delayed Meal Service Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient staff to effectively conduct food and nutrition services, resulting in delayed meal services for residents in the main dining room. Observations and interviews revealed that residents were not served meals at the posted times, leading to increased hunger, frustration, and decreased feelings of self-worth among the residents. For instance, on June 11, 2024, residents began congregating for lunch at 11:30 AM, but meal service did not start until 12:15 PM, with some residents expressing feelings of being undervalued due to the delay. The delay in meal service was attributed to the requirement for nursing staff to check meal tickets and trays before serving, which often resulted in prolonged waiting times. The dining room staff had to wait for a nurse to arrive to perform these checks, which were supposed to occur between 7:30 AM and 7:45 AM for breakfast and 11:30 AM for lunch. However, the nursing staff frequently arrived late, sometimes as late as 8:00 AM, causing residents to wait up to an hour or more for their meals. This issue was compounded by the lack of an effective schedule for nursing staff to ensure timely meal service. Interviews with various staff members, including the Dietary Manager (DM), Licensed Vocational Nurses (LVNs), and the Assistant Director of Nursing (ADON), confirmed the recurring delays and the ineffective measures taken to address them. Despite attempts to create a schedule and use the paging system to prompt timely arrival of nursing staff, these efforts were unsuccessful. The facility's policy required meals to be served at specified times, but the failure to adhere to this policy resulted in dissatisfaction and potential risks for the residents.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of four residents by not ensuring their call lights were within reach, which is a critical aspect of their care plans. Resident #56, a female with severe cognitive impairment and a fall risk, was observed without her call light in reach. Similarly, Resident #57, who also has severe cognitive impairment and multiple diagnoses including dementia and Alzheimer's disease, was found calling for help with her call light out of reach, wedged between the wall and her bedside table. Despite the presence of a CNA, the call light remained inaccessible. Resident #66, another individual with severe cognitive impairment and a fall risk, was observed with her call light in the trashcan, out of her reach. The facility's policy mandates that call lights be placed within reach of residents to ensure timely assistance, yet this was not adhered to, as evidenced by the observations. These failures could potentially place residents at risk for falls and delay in receiving necessary care and interventions.
Inaccurate MDS Assessment for Dialysis Services
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding dialysis services. A review of the records for a resident, who was admitted with end-stage renal disease among other diagnoses, revealed that the admission Minimum Data Set (MDS) assessment did not indicate that the resident was receiving dialysis services. This oversight was significant as the resident's care plan, dated after the admission MDS, included specific instructions related to dialysis care, such as maintaining and encouraging attendance at dialysis sessions and monitoring the dialysis shunt. Interviews with the resident confirmed that she attended dialysis three times a week and had a dialysis port in her right arm. The resident expressed satisfaction with the care received, noting no issues with dialysis or staff responsiveness. However, interviews with the Director of Nursing (DON) and the MDS nurses revealed a lack of awareness regarding the omission in the MDS assessment. The DON acknowledged that the MDS should reflect dialysis services and that inaccuracies could impact the care plan, which is triggered by the MDS assessment. The MDS nurses, responsible for completing the assessments, confirmed their training in ensuring accuracy but admitted to the oversight. One nurse, who had not completed the MDS for this resident, was unaware of the dialysis services omission. The facility's policy mandates a comprehensive and accurate assessment process, involving a review of the resident's medical record and coordination with the interdisciplinary team. Despite these procedures, the failure to accurately document dialysis services in the MDS assessment was identified, potentially affecting the resident's care plan and overall care.
Failure to Update Resident Care Plan After IV Discontinuation
Penalty
Summary
The facility failed to ensure that a resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan for a resident was not updated when her IV medication was discontinued. The resident, an elderly female with a history of acute kidney failure, Alzheimer's disease, and dysphagia, had a care plan that still included a problem statement regarding the need for IV medication, despite the IV being discontinued. Observations confirmed that the resident no longer had an IV access, and interviews with the resident indicated she was unaware of the specifics of her care. Interviews with facility staff, including the Director of Nursing (DON) and MDS nurses, revealed a lack of awareness regarding the outdated care plan. The DON expected care plans to be updated in real-time and acknowledged the potential harm of not doing so. The MDS nurses, responsible for updating care plans, were unsure why the care plan was not updated and noted that staff typically rely on physician orders rather than care plans. The facility's policy required care plans to be updated with changes in clinical status, but this was not adhered to in this instance.
Unsecured Crash Cart Poses Risk in Facility
Penalty
Summary
The facility failed to ensure that Crash Cart #1 was stored securely, as it was found unattended and unlocked in a frequently used hallway, not in view of the nursing station. The cart contained various medical supplies, including sharps, which could pose a risk if accessed by unauthorized individuals such as residents, staff, or visitors. The observation was made on 6/11/2024, and it was noted that the cart was supposed to be locked and secured with a numbered plastic tag when not in use. Interviews with staff, including an LVN and the DON, revealed a lack of clarity regarding the responsibility for ensuring the crash cart was locked. The LVN indicated that the night supervisor was thought to be responsible for checking the cart daily, but there was uncertainty about the process. The DON confirmed that the crash cart was considered a medication cart and should be secured when not in use. The ADM also expressed that all medication or supply carts should be secured per policy, although he was not aware of the specific contents of the crash cart.
Failure to Provide Physician-Ordered Diet
Penalty
Summary
The facility failed to ensure that a resident received the diet ordered by the physician, specifically 1 cream soup at all meals. This deficiency was identified during an observation of lunch service, where it was noted that the resident did not receive the cream soup as per the physician's order. The dietary manager confirmed that the resident had never been served cream soup with any of her meals, indicating a lack of communication or oversight in implementing the physician's dietary orders. The resident in question had a history of Alzheimer's disease, Parkinson's disease, and other medical conditions that put her at risk for malnutrition and weight fluctuations. The resident's care plan highlighted the need for a bite-sized diet due to difficulty chewing, and the physician's order for cream soup was intended to address these nutritional needs. Despite the facility's policy requiring physician orders for all therapeutic diets and ensuring accuracy in meal preparation, the resident's dietary needs were not met, as evidenced by the absence of cream soup in her meals.
Inaccurate Documentation of Resident's Mealtimes and Food Intake
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident, specifically regarding the recording of mealtimes and food intake. The resident, a female with multiple diagnoses including dementia, diabetes, and end-stage renal disease, was found to have inconsistencies in her medical records. The records inaccurately reflected her food intake at various mealtimes, with entries showing meals consumed at times that did not align with the facility's scheduled mealtimes. The review of the resident's records showed numerous instances where meal entries were recorded at the same time or before the meals were actually served. This inaccurate documentation was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the facility's policy required 100% documentation for tasks, leading staff to make entries even if the task did not occur during their shift. This practice resulted in inaccurate records that could potentially affect the resident's care, including her blood sugar levels and nutritional status. The facility's policy on documentation required nursing staff to accurately record care, treatment, observations, and assessments in the resident's clinical record. However, the interviews with the DON and the Administrator (ADM) revealed that the policy was not being followed correctly, as staff were making entries to fulfill documentation requirements rather than accurately reflecting the resident's actual food intake and mealtimes.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident with known wandering behaviors, resulting in an elopement incident. The resident, who had a history of dementia and cognitive impairment, was absent from the facility for approximately seven hours before staff noticed he was missing. The resident was eventually found at a nearby apartment complex and transported to a hospital by EMS. The facility's lack of a specific protocol for monitoring residents, especially those at risk for elopement, contributed to the incident. Interviews with staff revealed that there was no consistent practice or documentation to ensure residents were accounted for throughout their shifts. Staff members, including CNAs and RNs, were aware of the resident's wandering tendencies but did not have clear guidelines on how frequently to check on him or how to document his whereabouts. The absence of a structured system for monitoring residents, particularly those with elopement risks, led to a delay in recognizing the resident's absence. The facility's existing policies and procedures did not adequately address the supervision needs of residents with elopement risks. Staff interviews indicated a lack of training and awareness regarding the importance of regular checks and documentation of residents' locations. The deficiency highlighted the need for improved protocols and staff education to prevent similar incidents in the future.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care to a resident with quadriplegia, who required assistance in expelling mucus from his lungs. Despite the resident's repeated requests for cough assistance, staff members were either uncomfortable or unsure about performing the procedure due to the lack of a formal order. This led to the resident calling 911 for emergency assistance when his needs were not met by the facility staff. The resident's condition, including quadriplegia and the inability to cough effectively, was well-documented, and the need for cough assistance was noted by multiple healthcare providers, but no formal order was in place until much later. The resident's medical records and progress notes indicated that he had repeatedly requested to be leaned forward and have his back patted to help expel mucus. However, staff members, including LVNs and CNAs, expressed discomfort and uncertainty about performing the procedure without a formal order. This resulted in the resident experiencing emotional distress and calling emergency services to receive the necessary care. Interviews with various staff members, including the DON and MDs, revealed a lack of communication and follow-up on the resident's needs, leading to the deficiency in care. The deficiency was further highlighted by the fact that the resident's primary physician and consulting physician had both acknowledged the need for cough assistance. Despite this, the facility's staff did not obtain a formal order until after the resident had to call 911 for help. The DON admitted that there was a failure in communication and follow-up, which resulted in the resident not receiving the necessary care. The facility's policies on physician orders and communication were not adequately followed, leading to the resident's needs being unmet and the subsequent deficiency in care.
Failure to Respect Resident's Grievance and Maintain Dignity
Penalty
Summary
The facility failed to provide dignity and respect for a resident by allowing a staff member to provide direct patient care despite the resident's verbal and formal grievance requesting that the staff member not be involved in his care. The resident, who was cognitively intact and had multiple medical conditions including quadriplegia and anxiety disorder, had expressed concerns about the staff member's aggressive behavior and requested that she stay away from him. Despite this, the staff member continued to have contact with the resident, which was documented in progress notes and confirmed through interviews with various staff members and the resident himself. The resident's grievance was initially filed with the administrator and was supposed to be investigated by the Director of Nursing (DON). However, the investigation was incomplete, and there was no documentation instructing the staff member to stay away from the resident. Interviews with the Ombudsman, Social Worker, and other staff members revealed that the resident's concerns were known but not adequately addressed. The DON admitted that the staff member should have limited interactions with the resident, but there was no documentation to support this. The staff member in question, who was also the Assistant Director of Nursing (ADON), continued to provide direct care to the resident despite his explicit requests. The ADON and the administrator both acknowledged that the resident had the right to refuse care from a specific staff member, but failed to ensure that this right was respected. The facility's grievance process was not followed properly, leading to a failure in maintaining the resident's dignity and respect.
Failure to Update Care Plan for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for a resident with quadriplegia. The resident's care plan did not include necessary cough assistance, which was critical due to his inability to cough effectively on his own. This omission was identified despite the resident's medical history indicating the need for such assistance and multiple staff interviews confirming the necessity of the intervention. The resident, who was cognitively intact, had a history of quadriplegia and required assistance with personal care and other activities of daily living. Despite this, his care plan did not reflect the need for cough assistance, which was essential for clearing secretions due to his condition. On one occasion, the resident had to call 911 for emergency medical services to assist with expelling a mucous plug, highlighting the critical nature of the missing care plan component. Interviews with medical staff, including doctors and nurses, revealed that there was confusion and discomfort among the staff regarding the provision of cough assistance, as it was not documented in the resident's care plan. The Director of Nursing acknowledged the oversight and the importance of having a complete care plan to ensure personalized care. The failure to update and revise the care plan resulted in staff not having the necessary instructions to provide appropriate care for the resident.
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What surveyors actually found near you
We read the 579 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Humble
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Of Humble | 0.2 mi | ★★★★★ | 9 | 0 |
| Deerbrook Skilled Nursing And Rehab Center | 0.5 mi | ★★★★★ | 14 | 3 |
| Focused Care At Humble | 1.2 mi | ★★★★★ | 1 | 0 |
| Oakmont Healthcare And Rehabilitation Of Humble | 1.8 mi | ★★★★★ | 16 | 0 |
| Kingwood Rehabilitation And Healthcare Center | 4.3 mi | ★★★★★ | 0 | 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.