Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crossroads Nursing & Rehabilitation during CMS and state inspections, most recent first.
Failure to Provide Planned In-Room Activities: Three residents with significant cognitive and physical impairments did not receive the in-room activity visits called for in their care plans, including 1:1 visits and music-based stimulation. Records showed no participation documentation for the month reviewed, and one resident stated he had not been visited by activity staff or offered music despite preferring it.
Failure to Provide Required In-Room Activity Programming: The facility did not provide individualized in-room activity programming for three residents with significant cognitive and physical impairments. Care plans and activity assessments identified needs and preferences such as music, 1:1 socialization, toys, movies, and structured visits, but participation records showed missed or insufficient in-room activities. The AD stated the residents needed regular in-room visits, yet documentation showed one resident received none during the reviewed months and another received fewer visits than expected.
Medication administration errors exceeded the allowed rate, with a 12.9% error rate based on 4 errors in 31 opportunities. An MA failed to give a resident ordered acidophilus lactobacillus and artificial tears, gave only one B12 tablet instead of two, and administered an unordered multivitamin after already preparing a multivitamin-mineral tablet. The resident had chronic respiratory failure, protein calorie malnutrition, and macular degeneration, and was noted to have intact cognition.
Improper Hand Hygiene During Food Prep: A dietary aide and a dietary staff member were observed handling food after touching clothing, a door, and other contaminated items without washing or sanitizing their hands. One staff member poured salad dressing into cups after touching her pants and the kitchen door, and the other removed gloves, touched her scrub top and pants, then covered pureed green beans without hand hygiene. The Dietary Mgr and Admin stated staff were expected to wash hands and change gloves between tasks and after contamination.
Infection Control Failures During Wound Care and Medication Pass: An ADON performed wound care for a resident with DM and dementia without cleaning scissors, cleaning the overbed table, performing hand hygiene, or changing gloves between wounds, and she reused contaminated items after the wounds were covered with a dirty sheet. In a separate event, an MA prepared a resident's meds without hand hygiene, touched pills with bare hands, and used an unclean personal BP cuff during the med pass.
A resident who spoke Spanish did not receive full-time interpreter or translation support, despite staff using gestures, limited Spanish, and a phone app instead of a formal 24-hour interpreter process. Another resident with spastic quadriplegic CP and severe cognitive impairment was kept in bed because his wheelchair seat belt was broken and staff said it was not safe for him to get up, even though his care plan included transfers and use of a Geri-chair.
A resident with dementia, acute kidney failure, and difficulty walking had an incomplete care plan that did not address his primary Spanish language needs or his repeated shower refusals. Staff said he spoke mostly Spanish, that Spanish communication should have been included in the care plan, and that his ongoing refusal of showers was routinely reported but not care planned. The resident was observed speaking Spanish and smelling of urine, and his RP expressed concern that he did not appear to be showering.
Failure to Provide Needed Nail Care: Two residents with severe cognitive impairment and significant ADL dependence were observed with excessively long, dirty fingernails despite care plans directing staff to check, clean, and trim nails during baths and as needed. One resident with DM and stroke-related deficits had nails about 1 inch past the fingertips with debris under several nails, and another resident with stroke-related weakness had nails 2 to 3 inches long on both hands, with one thumb nail curling and difficulty using a fork. Staff interviews confirmed nail care was assigned to CNA and nursing staff, but neither resident’s nails had been addressed.
A medication cart was found with a staff member’s personal bag in the bottom drawer during med prep for a resident, and the bag contained the staff member’s personal BP cuff. The MA said she did not know personal items could not be kept on the cart, and the RNC stated personal items should not be stored on medication carts because they can cause cross contamination.
A resident with cognitive impairment and multiple health conditions experienced an unwitnessed fall resulting in an abrasion. Although documentation indicated the responsible party was notified, interviews and progress notes revealed that staff were unable to reach her and did not ensure follow-up, resulting in the responsible party learning of the incident several days later.
A resident with a history of falls, cognitive impairment, and multiple medical conditions experienced several falls, including an unwitnessed incident resulting in injury. The care plan was not updated to address the actual falls, their causes, or to add new interventions after each event, despite facility policy and staff acknowledgment that updates were required.
A resident with a history of falls, cognitive impairment, and mobility limitations experienced multiple falls, including an unwitnessed incident resulting in injury. Despite these events, the care plan was not updated to address the actual falls or implement individualized interventions, and staff confirmed that required reassessments and care plan modifications were not completed as per facility policy.
A resident with severe cognitive impairment exhibited behavioral issues that were not addressed in her care plan, leading to a deficiency. Despite incidents where she slapped another resident, the care plan was not updated until after a surveyor's inquiry. This oversight placed residents at risk of unmet needs and potential injury. Staff interviews revealed miscommunication about responsibilities for updating care plans.
A facility failed to maintain the dignity of a resident by not covering her urinary catheter bag, despite her care plan specifying the need for a privacy cover. Additionally, another resident experienced delays in meal service, waiting significantly longer than her tablemates on two occasions. Staff interviews revealed that these issues were due to oversight and communication lapses, contrary to facility policies.
A resident with a Stage 4 pressure ulcer did not receive the prescribed wound vacuum treatment due to a nurse's inability to follow orders. The nurse applied a wet to dry dressing without notifying the physician or documenting the change, potentially delaying wound healing. The resident expressed concern over the improper care, and the facility acknowledged the failure to adhere to physician orders and documentation requirements.
A resident with a Stage 4 pressure ulcer did not receive the prescribed wound vacuum treatment due to a nurse applying a wet to dry dressing instead. The nurse failed to document the change or notify the physician, potentially delaying the healing process. The resident expressed concern about the deviation from the care plan, and staff confirmed that supplies were available and the prescribed treatment should have been followed.
A facility failed to maintain an effective infection control program during wound care for a resident with a Stage 4 pressure ulcer. RN A contaminated supplies and used unclean scissors on the wound, despite the facility's policy requiring clean and dirty areas during procedures. The resident, with moderate cognitive impairment, was at risk of infection due to these breaches.
The facility failed to maintain respiratory equipment for two residents, leading to deficiencies in care. A resident with dementia and dysphagia did not have her oxygen tubing and humidifier bottle replaced weekly, and her air concentrator filter was dusty. Another resident with cerebral palsy and cystic fibrosis had outdated nebulizer equipment. Staff interviews confirmed that equipment should be changed weekly, but this was not done, risking respiratory infections.
The facility failed to provide necessary wound care treatments for three residents with pressure ulcers, as per physician's orders. The residents, who had various medical conditions and cognitive impairments, did not receive consistent care, with multiple missed treatments documented in April and May. Interviews with staff suggested possible documentation errors, but the incomplete records made it difficult to confirm whether the care was actually provided.
A resident's privacy was compromised during wound care when the DON, an RN, and a CNA failed to draw the privacy curtain, exposing the resident's chest area. Despite closing the room door, the oversight left the resident visible to anyone entering. Staff interviews confirmed the lapse, and records showed no recent training on privacy protocols.
Failure to Provide Planned In-Room Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities based on residents’ comprehensive assessments, care plans, and preferences for three residents who were reviewed for activities. The deficiency involved failure to provide in-room activities three times per week, as care planned, during March 2026 and April 2026 for three residents with significant physical and cognitive limitations. One resident was a male with cognitive communication deficit, spastic quadriplegic cerebral palsy, anxiety disorder, and bilateral elbow contractures. His assessments reflected poor short- and long-term memory recall, and his activity preferences included music and favorite activities. His care plan directed staff to provide simple, structured activities, materials for individual activities, and in-room social, spiritual, and stimulus activities, including toys and television. The activity participation record showed he did not receive in-room activities during March 2026 and April 2026. At observation, he was in bed watching television and was not interviewable. A second resident was a male with contractures of both elbows and hands, sequelae of cerebral infarction, anxiety disorder, and repeated falls. His MDS assessments reflected a BIMS score of 0, indicating severely impaired cognition, and his activity preference was listening to music. His care plan directed one-on-one in-room visits three times a week for mental and emotional stimulation, including listening to music, movement, and conversation. The activity participation record showed he did not receive in-room activities during March 2026 and April 2026. At observation, he was lying in bed watching television and was not interviewable. A third resident was a male with unspecified quadriplegia, bed confinement status, and an unspecified cervical spinal cord injury. His assessment reflected intact cognition with a BIMS score of 14, and his activity preference was listening to music. His care plan directed a program of activities that accommodated his abilities, task segmentation, in-room socialization and sensory stimulation, and one-on-one visits with sensory stimulation at least three times per week. During interview, he stated he was not receiving activity visits, had not been visited by activity staff that he could recall, and had not been offered an opportunity to listen to music. He said he would enjoy visits four or five times per week and that it would help him be around other people. The Activity Director stated she had not provided in-room activities to these residents and did not have participation records for them for March 2026.
Failure to Provide Required In-Room Activity Programming
Penalty
Summary
The facility failed to provide an ongoing activities program based on residents’ comprehensive assessments, care plans, and preferences for three residents who required in-room activities. The deficiency involved Resident #5, Resident #45, and Resident #46, all of whom had significant cognitive and physical limitations and were identified in their records as needing individualized activity support, including in-room visits, music, socialization, and other one-on-one stimulation. Resident #5 was documented as being in a vegetative state with total dependence for all care needs. Her care plan called for in-room visits, listening to music on a personal radio, and 1:1 socialization, and her activity assessment noted that music was somewhat enjoyed and that favorite activities were very important to her. However, the activity participation records showed she did not receive in-room activities during October and November 2025. During observations, she was found in bed with the television on during one visit and in bed staring toward the ceiling during another. The Activity Director stated Resident #5 was expected to receive in-room activities three to five times per week, but she did not provide any in-room activities during those months and had no documentation of visits. Resident #45 had diagnoses including cognitive communication deficit, spastic quadriplegic cerebral palsy, anxiety disorder, and contractures of both elbows. His assessments reflected poor short- and long-term memory, rare or no understanding, and inability to complete mental status testing. His care plan and activity assessment identified preferences for music, favorite activities, socialization with staff, toys, movies, and in-room visits, and stated he needed out-of-room social, spiritual, and stimulus activities as well as mental stimulation. Despite this, the activity participation records showed no in-room activities during October and November 2025. He was observed in bed watching television during both observations. The Activity Director stated he needed in-room activities at least five times per week, but she forgot to place him on the list and had no explanation for why he was not receiving them. Resident #46 had diagnoses including contractures, sequelae of cerebral infarction, anxiety disorder, and repeated falls, and his MDS reflected a BIMS score of 0. His care plan directed that he respond to in-room activities and that the Activity Director read and play music, with one-on-one visits three times per week. His activity assessment listed listening to music and favorite activities as preferences. The participation record showed he received in-room activities on five dates in November 2025, but the Activity Director stated this was not enough and that he did not receive in-room activities three to five times per week during October and November 2025. She stated he needed more visits, did not attend group activities, and that the facility did not meet his activity needs during those months.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent and was found to have a 12.9% medication error rate based on 4 errors out of 31 opportunities involving one resident and one medication aide observed during medication administration. Resident #13 was a female resident with chronic respiratory failure, protein calorie malnutrition, and macular degeneration, and her quarterly MDS reflected a BIMS score of 13 indicating intact cognition. Her care plan included a nutritional problem related to dysphagia and malnutrition, with interventions to administer medications as ordered. During observation of medication administration, MA D prepared seven medications for Resident #13 but did not include the physician-ordered acidophilus lactobacillus or artificial tears. MA D also placed a multivitamin tablet into the medication cup after already placing a multivitamin-mineral tablet, and then administered only one vitamin B12 500 mg tablet even though the order was for two tablets daily. In interview, MA D stated she did not give the acidophilus lactobacillus because it was not on the cart, did not give the artificial tears and did not know why, and acknowledged she gave only one B12 tablet instead of two. MA D also stated Resident #13 did not have an order for both a multivitamin-mineral tablet and a regular multivitamin, and provided no explanation for administering the additional multivitamin.
Improper Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety in the kitchen. During observation, Dietary Aide A opened the kitchen door leading to the dining room, touched her pants with her ring, middle, and fore fingers, and returned to the food prep table without washing her hands. She then poured salad dressing into small clear cups and touched the tops of the cups while handling the dressing. She later stated she did not wash her hands after touching the door and her clothing, and acknowledged her hands were considered contaminated. Dietary [NAME] B was also observed after removing gloves from pureeing green beans. She placed the gloves in the garbage can, touched her scrub top and scrub pants, and did not wash or sanitize her hands before returning to the food prep area. She then handled aluminum foil and covered the pureed green beans, with her fingers touching the foil and the food inside the silver container. She stated she did not follow the hand hygiene process for kitchen staff and acknowledged she did not wash her hands after removing her gloves and before continuing food preparation. The Dietary Manager stated staff were expected to change gloves and wash hands between tasks and after touching contaminated items such as clothing or doorknobs, and that she was responsible for ensuring kitchen staff followed hand hygiene protocol. The Administrator stated clothes and doorknobs were considered contaminated and that gloves were to be changed and hands washed anytime staff touched contaminated items. The facility’s hand hygiene in-service record showed both Dietary Aide A and Dietary [NAME] B attended the hand hygiene in-service, and the facility’s hand hygiene protocol reflected requirements for handwashing before food preparation, after touching bare body parts or soiled equipment, and after engaging in activities that contaminate the hands.
Infection Control Failures During Wound Care and Medication Pass
Penalty
Summary
The facility failed to maintain an infection prevention and control program during wound care for a resident with coronary artery disease, diabetes mellitus, and dementia who had a BIMS score of 6 and no wounds noted on the quarterly MDS. During observation, the ADON prepared wound care supplies on wax paper, placed scissors from her pocket onto the clean field without cleaning them, and took the supplies into the room without cleaning the overbed table. She used a sheet from the room that had food remnants on it to cover the table, removed dressings from both knees, changed gloves once, then cleaned one wound and the other without changing gloves between wounds. She later stated she was out of gloves, left the room with the wounds uncovered, returned without hand hygiene, and used the dirty scissors to cut xeroform dressing. She also did not reclean the wounds after they had been covered with the dirty sheet, and she returned unused supplies, including Medi-honey, xeroform, and saline vials, to the treatment cart. During interview, the ADON stated she should have cleaned the scissors before placing them on the clean field, cleaned the table before setting up, recleaned the wounds after they were covered with the sheet, performed hand hygiene and changed gloves between each wound, and not brought unused supplies back to the cart because they were considered dirty. The RNC stated the overbed table should have been cleaned with an approved cleanser before the clean field was placed, the scissors should have been cleansed, nothing from the room should have been returned to the treatment cart because it was contaminated, and each wound should have been treated independently with hand hygiene and glove changes between wounds. The facility also failed during medication administration for a resident with chronic respiratory failure, protein calorie malnutrition, and macular degeneration whose cognition was intact on the quarterly MDS. An MA finished another resident's medication pass, then began preparing this resident's medications without hand hygiene. While dispensing pills, she used her fingers to touch the pills to keep extra pills from falling into the medication cup. She then retrieved a blood pressure cuff from her personal bag, took it into the resident's room, and used it without cleaning it or performing hand hygiene before taking the resident's blood pressure and administering the medications. The MA stated she was new, did not perform hand hygiene, touched the pills with her bare hands, and did not know she could not use her personal blood pressure cuff without cleaning it.
Failure to Provide Interpreter Support and Safe Wheelchair Use
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a Spanish-speaking resident by not providing full-time translation or interpretation services. Resident #33 was a 76-year-old male with dementia, acute kidney failure, and difficulty walking. His record showed a severe cognitive impairment on the MDS, and his care plan included interventions related to communication and Spanish-speaking needs. During observation and interviews, he was identified as speaking Spanish, and staff described using a mix of gestures, limited Spanish, bilingual employees when available, and a phone translation app to communicate with him. Multiple staff members stated there was no interpreter available 24 hours a day, no formal communication board in place, and no formal program to communicate with him as a Spanish-speaking resident. Interviews with Resident #33, his RP, and staff reflected that he understood only a little English and that staff often relied on whoever was available to translate. The RP stated that there were only a few people at the facility who could translate and that Resident #33 would benefit from translation or communication services because the RP was not always present to interpret. The facility’s Interpreter Services policy stated that when language or communication barriers exist, arrangements will be made at the facility level for interpreters, that interpreters should be available on the premises or accessible by telephone 24 hours per day to the extent possible, and that the facility would maintain a list of interpreters and provide language assistance services. The facility also failed to ensure Resident #45’s specialty wheelchair was in safe working order so he could get out of bed. Resident #45 had spastic quadriplegic cerebral palsy, contractures of both elbows, and muscle wasting and atrophy, and his MDS reflected severe cognitive impairment and total dependence for ADLs. His care plan included transfer with a Hoyer lift with two staff and use of a Geri-chair. Observations showed him remaining in bed during the day, including during meals. A CNA stated that he was able to get up out of bed, but his wheelchair seat belt was broken and it was not safe for him to get up, and that this had been broken for awhile. Staff later stated they had not been getting him up because they did not think he could use a Geri-chair, and the RNC acknowledged the wheelchair was broken and that the situation had been going on for a while. The resident was later observed up in a Geri-chair in the communal area.
Incomplete Care Plan for Language Needs and Shower Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with dementia, acute kidney failure, and difficulty walking. Record review showed the resident’s MDS reflected severe cognitive issues, and the resident was observed speaking Spanish. The care plan included a communication-related focus, but it did not identify the resident’s primary language as Spanish or include specific language-related interventions. Multiple staff members stated that the resident spoke mostly Spanish, that Spanish communication was important for his care, and that the care plan should have addressed how to communicate with him. The facility also failed to care plan the resident’s repeated refusals to take showers. Staff interviews reflected that CNAs routinely asked the resident to shower, that he often refused, and that refusals were reported to nurses and documented on shower sheets. The resident was observed smelling of urine, and the resident’s Spanish-speaking representative expressed concern about whether he was receiving showers because he smelled and appeared not to have showered. Staff stated that shower refusals should have been included in the care plan and that interventions were needed to address the ongoing refusals. The facility’s Comprehensive Care Planning policy stated that each resident should have a comprehensive person-centered care plan with measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs identified in the assessment. In this case, the resident’s care plan did not reflect his Spanish language needs or his shower refusals, despite staff awareness of both issues and acknowledgment that these items should have been included in the care plan.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to ensure that two residents who were unable to perform activities of daily living received needed nail care to maintain good grooming and personal hygiene. Resident #27 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus with unspecified complications, and need for assistance with personal care. His quarterly MDS reflected a BIMS score of 6, indicating severely impaired cognition, and he was dependent on staff for toileting hygiene, showers, and dressing, with substantial to maximal assistance needed for personal hygiene and oral hygiene. His care plan directed staff to check nail length and trim and clean nails on bath day and as needed, with nurse involvement for toenail care if diabetic. During observation, Resident #27 was found lying in bed with fingernails on his left hand approximately 1 inch past the tips of his fingers, with blackish/brownish substance under the nails on several fingers. He stated he had asked staff to cut and clean his nails on Saturday and was told they would be trimmed and cleaned sometime the following week. He also stated he was afraid he would scratch himself and develop a sore. The Regional Nurse Consultant later observed that his nails were very long and dirty, and one thumb nail was beginning to curl. Resident #39 had diagnoses including cerebral infarction, pain in an unspecified joint, muscle weakness, and other lack of coordination. His quarterly MDS reflected a BIMS score of 5, indicating severely impaired cognition, and he required substantial to maximal assistance with personal hygiene and showers, with supervision or touching assistance for dressing, toileting hygiene, oral hygiene, transfers, and bed mobility. His care plan also directed staff to check nail length and trim and clean nails on bath day and as needed. On observation, his fingernails on both hands were approximately 2 to 3 inches long, with one right thumb nail beginning to curl. He stated he had asked staff to cut and clean his nails and that no one had done so, and on a later observation he again stated his nails had not been cleaned or cut and that the length made it difficult to pick up his fork to eat. Staff interviews confirmed that CNAs and nurses were responsible for nail care, that nail care was expected during showers or as needed, and that neither resident was known to have refused nail care.
Personal Items Stored on Medication Cart
Penalty
Summary
The facility failed to ensure medications used in the facility were stored in accordance with currently accepted professional principles for 1 of 3 medication carts reviewed. During observation and interview on 12/03/2025 at 8:05 AM, MA D was preparing medications for Resident #13 and opened the bottom drawer of the medication cart, where a large bag was stored. MA D removed a blood pressure cuff from the bag and stated that the bag and cuff were her personal items. In a later interview, MA D stated she did not know she could not place her bag on the medication cart and did not know why it should not be there. The RNC stated staff should not store personal items on medication carts because it can cause cross contamination. The facility's Medication Storage policy stated medications and biologicals are to be stored safely, securely, and properly, and medication storage areas are to be kept clean, well lit, and free of clutter.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify a resident's responsible party following an unwitnessed fall that resulted in an abrasion. The resident, who had a history of left femur fracture, diabetes mellitus type II, osteoarthritis, moderate cognitive impairment, and functional limitations, experienced a fall in her room early in the morning. Documentation indicated that the responsible party was notified shortly after the incident; however, nursing progress notes later revealed that attempts to contact the responsible party were unsuccessful due to a reported busy signal. The responsible party later stated she was not contacted and only learned of the fall several days later when the resident complained of pain. Interviews with facility staff confirmed that the night nurse was unable to reach the responsible party and passed the information to the ADON, who also failed to make successful contact and did not ensure follow-up. The responsible party clarified that she only uses a cell phone, which does not produce a busy signal, suggesting the wrong number may have been used. Facility policy requires notification of significant changes in resident status to the responsible party, but this was not achieved in this instance.
Failure to Update Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with measurable objectives and timetables to address the needs of a resident who had a history of multiple falls. The resident, who had a left hip fracture, unsteadiness on her feet, diabetes mellitus type II, osteoarthritis, and moderate cognitive impairment, experienced several falls during her stay. Despite these incidents, the care plan was not updated to reflect the actual falls, their causes, or to include new interventions after each event, particularly following an unwitnessed fall that resulted in an abrasion and bruising. Review of the resident's care plan showed that while some interventions were listed, such as fall risk signage, ensuring call lights were within reach, and providing non-skid footwear, the plan did not address the specific circumstances or root causes of the repeated falls. The care plan also lacked updates after significant events, including the most recent unwitnessed fall. Interviews with the resident revealed she was aware of her frequent falls and sometimes attempted to transfer herself if assistance was delayed, despite needing supervision or assistance with transfers. Staff interviews confirmed that the care plan should have been reviewed and updated after each fall to identify root causes and implement appropriate interventions. However, the care plan remained unchanged after the most recent incident, and the facility's policy requiring comprehensive, person-centered care planning with measurable objectives and timeframes was not followed. This failure resulted in the resident's individualized needs not being addressed in a timely manner.
Failure to Update Care Plan and Provide Adequate Supervision After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and individualized interventions to prevent accidents, specifically falls. The resident, who had a history of left femur fracture, unsteadiness, diabetes mellitus type II, and osteoarthritis, was assessed as having moderate cognitive impairment and functional limitations in both upper and lower extremities. Despite being identified as a fall risk and experiencing multiple falls over several months, the resident's care plan was not updated to address actual falls, including an unwitnessed fall that resulted in abrasions and bruising. The care plan contained general fall prevention interventions but was not revised after each incident to reflect new or individualized strategies based on the circumstances of the falls. Interviews with facility staff confirmed that the care plan should have been reviewed and updated after each fall, particularly following the most recent unwitnessed fall. The facility's policy required reassessment and immediate updating of the interdisciplinary plan of care after each fall, but this was not done. The lack of timely review and modification of the care plan after repeated falls constituted a failure to provide adequate supervision and assistance devices, as required to prevent further accidents.
Failure to Update Care Plan After Behavioral Incidents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with severe cognitive impairment, resulting in a deficiency. The resident, who had been admitted with diagnoses including dementia and diabetes, exhibited behavioral issues that were not reflected in her care plan. Despite incidents on two separate occasions where the resident slapped another resident, the care plan was not updated to address these behaviors until after the surveyor's inquiry. The first incident occurred when the resident slapped another resident's arm while he was asleep, and the second incident involved the resident repeatedly putting her hands in another resident's face, leading to a physical altercation that resulted in injuries to the resident's face. Despite these events, the care plan did not include any problems related to behaviors until it was updated on the day of the surveyor's visit. The lack of timely updates to the care plan placed residents at risk of not having their individualized needs met and could result in injury and a decline in physical well-being. Interviews with facility staff revealed that the care plan updates were overlooked due to miscommunication and assumptions about responsibilities. The Director of Nursing (DON) and the Assistant Director (AD) acknowledged the oversight and the importance of updating care plans promptly to ensure appropriate care. The facility's policy on comprehensive care planning emphasizes the need for ongoing discussions and timely updates to reflect changes in residents' goals, preferences, and needs, which was not adhered to in this case.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to maintain the dignity of Resident #7 by not ensuring her urinary catheter bag was covered with a privacy cover. Resident #7, who has severe cognitive impairment, was observed on two separate occasions with her catheter bag exposed, contrary to her care plan which specified the use of a privacy cover. Interviews with staff, including a CNA, RN, and the DON, confirmed that it is the facility's expectation to cover catheter bags to maintain resident dignity, although the facility's catheter care policy did not explicitly mention the use of covers. Resident #47 experienced a delay in being served lunch compared to other residents at her table on two consecutive days. Despite being present in the dining room and seated with other residents, she had to wait approximately 20 to 25 minutes longer than her tablemates to receive her meal. Interviews with the DON, Kitchen Manager, and RN A revealed that the facility's policy is to serve all residents at a table simultaneously when possible, but communication lapses between dining room staff and kitchen staff led to Resident #47 being overlooked. Both deficiencies highlight the facility's failure to adhere to its own policies and procedures, impacting the residents' dignity and quality of life. The lack of a privacy cover for Resident #7's catheter bag and the delayed meal service for Resident #47 were attributed to staff oversight and communication issues, respectively, as confirmed by staff interviews and observations.
Failure to Follow Wound Care Orders and Notify Physician
Penalty
Summary
The facility failed to immediately inform the resident's physician when a nurse was unable to follow wound care orders for a resident with a Stage 4 pressure ulcer. The resident, who had moderate cognitive impairment, was supposed to have a wound vacuum attached to his coccyx wound, but the nurse applied a wet to dry dressing instead. The nurse did not notify the physician or document the change in treatment, which could have delayed the healing process of the resident's wound. The nurse, identified as RN C, was a weekend supervisor and not specialized in wound care. She admitted to having difficulty with the wound vacuum and decided to use a wet to dry dressing without consulting the physician. RN C also failed to document her actions and did not request assistance from the on-call nurse. The resident expressed concern about the change in treatment and the lack of proper wound care, indicating that this was not the first time the wound vacuum was not replaced as ordered. The Director of Nursing (DON) and the facility's administration acknowledged the failure to follow physician orders and the lack of documentation. The DON stated that the nurse should have notified the physician and family of any changes in wound care. The facility's policy on skin integrity management requires wound care to be performed as ordered by the physician, which was not adhered to in this case.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for Resident #49, who had a Stage 4 pressure ulcer on the coccyx. The resident was supposed to have a wound vacuum dressing applied as per the physician's orders, but RN C applied a wet to dry dressing instead. This deviation from the prescribed treatment was not documented, and the physician was not notified of the change in wound care. Resident #49, a male with moderate cognitive impairment, was admitted with a diagnosis of a Stage 4 pressure ulcer. The care plan specified the use of a wound vacuum to be changed three times a week to promote healing. However, during an observation, the resident reported that the wound vacuum was not applied, and a wet to dry dressing was used instead. The wound vacuum machine was observed at the bedside, unattached and without a reservoir. Interviews revealed that RN C, who was not a specialized wound care nurse, decided to use a wet to dry dressing due to difficulties with the wound vacuum and did not document the care provided. The DON and other staff confirmed that supplies were available, and the nurse should have followed the physician's orders. The failure to adhere to the prescribed wound care regimen could have delayed the healing process for Resident #49.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper wound care provided to Resident #49, who had a Stage 4 pressure ulcer on the coccyx. During an observation, RN A was seen contaminating supplies prior to wound care and using contaminated scissors to cut foam, which was then placed into the open wound. This breach in standard precautions occurred despite the facility's policy that required a clean and dirty area to be maintained during wound care procedures. Resident #49, a male with moderate cognitive impairment, was admitted with a diagnosis of a Stage 4 pressure ulcer. The care plan required the use of a wound vac to be changed three times a week. RN A, who was not wound care certified and had received informal training, was temporarily assigned to perform wound care. The Director of Nursing and the Administrator acknowledged the failure to follow infection control protocols, which posed a risk of infection and delayed wound healing for the resident.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in the maintenance and replacement of respiratory equipment. Resident #1, a female with dementia and dysphagia, was observed receiving oxygen therapy via nasal cannula from an air concentrator. The facility did not replace her oxygen tubing and humidifier bottle every seven days as required, and the air concentrator filter was found to be covered in dust and debris. Despite having orders to change the respiratory concentrator water and clean the filter weekly, these tasks were not consistently completed, as evidenced by the dates recorded on the equipment. Resident #2, a female with athetoid cerebral palsy, cystic fibrosis, and dementia, was also not provided with proper respiratory care. Her nebulizer tubing and mask, including the nebulizing chamber, were not replaced every seven days as required. The nebulizer equipment was found bagged at her bedside with outdated markings, indicating a lack of adherence to the facility's schedule for equipment changes. The facility's records did not show any indication of treatment or completion of the required changes for the dates reviewed. Interviews with facility staff, including an LVN, RN, and the ADON, confirmed that respiratory equipment should be changed weekly or more frequently if soiled. However, observations and interviews revealed that these procedures were not followed, leading to potential risks of respiratory infection for the residents. The facility's policies and procedures manual also outlined the need for weekly cleaning and replacement of respiratory equipment, which was not adhered to, as confirmed by the ADON and the Administrator.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for three residents who were reviewed for medication and treatment errors. The facility did not follow physician's orders for providing wound care to these residents on a regular basis, which could place them at risk of delayed wound infection and healing processes. Resident #1, a male with multiple diagnoses including osteomyelitis and protein-calorie malnutrition, had a stage 3 pressure ulcer on his right heel. The care plan required specific treatments, including wound vac and dressing changes, which were not consistently administered as per the physician's orders. The Wound Administration Record (WAR) indicated missed treatments on several dates in April and May 2024. Resident #2, a female with severe cognitive impairment and multiple pressure ulcers, also did not receive prescribed wound care treatments on several occasions. Her care plan included cleansing and dressing of various wounds, which were not performed as ordered. Similarly, Resident #3, a female with a stage 3 pressure ulcer, did not receive the required treatments on multiple dates. Interviews with the LVN and DON suggested that the omissions might be due to documentation errors rather than neglect in care, but the incomplete WAR made it difficult to confirm this.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during wound care, as observed by surveyors. The incident involved a female resident with multiple diagnoses, including psychotic disturbance, anxiety, hemiplegia, and a stage 3 pressure ulcer. During a wound care procedure, the Director of Nursing (DON), an RN, and a CNA entered the resident's shared room, closed the door, but neglected to draw the privacy curtain. This oversight exposed the resident's chest area to the room, potentially visible to anyone entering unexpectedly. Interviews with the involved staff confirmed the lapse in privacy protocol. The CNA acknowledged the privacy curtain should have been closed, while the RN admitted the resident's privacy and dignity were compromised. The DON explained that the wound care team was nervous and forgot to draw the curtain, despite the resident's roommate being frequently in and out of the room. The facility's in-service records showed no training on residents' privacy or rights during the relevant period, and the facility's policy emphasized the resident's right to privacy and dignity.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hearne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franklin Nursing Home | 12.7 mi | ★★★★★ | 1 | 0 |
| Lampstand Nursing And Rehabilitation | 20.1 mi | ★★★★★ | 22 | 0 |
| Avir At Bryan | 20.3 mi | ★★★★★ | 19 | 0 |
| Crestview Retirement Community | 20.3 mi | ★★★★★ | 2 | 0 |
| Legacy Nursing And Rehabilitation | 20.8 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.