Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crown Point Health Suites during CMS and state inspections, most recent first.
Failure to Provide Grievance Procedure Information: The facility did not provide 10 of 10 confidential residents with information about the grievance process, including how to file an anonymous grievance, where to get a grievance form, who to submit it to, and the right to a written decision. Residents stated the grievance procedure had not been discussed in Resident Council and they had not seen required postings in prominent locations. The ADM said she was the grievance officer, forms were available from her and the DON, and there was no protocol for anonymous grievances.
Food service safety standards were not followed when a cook and kitchen staff failed to label and date multiple refrigerated and frozen food items, including meats, cheese, fruit, and prepared foods. Surveyors also observed dirt and stains on the iced tea machine, greasy stains on the refrigerator and freezer doors, and corrosion on the dish area faucets. Interviews showed the cook, RD, DM, and ADM each identified staff responsibility for dating, labeling, and cleaning, and facility policy required foods to be covered, labeled, and dated and equipment to be kept clean and free of corrosion.
Inaccurate PASARR Level 1 Screening for Resident with Mental Illness Diagnoses: A resident with psychotic disorder, major depressive disorder, and severe cognitive impairment had a PL1 that incorrectly indicated no mental illness, and no updated PL1 screening was provided. The MDS Coordinator and ADM acknowledged that the resident’s diagnoses met criteria for mental illness and that the PL1 should have been updated when the diagnosis was identified.
A resident with moderate cognitive impairment experienced a fall during a transfer, resulting in minor skin tears. Although the resident was assessed and treated by an LVN, the family was not notified of the incident until the following day, after they noticed a bandage during a video call. Facility staff confirmed that notification protocols were in place, but the responsible nurse did not follow them, and the delay was only discovered after the family inquired.
A medication aide left multiple oral medications unattended in open cups at a resident's bedside, following the family's instructions and the resident's home routine, without verifying facility approval for self-administration. The resident was only approved to self-administer an inhaler, and facility policy required staff to remain with residents until medications were taken and to store all medications securely.
A resident with Parkinsonism, UTI, and moderate cognitive impairment exhibited confusion and exit-seeking behaviors, including attempts to leave the facility. Despite staff awareness of these behaviors, there was a lack of communication and no increase in supervision. The resident ultimately eloped in a motorized wheelchair and was found at a nearby church, with staff only learning of the incident after being notified by a community member.
The facility failed to maintain the privacy and dignity of three residents during care. One resident received peri care with open blinds, exposing them to the street. Another resident's urinary catheter bag was visible from the hallway without a privacy cover. A third resident was assisted to the toilet with the door open, exposing them to the hallway. These actions were contrary to the facility's policy on resident privacy and dignity.
A facility failed to protect residents' privacy when a CNA left a report book open in a hallway, exposing sensitive information, and an MA dropped a sticky note with a resident's medication details in a public area. Both staff members had been trained in privacy protocols, yet these lapses occurred, violating the facility's confidentiality policy.
The facility's kitchens were found to have multiple deficiencies in food safety and cleanliness, including unclean equipment, improperly stored food, and uncovered dishes. Staff interviews revealed a lack of awareness and adherence to proper procedures, despite training. These issues were observed across four kitchens, with potential risks of food contamination and illness.
The facility failed to maintain an effective infection control program, with staff not adhering to hand hygiene and PPE protocols. An LVN and RN did not follow proper handwashing procedures during wound care, and an MA did not sanitize hands between medication administrations. A CNA did not wear a gown for a resident on EBP, and two CNAs did not follow hand hygiene during peri care. The DON and Administrator were unaware of these lapses, despite regular staff training.
A resident with a urinary catheter was found with the catheter tubing touching the floor, posing a potential risk for urinary tract infections. Despite staff training on proper catheter care, the tubing was unsecured, contrary to facility policy. Interviews with staff, including an LVN, DON, and ADM, confirmed the oversight and acknowledged the infection risk.
A loose Buspar 5 mg tablet was found in the Ruby House medication cart, indicating a failure in proper medication storage. MA A, responsible for the cart, was unsure how the pill became loose but acknowledged her responsibility to check for such issues. ADON A identified and destroyed the pill according to protocol. The DON and ADM were unaware of the incident but emphasized the importance of proper storage and staff training.
A resident's rights and dignity were violated when facility staff accessed and removed personal possessions without consent. The resident, who was cognitively intact and had multiple chronic conditions, reported feeling violated. The facility's policy requires consent for searches, but this was not obtained, and no inventory list was maintained, leading to the violation.
A resident's package was opened by the ADON without consent, violating privacy policies. The package, assumed to contain medication, actually contained ammunition. The resident was cognitively intact and known to receive VA medications by mail. Facility policy mandates unopened mail delivery unless assistance is requested.
The facility failed to maintain an effective infection control program, with staff not adhering to hand hygiene and PPE protocols. A resident's care was compromised when CNAs did not wear required PPE or change gloves during care. Another resident's care was affected by a CNA not sanitizing hands between glove changes. Despite training, staff inconsistently followed infection control measures.
Failure to Provide Grievance Procedure Information
Penalty
Summary
The facility failed to provide residents and their representatives with information about their rights related to filing grievances for 10 of 10 confidential residents. During interviews and record review, all 10 residents stated they did not know they could file a grievance anonymously, that the grievance procedure had never been discussed in Resident Council, and that they had not seen a posting of the grievance procedure in prominent locations. The residents also stated they did not know where to obtain a grievance form, who to submit it to, what happens after a grievance is filed, or that they had the right to receive a written decision once the grievance was resolved. Observation on 04/09/2026 at 12:45 PM showed the facility’s prominent postings did not include instructions regarding the grievance procedure. On 04/10/2026 at 9:35 AM, the ADM stated she was the grievance officer, that grievance forms were available from her and the DON, and that forms could be submitted to any staff member. The ADM also stated there was no protocol for submitting a grievance anonymously and that the grievance procedure should have been explained at admission and continued in monthly Resident Council meetings. Record review showed the undated grievance policy stated a copy of the grievance/complaint procedure should be posted on the resident bulletin board, and the policy last updated in 2017 stated the grievance officer would investigate grievances and inform the resident or person filing the grievance of the findings.
Food Items Not Dated and Kitchen Equipment Not Kept Clean
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During a kitchen tour, surveyors observed a reach-in refrigerator and freezer with food items stored in clear plastic bags that were not labeled with a use-by date. Items observed included sliced cheese, sliced turkey, sliced ham, tortillas, grapes, bacon, onion rings, waffles, egg rolls, chicken tenders, meatballs, cheese enchiladas, and beef steak. The refrigerator and freezer doors also had greasy stains on both the right and left sides. Surveyors also observed the iced tea machine inside the kitchen beverage station with dirt and stains on its outer surface. In the dish/pot washing area, faucets were observed with corrosion. These conditions were documented during the kitchen tour and were identified as part of the facility's food service safety review. During interviews, the cook stated he was responsible for labeling and dating food items and cleaning the equipment, but said the food items were not dated because of a rush and last-minute changes. The RD stated the cook or kitchen staff were responsible for dating and labeling food items and keeping the kitchen clean, and the DM stated she and her staff were responsible for dating and labeling all food items and monitoring them. The facility policies reviewed stated that refrigerated and frozen foods must be covered, labeled, and dated, and that utensils, counters, shelves, and equipment must be kept clean and free from corrosion and other damage.
Inaccurate PASARR Level 1 Screening for Resident with Mental Illness Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the PASARR process for one resident reviewed for PASARR screening. Resident #1 was admitted with a primary diagnosis of peripheral vascular disease and had a medical history that included psychotic disorder with hallucinations due to a known physiological condition, vascular dementia, and major depressive disorder. The resident did not have a primary diagnosis of dementia. The quarterly MDS showed severe cognitive impairment with a BIMS score of 3 and listed psychotic disorder, depression, and anxiety as active diagnoses. Record review showed the resident’s PASARR Level 1 form dated 11/06/2023 indicated “No” for mental illness, and no additional PL1 screenings were provided by the facility. During interviews, the MDS Coordinator stated the resident had diagnoses of major depressive disorder and psychotic disorder, which classified as mental illness, and said that if a resident was admitted with an incorrect PL1 it would need to be corrected and a new PL1 completed. The Administrator stated that when a resident had a new diagnosis of mental illness, it was to be reassessed by the intradisciplinary team and the MDS Coordinator was responsible for ensuring the PL1 was updated. Facility policy stated that all residents admitted would have an appropriate PASARR screening and that if new or worsening mental health indicators were present, nursing would notify social services and a PASRR resident review would be initiated.
Failure to Immediately Notify Resident Representative After Fall
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's representative of a change in the resident's condition following a fall. The resident, a male with a history of orthopedic aftercare following a surgical amputation, acquired absence of the left leg below the knee, and dysphagia, was assessed as having moderately impaired cognition. On the date of the incident, the resident experienced a fall during a sliding board transfer, resulting in minor skin tears to his right hand. The incident was witnessed by a CNA, and the resident was assessed and treated by an LVN, who then sent the resident to dialysis as scheduled. Despite the facility's policy requiring prompt notification of the resident's representative in the event of an accident or injury, the LVN did not notify the family on the day of the fall. The LVN later stated that she believed the resident had informed his family during a phone call and admitted that the notification slipped her mind due to being approached by another resident's family after the incident. The family only became aware of the fall after noticing a bandage during a video call with the resident the following day, prompting them to contact the facility for information. Interviews with facility staff, including the LVN, DON, and administrator, confirmed that the charge nurse was responsible for notifying families of falls or changes in condition. The facility's documentation and inservice training records indicated that staff had been trained on notification protocols, but the LVN could not recall the specific training date. The DON and administrator acknowledged that the family should have been notified immediately, as per facility policy, but were unable to provide reasons for the delay in this instance.
Unattended Medications Left at Bedside by MA
Penalty
Summary
A medication aide (MA) failed to ensure that medications for a resident were secured, leaving multiple pills unattended in open medication cups on the resident's bedside table and nightstand. The resident, who was cognitively intact and admitted for respite care, reported that the MA routinely left her medications in this manner, following the resident's home routine as described by her family. The MA did not verify whether the resident had been assessed and approved for self-administration of medications, and instead relied on the family's instructions. Facility records showed that the resident was only approved to self-administer a specific inhaler at bedside, with no approval for unsupervised administration of oral medications. The MA acknowledged that she did not check the resident's self-administration assessment and admitted to leaving medications unattended for this resident, but not for others. The MA also stated that she separated the medications into two cups for the resident's convenience and would check back later to see if the medications had been taken. Interviews with the Director of Nursing (DON) and the Administrator confirmed that facility policy requires staff to remain with residents until all medications are taken and prohibits leaving medications unattended. Both stated that staff must follow the facility's process for self-administration, regardless of family input. Facility policy and competency assessments further confirmed that medications must be stored securely and only authorized personnel should have access, and that staff are expected to remain with residents during medication administration.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with a history of Parkinsonism, urinary tract infection (UTI), and cognitive communication deficit. The resident, who was moderately cognitively impaired and used a motorized wheelchair, exhibited confusion and exit-seeking behaviors on the night prior to the incident, including attempts to leave the facility and searching for his keys and truck. Staff attempted to redirect him and involved family members, but did not implement increased supervision or remove the motorized wheelchair at that time. On the morning following these behaviors, the resident again attempted to leave the facility through an unlocked service door, and staff redirected him back inside. However, this incident was not clearly communicated up the chain of command, and no additional supervision or interventions were put in place. Later that afternoon, the resident successfully eloped from the facility in his motorized wheelchair and traveled to a local church approximately 0.17 miles away. Facility staff were unaware of his absence until notified by a community member, at which point the resident was retrieved and assessed for injuries. Interviews with staff revealed a lack of clear communication regarding the resident's exit-seeking behaviors and attempts to leave the facility. Several staff members, including CNAs and LVNs, were aware of the resident's confusion and attempts to exit, but these incidents were not consistently reported to nursing leadership or acted upon with increased supervision. The facility's policies required staff to report such behaviors and implement interventions, but these steps were not followed, resulting in the resident's unsupervised elopement.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the privacy and dignity of three residents during care, as observed by surveyors. For one resident, two CNAs provided peri care without closing the blinds, exposing the resident to the street view. The resident's medical history included high blood pressure, heart disease, and dementia, among other conditions. The CNAs admitted to not paying attention to the blinds and acknowledged the importance of privacy during care. Another resident, who had a urinary catheter due to urine retention, was observed with the catheter bag visible from the hallway without a privacy cover. The resident expressed a preference for the bag to be covered to maintain privacy. The facility's policy required privacy covers for urinary catheter bags, but this was not adhered to in this instance. A third resident, with a history of metabolic encephalopathy and moderate cognitive impairment, was assisted to the toilet by a CNA without the door being closed, leaving the resident exposed to the hallway. The CNA acknowledged the oversight and cited space constraints as a reason for not closing the door. The facility's policy emphasized the importance of maintaining resident privacy and dignity during care, which was not upheld in these cases.
Privacy Breach in Resident Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, affecting 14 residents. A Certified Nursing Assistant (CNA) left a 24-hour report book open on a table in the hallway of Emerald Hall, which was visible to others. This book contained sensitive information about residents, including their care needs and medical conditions. The CNA admitted that leaving the book in the hallway was a common practice, despite being trained in privacy protocols. Additionally, a Medication Aide (MA) compromised the privacy of a resident by writing the resident's name and medication information on a sticky note, which was then accidentally dropped in a public area. The MA acknowledged the mistake and recognized that it was inappropriate to write down personal information in such a manner. Both staff members involved had received training on privacy and confidentiality, yet these lapses occurred. The facility's policy on confidentiality and personal privacy, revised in October 2017, mandates the protection of residents' personal and medical records. The policy outlines that access to such information should be limited to authorized personnel. Despite this policy, the actions of the CNA and MA resulted in the potential exposure of residents' private information, which could lead to unauthorized access and misuse.
Food Safety and Cleanliness Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage in four kitchens, leading to potential risks of food contamination and foodborne illness. In Kitchen A, observations revealed unclean drawer and oven handles, improperly stored food in the refrigerator and freezer, and uncovered dishes. The ice machine was also found to have dried substances near the ice dispensing area. Staff interviews indicated a lack of awareness regarding labeling and covering food items, as well as maintaining cleanliness. In Kitchen B, a large bag of mozzarella cheese was found unsealed in the refrigerator, and the microwave was observed with dry, hard substances on various parts. Staff admitted to not sealing the cheese properly due to being in a hurry and acknowledged the potential for food to lose freshness or cause illness. Kitchen C had similar issues with unclean refrigerator and freezer handles and uncovered dishes. The dietary manager expressed surprise at these findings, indicating a belief that cleaning had been done the previous night. In Kitchen D, the ice machine was again found with a thick layer of dried substances. Staff interviews revealed uncertainty about the last cleaning date of the ice machine, despite training on maintaining cleanliness. Additionally, an incident was observed where a staff member delivered a plate of cake with a thumb in the icing, acknowledging the mistake but proceeding with the delivery. The dietary manager and assistant director of nursing expressed expectations for proper food sealing and cleanliness, yet were unsure how these failures occurred despite ongoing monitoring and training.
Infection Control Deficiencies in Hand Hygiene and PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple staff members not adhering to hand hygiene and personal protective equipment (PPE) protocols. LVN B and RN A did not follow proper handwashing procedures while providing wound care to residents with pressure ulcers, which could lead to the spread of infections. Both staff members acknowledged their understanding of the handwashing policy but failed to comply during the observed procedures. Additionally, MA A did not sanitize hands between administering medications to two residents, increasing the risk of cross-contamination. Despite being trained on proper hand hygiene, MA A admitted to making a careless mistake. Furthermore, CNA A did not wear the required gown while assisting a resident on Enhanced Barrier Precautions (EBP), and both CNA B and CNA C did not follow hand hygiene protocols while providing peri care to another resident. The Director of Nursing (DON) and the Administrator were unaware of these lapses in infection control practices. They stated that staff were trained on hand hygiene and EBP through regular in-services and competency checks. However, the failure to adhere to these protocols during care activities indicates a significant deficiency in the facility's infection prevention and control program.
Improper Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, leading to a potential risk of urinary tract infections. The resident, an 87-year-old female with a history of acute respiratory failure, influenza, and urinary retention, was observed with her catheter tubing touching the floor. This observation was made during a survey, and the resident was unable to recall when her urinary drainage bag was last emptied. Interviews with facility staff, including an LVN, the Director of Nursing (DON), and the Administrator (ADM), revealed that the staff had been trained to keep catheter tubing off the floor to prevent infections. However, the catheter tubing was found unsecured and touching the ground, contrary to the facility's policy. The DON and ADM acknowledged the potential risk for infection due to this oversight, as the facility's policy clearly stated that catheter tubing and drainage bags should be kept off the floor to prevent complications.
Improper Medication Storage on Ruby House Cart
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals, as evidenced by the discovery of a loose pill in the Ruby House medication cart. During an observation, a loose Buspar 5 mg tablet was found in the bottom drawer of the medication cart. Medication Aide (MA) A, who was responsible for the cart, was unsure how the pill became loose but acknowledged it was her responsibility to check for such issues. The Assistant Director of Nursing (ADON) A identified and destroyed the pill according to facility protocol. Both MA A and ADON A confirmed that loose pills should not be present on the cart, and that weekly spot checks were conducted to ensure proper medication storage. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of the loose pill incident. They reiterated that medications should be stored properly at all times and that staff were trained on proper storage through periodic in-services and weekly audits. The facility's policy on medication labeling and storage, revised in February 2023, outlines that medications should be stored in their original packaging and that nursing staff are responsible for maintaining clean and safe storage areas. The policy also specifies that each resident's medications should be stored separately to prevent mixing.
Violation of Resident's Rights and Dignity
Penalty
Summary
The facility failed to respect the rights and dignity of a resident by going through and removing personal possessions without consent. The resident, a cognitively intact male with multiple chronic conditions including PTSD and COPD, reported feeling violated when staff accessed his belongings during his hospitalization. The facility's administrator and DON acknowledged that the resident's family had not given consent for the search, and the maintenance supervisor, accompanied by the ADON, conducted the search, finding knives and a straight razor among the resident's possessions. The facility's policy on personal property states that residents are allowed to retain personal possessions unless they pose a risk to others, and searches should only be conducted with the resident's or representative's consent. However, the facility did not adhere to this policy, as there was no inventory list completed upon the resident's admission or updated during his stay. The lack of consent and inventory documentation contributed to the violation of the resident's rights.
Violation of Resident Privacy in Mail Handling
Penalty
Summary
The facility failed to ensure the right to personal privacy for a resident by opening a package addressed to him without his consent or presence. The resident, a cognitively intact male with multiple chronic conditions, was admitted to the facility and was known to receive medications by mail from the VA. A package addressed to him was opened by the Assistant Director of Nursing (ADON) under the assumption that it contained medication, as it arrived after the resident had been discharged to the hospital. However, the package contained ammunition, not medication. The facility's policy on mail and electronic communication, revised in May 2017, clearly states that residents' mail should be delivered unopened unless the resident requests assistance, which should be documented in their care plan. The ADON's action of opening the package without the resident's consent or presence was contrary to this policy. Interviews with other residents revealed no issues with staff, indicating this incident was isolated to the resident in question.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to proper hand hygiene and personal protective equipment (PPE) protocols. Specifically, three residents and four staff members were involved in these deficiencies. For Resident #1, CNA A and CNA B did not wear the required PPE, such as gowns, while providing care under Enhanced Barrier Precautions. Additionally, CNA A did not change gloves or sanitize hands during and after providing incontinent care, and failed to sanitize hands upon leaving the resident's room. For Resident #2, CNA D did not sanitize hands between glove changes during incontinent care, despite being trained on proper hand hygiene. This oversight occurred even though the resident's room had an Enhanced Barrier Precautions sign, indicating the need for strict adherence to infection control measures. CNA C, who was also involved in the care, followed proper procedures by sanitizing hands between glove changes. Resident #3's care was compromised when CNA E did not change gloves between clean and dirty aspects of incontinent care. Although CNA E washed hands before starting care, the failure to change gloves during the process was a breach of infection control protocols. Interviews with the staff involved revealed a lack of consistent adherence to infection control training, despite regular in-services and training sessions provided by the facility.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 158 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Lubbock | 2.2 mi | ★★★★★ | 17 | 3 |
| Hansford County Hospital District Dba Lakeridge Nu | 2.3 mi | ★★★★★ | 12 | 0 |
| Mesquite Post Acute Care | 3.5 mi | ★★★★★ | 11 | 0 |
| Mi Casita Nursing And Rehabilitation Center | 3.6 mi | ★★★★★ | 15 | 0 |
| Lakeside Rehabilitation And Care Center | 4 mi | ★★★★★ | 7 | 0 |
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