Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Cypress Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Resident Council grievances and recommendations were not consistently addressed or documented by facility leadership. Residents raised repeated concerns about food quality and temperature, housekeeping, staffing, activities, and staff interactions, but grievance records showed no grievances were created for the issues discussed in council minutes. Interviews with the SW, AD, and ADM showed unclear responsibility for follow-up and no clear process for sharing responses back to the council, despite facility policy requiring administrator review and responses to be presented at the next meeting.
Stained Carpets and Urine Odor on Resident Halls: The facility failed to maintain the 100-hall and 500-hall in a clean, comfortable, and homelike condition because both hall carpets had multiple red and grey stains and a foul odor similar to old urine. The MAINTD, FT, HKS, DON, and ADM all acknowledged the ongoing issue, stating the carpets had been professionally steam cleaned multiple times but the stains and odor remained, and grievances from residents and family members had been made about the odor.
Failure to Provide Individualized Activity Program: The facility did not provide an ongoing activity program based on residents’ assessments, preferences, and care plans for multiple residents. Several residents with dementia, stroke-related deficits, depression, mobility limitations, or other chronic conditions were observed sitting in the TV room for long periods without activities being offered, while others were not offered in-room activities or materials for independent activities. Records showed missing or incomplete activity assessments and no documentation of participation for many residents, despite stated preferences such as religious services, music, reading, socials, bingo, outside time, and one-to-one interaction.
Kitchen Food Items Found Undated and Unlabeled: An observation found multiple food items in the kitchen refrigerator stored without required labels or dates, including cheese, Vegetarian Burgers, bacon, turkey breast, and strawberries. Kitchen staff and the DM stated food should be labeled and dated after opening and described the facility's FIFO system, while the facility policy stated to label and date all food items.
A facility failed to include activity preferences in the comprehensive care plans for 6 residents, despite MDS assessments documenting interests such as going outside, religious services, reading, music, favorite activities, group activities, and keeping up with the news. Care plans instead focused on issues such as depression, wandering, mood, psychosocial well-being, or impaired cognition, and staff interviews showed confusion about who was responsible for activity-related care planning. Observations also showed residents sitting in the TV room without activity invitations and one resident reporting that staff had not asked him about activities.
Failure to Provide ADL Assistance and Hygiene Care: Two residents did not receive bathing, grooming, and dressing assistance as reflected in their care plans and facility documentation. One resident with hemiplegia, dementia, and diabetes had long, dirty fingernails, greasy hair, and limited shower documentation, while another resident with dementia and limited mobility remained in the same hospital gown for days and reported not getting a shower or clothing change. Staff interviews showed gaps in CNA documentation, shower tracking, and communication with the LVN, WCN, and DON.
Infection control failures occurred when an RN used the same BP cuff on two residents without cleaning it between uses, a CNA entered and exited a resident's room without sanitizing hands as required, and a CNA provided peri-care with inadequate cleansing using the same wipe on fecal matter and the buttocks area. The residents involved had significant medical conditions, including EBP needs, fractures, dementia, and ESRD with dialysis, and staff acknowledged the expected infection control practices.
A resident's confidential medical information was left visible on a tablet attached to a medication cart when an LVN left the device unattended during a med pass. Staff interviews confirmed awareness of HIPAA and privacy requirements, and facility policy restricts access to authorized personnel only. The incident resulted in a breach of privacy due to failure to lock or minimize the screen.
Two residents receiving hospice care, both with intact cognition, reported that a CNA failed to communicate respectfully when removing food trays and responding to call lights, leading to feelings of being devalued and emotional distress. Staff interviews confirmed the residents' complaints, and facility policy required immediate reporting and investigation of such incidents.
A resident with type 2 diabetes and moderate cognitive impairment repeatedly refused both insulin and oral diabetes medications over several weeks. Staff did not notify the provider of these refusals or document education provided to the resident, despite facility policy and staff expectations requiring such actions.
Surveyors identified multiple deficiencies in food safety and infection control, including improper hand hygiene by dietary staff, failure to check produce quality, lack of training and record-keeping for dishwasher sanitation, and improper storage and labeling of refrigerated foods. The facility also did not maintain required documentation for dietary in-services and staff training.
Surveyors observed persistent foul odors of urine and feces on two halls, with staff and a family member confirming the issue and attributing it in part to old carpeting. Despite some residents not noticing the odors, the facility did not meet its policy to maintain a clean and odor-free environment.
Staff failed to consistently treat residents with dignity and respect by not assisting a resident with feeding in an attentive manner and by entering the rooms of three residents without knocking, despite facility policy and staff training requiring respect for privacy and proper use of personal cell phones during care.
The facility did not ensure a private space for resident council meetings, resulting in repeated interruptions by staff and family members despite residents' requests for privacy. Interviews confirmed that meetings were routinely held in dining areas where privacy was not maintained, and staff acknowledged the lack of effective measures to provide a confidential environment as required by facility policy.
Three residents with significant medical and cognitive needs had personal care and treatment instructions posted in their rooms, including reminders for barrier cream application and positioning to prevent pressure sores. The signage, intended for staff, was visible in the residents' living spaces and made the residents feel uncomfortable and that their privacy was not respected. Staff interviews confirmed the use of these signs for care reminders, despite facility policies on resident privacy and dignity.
Staff failed to supervise a resident during medication administration, leaving pills unattended at the bedside without a self-administration evaluation or care plan. Expired medications and supplies were found on two medication carts and in the medication storage room, despite staff being responsible for regular checks. Residents affected had complex medical conditions and required careful medication management, but facility policies for safe administration and storage were not followed.
Surveyors found that medication carts and storage areas were left unlocked and unattended, contained loose and unlabeled prescription medications, and included opened glucose control solution without proper dating. Staff interviews confirmed that these actions were not in line with facility policy, which requires all drugs and biologicals to be stored securely, labeled correctly, and maintained in their original packaging.
Surveyors found that the facility failed to provide meals that met residents' nutritional needs and preferences, with food often served at improper temperatures, lacking flavor, and not following current menus. Multiple residents expressed dissatisfaction, frequently refusing meals or choosing alternatives due to poor quality. Staff did not consistently document meal refusals or substitutions as required by policy, and food storage practices were not properly followed.
The facility did not consistently prepare or serve food in a way that maintained flavor, appearance, or safe temperatures, with observations of early meal preparation, improperly stored and rotting produce, and meals lacking taste and proper temperature. Multiple residents reported dissatisfaction with the food, describing it as cold, flavorless, and unappetizing, and staff interviews confirmed awareness of these issues and lapses in documentation and food quality checks.
A resident with physical disabilities and diabetes did not receive required fingernail care, despite being unable to perform personal hygiene independently. Staff observations and interviews revealed the resident's nails were long and untrimmed, and there was confusion among CNAs and nurses about responsibility and procedures for nail care, especially for diabetic residents. The facility's policy required nurses to provide and document nail care, but this was not consistently followed, resulting in the resident not receiving adequate grooming.
The facility did not ensure pureed foods were prepared with appropriate liquids, as a cook used water instead of following established recipes, and residents reported dissatisfaction with meal quality, flavor, and variety. Staff interviews revealed lapses in training documentation and adherence to dietary policies, contributing to inadequate food service and unmet resident needs.
The facility failed to maintain a clean and homelike environment in four resident rooms, with observations of food particles, debris, and soiled briefs left in the rooms. Staff interviews revealed short-staffing issues, and the DON acknowledged the uncleanliness did not meet expectations, emphasizing the importance of cleanliness for infection control.
A resident with severe cognitive impairment received a COVID-19 vaccine without her representative's consent. The facility's outdated charting system led a nurse to mistakenly believe the resident could consent, despite her representative having previously declined the vaccine. Staff interviews highlighted the resident's inability to understand the vaccine, contradicting the DON's belief in her decision-making capacity.
The facility failed to store medications securely, with two residents found having medications at their bedside without proper orders. One resident had Chloraseptic lozenges and medicated vapor rub, while another had anti-fungal powder and wound dressing cream. Staff interviews revealed a lack of awareness and adherence to policies requiring orders for all medications, including over-the-counter ones, and secure storage. Facility policies emphasized the need for secure storage and administration according to orders, but these were not followed, leading to the deficiency.
The facility failed to ensure proper medication management for two residents, leading to deficiencies. A resident with Parkinson's disease had unauthorized Chloraseptic lozenges and vapor rub at her bedside, while another resident with diabetes had anti-fungal powder and wound dressing without a physician's order. Staff interviews revealed a lack of adherence to policies requiring orders for all medications, including over-the-counter ones, and proper storage to prevent unauthorized access.
A resident was subjected to physical and emotional abuse by a CNA who forcefully dragged her to the shower room and sprayed her with water while she was fully clothed. Despite the resident's distress and refusal to shower, the CNA continued the abusive behavior, claiming to act on instructions from the DON. The DON failed to take immediate action to protect the resident, allowing the CNA to continue working and taunting the resident. This failure resulted in an Immediate Jeopardy situation, highlighting the facility's inadequate response to abuse prevention and investigation.
A resident with a history of mental health issues was subjected to physical and emotional abuse by a CNA, who forcefully showered her against her will. Despite being notified, the DON failed to take immediate action, allowing the CNA to continue working with the resident, leading to further emotional distress. The facility's policies on abuse prevention were not followed, resulting in an Immediate Jeopardy situation.
A resident with a history of mental health disorders was forcefully dragged to the shower and sprayed with water by a CNA, despite her protests. The DON was informed but failed to act, allowing the CNA to continue working with the resident. Witnesses reported the abuse, but the facility did not report it to the Administrator in a timely manner, resulting in Immediate Jeopardy.
A cognitively intact resident was forcefully dragged to the shower room by a CNA, sprayed with water while fully clothed, and laughed at, causing distress and hair loss. Despite being informed, the DON failed to investigate or report the incident, allowing the CNA to continue working on the same hall, further traumatizing the resident. The facility's inaction led to an Immediate Jeopardy situation.
Resident Council Grievances Not Addressed
Penalty
Summary
The facility failed to consider the views of the Resident Council and act promptly on grievances and recommendations raised in council meetings from October 2025 through June 2026. Review of Resident Council minutes showed repeated resident requests and concerns, including more weekend activities, more staff in the dining room during meals, better restroom cleaning, more hot chocolate, staff introductions when agency staff were used, reminders for staff to knock before entering, improved food texture and temperature, more crafts and art-related activities, updated busy boards, and additional snacks and tea parties. The minutes also reflected requests for a garden, beef enchiladas, and more frequent review of no-name clothing for donations. Review of the grievance records showed no grievances were created for any of the concerns and requests listed in the Resident Council minutes from October 2025 through June 2026. During a confidential group interview, seven residents stated staff did not follow up with them on grievances discussed in the monthly Resident Council meetings. They reported ongoing concerns with food, housekeeping, facility administration, and requested activities that were not happening. They also stated staff told them their concerns were small, but the residents did not view them that way. During interviews, the SW stated she was the grievance official but was not sure she had received any grievances from Resident Council since starting at the facility in August 2026. The AD stated grievances from Resident Council were written on separate paper and given to the ADM, but she did not know what happened after that and did not think about sharing resolutions back with the Resident Council. The ADM stated she felt she had addressed all Resident Council grievances, but also stated some issues kept arising and might not have continued to be addressed. Facility policy required the Administrator to review minutes and responses from departments, with responses presented at the next meeting or sooner if indicated.
Stained Carpets and Urine Odor on Resident Halls
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment on the 100-hall and 500-hall because the carpets in both areas were stained and had foul odors. Observation on 06/24/2026 found 15 red or grey stains on the 500-hall carpet outside resident rooms, including three red stains measuring 3-4 inches in diameter and grey stains measuring 9-14 inches in diameter, along with a moderate unpleasant odor similar to old urine coming from the carpet. Observation on 06/25/2026 found 24 red or grey stains on the 100-hall carpet and a mild foul odor similar to old urine coming from the carpet. During interviews, the MAINTD, FT, HKS, DON, and ADM all acknowledged the stains and urine odor on the 100-hall and 500-hall carpets. They stated the carpets had been professionally steam cleaned multiple times over the previous months, but the stains and odor remained. The FT stated he could only do spot treatments and that the only way to eliminate the smell would be to tear up the carpets and install new flooring. The HKS stated residents and family members had complained about the stains and especially the odor. Review of grievances from January 2026 to June 2026 included complaints about odor on the 500-hall and a resident room smelling like urine on the 500-hall.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program based on residents’ comprehensive assessments, care plans, and preferences for 13 of 17 residents reviewed for quality of life. The deficiency involved residents who were observed spending prolonged periods in the central television room in their wheelchairs without activities being offered beyond watching television, residents who were not offered in-room activities, and residents who were not provided materials for independent activities. The report states these failures placed residents at risk of boredom, depression, and loneliness. Resident #16 had diagnoses including transient cerebral ischemic attacks, malnutrition, and atherosclerosis. His MDS reflected moderately impaired cognition, and his activity preferences included going outside when the weather was good and participating in religious services. His initial activity assessment noted he was interested in activities, but there was no information documenting specific interests or notes, no activity care planning, and no documentation of his participation in activities anywhere in the clinical record. Resident #22 had diagnoses including repeated falls, moderate dementia, adjustment disorder with depressed mood, and mobility-related impairments. Her records reflected intact cognition on MDS, but her quarterly activity assessment described her liking the TV room, coffee, outside socials, bowling, movies, and watching sports with friends. Her care plan addressed wandering and suggested pleasant diversions, but her participation in activities was not documented anywhere in the record. Resident #24 had diagnoses including cerebral infarction, aphasia, hemiplegia, bipolar disorder, major depressive disorder, vascular dementia, anxiety, insomnia, and tremor. Her MDS reflected intact cognition, her care plan addressed dependence on staff for activities and social interaction, and her participation in activities was not documented anywhere. Resident #36 had hemiplegia, gait and coordination problems, vascular dementia, dysphasia, and malaise; his MDS showed moderately impaired cognition and his preferences included music, group activities, favorite activities, and religious services, but his activity assessment lacked specific interests and his participation was not documented. Resident #51 had hypertensive heart disease, chronic kidney disease, dementia, depression, insomnia, pain, and anxiety; her activity assessment noted food socials and her care plan identified preferred activities such as bingo, going outside, and Catholic Mass, but her participation was not documented. Similar findings were documented for Residents #60, 67, 72, 85, 8, 52, 31, and 63, including missing or incomplete activity assessments, lack of documentation of participation, failure to offer in-room or independent activities, and care plans that did not reflect residents’ stated preferences or needs.
Kitchen Food Items Found Undated and Unlabeled
Penalty
Summary
The facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. On 06/23/2026 at 9:10 AM, an observation of the facility refrigerator found multiple food items stored without the required labeling and date marking, including one large plastic bag of cheese, one large bag of Vegetarian Burgers, one box of natural smoked bacon, one bag of turkey breast, and three containers of strawberries. The items were identified as undated and unlabeled during the kitchen observation. During interviews on 06/25/2026, kitchen staff stated they had recently been trained on labeling and dating food and described the facility's use of a first in, first out system. Staff stated food should be labeled and dated after opening, and that failure to do so could result in residents becoming sick. The DM stated it was his expectation that all kitchen items be labeled and dated and that he had trained staff daily on these topics. Review of the facility policy titled, Food Storage Dated, dated 6/1/2026, stated to label and date all food items.
Missing activity preferences in resident care plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for activity preferences for 6 of 13 residents reviewed. Residents #16, #22, #31, #8, #67, and #72 each had documented activity preferences on their MDS assessments, but their care plans did not include those preferences. The report states that this left no care planning for activity preferences in each of those residents’ care plans. Resident #16 was admitted with diagnoses including transient cerebral ischemic attacks, malnutrition, and atherosclerosis. His admission MDS reflected moderately impaired cognition and noted that it was somewhat important to him to go outside when the weather was good and to participate in religious services. His care plan addressed risk for depression, but did not include activity preferences. Resident #22 had diagnoses including repeated falls, moderate dementia, adjustment disorder with depressed mood, gait and mobility abnormalities, muscle wasting and atrophy, and muscle weakness. Her admission MDS showed intact cognition and recorded no activities as important to her, and her care plan addressed elopement risk/wandering but did not include activity preferences. Resident #31 had diagnoses including cerebral infarction, memory deficit following cerebrovascular disease, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, lack of coordination, Alzheimer’s disease, major depressive disorder, and anxiety disorder. Her admission MDS showed severely impaired cognition and identified that it was very important to her to do things with groups of people and favorite activities, and somewhat important to have books, magazines, or newspapers to read; her care plan addressed wandering but not activity preferences. Resident #8 had diagnoses including cognitive communication deficit, muscle weakness, muscle wasting and atrophy, and mild cognitive impairment. His annual MDS showed moderate cognitive impairment and recorded no activities as important to him; his care plan addressed impaired cognitive function but not activity preferences. Resident #67 had diagnoses including cerebral infarction, hypertensive heart disease, mood disorder, gait and mobility abnormalities, cognitive communication deficit, lack of coordination, and muscle weakness. His admission MDS showed intact cognition and noted that it was somewhat important to keep up with the news; his care plan addressed mood problems but not activity preferences. Resident #72 had diagnoses including age-related cognitive decline, muscle wasting and atrophy, lack of coordination, muscle weakness, repeated falls, cognitive communication deficit, and history of falling. Her annual MDS showed severe cognitive impairment and identified that it was very important to go outside when the weather was good and somewhat important to have books, magazines, newspapers, music, favorite activities, and time with groups of people; her care plan addressed psychosocial well-being but not activity preferences. During observation, Resident #8 stated staff did not give him much to do and that he mostly watched television, and he said no staff had asked him about activities. Resident #31 was observed walking around the facility looking for her car and checking doors and windows. Residents #67, #72, #22, and #16 were observed in wheelchairs in the central television room, and the AD did not enter the room to invite any residents to an activity during the observation period. Facility staff interviews reflected uncertainty about responsibility for activity-related care planning, and the ADM stated she had not noticed that several residents did not have care planning for activity preferences during audits. Facility policy required an individualized activity care plan for each resident after the activity assessment and MDS, with review and updates at least quarterly and with changes of condition.
Failure to Provide and Document ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the necessary assistance with bathing, grooming, and personal hygiene for two residents reviewed for ADL care. Resident #13, a male with diagnoses including hemiplegia and hemiparesis, sequela of cerebrovascular disease, muscle weakness, type 2 diabetes mellitus, vascular dementia, and cognitive deficits, had a care plan requiring extensive assistance with bathing at least 3 times per week and extensive assistance with personal hygiene and oral care. His CNA documentation did not include a task item for nail care, and bathing documentation showed only one bath in the review period on the POC and one handwritten shower sheet entry that documented a refused shower. During observation, his fingernails were long and dirty with a brown substance, and he stated his hair was greasy and that he did not get all of his showers. Resident #52, a female with diagnoses including heart disease, dementia, cognitive communication deficit, lack of coordination, anxiety disorder, major depressive disorder, muscle weakness, chronic pain syndrome, and malaise, had a care plan stating she was totally dependent on one staff member for a bath or shower at least once weekly and as necessary, and required extensive assistance with dressing. Her CNA documentation also did not include a task item for nail care. Bathing documentation showed only one bath in the review period on the POC and two handwritten shower sheet entries. During multiple observations, she remained in the same hospital gown over several days, stated she had not received assistance with changing clothes, and said she had not received a shower. Her closet contained several t-shirts and pants, but she remained in the gown throughout the observations. Staff interviews showed inconsistent understanding and documentation of the bathing and grooming process. A CNA stated Resident #52 sometimes refused showers, that shower sheets were sometimes not completed, and that she did not provide a bed bath on the day of interview. She also stated Resident #13 did not typically refuse showers and that she gave him a shower the day before but did not provide nail care because someone else was supposed to do it. An LVN stated CNAs should document refusals and report them, and said he did not realize Resident #52 had remained in a hospital gown all week. The WCN stated she oversaw the bathing program, monitored shower sheets, and was not aware that either resident was missing baths, while the DON stated bathing should have been offered three times per week or according to resident preference and that CNAs were responsible for completing and documenting the bathing task. The facility policy stated residents would receive individualized ADL support, that staff would assist with ADLs as identified in the care plan, and that residents would be offered a shower at least weekly.
Infection Control Failures During Equipment Use, Hand Hygiene, and Perineal Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During an observation of medication administration, RN A used the same blood pressure cuff on Resident #53 and then on Resident #41 without cleaning the cuff between residents. RN A stated she should have cleaned the cuff with sanitary wipes between uses and acknowledged she had forgotten to do so. The DON stated nurses were expected to clean the blood pressure cuff between each resident and after use. The facility also failed to ensure hand hygiene was followed when CNA D entered and exited Resident #5's room. Resident #5 had diagnoses including a right lower leg fracture, osteoporosis with current pathological fracture, and polyosteoarthritis, and the care plan included Enhanced Barrier Precautions and standard precautions. Observation showed CNA D entered the room without sanitizing her hands, left the room without sanitizing her hands, returned with a box of cereal without sanitizing her hands before re-entering, and only sanitized her hands after leaving again. CNA D stated she had been trained in infection control and that staff were to sanitize hands before entering and after exiting residents' rooms. The facility further failed to ensure proper infection control during incontinent care for Resident #76, an 81-year-old male with end stage renal disease, renal osteodystrophy, and a cognitive communication deficit. Resident #76's care plan included Enhanced Barrier Precautions for a Foley catheter and dialysis. During observed peri-care, CNA F and ADON D donned PPE, performed hand hygiene, and then provided care; however, CNA F used one wipe to clean the resident and then used the same wipe again on fecal matter and the buttocks area before applying a clean brief. CNA F stated she should have thoroughly cleaned the anal area and both sides of the buttocks, and the DON stated staff were expected to use as many wipes as needed to thoroughly clean residents during perineal care.
Resident Information Left Visible on Unattended Medication Cart Tablet
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records by leaving a tablet on the medication cart open and displaying resident information during a medication pass. Observation revealed that the LVN left the tablet unattended and visible for approximately three minutes while in a resident's room, during which time anyone passing by could have viewed the confidential information. The LVN acknowledged that leaving the laptop open with resident information visible was a violation of HIPAA and facility policy. Interviews with other nursing staff, including RNs and the ADON, confirmed that staff were aware of the requirement to lock or minimize screens when leaving computers unattended and recognized that failing to do so constituted a breach of privacy and HIPAA regulations. Review of the facility's Electronic Medical Records policy indicated that only authorized personnel with appropriate credentials should access electronic records, and access should be limited to necessary data. The policy also stated that user codes are confidential and secured by the Administrator and DON. Despite staff training on HIPAA and resident rights, the incident demonstrated a lapse in following established procedures to protect resident information, resulting in a deficiency related to the security and confidentiality of medical records.
Failure to Ensure Respectful Communication and Dignified Care
Penalty
Summary
The facility failed to treat two residents with respect and dignity, and did not provide care in a manner that promoted or enhanced their quality of life. Both residents were on hospice care and had intact cognition, as indicated by their BIMS scores of 15. Their care plans included goals to remain comfortable and free from distress, with interventions to monitor and document for side effects and effectiveness of medications. Despite these plans, both residents reported negative interactions with a CNA, specifically regarding the removal of food trays and the manner in which call lights were answered. One resident reported that the CNA acted as if she was in charge, was not patient, and removed coffee cups and a milk carton from her table without asking. The resident stated she had reported the CNA's rude behavior to a nurse several times. The second resident described the CNA as unwilling to help, recounting an incident where the CNA responded to a request for pain medication with impatience and a dismissive tone. This resident expressed feeling sad as a result of the CNA's behavior and stated she no longer wanted the CNA to care for her. Both residents communicated their concerns to nursing staff, and one also spoke with the social worker during an interview. Interviews with staff revealed that the CNA in question had worked at the facility on an as-needed basis and claimed to always ask residents before removing items. The CNA also stated she was aware of abuse, neglect, and exploitation (ANE) policies. Other staff, including nurses and the DON, confirmed they had received ANE training and understood the requirement to report suspected abuse or neglect. The administrator reported that she had not previously received complaints about the CNA, but upon learning of the allegations, she suspended the CNA and initiated an investigation. Facility policy required immediate reporting and investigation of any suspected abuse or neglect.
Failure to Notify Provider of Repeated Diabetes Medication Refusals
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant need to alter treatment, specifically regarding repeated refusals of prescribed diabetes medications. The resident, an older male with diagnoses including type 2 diabetes, hypertensive heart disease, cerebral infarction, and moderate cognitive impairment, refused his prescribed insulin injections three times daily and his oral diabetes medication on multiple occasions over a period of nearly three weeks. Despite these refusals, there was no documentation that the provider was notified, nor was there evidence that the resident received education about the importance of medication compliance during this time. Record reviews showed that the resident's blood sugar levels fluctuated, with readings ranging from 110 mg/dL to 307 mg/dL, but the provider was only to be notified if levels exceeded 399 mg/dL. Interviews with nursing staff confirmed that the protocol required provider notification and documentation in the resident's chart when medications were refused, as well as education for the resident. However, staff interviews and documentation review revealed that these steps were not consistently followed, and the provider was not informed of the ongoing refusals until the day of the survey interview. Facility policies required that refusals and the reasons for them be documented, and that the provider be notified after two or more consecutive refusals. Despite these policies, the resident's repeated refusals were not communicated to the provider in a timely manner, and there was no documentation of education provided to the resident regarding the consequences of refusing diabetes medications.
Deficiencies in Food Safety, Hand Hygiene, and Dietary Staff Training
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed multiple lapses in food safety practices, including improper hand hygiene by dietary staff while preparing foods and when entering and exiting the kitchen. Specifically, one staff member was observed returning from a personal phone call and resuming food preparation without washing or sanitizing hands, while another staff member handled ice and water for residents without performing hand hygiene. Additionally, the facility did not check produce for quality prior to delivery, as evidenced by a large, unlabeled, and uncovered box of lettuce with black, rotting leaves found in the walk-in refrigerator. Further deficiencies were noted in the facility's dishwasher sanitation practices. Staff members responsible for dishwashing had not received adequate training on using the dishwasher or on monitoring and recording sanitation checks. There were no records or logs maintained for dishwasher sanitation, and staff were under the impression that only the hot water temperature needed to be checked, not the sanitation levels. The facility also failed to keep refrigerated foods tightly wrapped or packaged, and did not label and date all refrigerator and freezer items as required. The facility lacked proper documentation and training for dietary staff. There was no outline of dietary in-services or sign-in attendance sheets for food service employees, despite policies requiring yearly in-services on proper food handling and mandatory attendance records. Interviews with staff and the dietician confirmed gaps in training, monitoring, and adherence to established policies for infection control, hand hygiene, and food safety procedures.
Failure to Maintain Sanitary and Odor-Free Environment on Two Halls
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on two of five halls observed. Specifically, persistent foul odors were noted on the 400 and 500 halls, with surveyors detecting the smell of urine and feces during multiple observations over two consecutive days. The 400 hall was repeatedly noted to have a strong urine odor, while the 500 hall was reported to smell like feces. These conditions were directly observed by surveyors at various times of day. Interviews with staff and family members corroborated the presence of foul odors, with one CNA attributing the persistent smell on the 500 hall to old carpeting. A family member also reported noticing the odor over several days and expressed concern about the cleanliness of the area. However, several residents interviewed stated they did not notice any foul odors in the halls or their rooms. Review of the facility's policy indicated an expectation to maintain a clean environment and minimize odors, which was not met in these instances.
Failure to Ensure Resident Dignity and Privacy During Care and Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, and that care was provided in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, one resident who was totally dependent on staff for eating, with severe cognitive impairment and dysphagia, was observed being fed by a CNA who interrupted the feeding to use her personal cell phone for three minutes. This action occurred in the assisted dining room, where the resident required full assistance with feeding, and the CNA's attention was diverted from the resident during the meal. Additionally, staff members, including an LVN and another staff member, were observed entering the rooms of three residents without knocking. These residents had varying degrees of cognitive impairment and multiple medical diagnoses, including dementia, heart failure, and mobility issues. Observations confirmed that staff entered rooms and even opened bathroom doors without first knocking or waiting for a response, despite facility policy and staff training requiring them to do so to respect residents' privacy and dignity. Interviews with residents, staff, and facility leadership confirmed that the expectation was for staff to knock before entering resident rooms, except in emergencies. Some residents expressed a preference for staff to knock, while others were indifferent. Staff interviews revealed awareness of the policy, but lapses were attributed to being in a hurry or complacency. The facility's policies on resident rights and cell phone use were reviewed, indicating that staff should not use personal phones while providing direct care, especially during feeding, and that residents have the right to privacy and dignity.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide residents with a private space for resident council meetings, as required by their own policy and resident rights regulations. Observations showed that during the resident council meeting, staff and family members repeatedly entered the meeting space, which was held in the assisted dining room. Despite residents informing staff that a meeting was in progress and requesting privacy, staff continued to enter the room. Interviews with residents confirmed that these interruptions were a regular occurrence, and that requests for privacy were not respected. The administrator and other staff acknowledged that the meetings were always held in the dining room and that this was the first time the meeting was moved to the small dining room, which still did not provide adequate privacy due to ongoing interruptions. Interviews with the administrator, assistant director, and DON revealed that all were trained on resident rights and understood the requirement for a private meeting space for resident council. However, they were either unaware of the residents' requests for more privacy or did not take effective action to ensure a private environment. The facility's policy stated that a private space would be provided for resident council meetings, but this was not implemented in practice, as evidenced by the repeated intrusions during the meeting and staff statements that there was nothing the facility could do to prevent these interruptions.
Failure to Protect Resident Privacy Due to Display of Personal Care Signage
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of personal and medical information for three residents by displaying personal care and medical treatment signage in their rooms. Observations revealed that signage with specific care instructions, such as reminders to apply barrier cream and position cushions, was hung on the walls behind the residents' beds. These signs were visible in the rooms and contained information about the residents' care needs, which was intended for staff but was also visible to others entering the room. Interviews with the affected residents indicated that they were uncomfortable with the signage. One resident expressed that the signs made her feel uncomfortable and that she had previously discussed her concerns with staff, who told her the signs were necessary for care. Another resident stated she would prefer the signage not be present and felt staff should know her care needs without such reminders. A third resident reported feeling unimportant and unwelcome due to the signage, and although she had raised the issue with staff, she was told it was necessary for staff communication. Staff interviews confirmed that the signage was used to remind staff, especially those not regularly assigned to the facility, of specific care needs. While some staff acknowledged that the signage could negatively affect residents' sense of dignity and privacy, they also stated that they had not received formal complaints. Facility policies reviewed indicated that residents have the right to privacy, dignity, and self-determination, and that staff are to be educated on these rights. Despite this, the practice of posting personal care instructions in resident rooms was observed and reported by both residents and staff.
Failure to Ensure Safe Medication Administration and Removal of Expired Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by multiple deficiencies in medication administration and storage. One resident was observed with a cup containing nine unidentified pills left at the bedside without staff supervision, and the responsible nurse admitted to leaving the room to retrieve batteries, leaving the medication unattended. The resident did not have a self-administration evaluation or care plan in place, and the facility's policy required staff to ensure residents took their medication completely before leaving their side. Additionally, expired medications and supplies were found on two medication carts and in the medication storage room. Items such as insulin pens, suppositories, lubricating jelly, melatonin, dressing change trays, glucose control solution, intravenous solution, inhalation solution, hypodermic needles, zinc, and peri-stoma wipes were all found to be expired. Some medications were also labeled for individuals who were no longer residents at the time of the survey. Staff interviews confirmed that nurses, the ADON, the DON, and the pharmacist were all responsible for checking for expired medications and supplies, but these checks were not effectively carried out. The residents involved had significant medical histories, including diabetes mellitus type II, cerebral infarction, hypertension, atrial fibrillation, pain, dysphagia, apraxia, chronic kidney disease, dysarthria, vascular dementia, hyperlipidemia, anxiety, transient ischemic attack, and hypertensive heart failure. Care plans and medication orders were in place for these residents, but the facility failed to ensure medications were administered and stored according to policy, including removing expired items and supervising medication administration.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of medications and biologicals. On one occasion, a medication cart on the 500 hall was observed unlocked and unattended while the responsible LVN was at the other end of the hall. Additionally, both the 400-hall and 500-hall medication carts contained loose pills not secured in their original packaging, and the 500-hall cart had a bottle of glucose control solution that was opened but not labeled with the date it was first used, despite manufacturer instructions to discard after three months of opening. Further observations in the medication storage room revealed a large bag containing 100 individually wrapped ondansetron tablets without any prescription or resident label. The 500-hall medication cart also contained two unopened, unlabeled packages of Budesonide, a prescription medication, and an unlabeled blue pill. Interviews with nursing staff, the ADON, DON, and ADM confirmed that all prescription medications are required to have proper labeling, and that medication carts and storage areas should be kept locked and free of loose or unlabeled medications. Staff acknowledged that failure to follow these procedures could result in residents missing doses or receiving medications not intended for them. Facility policy review indicated that drugs and biologicals must be stored in their original packaging, labeled correctly, and kept in locked compartments when not in use. Only the issuing pharmacy is authorized to transfer medications between containers, and nursing staff are responsible for maintaining clean and secure medication storage areas. The observed failures to adhere to these policies were confirmed through staff interviews and direct observation.
Failure to Provide Nutritious, Palatable Meals and Document Substitutions
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to provide meals that meet residents' nutritional needs and preferences, as required by national guidelines and facility policy. Observations revealed that the kitchen stored unlabeled and uncovered produce, including rotting lettuce, and used old menus that were not current. During meal service, food was found to be served at suboptimal temperatures and described as flavorless and unappetizing by both surveyors and residents. Additionally, a cook was observed pureeing food with water instead of more nutritious liquids, and not following a specific recipe. Interviews with residents consistently indicated dissatisfaction with the meals, citing issues such as lack of flavor, repetitive menu items, poor food quality, and unappetizing alternatives. Several residents reported regularly refusing meals or choosing alternatives like cereal due to the poor quality of the main offerings. Staff interviews confirmed awareness of these complaints, and the Dietary Manager (DM) acknowledged that substitutions were offered but not documented, as required by facility policy. The DM also admitted to not inspecting food quality at delivery and not labeling returned items, and was unaware of some staff meal preparation practices that could affect food quality. Record reviews showed that facility dietary policies require proper labeling, dating, and storage of food, prompt and efficient meal service to maintain appropriate temperatures, and documentation of resident acceptance or refusal of meal substitutions. However, these policies were not consistently followed, as evidenced by the lack of documentation for meal refusals and substitutions, improper food storage, and failure to ensure meals were appetizing and at the correct temperature. No information was provided regarding corrective actions or follow-up after these deficiencies were identified.
Deficient Food Preparation and Service Practices
Penalty
Summary
The facility failed to ensure that food and drink were prepared and served in a manner that conserved nutritive value, flavor, and appearance. Observations revealed that food was being prepared more than two hours before meal service, and test trays for both regular and puree diets were served at suboptimal temperatures and lacked flavor. The kitchen was also found to have unlabeled, uncovered, and rotting produce, as well as outdated menus posted in the dining room. Additionally, a cook was observed pureeing cornbread muffin with water instead of following a specific recipe or using recommended ingredients, which was contrary to facility protocol. Multiple residents reported dissatisfaction with the meals, describing the food as flavorless, cold, tough, and unappetizing. Several residents stated they often declined the main meals and alternatives due to poor quality, lack of variety, and unappealing presentation. Some residents preferred to eat cereal or food brought by family members rather than consume the facility's offerings. Staff interviews confirmed awareness of resident complaints regarding food temperature, taste, and lack of variety, and the Dietary Manager acknowledged not inspecting food quality at delivery, not labeling returned items, and not documenting meal substitutions. Record reviews indicated that facility dietary policies required proper labeling, dating, and storage of food, prompt and efficient meal service to maintain appropriate temperatures, and documentation of meal refusals and substitutions. However, these policies were not consistently followed, as evidenced by the presence of improperly stored food, lack of documentation, and failure to ensure meals were appetizing and served at safe temperatures.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with significant physical impairments, including hemiplegia, hemiparesis, Parkinson's disease, and diabetes mellitus, did not receive necessary fingernail care. The resident was unable to open her left hand due to contracture and required assistance with activities of daily living, including personal hygiene. Despite being scheduled for nail care by a licensed nurse twice a week, observations on multiple occasions revealed that the resident's left thumb nail was long and had rough edges. The resident expressed a desire for her nails to be trimmed and denied refusing nail care. Interviews with staff revealed confusion and lack of clarity regarding responsibility and procedures for nail care, especially for diabetic residents. CNAs reported that they could not trim the resident's nails due to her diabetes and contracture, and stated they would report concerns to the nurse. Licensed nurses, including LVNs and RNs, acknowledged the importance of nail care but were either unaware of the resident's need, unsure of the schedule, or did not know where to document the care provided. The DON and ADON confirmed that nail care for diabetic residents should be performed by nurses and expected it to be done promptly when needed, but there was inconsistency in staff knowledge and execution of these expectations. The facility's policy required routine cleaning, inspection, and trimming of nails by nurses for diabetic residents, with documentation in the care system. However, the care plan for the resident did not address nail care, and there was no physician order for it. Multiple staff members, including the administrator, were unaware of the specific requirements for diabetic residents' fingernail care and the frequency of checks. This lack of coordination and adherence to policy resulted in the resident not receiving necessary nail care, as evidenced by repeated observations of long, untrimmed nails and staff interviews confirming the deficiency.
Failure to Prepare Pureed Foods Appropriately and Provide Palatable Meals
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual resident needs, specifically in the preparation of pureed foods. Observation revealed that a cook used water as the liquid to puree a cornbread muffin, rather than following a specific recipe or using appropriate liquids such as milk, butter, gravy, or broth as outlined by facility protocol. The cook was not adhering to established recipes, and the dietary manager (DM) confirmed that water should not be used for pureeing due to its lack of nutritional value. The DM also stated that he was unaware of the cook's actions and that all necessary supplies for proper pureeing were available. Multiple residents expressed dissatisfaction with the meals provided, citing issues such as lack of flavor, repetitive menu items, poor food quality, and unappetizing alternatives. Several residents reported not eating the facility meals due to these concerns, with some preferring to eat cereal or food brought by family members. Residents also noted that food was sometimes cold, tough, or poorly prepared, and that alternatives offered were not appealing or well-cooked. Interviews with staff revealed gaps in documentation and training practices. The DM stated that he receives training from the dietician and is responsible for training dietary staff, but in-service logs were not maintained or provided to the surveyor. The DM also acknowledged not inspecting food quality at delivery and not labeling returned items as required by policy. Facility dietary policies reviewed included requirements for proper food storage, prompt meal service, and documentation of food refusals and substitutions, but these were not consistently followed.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four of six resident rooms reviewed. Observations revealed that the floors and bedside tables in these rooms were caked with food particles and debris, and bags of soiled briefs were left in the rooms. Specific observations included sticky brown substances on the floors, dirt and debris on fall mats, brown streaks on the floors, and a dried blood-like substance on the ground. Additionally, a tied trash bag filled with soiled briefs and wipes was found on the floor of one room. Interviews with staff revealed that the facility was short-staffed on the day of the observations, with no housekeeper assigned to the hallway containing two of the affected rooms. The housekeeper interviewed stated that their responsibilities included sweeping, mopping, cleaning the sink and toilet, and taking out the trash. The Director of Nursing (DON) acknowledged that the uncleanliness did not meet her expectations and emphasized that maintaining clean resident rooms is crucial for infection control. The facility's Homelike Environment Policy mandates maintaining a clean environment in accordance with residents' rights.
Failure to Obtain Consent from Resident's Representative for COVID-19 Vaccine
Penalty
Summary
The facility failed to extend the right to make decisions on behalf of a resident to their representative, resulting in the administration of a COVID-19 vaccine without the representative's consent. The resident, an elderly female with severe cognitive impairment, was admitted with diagnoses including unspecified dementia and major depressive disorder. Her representative had previously declined the COVID-19 vaccine on her behalf. However, a nurse documented receiving verbal consent from the resident herself, despite her cognitive limitations. Interviews revealed that the nurse administered the vaccine based on outdated information in the facility's charting system, which incorrectly listed the resident as her own representative. The Director of Nursing believed the resident was capable of making the decision at the time, although interviews with other staff indicated otherwise. Attempts to contact the resident's representative were unsuccessful before the survey concluded. The facility's policy stated that the resident representative has the right to exercise the resident's rights as delegated.
Deficiency in Medication Storage and Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, making them inaccessible to unauthorized staff, visitors, and residents. This deficiency was observed in two residents who had medications stored at their bedside without proper orders. Resident #1, a woman with Parkinson's disease and moderate cognitive impairment, was found with Chloraseptic lozenges and medicated vapor rub in her room. There were no physician orders for these medications or for self-administration, and the resident's care plan indicated that medications should be administered as ordered. Similarly, Resident #2, who had Type 1 diabetes mellitus and other health conditions, was found with clinical anti-fungal powder and Triad Hydrophilic wound dressing at her bedside. There were no orders for self-administration or for the wound dressing, although there was an order for the anti-fungal powder to be applied by staff. Interviews with staff, including LVNs, CNAs, the NP, and the DON, revealed a lack of awareness of any residents having medications at bedside without orders. The staff confirmed that all medications, including over-the-counter ones, required an order and should not be stored in residents' rooms unless approved. The facility's policies and in-service training emphasized that medications should be administered according to established schedules and stored securely. The ADM and DON expressed concerns about the potential risks of having medications accessible in residents' rooms, highlighting the need for orders and secure storage. Despite these policies, the facility did not ensure compliance, leading to the observed deficiencies in medication storage and administration.
Deficiency in Medication Management and Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication management. Resident #1, an elderly woman with Parkinson's disease and moderate cognitive impairment, was found to have Chloraseptic throat lozenges and medicated vapor rub at her bedside without a physician's order. The resident and her family member confirmed that these medications were kept in her room for occasional use, but there was no documentation or order for self-administration of these over-the-counter medications. Similarly, Resident #2, who has Type 1 diabetes mellitus and other health conditions, had clinical anti-fungal powder and Triad Hydrophilic wound dressing at her bedside. The resident stated that the anti-fungal powder was used by staff after her showers, but there was no physician's order for these medications. Interviews with staff, including LVNs, CNAs, the NP, and the DON, revealed a lack of awareness and adherence to the facility's policy that all medications, including over-the-counter ones, require a physician's order and should not be stored in residents' rooms unless approved. The facility's policies on medication administration, storage, and orders were not followed, as evidenced by the presence of unauthorized medications in residents' rooms. Staff interviews indicated that medications should be secured and only administered with a proper order, yet there was a disconnect between policy and practice. The ADM acknowledged the potential risks associated with unsecured medications and emphasized the need for orders and proper storage to prevent unauthorized access and ensure resident safety.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by a CNA. The incident involved the CNA forcefully dragging the resident to the shower room, spraying her with water while she was fully clothed, and laughing at her distress. The resident, who was cognitively intact, had refused to shower, but the CNA claimed to be acting on instructions from the DON to ensure the resident was showered. Despite the resident's screams and cries, the CNA continued the abusive behavior, which included combing the resident's hair aggressively, causing hair loss. The DON was notified of the incident but failed to take immediate action to protect the resident from further abuse. The CNA continued to work at the facility and on the same hall as the resident, where she continued to taunt and emotionally abuse the resident. Other CNAs witnessed the incident but did not intervene to stop the abuse. The DON did not report the incident to the ADM or take steps to remove the CNA from the resident's care, allowing the abusive behavior to continue. The facility's failure to address the abuse promptly and effectively resulted in the identification of an Immediate Jeopardy situation. The lack of immediate action placed the resident at risk of further abuse and emotional distress. The facility's policies on abuse prevention and investigation were not followed, leading to a delay in addressing the situation and ensuring the resident's safety.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse for one resident. The incident involved a Certified Nursing Assistant (CNA) who forcefully dragged a resident to the shower room and sprayed her with water while she was still clothed, despite her protests. This act of physical and emotional abuse was witnessed by other CNAs who did not intervene. The Director of Nursing (DON) was notified but failed to take immediate action to protect the resident, allowing the abusive CNA to continue working with the resident and subjecting her to further emotional abuse. The resident involved was a cognitively intact female with a history of major depressive disorder, anxiety disorder, and unspecified psychosis. She was admitted to the facility with a care plan that required assistance with activities of daily living (ADLs), including showering. Despite her refusal to shower, the CNA, under the pretext of instructions from the DON, forcibly showered the resident, causing her significant distress and humiliation. The resident reported feeling helpless and humiliated, and the incident left her fearful and traumatized. The facility's failure to act promptly and appropriately in response to the abuse allegations resulted in the identification of an Immediate Jeopardy (IJ) situation. The DON's lack of documentation and delayed response to the incident further exacerbated the situation, as the abusive CNA continued to work in the facility and interact with the resident. The facility's policies on abuse prevention and investigation were not followed, leading to a significant risk of harm to the resident and a breach of her rights and dignity.
Failure to Report and Address Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect were reported to the facility Administrator immediately, but no later than two hours, for one resident reviewed for abuse and neglect. The incident involved a Certified Nursing Assistant (CNA) who forcefully dragged a resident to the shower room, sprayed her with water while she was still clothed, and continued to emotionally abuse her. Despite the resident's screams and cries, the Director of Nursing (DON) was notified but failed to take any action to protect the resident from further abuse, allowing the CNA to continue working at the facility and with the resident. The resident involved was a cognitively intact female with a history of major depressive disorder, anxiety disorder, and unspecified psychosis. She required assistance with activities of daily living (ADLs) but was able to ambulate without a wheelchair or walker. The incident occurred when the resident refused to shower, and the CNA, following alleged instructions from the DON, forcibly took her to the shower room. The resident was humiliated and traumatized by the experience, which included being sprayed with water and having her hair combed aggressively, resulting in hair loss. Witnesses to the incident, including other CNAs, reported the abuse to the DON, who did not document the incident or report it to the Administrator. The DON claimed to have been unaware of the incident until weeks later and did not take immediate action to remove the CNA from the resident's care. The facility's failure to report and address the abuse promptly resulted in the identification of an Immediate Jeopardy situation, placing residents at risk of further abuse and harm.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was cognitively intact and required assistance with activities of daily living. The incident involved a CNA who forcefully dragged the resident to the shower room, sprayed her with water while she was fully clothed, and laughed at her distress. Despite the resident's screams and resistance, the CNA continued the abusive behavior, which included combing the resident's hair aggressively, resulting in hair loss. The incident was witnessed by other CNAs who reported it to the Director of Nursing (DON), but no immediate action was taken to investigate or protect the resident. The DON was informed of the incident by multiple staff members, including an occupational therapist who received a text message detailing the abuse. However, the DON failed to document the investigation properly and did not report the incident to the Administrator or the appropriate authorities in a timely manner. The alleged perpetrator continued to work on the same hall as the resident, further traumatizing her. The DON's inaction and lack of documentation led to the identification of an Immediate Jeopardy situation, as the facility did not ensure the safety and protection of the resident. Interviews with staff and the resident revealed that the DON was aware of the incident but did not take appropriate steps to address the abuse or prevent further harm. The resident expressed feelings of humiliation and fear, and staff members reported that the DON appeared unconcerned about the resident's safety. The facility's failure to follow its abuse prevention and investigation policy placed residents at risk of further abuse and psychosocial harm.
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 221 citations issued within 25 miles in the last 12 months — including the 5 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 San Marcos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hays Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 10 | 0 |
| San Marcos Rehabilitation And Healthcare Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Legend Oaks Healthcare And Rehabilitation - New Br | 11 mi | ★★★★★ | 9 | 0 |
| Sundance Inn Health Center | 11.7 mi | ★★★★★ | 3 | 0 |
| Avir At New Braunfels | 11.8 mi | ★★★★★ | 20 | 1 |
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 October 2026) and official state health department websites.