Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Downtown Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and schizophrenia physically assaulted another resident during a supervised smoking break, and a CNA witnessed the resident get in the other resident’s face, accuse him of taking his hat, and smack him in the face. In a separate event, an LPN and a resident with severe cognitive impairment had a conflict over PRN pain medication, and a CNA reported hearing the LPN use derogatory language and say, “Fuck you too, I’m not giving you anything!” The resident later stated he was in pain and did not receive the medication.
Failure to Report Alleged Verbal Abuse: A resident with significant cognitive impairment and multiple chronic conditions was involved in an overnight interaction with an LPN over PRN pain medication, during which profanity was reportedly exchanged and the resident did not receive the medication. Staff gave conflicting accounts of the event, but the DON and Administrator both acknowledged the allegation should have been reported to HHSC and was not reported within the required timeframe.
Failure to Thoroughly Investigate Alleged Staff Mistreatment: A resident with significant cognitive impairment and multiple chronic conditions requested PRN pain medication and later became involved in a profanity-filled exchange with an LPN at the nurse’s station. A CNA reported hearing the resident and the LPN cuss at each other, while the resident said he was in pain and did not receive the medication. The DON and Administrator reviewed the allegation but did not report it to HHSC, despite facility policy requiring all allegations of abuse or mistreatment to be investigated and reported.
The facility failed to maintain an infection prevention and control program, including a water management program for Legionella, and failed to keep a resident's draining right foot wound covered when the resident was in common areas. The Maintenance Director and DON could not describe or document a Legionella control program, while the resident with a right foot arterial wound was observed in a wheelchair with the foot uncovered and drainage present; staff reported the resident often refused wound care and resisted treatment.
A resident with DM, dysphagia, cognitive communication deficit, PTSD, and bilateral BKA had a call light left on the floor under his wheelchair and out of reach while he was in bed. Staff said the call light should have remained within reach and that all staff entering the room were responsible for keeping it accessible, but it remained in the same location for hours. The DON and Administrator stated call lights were expected to stay within residents’ reach, and the facility had no call light policy.
A resident with interstitial pulmonary disease, ESRD, and COPD was readmitted without a physician order for oxygen, even though staff documented oxygen use and observed the resident on oxygen with the concentrator set to 3.5 LPM. The care plan addressed altered respiratory status and included oxygen as ordered, but the chart had no oxygen order. Nurses and the DON stated the admitting nurse should have obtained and verified the correct oxygen order on readmission.
A resident with Parkinson’s disease, diabetes, weakness, and a cognitive communication deficit was observed sitting in her wheelchair with food debris on her shirt and pants after lunch. She said she wanted help changing because it made her feel dirty. CNA C, who assisted her with lunch, said she got busy and did not change the resident’s clothes. Staff interviews confirmed the resident should have been changed promptly to preserve dignity and provide needed ADL assistance.
A resident with multiple chronic conditions, frequent incontinence, and intact cognition, who required assistance and supervision for bathing, was not provided scheduled showers on designated shower days. Over a multi‑day period, showers were documented as not applicable and there was no record of bathing, while the resident reported going several days without a shower after a CNA stated she ran out of time and did not offer an alternative. The CNA acknowledged not coordinating with other staff or notifying nursing, despite adequate staffing, and facility leadership confirmed that residents are expected to receive showers at least twice weekly in accordance with their care plans and resident rights.
A CNA engaged in verbally abusive behavior by calling a resident with moderate cognitive impairment a derogatory name after the resident used inappropriate language. The incident was overheard by HR staff, and the CNA did not deny the behavior when questioned. The resident's care plan required staff to avoid reacting to negative behavior, but this was not followed.
Staff failed to immediately report a resident's allegation of abuse and neglect to the facility's Abuse Coordinator as required by policy. The incident involved a resident with paraplegia who alleged that a CNA attempted to choke him after he was left waiting for incontinence care. Multiple staff members were informed of the allegation, but none reported it within the required timeframe, and no injuries were observed.
A resident's discontinued Diazepam remained in the medication cart on the memory care unit, with incomplete documentation and failure to follow facility procedures for removal and destruction. Nursing staff and the DON confirmed that discontinued medications should be promptly removed and properly documented, but these steps were not followed.
A resident with hypertension and other chronic conditions was given Lisinopril and Metoprolol by nursing staff on multiple occasions, even though their blood pressure readings were below the physician-ordered parameters for holding these medications. Medication administration records showed that both medications were administered outside the prescribed limits, and interviews with the DON and Administrator confirmed that this was not in accordance with physician orders or facility policy.
A resident with multiple chronic conditions and moderate cognitive impairment repeatedly refused essential care and services, including wound care, medication, and showers. The facility's care plan did not include interventions to address these refusals, despite documentation of ongoing issues and facility policy requiring such measures. Interviews with the DON and Administrator confirmed that these refusals were not properly addressed in the care plan.
A Treatment Nurse failed to follow infection control protocols by placing a contaminated gloved hand into a package of clean gauze during wound care for a resident with chronic wounds, then returning the package to the treatment cart for future use. This action was observed and acknowledged by facility leadership as a breach of infection control policy.
A resident with multiple chronic conditions, including malnutrition and end stage renal disease, experienced a significant weight loss of nearly 26% over four months. Despite care plans identifying the risk, staff did not consistently monitor or intervene, and the resident was not included in the facility's red cup program for at-risk individuals. Communication gaps and lack of follow-through on dietary recommendations contributed to the deficiency.
A resident with significant fall risk factors experienced a fall, but the responsible LVN did not complete the required fall assessment or implement new interventions as mandated by facility policy. Although initial notifications and neuro checks were performed, the assessment was delayed, and the care plan was not updated in a timely manner, resulting in a lapse in supervision and accident prevention.
A resident receiving hospice care and requiring oxygen and nebulizer treatments was found with nasal cannula tubing on the floor, an undated humidifier bottle, and an unbagged nebulizer mask. Staff interviews confirmed that respiratory equipment should be clean, dated, and properly stored, in accordance with facility policy and professional standards. These lapses resulted in a failure to provide safe and appropriate respiratory care.
A resident with a known history of physical and verbal aggression attacked another resident, causing a serious eye injury that required hospitalization and surgery. Despite ongoing behavioral issues and interventions such as medication adjustments and psychiatric referrals, the aggressive resident remained in the unit and continued to display threatening behaviors, ultimately leading to the assault. The facility did not prevent the abuse, resulting in significant harm.
A resident with paraplegia and chronic osteomyelitis missed a scheduled dose of Vancomycin due to staffing issues at the facility. The resident reported the missed dose to the ADON, who confirmed the oversight and noted that the facility was short-staffed over the weekend. The facility's medication administration policy, which includes the right time for medication, was not adhered to.
The facility failed to secure medications in Med Room A, leaving them on a cart outside the room. An ADON left medications, including an albuterol inhaler and Afrin nose spray, unsecured, allowing residents to pass by them. The ADON admitted the oversight, acknowledging the responsibility to secure medications. The AIT confirmed that the facility's policy requires medications to be secured, and it was the DON's responsibility to ensure compliance.
The facility failed to properly label and date stored food items in the kitchen, as observed during a survey. Unlabeled and undated items, such as frozen pancakes and broccoli, were found in the walk-in freezer, and an open box of ice cream containers had ice crystal accumulation. The Dietary Manager confirmed that staff are expected to label items with the name, open date, and use-by date, as per the facility's policy and the U.S. Public Health Service Food Code.
The facility failed to provide specialized rehabilitative services for two residents, leading to a deficiency in care. One resident with multiple health issues was not screened for physical therapy despite needing it, and another resident expressed a desire to walk but only received occupational therapy for her hands. Interviews revealed systemic issues in the therapy screening process, with staff acknowledging inconsistencies and a lack of specific policies. Staffing shortages and a new Director of Rehabilitation contributed to the oversight.
A long-term care facility failed to adhere to infection control protocols, including a nurse not wearing a gown while administering medication to a resident on Enhanced Barrier Precautions, a wound care physician and ADON not wearing gowns during wound care for a resident on contact isolation, and a CNA not sanitizing hands between feeding two residents. These lapses increased the risk of infection transmission.
Two residents' dignity was compromised during a meal when a CNA yelled across the dining room and fed multiple residents simultaneously. The incident involved residents with cognitive and communication deficits, and the facility's policies on resident rights and feeding were not followed.
A resident was found smoking unsupervised in the courtyard during non-smoking times, despite the facility's policy requiring direct supervision for residents assessed as needing it. The resident, who was cognitively intact and had a history of MRSA infection and hypertension, kept his own cigarettes and lighter, unaware they should be stored at the nurse's station. Staff interviews revealed inconsistencies in enforcing the smoking policy, leading to the resident smoking unsupervised.
A facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for two residents. An LVN administered Furosemide to a resident despite their blood pressure being below the prescribed parameter, and Vancomycin was given to another resident without checking the necessary trough levels. The facility's policies emphasize the importance of reviewing orders and lab results, but these were not followed, leading to the deficiencies.
A facility failed to ensure a PASRR Evaluation for a resident with mental illness after a positive Level I screening. The resident, admitted with cognitive and mental health issues, did not have a care plan addressing the PASRR findings. The administrator lacked training on the PASRR process, and the MDS Coordinator did not follow up on communications with the local authority. Although the evaluation was completed, it was not documented in the resident's records, contrary to facility policy.
A facility failed to develop a baseline care plan within 48 hours for a resident with cognitive and mental health issues, including anxiety and depression. The resident's care plan did not address his PASRR Level I for mental illness, and the facility lacked a DON, leaving care plan responsibilities to all nurses and the ADM. The MDS RN was not responsible for care plan monitoring, and the corporate nurse was assisting with clinical concerns.
The facility failed to ensure a safe environment by allowing residents to keep cigarettes and lighters on themselves and pick up cigarette butts, leading to potential burn risks. Despite care plans and policies requiring supervision and secure storage of smoking materials, residents were observed engaging in unsafe smoking practices without adequate oversight.
A resident with severe cognitive impairment and multiple medical conditions did not receive proper foot care, as her toenails were not trimmed by a podiatrist despite being referred in April. Observations revealed thick, yellow, and curled toenails, and staff interviews indicated confusion over responsibility for nail care. The facility's outdated foot care policy lacked a clear referral process, contributing to the oversight and delay in providing necessary podiatry services.
The facility failed to provide necessary nail care for two residents, leading to deficiencies in maintaining personal hygiene. One resident with cognitive impairment and a hand contracture had long, untrimmed nails with a yellow substance, while another resident with severe cognitive impairment was observed with long fingernails. Staff interviews revealed inconsistencies in nail care responsibilities and adherence to facility policies.
The facility failed to provide scheduled showers to two residents, both requiring assistance with activities of daily living. Despite having intact cognition and no documented refusals, the residents received significantly fewer showers than scheduled. Staff interviews revealed inconsistencies in documentation and communication regarding shower refusals and completions, with unclear documentation processes contributing to the deficiency.
A facility failed to ensure a safe environment in a secured unit dining room by installing a temporary window air conditioning unit with unsecured cords, posing a hazard to residents. Staff interviews revealed awareness of the risks, especially for residents with conditions like dementia, but the temporary solution lacked adequate safety measures. The administration acknowledged the oversight, and the facility's policy emphasized the importance of a safe environment.
A facility failed to implement policies to prevent abuse and neglect when a CNA did not report an incident of alleged abuse involving a resident with Alzheimer's disease. Despite recent training, the CNA did not report the incident due to fear of retaliation. Other staff members and the Administrator were unaware of the incident until it was brought to their attention by a surveyor.
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator. A CNA did not report an incident where another CNA allegedly grabbed a resident by the neck and held him down in a choke hold. The CNA did not intervene or report the incident due to fear of retaliation and physical harm.
The facility failed to revise care plans for two residents requiring direct supervision while smoking. Both residents were found smoking unsupervised despite assessments indicating the need for supervision, placing them at risk of harm.
The facility failed to ensure adequate supervision for five residents who required supervision while smoking. Observations revealed these residents smoking without staff supervision, contrary to their care plans and safe smoking assessments. Interviews confirmed that residents often kept their own smoking materials and smoked without supervision, despite the facility's smoking policy requiring direct supervision and regular assessments.
The facility failed to provide privacy curtains for two residents while their curtains were being laundered, leaving them without privacy during personal care activities. The residents were moved back into their room after a bed bug treatment, but the curtains were not replaced, causing discomfort and lack of privacy.
The facility failed to ensure proper foot care for four residents, leading to overgrown and potentially problematic toenails. Interviews revealed inconsistencies in the approach to toenail care, with some staff stating that nurses could trim toenails while others indicated that only a podiatrist could perform this task. A review of podiatry visits showed that the residents had not been seen by the podiatrist and were not scheduled for an upcoming visit.
Abuse and Verbal Abuse Not Prevented
Penalty
Summary
The facility failed to ensure residents were free from abuse and verbal abuse in three separate events involving three residents. One resident with dementia, schizophrenia, cognitive communication deficits, and multiple chronic medical conditions was involved in an altercation with another resident during a supervised smoking break. According to the record, the first resident blocked the doorway with his arms out, refused to let anyone pass, and then struck the second resident in the face. Staff redirected the situation and separated the residents. The second resident, who had severe cognitive impairment, was documented as not being the aggressor and was later described as calm and without visible injury. A second abuse event involved the same two residents. One resident stated that the other resident slapped him first and that he hit him back. A CNA who witnessed the incident stated the first resident got in the second resident’s face, accused him of having his hat, yelled at him, and then smacked him in the face, causing him to fall until the CNA caught his head before it hit the ground. The CNA separated the residents and ensured the second resident was safe. The records and interviews showed the second resident did not sustain visible injuries, but the event involved resident-to-resident physical abuse. The third event involved a resident with significant cognitive impairment who had a PRN oxycodone-acetaminophen order for pain. The resident requested pain medication during the night, but an LVN told him it was too early. Later, when the medication was due, the LVN went to the resident’s room, but the resident did not respond and the medication was wasted instead of being administered. When the resident later returned to the nurse’s station asking for the medication, the LVN again told him she had already gone to his room and that he had not responded. One CNA stated she heard the LVN tell the resident, “Now you want to talk to me in the correct way,” and then heard the resident curse and the LVN respond, “Fuck you too, I’m not giving you anything!” Another LVN stated the medication was wasted because the resident had said, “Fuck you,” and the resident later stated he was in pain and had not received the medication. The facility policy defined verbal abuse as disparaging or derogatory language toward residents.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that an alleged verbal abuse incident involving one resident was reported immediately, and no later than 2 hours after the allegation was made, to the administrator and to HHSC. The resident involved had multiple diagnoses including vascular dementia with mood disturbance, major depressive disorder, anxiety disorder, cognitive communication deficit, muscle weakness, unsteadiness on feet, and significant cognitive impairment with a BIMS score of 07. The resident’s care plan included interventions for potential or uncontrolled pain, and he had an active PRN order for oxycodone-acetaminophen for pain. According to progress notes and staff interviews, the resident requested pain medication during the overnight shift and was told it was too early. Later, when the medication was brought to his room, he did not accept it and the medication was wasted with another nurse as witness. The resident later returned to the nurse’s station asking for his pain pill. One staff member reported hearing the resident and the nurse exchange profanity, including the nurse saying, “Fuck you too, I’m not giving you anything!” Another staff member stated she heard the resident curse at the nurse and believed the nurse responded in kind. The resident stated he was upset, felt the interaction was uncalled for, and said he did not receive the medication from the nurse. The DON and Administrator both described receiving information about the incident from staff and conducting an investigation. The DON stated that if she had gotten any other confirmation about the alleged incident, she would have reported it to HHSC, and the Administrator stated she knew the incident should have been reported but did not know why it was not. The facility policy required immediate verbal reporting of suspected abuse to the Abuse Preventionist or designee and required the administrator or designee to report allegations involving abuse to HHSC within 2 hours. The report states the facility failed to report the alleged verbal abuse incident involving the resident.
Failure to Thoroughly Investigate Alleged Staff Mistreatment
Penalty
Summary
The facility failed to have evidence that an allegation of abuse or mistreatment involving a resident was thoroughly investigated. The resident involved was a male with multiple diagnoses including heart failure, prior TIA/cerebral infarction, protein-calorie malnutrition, type 2 diabetes, vascular dementia with mood disturbance, major depressive disorder, cognitive communication deficit, muscle weakness, unsteadiness on feet, anxiety disorder, hypertension, atherosclerotic heart disease, old myocardial infarction, and GERD. His quarterly MDS reflected a BIMS score of 07, indicating significant cognitive impairment, and he was documented as independent with eating, toileting, and ambulation. The incident occurred when the resident requested his PRN oxycodone-acetaminophen for pain and was told it was too early. Progress notes documented that he responded with profanity and returned to his room, and later again requested the medication. The nurse documented that the medication had been taken to the resident’s room, but he would not accept it, and the dose was wasted with another nurse as witness. A CNA later reported hearing the resident and the nurse cuss at each other at the nurse’s station, including the nurse allegedly saying, "Fuck you too, I'm not giving you anything!" The resident stated he was in pain and went back to his room, and he reported he had not received the medication from the nurse. Interviews showed conflicting accounts of what occurred, including whether the nurse used profanity toward the resident and whether the resident refused the medication. The CNA stated she reported the incident to the DON and was told to write a statement. The DON stated she investigated by asking the resident and other staff about the incident, but she did not have confirmation that it occurred and did not report it to HHSC. The Administrator stated she was informed of the allegation, asked staff about it, and knew the DON would investigate, but she also did not report the allegation to HHSC. The facility policy stated that all allegations of abuse, neglect, exploitation, mistreatment, misappropriation, and injuries of unknown source would be investigated, that the administrator would be responsible for reporting cases to HHSC, and that allegations involving employees would result in immediate suspension pending investigation.
Infection Control Program and Wound Coverage Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and help prevent the development and transmission of communicable diseases and infections. Surveyors found that the Maintenance Director was not aware of a facility water management plan and could not describe or provide evidence of identification of situations that could lead to Legionella growth, measures used to control the introduction or spread of Legionella, or documentation showing implementation of those measures. He stated the facility did not need to flush water lines because it was on city water and said the water system was not at risk for bacterial growth because the facility had water softeners. He also stated he did not know what Legionella or Legionnaires' disease was and did not know the risks of not having a water management plan. The DON provided an undated policy titled Legionella Water Management Program, a list of water management team members, and a facility map with highlighted water heater areas, but was unable to describe or provide documentation of a water management program that included identification of situations that could lead to Legionella growth, control measures, or documentation of implementation. The Administrator stated water management was not an issue because there was no stagnant water and water temperatures were monitored. She also stated the facility had two resident rooms not in use, one out of commission, and that housekeeping turned on sinks and flushed toilets when cleaning. The Administrator identified the DON, Maintenance Director, Medical Director, and herself as responsible for the water management plan. The facility also failed to cover Resident #4's right foot wound before the resident left the room and entered common areas. Resident #4 was a male with a diagnosis of unspecified atherosclerosis of the native arteries of the right leg and had a care plan for an arterial wound to the right foot, impaired mobility, incontinence-related skin issues, and enhanced barrier precautions. Records showed daily wound care orders, including cleansing the right foot, applying Betadine, and bandaging draining areas. During observation, the resident was seen self-propelling in a wheelchair in the hallway near the dining room and later in his room with the right foot uncovered, with subcutaneous drainage and lower extremity edema noted onto the floor under the wheelchair. Staff stated the resident was non-compliant with wound care, often refused treatment, and would resist attempts to clean and cover the foot.
Call Light Left Out of Resident’s Reach
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident’s needs and preferences when Resident #91’s call light was left on the floor and out of his reach. Resident #91 was a male with Type 2 DM with diabetic polyneuropathy, dysphagia, cognitive communication deficit, PTSD, and bilateral below-the-knee amputations. His quarterly MDS showed a BIMS score of 11, indicating mild cognitive impairment, and his care plan directed staff to keep his call light within reach and encourage him to use it for assistance. During observation, Resident #91 was lying in bed and his call light was observed on the floor underneath his wheelchair next to the wall. When asked, he said he did not know where his call light was and stated he used it to get help from staff. A later observation showed the call light remained in the same location several hours later, still on the floor under the wheelchair. At that time, Resident #91 was coughing repeatedly and was unable to answer questions. In interviews, CNA A said she had just arrived for the evening shift and did not know why the call light had been on the floor for hours. RN B said every staff member who entered the room was responsible for ensuring the call light stayed within reach, and CNA C said CNAs were responsible for keeping call lights within reach and that staff clip them onto residents’ clothing when they are in bed. The DON and Administrator both stated that call lights were expected to remain within residents’ reach, and the Administrator said the facility did not have a call light policy.
Missing Oxygen Order on Readmission
Penalty
Summary
The facility failed to ensure that Resident #25 had a physician order for immediate care at the time of readmission, specifically for oxygen use. Resident #25 was a cognitively intact female with diagnoses including interstitial pulmonary disease, end-stage renal disease, and COPD, and her care plan reflected altered respiratory status, difficulty breathing, shortness of breath anxiety, and the intervention to provide oxygen as ordered. Record review showed a progress note stating the resident was readmitted from the hospital and was on oxygen at 2 lpm via nasal cannula, but the physician orders dated the next day contained no oxygen order. Observation and interview showed the resident in bed with an oxygen concentrator in her room set to 3.5 liters per minute, and she was wearing the oxygen tubing correctly. Additional observations on subsequent days showed the concentrator still set at 3.5 liters per minute while the resident remained in bed. During interview, the evening nurse stated there was no oxygen order upon admission and that the admitting nurse should have contacted the physician and obtained an order for oxygen at the correct liters per minute. The day nurse stated residents with COPD should have oxygen saturation checked on admission and, if low, the physician should be notified to obtain an oxygen order for the correct rate. The DON stated it was the admitting nurses' responsibility to ensure orders were received and entered correctly, and that the admitting nurse should have obtained an oxygen order and appropriate liters per minute for the resident.
Resident Left in Food-Soiled Clothing After Lunch
Penalty
Summary
The facility failed to ensure Resident #104 received the necessary assistance with activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene. Resident #104 was a [AGE]-year-old female admitted with Parkinson’s Disease, Type 2 Diabetes Mellitus, muscle weakness, unsteadiness on feet, cognitive communication deficit, and glaucoma. Her MDS showed a BIMS score of 14, indicating she was cognitively intact, and documented that it was very important to her to choose her clothes and care for her personal things. The care plan also identified that she required one staff member for assistance with dressing and eating and needed help choosing clothes to wear. During observation on 3-10-2026 at 3:37 PM, Resident #104 was sitting in her wheelchair in her room with a substantial amount of food debris on the front of her shirt and on both pant legs. She stated that she had gotten the food on her while eating lunch in the dining room and said she wanted help changing into clean clothes because it made her feel dirty. Record review showed CNA C assisted her with eating lunch that day. CNA C later stated she brought Resident #104 to the dining room because the resident was getting confused about eating lunch, and that the resident was left with food on her clothes because she got busy and did not have time to change her. Interviews with staff showed agreement that the resident should have been changed promptly after lunch. RN B stated the resident should have had her clothes changed when she returned from lunch and that leaving her in dirty clothes could be a dignity issue. CNA A stated that if a resident’s clothes became dirty at lunch, the CNA working the earlier shift was responsible for changing them, and that leaving a resident in food-covered clothes could make the resident feel staff did not care for her. The DON and Administrator both stated that residents needing ADL assistance should not be left with food on their clothes after eating and that CNAs or nurses working in the resident’s hallway were responsible for timely ADL care. The facility policy on Resident Rights stated residents have a right to dignity and a safe, clean, comfortable environment.
Failure to Provide Scheduled Showers and ADL Assistance for Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate ADL care, specifically showers, to maintain a resident’s personal hygiene as required by her care needs and facility policy. Record review showed that a cognitively intact female resident, admitted from an acute care hospital with multiple complex medical conditions including heart failure, kidney failure, diabetes, cerebrovascular accident, depression, and frequent bowel and bladder incontinence, required set-up or clean-up assistance with personal hygiene and supervisory assistance with showers/baths. Her admission MDS documented that she was independent with eating, oral hygiene, and upper body dressing, but needed assistance for personal hygiene and bathing. Review of her electronic medical record over a 20‑day look‑back period showed that showers on two specific dates were documented as “not applicable,” and there was no documentation of a shower over a three‑day span. During interview, the resident reported that earlier in the month she went multiple days without a shower because the CNA assigned to her stated she would provide the shower at the end of the shift, then later reported she had run out of time and did not provide the shower or offer an alternative opportunity. The resident stated she did not refuse care, did not report the missed showers to nursing, and felt unclean after going three days without a shower, expecting to receive one every other day. CNA A confirmed that the resident’s shower days were Monday, Wednesday, and Friday, and admitted that on the days documented as “not applicable” she simply ran out of time, despite having enough staff, and did not coordinate with other staff or notify the nurse. Facility leadership interviews confirmed that residents were expected to receive showers at least twice weekly according to their care plan and that the resident should have been offered showers on her scheduled days, consistent with the facility’s Bath and Resident Rights policies, which state that residents will receive assistance with bathing per their care plan and have a right to a dignified existence.
Verbal Abuse of Resident by CNA
Penalty
Summary
A certified nurse aide (CNA) engaged in verbally abusive behavior toward a female resident with moderate cognitive impairment and a diagnosis of a rare genetic disorder associated with intellectual disability and poor coping skills. The incident occurred when the CNA called the resident an expletive in response to the resident using inappropriate language. The exchange was overheard by the facility's human resources staff, who recognized both voices and confirmed the use of the derogatory term by the CNA. The resident later reported feeling bad after being called the name, and the CNA did not deny the use of inappropriate language when questioned by staff. The resident's care plan included interventions for staff to provide positive interactions and avoid reacting to negative behavior due to her impaired cognition and behavioral challenges. Despite this, the CNA failed to maintain professional conduct and engaged in a verbal altercation with the resident. The facility's abuse policy defined verbal abuse as the use of disparaging or derogatory language toward residents, regardless of their cognitive status. The CNA had previously received training on abuse and neglect prevention.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, as required. Specifically, staff members including two LVNs and two CNAs did not report a resident's allegation of abuse and neglect to the facility's Abuse Coordinator (the Administrator). The incident involved a male resident with paraplegia, major depressive disorder, insomnia, chronic pain, neurogenic bowel, and neuromuscular dysfunction of the bladder, who was cognitively intact and required partial to moderate assistance with toileting hygiene. The resident alleged that a CNA attempted to strangle or choke him after he confronted her about not being changed for several hours. Multiple staff interviews and record reviews revealed that the resident had his call light on for an extended period, called the front desk, and eventually wheeled himself to the nurse's station to seek assistance. When he found the CNA, a confrontation occurred during which the resident felt threatened by the CNA's actions, though no physical injuries were observed or documented. The incident was communicated to several staff members, including LVNs and CNAs, but none of them reported the allegation to the Abuse Coordinator or completed an incident report in a timely manner. The facility's policy required immediate verbal reporting of suspected abuse, neglect, or exploitation to the Abuse Preventionist or designee, with a two-hour reporting window for allegations involving abuse or serious bodily injury. Despite this, the staff involved did not follow the policy, resulting in a delay in reporting the resident's allegation. The deficiency was identified through interviews, record reviews, and examination of facility policies, which confirmed that the required immediate reporting did not occur as stipulated.
Discontinued Medication Not Removed from Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that discontinued medications were promptly removed from the medication cart on the memory care unit. Specifically, a resident's Diazepam, which had been discontinued by physician order, remained in the narcotic box on the secure unit medication cart well after the discontinuation date. Record reviews showed inconsistencies and incomplete documentation on the narcotic sheet, including missing dates and signatures for administered and wasted doses. Observations revealed that the discontinued Diazepam was still present in the medication cart, and the medication administration records did not reflect proper removal or destruction of the drug. Interviews with nursing staff and the DON confirmed that discontinued medications should be removed from the cart immediately and that two nurses are required to sign off on the disposal of narcotics. However, the process was not followed, and the discontinued medication was not brought to the DON as required. Facility policies reviewed indicated that discontinued medications must be marked, removed from the cart, and stored securely until destroyed, but these procedures were not adhered to in this instance.
Failure to Hold Antihypertensive Medications per Physician Parameters
Penalty
Summary
A deficiency occurred when a resident with a history of multiple sclerosis, cognitive communication deficit, essential hypertension, and a history of transient ischemic attack was administered Lisinopril and Metoprolol despite physician orders specifying to hold these medications if the resident's systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) was less than 60, or heart rate (HR) was less than 60. On four separate occasions, nursing staff administered both medications even though the resident's SBP and/or DBP were below the ordered parameters. Specifically, the medications were given when the SBP was recorded as 106, 104, and 98, and the DBP was as low as 59, all of which were outside the prescribed limits. The medication administration records confirmed that the medications were marked as given on these dates by two different nurses, both of whom no longer worked at the facility at the time of the survey. There was no documentation of adverse effects in the resident's progress notes. Interviews with the DON and Administrator confirmed that the medications should not have been administered outside the physician's parameters and that all physician orders are expected to be followed. The facility's medication administration policy also required adherence to specific monitoring and the 10 rights of medication administration.
Failure to Address Repeated Refusals of Care in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical diagnoses, including Multiple Sclerosis, Cognitive Communication Deficit, and a history of Transient Ischemic Attack. Despite the resident's moderate cognitive impairment and repeated refusals of essential care and services such as wound care, perineal care, medication administration, showers, and nutritional supplements, the care plan did not include any interventions to address these refusals. Documentation in the resident's progress notes showed numerous instances where the resident declined wound debridement, application of prescribed creams, blood sugar checks, and other necessary treatments over an extended period. Interviews with the DON and Administrator confirmed that the resident's refusals should have been addressed in the care plan, with specific interventions to encourage acceptance of care. The facility's own policy required that the care plan identify declined care, the associated risks, and efforts by the interdisciplinary team to educate the resident and seek alternative solutions. However, the care plan lacked these elements, resulting in a failure to meet the resident's identified needs as outlined in the comprehensive assessment.
Failure to Maintain Infection Control During Wound Care
Penalty
Summary
A deficiency occurred when a Treatment Nurse failed to follow proper infection control procedures during wound care for a female resident with chronic venous hypertension and diabetic foot ulcers. During the wound care process, the nurse wiped the resident's toes, then placed her gloved hand—contaminated from contact with the wounds—back into a package of clean gauze multiple times. The nurse subsequently closed the package and returned it to the treatment cart for future use with other residents. This action was observed by surveyors and confirmed in interviews with the nurse, the DON, and the Administrator, all of whom acknowledged the risk of contamination and infection resulting from this practice. The resident involved had been admitted with significant risk factors for infection, including chronic venous ulcers and diabetes-related foot ulcers. The facility's infection control policy required maintaining a safe and sanitary environment to prevent the transmission of disease and infection. Despite this, the nurse's actions directly contradicted established infection control protocols, as confirmed by both her own admission and statements from facility leadership.
Failure to Prevent Significant Weight Loss in Resident with Complex Medical Needs
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by a 25.96% weight loss over four months. The resident, who had multiple complex medical diagnoses including protein-calorie malnutrition, diabetes mellitus, end stage renal disease requiring dialysis, and Parkinson's Disease, was admitted on a mechanically altered diet and required setup or clean-up assistance with eating. Despite being identified as at risk for unplanned weight loss on her care plan, interventions such as monitoring weight, encouraging meal completion, and offering supplements or alternatives were not effectively implemented or documented. The resident's weight declined from 195.00 pounds to 169.40 pounds over the review period. Nutrition assessments noted significant weight loss, but the only dietary change recommended was a modification in diet texture. The resident refused several meal trays, citing dislike for the food options, particularly ground meats and salty alternatives, and expressed a preference for specific meals like chicken pot pie. The facility's red cup program, designed to alert staff to residents at risk for malnutrition, did not include this resident, and there was confusion among staff regarding responsibility for monitoring and implementing this program. Interviews with staff revealed gaps in communication and follow-through regarding the resident's nutritional needs. The dietitian was aware of the weight loss but questioned the accuracy of weights and did not consistently review dialysis weights or logs. The DON acknowledged awareness of the weight loss but did not recognize its severity until recent training and had left intervention planning to the dietitian. The CNA and LVN assigned to the resident were either unaware of the weight loss or not involved in monitoring intake. The facility's policies required more frequent weights and interventions for significant weight loss, but these were not consistently followed for this resident.
Failure to Complete Timely Fall Assessment and Interventions After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors for falls, including alcohol-induced dementia, reduced mobility, history of falling, unsteadiness, and muscle weakness, experienced a fall. The resident required supervision and assistance with several activities of daily living and had a documented fall with no injuries prior to the incident. The care plan included interventions such as keeping the call light within reach, educating on walker use, and providing environmental cues. However, after the resident's fall, a fall assessment was not completed as required by facility policy. The LVN responsible for the resident did not complete the fall assessment or implement new interventions following the fall. Although the resident was found on the floor with a twisted knee and reported pain, and appropriate notifications and neuro checks were initiated, the required fall assessment was not performed. The ADON was notified of the fall and requested the LVN to return to complete the assessment, but the assessment was delayed and not completed in a timely manner. The DON and Administrator both confirmed that assessments should be completed after every fall to ensure appropriate care and interventions are provided. Facility policy mandates that a fall risk assessment be completed after each fall, with interventions updated as indicated. The failure to complete the assessment meant that the resident did not receive a timely evaluation of her condition or updated interventions to prevent further incidents. This lapse in protocol could result in residents not having the necessary resources or supervision to ensure their safety and appropriate care.
Failure to Maintain Safe and Appropriate Respiratory Equipment Storage and Labeling
Penalty
Summary
A deficiency was identified when a resident requiring respiratory care was not provided with care consistent with professional standards of practice and the resident's care plan. During observation, the resident's nasal cannula and tubing were found on the floor, and the humidifier bottle attached to the oxygen concentrator was not dated. Additionally, a nebulizer mask was found unbagged in the resident's drawer. The resident reported receiving breathing treatments every morning but was unaware of how the equipment was stored after use. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that all respiratory equipment should be clean, dated, labeled, and properly stored when not in use. Staff acknowledged that tubing found on the floor or unbagged should be discarded and replaced, and that humidifier bottles should be dated to prevent overuse. The facility's policy also required that nasal cannulas and related equipment be stored in a treatment bag when not in use and that non-disposable humidifier bottles be changed and dated regularly. The resident involved had a history of alcohol-induced dementia, chronic pain, a benign lung neoplasm, and was receiving hospice care. The care plan included monitoring for respiratory distress, and physician orders indicated the use of oxygen therapy and nebulizer treatments. Despite these documented needs and protocols, the observed lapses in equipment storage and dating constituted a failure to provide safe and appropriate respiratory care as required.
Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a serious injury. One resident, who had a documented history of physical and verbal aggression towards both staff and other residents, physically attacked another resident on the secure unit. The aggressive resident had previously exhibited behaviors such as yelling, name-calling, threatening, and even exposing himself in common areas. Despite these ongoing behaviors, interventions such as redirection, medication adjustments, and referrals for psychiatric consultation were documented, but the resident remained in the unit and continued to display aggressive tendencies. On the day of the incident, the aggressive resident pushed another resident, causing the victim to fall and sustain a laceration to the head and a serious injury to the right eye, which required hospitalization and surgical repair. The incident was witnessed by a staff member, who immediately called for nursing assistance. The injured resident was assessed, emergency services were contacted, and the resident was transported to the hospital for treatment. Prior to this event, the aggressive resident's care plan and progress notes reflected ongoing concerns about his behavior, including multiple documented episodes of aggression and staff interventions. The facility's policy stated that residents should not be subjected to abuse by anyone, including other residents, and outlined the need for interventions to prevent such incidents. However, despite the known risk and repeated aggressive behaviors, the facility did not prevent the assault that resulted in significant harm to another resident. The deficiency was identified as past non-compliance, with the immediate jeopardy beginning and ending on the day of the incident.
Missed Antibiotic Dose Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident, specifically for one resident who missed a dose of antibiotic medication. The resident, who was admitted with paraplegia and chronic osteomyelitis, had a physician's order for Vancomycin to be administered intravenously every 12 hours. However, the resident did not receive the scheduled 9:00 PM dose on a specific date. This oversight was discovered when the resident reported the missed dose to the ADON at 2:00 AM the following day. The ADON confirmed the missed dose and noted that the facility was short-staffed over the weekend, which contributed to the error. The nurse responsible for the resident's care had completed her shift before the scheduled dose, and the unit nurse who took over was not reachable for comment. The facility's policy on medication administration emphasizes the importance of adhering to the 10 rights of medication administration, including the right time, which was not followed in this instance.
Failure to Secure Medications in Med Room A
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with currently accepted professional standards in one of the two medication rooms reviewed. Specifically, the Assistant Director of Nursing (ADON) left medications unsecured outside Med Room A on top of a cart. These medications included four boxes of breathing treatment medication, an albuterol inhaler, Afrin nose spray, and a Geri Tussin DM cough medication bottle. During this time, residents were observed passing by the unsecured medications, which were accessible to them. The door to Med Room A was closed and locked, and the ADON was inside the room, unable to see the residents passing by due to the limited view from the med room window. In an interview, the ADON acknowledged the oversight, stating that she should have taken the cart inside Med Room A to prevent resident access to the medications. She admitted that it was her responsibility to secure medications when they were in her possession. The Administrator in Training (AIT) also confirmed that medications should be secured and stored according to facility policy, and it was the Director of Nursing's (DON) responsibility to ensure that the ADON followed the policy. The facility's policy on medication labeling, revised in April 2007, requires that all medications be properly labeled and secured, but this was not adhered to in this instance.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not ensure that stored food items were properly labeled and dated. During an inspection of the walk-in freezer, it was found that an unopened bag of pre-made frozen pancakes and a bag of broccoli were not labeled with their contents or the date they were received into the facility. Additionally, these items were not in their original packaging. An open cardboard box containing individual ice cream containers was also found with ice crystal accumulation on top, indicating improper storage. An interview with the Dietary Manager confirmed that the facility's expectation is for staff to properly close boxes and label them with the name of the item, the date it was opened, and the use-by date. The facility's Food Storage and Supplies policy, dated 2012, requires that open packages of food be stored in closed containers or sealed bags and dated when opened. The U.S. Public Health Service Food Code mandates that ready-to-eat, time/temperature control for safety food held for more than 24 hours must be clearly marked with a date to ensure it is consumed, sold, or discarded within a safe timeframe. The failure to comply with these standards could lead to cross-contamination and food-borne illness among residents.
Failure to Provide Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for two residents, leading to a deficiency in care. Resident #1, a female with a history of type 2 diabetes mellitus, transient ischemic attack, heart failure, and chronic obstructive pulmonary disease, was admitted to the facility without being screened for physical therapy, despite her care plan indicating a need for PT/OT evaluation and treatment. Similarly, Resident #111, a female with diastolic heart failure, muscle weakness, and a history of transient ischemic attack, was not screened for physical therapy, although she expressed a desire to walk and had only received occupational therapy focused on her hands. Interviews with facility staff revealed systemic issues in the screening process for therapy services. The Director of Rehabilitation (DOR), who had been at the facility for two weeks, acknowledged that the goal was to screen new admissions for therapy within 48 hours, but Residents #1 and #111 were not screened for physical therapy. The Corporate RN noted that the facility's procedures for therapy screening were inconsistent and dependent on various factors, including the payor source and changes in residents' conditions. The RN also mentioned that the facility lacked a specific policy on therapy screening, which contributed to the oversight. The Administrator in Training (AIT) confirmed that the expectation was for all residents to be screened for therapy services, but acknowledged that the new DOR and staffing shortages had impacted the facility's ability to meet this expectation. The AIT stated that morning meetings were held to identify residents who might need therapy, but the facility was currently short-staffed and rushing through work, which may have led to residents being missed. The facility's Admission/Readmission policy, dated 2003, indicated the need for an interdisciplinary plan of care, but did not specifically address therapy screening procedures.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several incidents involving staff not adhering to established protocols. In one instance, a Licensed Vocational Nurse (LVN) did not wear a gown while administering medication to a resident on Enhanced Barrier Precautions (EBP) due to a gastrostomy tube. The LVN was unaware that a gastrostomy tube required EBP and had not been trained on this aspect of infection control, leading to a lapse in protocol adherence. Another incident involved a wound care physician and an Assistant Director of Nursing (ADON) who did not wear gowns while providing wound care to a resident on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA) and other multi-drug-resistant organisms (MDROs). Although the ADON wore gloves and a mask, the lack of gowns was a breach of the contact isolation precautions. The ADON acknowledged the oversight and the importance of following isolation precautions to prevent the spread of infection. Additionally, a Certified Nursing Assistant (CNA) failed to sanitize her hands between feeding two residents, which is a critical step in preventing the transmission of infections. The CNA admitted to sometimes feeding multiple residents at once without performing hand hygiene, which contradicts the facility's policy on hand washing and feeding procedures. These failures collectively placed residents at an increased risk of exposure to communicable diseases and infections.
Violation of Resident Dignity During Meal Service
Penalty
Summary
The facility failed to uphold the dignity and rights of two residents during a breakfast meal. CNA C was observed feeding two residents simultaneously and yelled across the dining room at Laundry Aide D, disrupting the meal environment. This incident involved Resident #59, who had major depressive disorder and cognitive communication deficits, and Resident #88, who had cognitive communication deficits, dysphagia, and legal blindness. Both residents were dependent on staff for eating and had care plans that emphasized the need for calm communication and protection of their rights. During the incident, Laundry Aide D stood over Resident #88 while conversing with CNA C about social matters, further compromising the residents' dining experience. Interviews with CNA C and Laundry Aide D revealed an acknowledgment of the importance of respecting residents' dignity and the inappropriateness of the behavior observed. The facility's policies on resident rights and feeding emphasize the need for a dignified existence and a pleasant dining environment, which were not adhered to in this situation.
Resident Smokes Unsupervised Due to Lapse in Facility's Smoking Policy Enforcement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was observed smoking unsupervised in the courtyard during non-smoking times. The resident, who was cognitively intact and had a history of MRSA infection and hypertension, was found smoking without staff supervision, contrary to the facility's smoking policy which required direct supervision for residents assessed as needing it. The resident had been keeping his own cigarettes and lighter, unaware that these items were supposed to be stored at the nurse's station. The facility's smoking policy outlined specific times and staff responsibilities for supervising smoking breaks, but the resident was observed smoking outside of these designated times without supervision. Interviews with staff revealed inconsistencies in the enforcement of the smoking policy, with some staff unaware of the resident's possession of smoking materials and others not ensuring the resident's smoking items were stored securely. The resident had been informed he could leave his room as long as his wounds were covered, which may have contributed to the misunderstanding about smoking supervision. The facility's policy required regular assessments and revisions of the smoking care plan, but it appears there was a lapse in communication and enforcement of these procedures. Staff interviews indicated that while there was a process for assessing and supervising smoking, it was not consistently followed, leading to the resident smoking unsupervised. The facility's failure to adhere to its own smoking policy placed the resident and potentially others at risk of injury or accidents.
Medication Administration Errors Due to Inadequate Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to medication administration errors. For Resident #34, a Licensed Vocational Nurse (LVN E) administered Furosemide 40 mg despite the resident's blood pressure being below the prescribed parameter of SBP <110. The resident's blood pressure was recorded at 95/84, which should have prompted the nurse to hold the medication. LVN E admitted to not checking the parameters in the electronic record before administering the medication, which could have been avoided by expanding the order details. For Resident #74, LVN E administered Vancomycin without checking the vancomycin trough levels, which are crucial for ensuring the medication is within the therapeutic range. The trough level was available in the electronic record, but LVN E did not review it before administration. The resident inquired about the trough results, and LVN E only checked them after starting the medication administration, revealing a trough level of 2.2, which was below the expected range. The facility's Assistant Director of Nursing (ADON A) mentioned that the physician had ordered random trough levels due to the resident's previous medication refusals. Interviews with LVN E and the corporate Director of Nursing (DON) highlighted that the facility's expectation was for lab results to be reviewed prior to medication administration and for all parameters to be followed. The facility's policies on medication administration and physician orders emphasize the importance of reviewing orders and lab results to prevent medication errors and adverse drug reactions. However, these procedures were not followed, leading to the deficiencies observed.
Failure to Complete PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment. This deficiency was identified for one resident who was reviewed for preadmission screenings. The resident, a 68-year-old male, was admitted with diagnoses including cognitive communication deficit, anxiety disorder, and depression disorder. Despite a positive Level I PASRR screening indicating mental illness, the facility did not refer the resident for a PASRR Evaluation at the time of admission. The resident's care plan did not address the positive PASRR Level I for mental illness, and there were no orders for therapy or medication management for depression and anxiety. The facility's administrator, who was covering social worker tasks, admitted to not having received training on the PASRR process. The MDS Coordinator was unaware of the timeline or facility policy for notifying state authorities about positive Level I PASRR residents. Although an email from the local authority confirmed receipt of the PASRR email, the MDS Coordinator did not follow up or document the communication. The resident's PASRR Evaluation was eventually completed, but the documentation was not filed in the resident's medical records at the time of the investigation. The facility's policy requires all PASRR-related forms and communications to be maintained in the resident's medical record, but this was not adhered to. The lack of documentation and follow-up could have resulted in the resident not receiving necessary mental health services, although the evaluation was completed prior to the resident's discharge.
Failure to Develop Timely Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, which is necessary to provide effective and person-centered care. The resident, a 68-year-old male, was admitted with diagnoses including cognitive communication deficit, anxiety disorder, and depression disorder. Despite these conditions, the baseline care plan did not address the resident's positive PASRR Level I for mental illness, anxiety disorder, and depression disorder. This oversight was identified during a record review, as the resident had already been discharged and was not available for interview or observation. The facility was operating without a Director of Nursing (DON) at the time, and the responsibility for initiating and completing baseline care plans fell to all facility nurses, including the Administrator (ADM). The ADM acknowledged the expectation for accurate and individualized care plans to prevent a decline in resident abilities. The MDS RN stated she was not responsible for monitoring care plans during the interim period without a DON, and the corporate nurse was visiting the facility daily to address clinical concerns. The facility's policy requires comprehensive care plans to be developed and implemented to meet residents' medical, nursing, and psychosocial needs, but this was not adhered to in the case of the resident in question.
Unsafe Smoking Practices and Supervision Deficiencies
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for four residents who were reviewed for hazards. Specifically, the facility did not ensure that two residents did not keep cigarettes and lighters on themselves, and two other residents were observed picking up cigarette butts from the ground to reuse. These actions placed the residents at risk of being burned. Resident #1, a male with a history of dementia, anxiety disorder, and nicotine dependence, was observed smoking outside unsupervised and keeping cigarettes and a lighter in his pocket. Similarly, Resident #4, diagnosed with chronic obstructive pulmonary disease and mild cognitive impairment, was also seen smoking unsupervised with smoking materials in his possession. Both residents had care plans indicating they should not store smoking materials in their rooms, yet they were able to keep these items on their person. Resident #2, diagnosed with dementia and schizophrenia, and Resident #3, with type 2 diabetes and cognitive communication deficit, were both observed picking up cigarette butts from the ground and storing them in their pockets. Despite having intact cognition scores, these residents engaged in unsafe smoking practices. The facility's policy stated that smoking materials should not be kept in residents' rooms and that residents assessed as unsafe should be supervised, yet these guidelines were not followed, leading to the observed deficiencies.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure that a resident received proper foot care, specifically by not having her toenails trimmed by a podiatrist. The resident, who has severe cognitive impairment and multiple medical conditions including Alzheimer's Disease, was observed with untrimmed and thick, yellow toenails, some of which were curled and potentially causing discomfort. Despite being referred to a podiatrist in April, the resident did not receive the necessary services, and there was no indication in the progress notes that she was referred or received care from a podiatrist. Interviews with staff revealed a lack of clarity and consistency in the responsibility for nail care. A CNA mentioned that she had not seen a podiatrist visit the resident and that she would trim nails if they were long, except for diabetic residents. An LVN expressed discomfort in trimming the resident's thick and fungal toenails and mentioned that the podiatrist was scheduled to visit soon. The DON and Administrator acknowledged the issue, with the Administrator noting a change in podiatry provider and a failure to re-refer the resident in July. The facility's policy on foot care, dated 2003, outlines goals for maintaining skin integrity, preventing infection, and avoiding injury to the feet. However, the policy does not include a procedure for referring residents to outside services, which contributed to the oversight in ensuring the resident received appropriate podiatry care. The lack of a clear referral process and follow-up led to the resident not receiving timely and necessary foot care, potentially placing her at risk of discomfort and further complications.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide necessary nail care for two residents, leading to deficiencies in maintaining personal hygiene. Resident #2, a male with cerebral infarction, vascular dementia, and a left-hand contracture, was observed with long nails on his right hand, with a yellow substance underneath and around them. His care plan indicated that nail care should be performed on bath days and as necessary, with specific instructions for diabetic residents. However, the staff did not notice or address the condition of his nails. Resident #3, a male with encephalopathy and severe cognitive impairment, was observed with long fingernails in the dining room. Interviews with staff revealed that nail care responsibilities were shared between CNAs, nurses, and a podiatrist, with specific protocols for diabetic residents. Despite these protocols, Resident #3's nails were not trimmed, and staff cited difficulty in managing his nail care due to his mood. The facility's policy on nail care emphasized regular and safe performance to prevent infection and injury, but these guidelines were not followed for the residents in question.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene. Specifically, two residents, identified as Resident #10 and Resident #11, did not receive showers as scheduled. Resident #11, a male with chronic respiratory failure, end-stage renal disease, and muscle weakness, required partial/moderate assistance for showering. Despite having a BIMS score indicating intact cognition and no documented refusals, Resident #11 received only 4 out of 12 scheduled showers in April and 4 out of 13 in May. Similarly, Resident #10, a male with paraplegia requiring supervision or touching assistance, received only 2 out of 11 scheduled showers in May and 2 out of 12 in June. Interviews with staff revealed inconsistencies in documentation and communication regarding shower refusals and completions. The ADON explained the shower schedule and the process for documenting refusals, which involved CNAs attempting to persuade residents up to three times before notifying a nurse. However, the ADL sheets for both residents contained blanks and entries indicating that the activity did not occur, without clear documentation of refusals. Staff interviews indicated a lack of clarity and consistency in the documentation process, with some staff assuming that blanks meant showers were not given and others interpreting the code '8' as a refusal or other reasons. The facility's policy on bed baths and showers did not include procedures for documenting showers or refusals, contributing to the lack of proper documentation. The DON stated that documentation was crucial for tracking whether showers were given or refused, but acknowledged the absence of a specific policy on showers. The MDS Coordinator and CNAs confirmed that training on documentation was provided, but discrepancies in understanding and execution were evident, leading to the deficiency in providing scheduled showers to the residents.
Unsafe Installation of Temporary Air Conditioning Unit
Penalty
Summary
The facility failed to maintain a safe environment in the secured unit dining/activity room, where a window air conditioning unit was installed due to a malfunctioning wall unit. The installation involved a loose power cord from the window unit connected to an unsecured extension cord, which was coiled and resting above a doorway. This setup posed a potential hazard to approximately 22 residents present in the room, as the cords were easily accessible and could lead to accidents or injuries. Interviews with staff, including CNAs, LVN, and maintenance personnel, revealed awareness of the potential risks associated with unsecured cords, especially for residents with conditions such as dementia, bipolar disorder, or impulse disorders. These conditions could increase the likelihood of residents interacting with the cords in harmful ways, such as chewing, choking, or using them as weapons. Despite the staff's understanding of these risks, the temporary solution was implemented without adequate safety measures to secure the cords. The facility's administration acknowledged the use of the window unit as a temporary measure due to high temperatures and the malfunctioning wall unit. However, the ADM admitted to not noticing the unsecured extension cord, and the facility's policy emphasized the responsibility of all staff to report and address hazards immediately. The facility's policy on resident rights also highlighted the importance of providing a safe environment, which was not upheld in this instance.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for one resident involved in an incident. CNA A did not follow the facility's policy to report allegations of abuse when she allegedly observed CNA B holding a resident down in a choke hold. This failure to report the incident could place residents at risk of abuse and lack of timely reporting of incidents. The resident involved was an elderly male with Alzheimer's disease and other cognitive impairments. He required substantial assistance with activities of daily living, including toileting. On the day of the incident, CNA A observed CNA B being verbally aggressive and physically abusive towards the resident. Despite being aware of the facility's policy and having recently attended an in-service on abuse and neglect, CNA A did not report the incident due to fear of retaliation. Interviews with other staff members, including the ADON, RN G, and other CNAs, revealed that they had not observed any signs of abuse or changes in the resident's behavior. The Administrator was also unaware of the incident until it was brought to her attention by the surveyor. The facility's policy requires all staff to report any allegations of abuse immediately, but this protocol was not followed in this case.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator. CNA A did not report an incident where CNA B allegedly grabbed a resident by the neck and held him down in a choke hold. CNA A stated she did not intervene or report the incident due to fear of retaliation and physical harm from CNA B. CNA A also mentioned that she had observed CNA B being verbally aggressive with residents and that other staff, including RN G, were aware of CNA B's behavior but did nothing to address it. The resident involved, a male with Alzheimer's disease and other cognitive impairments, required substantial assistance with daily activities. The incident allegedly occurred during CNA A's training period, and despite being aware of the facility's policy on reporting abuse, CNA A chose not to report the incident to the appropriate authorities. CNA A discussed her observations with other staff members, who advised her to report the abuse to an outside entity rather than the facility. Interviews with other staff members, including CNA E and Hospitality Aide F, revealed that they were not aware of any abuse in the Memory Care Unit and denied that CNA A had reported any such incidents to them. The Administrator was also unaware of the alleged abuse until the surveyor's inquiry. The facility's policy on abuse and neglect emphasizes the residents' right to be free from abuse and the importance of immediate reporting, which was not followed in this case.
Failure to Revise Care Plans for Smoking Supervision
Penalty
Summary
The facility failed to review and revise care plans for two residents, leading to a deficiency in ensuring their safety while smoking. Resident #1, a [AGE] year-old female with diagnoses including paralysis, seizures, and stroke, required direct supervision while smoking as per her Safe Smoking Assessment. However, her care plan did not reflect this need. During an observation, Resident #1 was found smoking unsupervised, with evidence of a cigarette burn on her pants. The resident admitted the burn occurred about a month ago, indicating a prolonged period of unsupervised smoking despite the assessment's findings. Similarly, Resident #2, a [AGE] year-old female with diagnoses including diabetes and a history of falls, also required direct supervision while smoking according to her Safe Smoking Assessment. Her care plan, however, did not include this requirement. During an observation, Resident #2 was found smoking without staff supervision and refused to disclose who had lit her cigarette. The Director of Nursing (DON) acknowledged that residents were only allowed to smoke at designated times with staff present but admitted it was challenging to prevent residents from smoking unsupervised. This failure to update and enforce care plans placed both residents at risk of harm.
Failure to Supervise Residents While Smoking
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for five residents who required supervision while smoking. Observations revealed that these residents were found smoking without staff supervision, contrary to their care plans and safe smoking assessments. For instance, Resident #1, who required direct supervision while smoking, was observed smoking alone in the designated area, with evidence of a cigarette burn on her pants. Similarly, Resident #2 was found smoking without supervision and refused to disclose who had lit her cigarette. Resident #3 admitted to keeping his own smoking materials in his room and smoking without staff supervision, despite his assessment indicating the need for direct supervision. Resident #4, who had a care plan intervention for supervision while smoking due to non-compliance with the smoking policy, was also observed smoking without staff present. Resident #5, who required direct supervision while smoking, was found smoking alone, and her monthly smoking assessments had not been completed since October 2023. Interviews with the DON and the Administrator confirmed that residents were not permitted to smoke except at designated times with staff supervision, and that smoking materials were to be kept at the nurse's station. However, it was acknowledged that residents often kept their own smoking materials and smoked without supervision. The facility's smoking policy, dated November 1, 2017, mandates that matches, lighters, or other ignition sources are not to be kept in residents' rooms, and that residents classified as unsafe must be directly supervised while smoking. The policy also requires regular safe smoking assessments and inclusion of supervision needs in the residents' care plans. The facility's failure to enforce these policies and ensure proper supervision placed the residents at risk of injury or harm.
Failure to Provide Privacy Curtains
Penalty
Summary
The facility failed to assure full visual privacy for two residents while their privacy curtains were being laundered. Resident #6, a cognitively intact male with a history of bone infection, diabetes, and amputation, and Resident #7, a cognitively intact male with diabetes, legal blindness, and amputation, were both affected. The privacy curtains were removed on April 13, 2024, due to a bed bug treatment and were not replaced when the residents were moved back into their room on April 17, 2024. This left the residents without privacy during personal care activities such as wound care and incontinence care. Observations on April 20, 2024, confirmed the absence of privacy curtains in the room shared by Residents #6 and #7. Interviews with both residents revealed their discomfort and lack of privacy, with Resident #7 expressing particular concern due to his blindness and reliance on staff for privacy. The facility's Administrator acknowledged that the curtains should have been replaced before the residents were moved back into their room but did not know why this had not occurred. There was no policy in place for privacy curtains at the time of the incident.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure proper foot care for four residents, specifically in the trimming of toenails, which could lead to complications such as fungal infections or other podiatric problems. Resident #1, a [AGE] year-old female with severe cognitive decline and high blood pressure, had overgrown toenails, including a thick and blackened left great toenail. Resident #2, a [AGE] year-old female with severe cognitive deficits and difficulty walking, had grossly overgrown, thick, and curved toenails. Resident #3, a [AGE] year-old male with dementia and diabetes, also had overgrown toenails. Resident #4, a [AGE] year-old male with metabolic encephalopathy and seizures, had severely overgrown toenails and could not recall the last time they were trimmed. Interviews with nursing staff revealed inconsistencies in the facility's approach to toenail care. RN A stated that nursing staff could trim all toenails unless they were thick and deformed, in which case a podiatrist would be consulted. However, LVN B indicated that all toenails had to be trimmed by the podiatrist, and the nursing staff did not perform this task. The DON confirmed that nurses should trim toenails unless they were thickened or deformed, in which case the podiatrist, who visited quarterly, would handle it. A review of podiatry visits showed that the four residents had not been seen by the podiatrist and were not scheduled for an upcoming visit. The facility's policy on nail care emphasized regular and safe nail care to prevent abnormal conditions and infections, but this was not adhered to in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 745 citations issued within 25 miles in the last 12 months — including the 37 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Lake Nursing & Rehabilitation, Llc | 0.2 mi | ★★★★★ | 2 | 0 |
| Dfw Nursing & Rehab | 0.3 mi | ★★★★★ | 13 | 4 |
| James L West Center For Dementia Care | 0.6 mi | ★★★★★ | 0 | 0 |
| Trinity Terrace | 0.7 mi | ★★★★★ | 0 | 0 |
| Fort Worth Transitional Care Center | 0.8 mi | ★★★★★ | 18 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.