Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eagle Crest Rapid Recovery during CMS and state inspections, most recent first.
A resident with advanced dementia, anxiety, depression, and significant cognitive impairment became physically aggressive toward staff during a transfer, hitting and scratching a CNA and an LVN. During this period, a CNA spoke to the resident in a rude and demeaning manner on more than one occasion, which was identified as verbal and emotional abuse and a violation of the resident’s right to dignity and respect. The NP later reported not being informed of the specific abusive comments or the resident’s sensitivity to certain language, despite expecting detailed information on abuse allegations and behavior issues. These actions occurred despite facility policies requiring protection from abuse and respectful, dignified treatment of all residents.
A resident with severe cognitive impairment, dementia, anxiety, and depression became physically aggressive during transfers, striking an LVN and scratching both an LVN and a CNA. Audio/video later captured a CNA telling the resident, "You do not hit anyone in the face. Ugly, ugly, ugly," after which the resident was heard screaming; the resident’s representative later found the resident crying and repeatedly stating she was not ugly. Although the NP later assessed the resident related to an abuse allegation, the MD reported he was never informed of the allegation, and the NP stated she was not told the specific details of the verbal abuse or the resident’s sensitivity to the word used. This sequence of events shows the facility did not immediately consult the physician or fully inform the resident representative about a significant change and abuse allegation, contrary to its own condition-change reporting policy.
A resident with severe cognitive impairment, total dependence for toileting, and continuous bladder and bowel incontinence was found with a heavily urine-soiled brief and strong urine odor after not receiving incontinent care for over four hours, despite a care plan requiring check-and-change as needed. The assigned CNA reported the last care was provided in the morning, then assisted with meals and went on break without checking the resident beforehand or arranging clear coverage, and the RN on duty did not recall being informed of the break. The DON stated residents should be checked for incontinence every two hours and that the nurse in charge and CNAs are responsible for ensuring timely incontinent care and communication around breaks, while facility documents showed an incontinence care policy and peri-care training materials.
A resident with severe cognitive impairment and total dependence for toileting was found in a heavily urine-soiled brief with a strong odor after more than four hours without incontinence care, despite a care plan and expectation for checks and changes about every two hours. The assigned CNA reported last providing care in the late morning, then assisted with meals and went on break without re-checking the resident or confirming relief coverage, while the RN on duty did not recall being notified of the CNA’s break. During observed incontinence care, the CNA cleaned the resident’s perineal area from back to front rather than front to back, contrary to facility training materials, although the resident’s skin was intact at the time. The DON stated residents should be checked every two hours for incontinence and that the nurse in charge is responsible for ensuring timely incontinence care.
A resident with multiple serious medical conditions had a documented DNR order and a care plan intervention requiring staff to check DNR status before calling a code. During rounding, a nurse found the resident gasping, sweating, and then unresponsive, and an LVN called a code and initiated CPR and other life-saving measures without first verifying code status. EMS continued life-saving efforts until the resident’s active DNR was later located and confirmed, and interviews and records showed this action was contrary to facility policy requiring verification of DNR status before initiating life-saving measures.
Incomplete care plans failed to address pressure injury prevention and other identified needs for multiple residents. Residents with heel and foot wounds did not have specific heel boot interventions in their plans, one resident with a leg pressure ulcer did not have the ordered pillow intervention clearly included, and another resident with significant weight loss lacked a care plan for that issue. Observations and record review showed turning/repositioning tasks were not consistently completed as ordered, and staff reported inconsistent use of heel protectors and the special pillow.
Failure to Provide Ordered Pressure Ulcer Prevention and Care: Multiple residents with impaired mobility, cognitive impairment, and elevated Braden risk developed in-house pressure injuries while turning/repositioning was not completed as ordered and pressure-relieving devices were not consistently in place. Records and observations showed missed q2h turns, heel boots left off or not ordered in the care plan, a low-air-loss mattress not being used as intended, and a pressure-relieving pillow not consistently applied, with several residents developing heel and lower-extremity ulcers that progressed to stage 3 or stage 4.
A hospice-respite resident with Alzheimer’s disease and severe cognitive impairment was admitted with PRN morphine orders, but staff did not continuously assess pain, did not document pain levels, and did not administer any morphine after admission. Admission records left pain sections blank or marked pain as none, while later notes described agitation, yelling, refusal of care, and statements such as “I don’t feel good” and “that hurts.” Staff reported the morphine syringes were improperly labeled and unavailable for use, and the DON and MD stated hospice was expected to provide the medications.
A facility failed to manage meds accurately for a hospice-respite resident and several residents receiving insulin. A resident admitted with Alzheimer’s disease and malnutrition arrived without usable morphine or ABH gel because the controlled meds were not properly labeled or tracked, while staff documented agitation, combativeness, and poor intake. Surveyors also found an expired open insulin vial on a med cart and noted that sliding-scale insulin for multiple residents was given before meals, including doses administered well before the scheduled breakfast time.
Inaccurate MDS coding affected two residents. One resident with a fracture had an admission MDS that did not reflect scheduled and PRN oxycodone use or other pain interventions, even though the MAR and progress notes showed pain meds and lidocaine patch use. Another resident’s Annual MDS did not reflect significant weight loss despite documented decline in weight and RD notes showing a 12.7% loss over 6 months; the care plan also lacked a weight-loss focus area.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found a 9% med error rate based on 3 errors in 32 opportunities. An LVN omitted one resident’s ordered Lexapro and prepared the wrong dose of levetiracetam for a resident with PEG-tube meds, and she also crushed an ER guaifenesin tablet for another resident. The DON stated staff are expected to verify orders and ensure meds are the correct formulation before administration.
Significant medication errors occurred when nursing staff gave rapid-acting insulin too early or outside the ordered meal-related times for multiple residents. An LPN reported giving insulin before meals, while survey observations showed breakfast had not yet been served when insulin had already been administered. Residents involved had DM and significant cognitive impairment, and MAR review showed lispro doses given at times that did not match the meal schedule or ordered timing.
Medication storage and labeling were deficient in several cart and med room areas. Surveyors found a med room refrigerator without a thermometer and with incomplete temp logs, an open supplement bottle without an open date, loose pills in a med aide cart drawer, a probiotic stored at room temp despite refrigeration instructions, and prefilled morphine syringes lacking required pharmacy and resident labeling. Staff stated carts were expected to be checked daily for labeling and storage issues, and the DON said meds were to be stored at the correct temp and in proper pharmacy-labeled packaging.
Infection control practices were not followed during wound care, hand hygiene, and medication administration. A PT and CNA used the clean utility room sink after handling contaminated items instead of performing hand hygiene before leaving resident care areas, and an LPN touched medications with bare hands and entered a resident’s room without the required gown during PEG-tube medication administration. The observations involved residents with a stage 4 pressure injury, a feeding tube, and other complex medical conditions.
A resident with hypotension, chronic heart failure, anemia, and irregular heartbeat reported feeling unwell during PT, then developed new chest pain and SOB with fluctuating O2 sat, elevated RR, and heart rate changes. PT stopped the session and notified an LPN, but the physician and NP were not informed even though the symptoms were a change in condition. The resident later said the chest pain was new and improved after being laid back in bed.
A resident admitted for hospice-respite care had a baseline care plan that omitted key admission needs, including opioid pain medication, behavioral concerns, and hospice/respite-related instructions. The resident was observed screaming, biting objects, threatening staff, and showing severe agitation, while staff reported combative behavior, no pain assessments, and no clear plan in place to address her behaviors or PRN meds such as morphine, lorazepam, or ABH gel.
Failure to provide needed nail care: A resident with post-stroke weakness/paralysis, impaired cognition, and an ADL self-care deficit was observed with fingernails and toenails significantly overgrown. The resident said he preferred short nails and had no problem with them being cut, and there was no documented refusal of nail care. The DON stated CNAs and nurses were responsible for nail care for residents without diabetes and that nail care was part of ADL assistance.
Missed Ordered Wound Care: A resident with a right forearm fracture, laceration, and orthopedic aftercare needs did not receive ordered wound care on a scheduled day. Nursing notes said the resident was out on pass with family, but there was no documentation of the pass, the resident’s departure or return, or a refusal of care. The resident later stated she missed wound care because the facility did not provide it on weekends, and the Wound Care Nurse and DON stated wound care should have been completed before leaving, after return, or on the next shift.
An LVN failed to verify G-tube placement before giving meds and a bolus feed to a resident with PEG status, severe cognitive impairment, dysphagia, and total ADL dependence. She crushed and administered seven meds through a syringe, then gave enteral formula through the same syringe, despite the resident becoming visibly agitated during the process. The DON stated placement must be checked before meds or feeding and that meds and bolus feeds should not be given concurrently; the MAR also showed one scheduled escitalopram dose was missed.
A resident's insulin was left unattended at her bedside by an LVN, contrary to the facility's policy requiring medications to be secured and locked. The resident, who had Type 2 diabetes and intact cognition, did not notice the medication. The LVN acknowledged the mistake and the risk involved, while the facility's policy emphasized secure storage of medications.
A resident with multiple health conditions and a high fall risk rolled off the bed during incontinent care due to inadequate supervision and assistance. The resident required extensive assistance for bed mobility, but only one CNA was present, contrary to the care plan. The CNA reported the resident was rocking and did not hold her weight, leading to the fall. The resident was sent to the hospital for evaluation, where no abnormalities were found.
Verbal and Emotional Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from abuse, neglect, and to be treated with dignity and respect. The resident was an elderly female with multiple diagnoses including Alzheimer’s disease, dementia with severe cognitive impairment (BIMS score of 02), generalized anxiety disorder, major depressive disorder, psychotic and mood disturbances, a history of transient ischemic attack, muscle weakness, difficulty walking, dysphagia, and a cognitive communication deficit. These conditions contributed to significant cognitive and functional limitations. On the date of the incident, the resident was being assisted with a transfer from bed to wheelchair by CNA A and LVN A when she became physically aggressive, hitting both staff in the face, pulling LVN A’s hair, and digging her nails into both staff members’ arms. Staff attempts at redirection were documented as unsuccessful. During this same period, CNA A spoke to the resident in a rude manner on at least two occasions, which the facility and surveyors identified as verbal and emotional abuse and a violation of the resident’s right to dignity and respect. The report states that on one date CNA A verbally and emotionally abused the resident by speaking rudely to her, and on another date CNA A again spoke rudely to the resident, failing to treat her with dignity and respect. The report further notes that the resident had anxiety, memory issues, and a pattern of lashing out physically toward staff when feeling scared or having difficulty remembering people, places, and events throughout the day, making the manner of staff communication particularly significant. The NP who evaluated the resident after the abuse allegation reported that she had not been informed that staff had commented to the resident that she or her behavior was “ugly,” nor that the resident had issues with the use of the word “ugly” from childhood. The NP stated it was her expectation to be informed of the specifics of abuse allegations and behavior issues so she could address the resident’s behavior concerns more specifically. The facility’s own policies on Abuse Prevention and Resident Rights required that residents be protected from abuse by anyone and be treated with respect and dignity in an environment that promotes or enhances quality of life. Despite these policies, CNA A’s rude and demeaning communication toward the resident on the identified dates constituted the abusive and undignified treatment that led to the cited deficiency. The noncompliance was identified as past noncompliance, beginning on 02/18/2024 and ending on 02/23/2026, and involved at least one resident who was subjected to rude, emotionally harmful communication by a CNA. The survey findings specify that this failure could place residents at risk of abuse, mental anguish, and fearfulness. The documentation and interviews collectively show that, although the resident had significant cognitive and behavioral issues and sometimes became physically aggressive during care, staff were still required by policy and regulation to interact with her in a respectful, compassionate manner, which did not occur when CNA A spoke to her rudely and in a way characterized as demeaning and emotionally abusive.
Failure to Notify Physician and Representative of Abuse Allegation and Significant Change
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident representative when there was a significant change in condition related to an abuse allegation. The resident was an elderly female with Alzheimer’s disease, dementia with severe cognitive impairment (BIMS score of 02), generalized anxiety disorder, major depressive disorder, and other mood and psychotic disturbances. On the date of the incident, progress notes documented that the resident became physically aggressive during a bed-to-wheelchair transfer, hitting an LVN in the face, pulling the LVN’s hair, and scratching both the LVN and a CNA. A subsequent behavior note documented that the resident refused morning medications and again became physically aggressive during transfer attempts, with staff attempting but failing to redirect her behavior. Audio/video recordings from the resident’s room later showed that after the transfer, when the LVN had left the room, the CNA told the resident, “You do not hit anyone in the face. Ugly, ugly, ugly,” in reference to the resident’s behavior, while the resident was heard screaming. The ADM and DON confirmed that the CNA used the phrase “ugly, ugly, ugly” toward the resident and that this was hurtful to the resident due to a past history of being called ugly as a child. The resident’s representative reported that on the same day, the resident was crying and repeatedly saying, “I am not ugly,” and that she had to reassure the resident that she was not ugly. The representative also stated that the resident had pain when moved due to metal in various parts of her body and placed signage on the door asking staff to be careful when moving the resident. Despite the abuse allegation and the emotional impact on the resident, the resident’s physician stated he was not informed of the allegation and was unaware of the incident. The NP reported that she assessed the resident several days later related to an abuse allegation made on the date of the incident but was not informed that staff had called the resident or her behavior “ugly,” nor that the resident had a specific sensitivity to that word from childhood. The NP stated it was her expectation to be informed of the specifics of abuse allegations and behavior issues in order to assess and treat the resident appropriately. The facility’s undated policy on condition change required observing, recording, and reporting any condition change to the physician so proper treatment could be implemented, but the MD confirmed that the abuse allegation involving this resident was not reported to him immediately as he expected.
Failure to Provide Timely Incontinent Care and Personal Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and necessary services to maintain personal hygiene for one resident who was totally dependent on staff for toileting and was always incontinent of bladder and bowel. The resident, an elderly female with severe cognitive impairment (BIMS score of 4) and multiple neurologic and medical conditions including aphasia, hemiplegia/hemiparesis, and a history of severe sepsis, had a care plan intervention for bladder and bowel incontinence that included checking and changing as required. During an observation of incontinent care in the afternoon, surveyors noted a strong odor of urine when the resident’s brief was removed, and the brief was heavily soiled with urine, although the skin remained intact without redness or rash. CNA A reported that the last incontinent care provided to this resident had been at 10:00 a.m., and that she usually checked and changed the resident every two hours. CNA A stated she had been assisting residents in the dining room with meals and then went on break, telling the nurse but not checking the resident for incontinence before leaving and not arranging specific coverage with another CNA. She did not answer when asked why she failed to check the resident before her break and said she did not know who was supposed to relieve her. RN C stated she did not recall being told that CNA A was going on break and did not know which CNA was covering. The DON stated residents should be checked for incontinence every two hours, that failure to do so placed residents at risk, and that the nurse in charge is responsible for ensuring timely incontinent care, with CNAs expected to notify other CNAs and the charge nurse before going on break and to check residents’ needs, including incontinence, prior to leaving. Facility documents included an incontinence care policy and a peri-care training form, but the DON reported there was no specific policy on female incontinence.
Failure to Provide Timely and Proper Incontinence Care and Peri-Care Technique
Penalty
Summary
The facility failed to provide appropriate incontinence care and maintain continence for a resident who was always incontinent of bladder and bowel, as documented on the quarterly MDS. The resident, an elderly female with severe cognitive impairment (BIMS score of 4) and multiple neurologic and medical conditions including aphasia, hemiplegia/hemiparesis, and severe sepsis, was care planned for bladder and bowel incontinence related to impaired mobility, with an intervention to check and change as required for incontinence. On observation, when staff removed the resident’s brief in the afternoon, there was a strong odor of urine and the brief was heavily soiled, despite CNA A stating that the last incontinence care provided had been at 10:00 a.m. and that care was usually provided every two hours. CNA A reported assisting residents in the dining room and then going on break without checking the resident for incontinence prior to the break and without knowing which CNA was to relieve her, while the RN on duty did not recall being informed of the break or knowing who was covering for CNA A. During the observed incontinence care, CNA A did not follow proper peri-care technique for a female resident. After the resident was repositioned to her right side, CNA A cleaned the perineal area from back to front using the same disposable washcloth, then continued to clean the buttocks in the same back-to-front manner with a new washcloth, contrary to the facility’s training form that directed washing the genital area from front to back. The resident’s skin was intact with no redness or rash at the time of observation. The DON stated that residents should be checked for incontinence every two hours and that failure to do so placed residents at risk for skin breakdown, urinary tract infections, and moisture-associated dermatitis, and also stated that CNAs are expected to notify other CNAs and the charge nurse when going on break and to ensure residents’ needs, including incontinence care, are met before leaving. The facility’s incontinence care policy emphasized keeping skin clean, dry, and free of irritation and odor, and preventing skin breakdown and infection.
Failure to Verify and Honor Resident DNR Prior to Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) order by not verifying code status before initiating life-saving measures. The resident was an older male with multiple significant diagnoses, including cerebral infarction, muscle weakness, hyperlipidemia, type 2 diabetes without complications, quadriplegia, acute posthemorrhagic anemia, and hypotension. His care plan documented that he was DNR, and an intervention required staff to check the resident’s file for DNR status before calling a code. During routine rounding, a nurse observed the resident gasping for air, sweating profusely, and then becoming unresponsive. A code was called, life-saving measures were initiated, and 911 was contacted. Cardiopulmonary resuscitation (CPR) and other life-saving interventions were provided by LVN A and then continued by emergency medical services (EMS) upon their arrival, before the resident’s DNR documentation was located and confirmed as active. Interviews and record reviews showed that facility policy required staff to determine whether a resident had a DNR in place before taking any life-saving measures. The Administrator, ADON, and nursing staff stated that the nurse who calls a code is responsible for verifying DNR status prior to initiating CPR, and that failing to do so violates facility policy. The facility’s provider report documented that the nurse on duty failed to comply with the resident’s DNR by calling a code and initiating life-saving measures despite the DNR order being in place.
Incomplete Care Plans for Pressure Injury Prevention and Other Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for multiple residents whose assessments identified medical and psychosocial needs. The report states that 6 of 7 residents reviewed did not have care plans that fully addressed their needs, including prevention of facility-acquired pressure injuries, continuous use of heel protectors for residents with heel and foot wounds, use of a special pillow for a resident with a leg pressure ulcer, and significant weight loss for one resident. The deficiency was identified during observation, interview, and record review, and an Immediate Jeopardy situation was identified on 08/08/25. For one resident with a stage 4 pressure injury to the right medial heel, the care plan included treatment orders and a low air loss mattress, but did not include heel protector boots. The resident’s turning and repositioning task was initially scheduled every 2 hours, but the task was not completed as ordered and later changed to every shift. During observation, the resident was in bed without heel protector boots, and the boots were found in the room away from the resident. The resident stated the wound hurt and did not know how he got it. The wound care nurse applied the boots during the surveyor’s observation. Another resident with severe cognitive impairment, functional dependence, tube feeding, and new stage 3 and unstageable pressure injuries to the left foot had care plan interventions for low air loss mattress use and skin monitoring, but no intervention for bilateral heel boots every shift and no overall pressure injury prevention plan. A third resident with a stage 4 pressure ulcer to the right medial calf had a care plan that referenced a pressure reducing device on the bed/chair, but did not specify the special pillow between the legs that was ordered for pressure reduction. During observation, the resident was sleeping with contracted legs and no pressure-relieving pillow between them, and the wound care nurse stated the resident was supposed to have a donut pillow placed between the knees. The report also states that a resident with significant weight loss did not have a care plan addressing that issue.
Failure to Provide Ordered Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to ensure pressure ulcer care was provided as ordered and failed to prevent new pressure injuries for multiple residents who were at risk. Resident #4 had hemiplegia, diabetes, severe cognitive impairment, and required substantial to maximum assistance with bed mobility. His Braden score indicated moderate risk. He was scheduled for turning and repositioning every 2 hours, but the task records showed it was not completed as ordered and later changed to every shift. He developed an in-house stage 4 pressure injury to the right medial heel, first identified on 06/26/25. During wound care observation, he was lying in bed on a low-air-loss mattress without heel protector boots on his feet, and the boots were found in the room. The CNA stated the resident was supposed to have the boots on but they were not on because she forgot to notify the nurse. Resident #41 had dementia, COPD, reduced mobility, severe cognitive impairment, and was dependent on staff for all ADLs with a feeding tube. Her Braden score indicated high risk. She was also scheduled for turning and repositioning every 2 hours, but the task records showed it was completed only three times per day after being changed from the 2-hour schedule. She developed new in-house stage 3 pressure injuries to the left medial great toe and left medial forefoot, first identified on 08/01/25. The record showed an order for bilateral heel boots every shift, but the care plan did not include heel boots every shift and the resident was found with heel protection and cushions in place during observation. The wound care nurse documented that new wounds had been found and that the resident had multiple new wounds to the left foot. Resident #30 had dementia, stroke, anxiety, chronic pain, palliative care, severe cognitive impairment, and was dependent on staff for all ADLs. Her Braden score indicated moderate risk. She was scheduled for turning and repositioning every shift rather than every 2 hours, and the task records showed it was completed no more than three times per day. She developed an in-house stage 3 pressure ulcer to the right medial calf, and the facility record showed the ulcer was identified on 03/04/25. The order summary included a nurse order to ensure a pillow between the legs for pressure reduction, but observation showed no pressure-relieving pillow in place and the wound care nurse stated the resident was supposed to have a donut pillow between the knees. A roommate stated staff were inconsistent in applying the pillow and that it was sometimes removed. Resident #1 had cancer of the tongue and throat, hemiplegia following a stroke, muscle wasting, and required substantial to maximum assistance with bed mobility. His Braden score indicated risk for pressure injury. He was scheduled for turning and repositioning every shift rather than every 2 hours, and the task records showed it was completed only three times per day. He developed an in-house unstageable pressure injury to the left heel, later documented as a stage 4 pressure injury. The care plan included floating heels on a pillow and weekly wound evaluation, but there was no specific intervention for heel protector boots and the order summary did not include heel boots. The wound care NP documented continued offloading boots for pressure relief. Resident #37 had Guillain-Barre syndrome, quadriplegia, dementia, and required substantial to maximal assistance with bed mobility. Her Braden score indicated high risk. She was scheduled for turning and repositioning every 2 hours, but the task records showed it was not completed as ordered and later changed to every shift. She developed an in-house deep tissue injury to the right heel that later became a stage 4 pressure ulcer. The wound care NP recommended air boots while in bed, and the resident later stated her heel pressure ulcer started as a blister and that she did not use pressure relieving boots until after the ulcer developed.
Failure to Assess and Manage Pain for Hospice Resident
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences for a hospice-respite resident admitted with Alzheimer’s disease and protein-calorie malnutrition. The resident arrived by EMS on a stretcher without a family or support person present. Her baseline neurological status was unknown, and admission documentation described severe cognitive impairment, disorganized thinking, highly impaired hearing, and confusion/blindness. The baseline care plan did not document opioid use or terminal care, and the admission clinical documentation left pain-related sections blank or marked pain indicators as none. The resident had an order for morphine 20 mg/5 ml, 0.5 ml by mouth every 1 hour as needed for shortness of breath/pain, along with orders to monitor pain and record it using the 0-10 Pain Scale or PAINAD Scale, document vital signs, interventions, and outcomes, and monitor for medication side effects every shift. However, the resident had no pain monitoring orders active on the day of admission, had not received morphine since admission, and the August MAR showed no morphine administration. The facility’s pain level and vital signs records showed no pain levels had been assessed or recorded, and a pain assessment completed by the Unit Manager documented a numeric pain score of 0 while also stating the resident was unable to answer questions about pain frequency or effect on function and that the verbal descriptor scale was not assessed. During the resident’s stay, staff documented agitation, combativeness, yelling, screaming, biting the bed remote and her hand, refusing care, and repeated statements such as “I don’t feel good” and “that hurts.” Nursing notes also described chronic disruptive behaviors, delusions, anxiety, and refusal of transfers and repositioning. Staff interviews showed the resident had been checked only a few times during a shift, no specific pain monitoring had been done, and no morphine was available for use because the prefilled syringes were in a bag labeled as loose narcotics and lacked pharmacy, prescriber, resident, and directions-for-use information. The DON stated the hospice provider had not delivered the resident’s pain medication, the facility had no medications available for pain management at that time, and the Medical Director stated hospice was expected to provide all medications for hospice residents. The hospice nurse later stated the resident had a bad headache and that the morphine order was PRN every hour, but the resident did not always receive pain medication.
Pharmaceutical Services and Medication Control Failures
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of drugs and biologicals, and failed to maintain a sufficient system of records for controlled drugs. Surveyors found problems involving a hospice-respite resident, insulin storage and use on the 200 Hall medication cart, and the timing of pre-prandial insulin administration for multiple residents. The report also states the failures could place residents at risk for misappropriation of controlled substances, uncontrolled pain, uncontrolled behaviors, and hospitalization. A hospice-respite resident admitted from home with diagnoses including Alzheimer’s disease and protein-calorie malnutrition arrived without family present and with orders for morphine, lorazepam, ABH gel, escitalopram, and mirtazapine. Facility documentation showed the resident had agitation, disorganized thinking, severe cognitive impairment, and chronic behaviors shortly after admission. Nursing staff found 12 prefilled morphine syringes in a Ziploc bag labeled as loose narcotics, but the syringes lacked pharmacy, prescriber, resident, and directions-for-use information. Staff reported the morphine could not be used because it was not properly labeled, and the resident had no pain medication available at admission. The resident also did not have ABH gel available when behaviors escalated, and staff documented repeated screaming, combativeness, refusal of care, and difficulty eating during the first days after admission. The report also found an expired open vial of HumaLOG insulin on the 200 Hall cart. The vial had been opened on 07/01/25 and was still in use after the 28-day expiration period. The nurse who inspected the cart stated she had administered insulin from that vial after it was expired. In addition, the facility did not have control sheets for the morphine syringes, and staff stated there was no record of receipt or disposition for the controlled medications. For another resident with diabetes, the MAR showed sliding-scale insulin scheduled for 6:00 AM, and doses were administered at 5:04 AM and 5:25 AM on separate dates, before the scheduled meal time. The report also identified similar early administration concerns for other residents reviewed for insulin timing.
Inaccurate MDS Coding for Pain Medication and Weight Loss
Penalty
Summary
The facility failed to ensure assessments accurately reflected resident status for two residents. For one resident admitted with a right forearm fracture after a traffic collision, the admission MDS documented intact cognition and pain that was occasional and rated 2/10, but it was coded as not having received scheduled pain medication, not having received or declined PRN pain medication, and not having received non-medication pain interventions. The record showed the resident had orders for acetaminophen, multiple oxycodone regimens, and lidocaine patches, and the July-August MAR showed scheduled and PRN oxycodone administration as well as lidocaine patch use. The resident stated she had received scheduled pain medication, that it later stopped when she felt better, and that she then received PRN pain medication when pain returned. For the second resident, admitted with seizures, anxiety disorder, hypertension, and alcohol dependence with alcohol-induced persisting dementia, the Annual MDS documented intact cognition with a BIMS score of 14 and stated the resident did not have weight loss of 5% or more in the last month or 10% or more in the last 6 months. However, the weight record showed a decline from 129 lbs. to 112.6 lbs. over about 6 months, and dietary notes documented weight trends of -10.9% over 180 days on 05/02/25 and -12.7% over 180 days on 07/09/25. The resident’s care plan included impaired cognitive function, antipsychotic use, and appetite loss/weight loss, but there were no focus areas addressing dietary or weight loss concerns. During interview, the MDS nurse stated she was responsible for completing MDSs and care planning and that the MDS was inaccurate for both residents. She said the resident with the fracture had received scheduled and PRN pain medications in July before the MDS was completed and should have been coded for receiving pain medications. She also stated the resident with weight loss should have had significant weight loss coded in the care plan. She could not provide a reason the MDSs were inaccurate.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors identified 3 medication errors out of 32 opportunities, resulting in a 9% error rate, involving 2 residents and 1 LVN. The errors included crushing an extended-release medication for one resident and administering another resident’s medications incorrectly by omitting one ordered medication and preparing an incorrect dose of seizure medication. Resident #56 had diagnoses including brain damage, type 2 diabetes, epilepsy, dysphagia, protein-calorie malnutrition, quadriplegia, and gastrostomy status. His orders included medications and nutrition administered via PEG tube, including Levetiracetam 7.5 mL twice daily and Lexapro 5 mg once daily. During observation, the LVN prepared the resident’s medications, could not locate Lexapro, and proceeded without it. She also prepared 10 mL of Levetiracetam instead of the ordered 7.5 mL, then crushed and dissolved the medications and administered them through the G-tube. Resident #48 had diagnoses including a stage 4 pressure ulcer to the hip, left-sided weakness and paralysis, and end stage renal disease. His care plan directed that medications be crushed, and his order included Guaifenesin ER 600 mg every 12 hours. During observation, the LVN retrieved the Guaifenesin ER tablet, crushed it with other solid medications, mixed them in pudding, and administered them to the resident. The DON stated staff are expected to check orders before administering medications and ensure the medications are the appropriate formulation that can be crushed. The facility policy stated that only medications ordered to be crushed should be crushed and that sustained or extended-release tablets should not be crushed.
Significant Medication Errors With Pre-Prandial Insulin Timing
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors related to the timing of pre-prandial insulin administration for 4 of 11 residents reviewed. The report states that nursing staff administered short-acting insulin more than 30 minutes before meals for Residents #2, #8, #19, and #65. The facility’s schedule of mealtimes showed breakfast, lunch, and dinner times for the dining room and hallways, and survey observations on 08/06/25 showed that breakfast was not yet served when nursing staff reported that insulin had already been given. During interviews on 08/06/25, LVN K, LVN C, and LVN M each stated that they had already administered insulin to residents before meals. LVN C said she gave morning insulin at approximately 6:45 AM because it was scheduled for 7:00 AM, while breakfast was normally served at 8:00 AM. Survey observations documented that no breakfast was present in the halls or dining area from 7:34 AM through 8:15 AM, and breakfast was not passed on several halls until 8:35 AM. The Medical Director stated that pre-prandial/short acting insulin should be given 15 to 30 minutes before meals, and the DON stated staff were expected to wait until meal trays were on the halls and being passed before administering insulin. Resident #2 was a female with Type 2 DM, blindness, generalized anxiety disorder, and muscle weakness, with severely impaired cognition and an insulin order for sliding scale lispro with meals. Her MAR showed lispro was administered at 7:17 AM. Resident #8 was a male with Type 2 DM with hyperglycemia, atherosclerotic heart disease, high blood pressure, and end stage renal disease on dialysis, with moderately impaired cognition and an order for lispro before meals and at bedtime; his MAR showed lispro was administered at 6:49 AM. Resident #19 was a male with Alzheimer’s disease, Type 2 DM, high blood pressure, and muscle wasting and atrophy, with severely impaired cognition and an order for lispro before meals and at bedtime; his MAR showed an 11:00 AM dose was administered at 1:07 PM. Resident #65 was a female with aphasia following cerebral infarction, Type 2 DM, high blood pressure, unspecified psychosis, and muscle weakness, with severely impaired cognition and orders for lispro before meals and at bedtime; her MAR showed multiple insulin administrations that were given outside the scheduled meal-related times, including doses given before and after the scheduled times listed in the record.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored in accordance with facility policy and accepted professional principles in multiple medication storage areas. During observation of the 500/600 Hall medication room cart, the medication refrigerator had no thermometer or other device to determine the temperature, and the refrigerator temperature log had not been signed on 08/05/25 or 08/06/25. The refrigerator contained insulin, eye drops, vaccinations, and a TB test, and the LVN stated the thermometer was supposed to be on the shelf but was missing. During observation of the 500/600/700 Hall medication aide cart, an open bottle of Pro-stat protein supplement was found with no open date, even though the manufacturer instructions stated to discard it 3 months after opening. The same cart also contained 11 loose pills of assorted colors and sizes in a drawer. The CMA stated staff were expected to check carts daily for loose pills and improperly labeled medications, and that multidose containers must be labeled with the date opened to track expiration. During observation of the 200 Hall nurse cart, an open bottle of acidophilus probiotic was stored at room temperature even though the manufacturer instructions said to refrigerate after opening. The cart also contained a clear plastic bag with 12 prefilled syringes of morphine 20 mg/5 ml that lacked pharmacy information, prescriber information, resident information, and directions for use. The LVN stated the syringes arrived with the resident but could not be used because all medication was supposed to have pharmacy labeling identifying the resident, drug, provider, dose, and instructions for use.
Infection Control and Hand Hygiene Failures During Resident 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. The deficiency involved observations of wound care, hand hygiene, medication administration, and use of PPE for residents with wounds, feeding tubes, and other high-contact care needs. For Resident #37, who had Guillain-Barre syndrome, quadriplegia, dementia, and a stage 4 pressure injury to the right heel, PT E and the Wound Care Nurse performed wound care while wearing gowns and gloves. After the wound care was completed, PT E removed the used gown and gloves, placed them in a trash bag, stepped out of the room, walked to the dirty utility room to dispose of the bag, and then crossed the hallway to wash hands in the clean utility room. During interview, PT E stated she should have sanitized hands before leaving the resident room and acknowledged that infection could be spread by using the clean utility room sink after handling the trash bag. CNA N was also observed walking from the dirty utility room, touching the clean utility room keypad and door handle, and washing hands in the clean utility room sink. CNA N stated she used the clean utility room to wash hands all the time and acknowledged that bacteria could be transferred from the dirty utility room to the clean utility room and then possibly to residents. For Resident #56, who had brain damage, diabetes, epilepsy, dysphagia, malnutrition, quadriplegia, and gastrostomy status, LVN M prepared multiple medications for PEG-tube administration. She touched a tramadol tablet with her hands while placing it into a medication cup and entered the resident’s room without wearing a gown during the medication administration process, despite the resident’s care plan and facility policy identifying feeding tube care and high-contact resident care activities as requiring PPE. She also administered the medications through the G-tube after dissolving them and flushing between medications. For Resident #48, who had a stage 4 pressure ulcer, left-sided weakness and paralysis, and end stage renal disease, LVN M touched a cholecalciferol caplet with her bare hands before placing it in a medication cup and administering it with other crushed medications in pudding.
Failure to Notify Physician of Resident’s Chest Pain and Shortness of Breath
Penalty
Summary
The facility failed to immediately inform the resident, consult the resident’s physician, and notify the resident representative when the resident experienced a significant change in condition. The deficiency involved a resident with diagnoses including osteoarthritis, lack of coordination, irregular heartbeat, hypertension, anemia, and back fracture, with care plan focus areas for chronic heart failure and hypotension. The resident’s record showed repeated low blood pressure readings and orders for Midodrine for hypotension and Ivabradine for chronic heart failure. During a PT session, the resident reported feeling unwell, became very lightheaded with position changes, and later reported chest pain and shortness of breath. PT documented that the session was stopped after these complaints, the resident was returned to bed, and the floor nurse was notified immediately. PT also documented fluctuating oxygen saturation, elevated respirations, and changes in heart rate during the episode. The floor nurse later stated he did not notify the physician because the resident was not symptomatic when he checked on her, and he said the resident’s low blood pressure was normal for her. Interviews with the Medical Director, NP, DON, PT, and the resident confirmed that the chest pain and shortness of breath were not reported to the physician or NP. The Medical Director stated staff had not notified him of the chest pain and SOB and that notification should have been sent because the symptoms indicated possible syncope. The NP stated she was not notified and should have been because the symptoms were a change in condition. The resident stated the chest pain was new, her breathing became heavy and short, and she felt better after being laid back in bed.
Baseline Care Plan Not Completed for Immediate Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan for one resident admitted for hospice-respite services. The resident’s face sheet identified her as an older female with Alzheimer’s Disease and protein-calorie malnutrition. Her baseline care plan, signed by an LVN, documented impaired vision and hearing, confusion, and blindness, but did not document active diagnoses contributing to admission, initial admission goals, opioid use, terminal care needs, or any goals or interventions for the areas listed. Social services sections for mental health needs and behavioral concerns were left blank, and the care plan did not include instructions for the resident’s immediate needs. The resident’s admission documentation noted that she arrived on a stretcher without a family or support person, with highly impaired hearing, chronic disorganized thinking, severe cognitive impairment, and no clear baseline neurological information. The admission record also showed that hospice, respite, and palliative care were not selected in the special care section, and the behavior care planning section was blank. The resident had orders for escitalopram, mirtazapine, lorazepam as needed for anxiety/agitation, ABH gel as needed for severe agitation, and morphine as needed for shortness of breath or pain, but the baseline care plan did not document opioids or address these ordered treatments. During the stay, the resident was observed screaming, biting the bed remote and cord, accusing others of stealing her clothes, threatening staff, and calling people names. Staff interviews described her as combative with incontinence care, fidgety, trying to get out of bed, and aggressive when awake. The facility had not assessed or recorded any pain levels for the resident, and staff later stated there was nothing in place to prevent or treat her behaviors other than morphine because it was a liquid. The DON also contacted hospice because the resident had behaviors and hospice needed to come to the facility to complete an evaluation. The VP stated the baseline care plan should have been completed within 48 hours and should have addressed immediate needs, but the resident’s opioid pain medication use and behaviors were not accurately captured.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #43 was a male with diagnoses including weakness and paralysis after a stroke, high cholesterol, muscle weakness, and muscle wasting. His Quarterly MDS showed moderately impaired cognition with a BIMS score of 9 out of 15, no behavioral symptoms, no rejection of care, and supervision or touching assistance with personal hygiene. His care plan identified an ADL self-care performance deficit related to hemiplegia and called for personal hygiene assistance with one person, and the facility’s POC response history showed no manicures received and no refusals in the prior 30 days. Record review showed no documented refusal of nail care from 10/30/24 through 08/06/25. During observation, the resident was seen in bed with long fingernails and stated he preferred them short and had no problem with them being cut. On a later observation, the DON and a staff nurse interrupted medication administration to assess the resident, and the DON began cutting his nails. At that time, his fingernails were approximately 1/2 inch beyond the nail bed on the right hand except for one short finger, all left fingernails were greater than 1/2 inch beyond the nail bed, and his toenails were overgrown with some curling around the tips of his toes. The DON stated nursing staff were expected to provide ADL care including personal hygiene and nail care, that CNAs and nurses were responsible for nail care for residents without diabetes, and that failure to provide nail care and maintain nails at a short length placed residents at risk for infection, skin breakdown, and injury if nails snagged.
Missed Ordered Wound Care
Penalty
Summary
The facility failed to provide ordered wound care to a resident with a right forearm fracture, right medial first digit laceration, and orthopedic aftercare needs. The resident’s admission assessment documented intact cognition, upper extremity functional limitation, and a pain score of 2 out of 10 with occasional pain. Her care plan identified risk for pain related to the recent fracture and directed staff to administer analgesics as ordered and monitor pain characteristics each shift and as needed. The resident’s orders required cleansing the surgical incision to the right inferior forearm and the laceration to the right medial first digit with dermal wound cleanser, applying Adaptec, wrapping with kerlix, applying a splint, and securing with ace bandage every other day. The MAR showed wound care was scheduled on 08/01/25, 08/03/25, and 08/05/25. On 08/03/25, the MAR documented that wound care was not provided, while nursing notes stated the resident was out on pass with family and unable to receive wound care. There was no documentation showing the resident went out on a day pass, when she left or returned, or that she refused wound care. During observation, the resident was in bed with a cast and bandage wrap on her right lower arm and stated she had not received wound care over the weekend because the facility did not provide wound care on weekends. The Wound Care Nurse stated floor nurses provided weekend wound care and that care should be done before a resident leaves or immediately after return if the resident is out on pass. The DON stated wound care should not be missed and that the resident did not go out for the entire day, so care should have been moved to the next shift.
Improper G-tube Medication and Feeding Administration
Penalty
Summary
LVN M failed to administer enteral medications and bolus feeding to a resident with a gastrostomy tube in the manner described in the facility record and policy. The resident was a male with brain damage, type 2 diabetes, epilepsy, dysphagia, protein-calorie malnutrition, quadriplegia, aphasia, severe cognitive impairment, total dependence for ADLs, and gastrostomy status. His orders included bolus Isosource 1.5 six times daily, tube flushes before and after feeding and medications, and multiple medications to be given via PEG-tube. During observation, LVN M prepared seven medications for G-tube administration, crushed and mixed them, and then entered the resident’s room. She administered 30 mL of warm water through the G-tube before checking tube placement and did not verify placement by auscultation or residual before beginning the administration. She then pushed all seven medications through a connected syringe with water flushes between each medication, and afterward administered the enteral feeding through the same syringe. The resident became visibly agitated during the feeding, with increased non-verbal sounds, more frequent exaggerated grins, bulging eyes, darting eyes, and biting of his fingers, but the nurse continued the feeding. The nurse later stated she had checked placement earlier in the morning and believed the resident’s behaviors were baseline and not signs of discomfort. She also stated that G-tube medications and feeding should be given by gravity, not by syringe push, and that pushing could cause vomiting, tubing damage, or internal injury. The DON stated that staff must check placement before medication or feeding, that medications and bolus feeds should not be completed concurrently because of dilution concerns, and that forceful syringe administration could injure the GI system and damage the tube. The resident’s MAR also showed one scheduled dose of escitalopram was not administered.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional principles, as observed with a resident who had Type 2 diabetes mellitus. The resident's insulin was left unattended at her bedside by an LVN, which was against the facility's policy for medication security. The resident, who had an intact cognitive status and required supervision for mobility, did not notice the medication left on her table. This incident was observed during a routine medication administration when the LVN placed the insulin pen on a table approximately five feet from the resident's bed and left it unattended while washing her hands in the bathroom. Interviews with the covering DON and the Administrator revealed that the facility's policy required all medications to be secured and locked to prevent unauthorized access. The LVN admitted to leaving the insulin unattended and acknowledged the risk of the resident accessing the medication. The facility's policy, as reviewed, emphasized the importance of storing drugs and biologicals in locked compartments and maintaining medication storage areas in a safe and sanitary manner. The failure to adhere to these policies posed a risk of drug diversion or accidental ingestion.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who rolled off the bed during incontinent care. The resident, a 64-year-old woman with multiple health conditions including reduced mobility and a high risk for falls, was being assisted by a CNA when the incident occurred. The resident's care plan indicated she required extensive assistance for bed mobility, yet only one CNA was present during the care, contrary to the care plan's requirements. During the incident, the CNA was performing incontinent care and attempted to change the resident's position on the bed. The CNA reported that the resident was rocking and did not hold her weight, which led to the resident rolling off the bed. The bed was at hip height, and the CNA believed the resident was in the middle of the bed, not near the edge. However, the resident fell, hitting her legs on the bedside table, and complained of pain. The resident was subsequently sent to the hospital for evaluation, where no abnormalities were found. Interviews with other CNAs revealed that the resident was considered difficult to work with due to her size and required careful handling during care. It was noted that the resident did not have side rails to hold onto at the time of the fall, which were added later. The facility's DON confirmed that the resident was a one-person assist for bed mobility, but the incident highlighted a lack of adherence to the care plan and insufficient supervision during care, leading to the resident's fall.
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Illustrative
What surveyors actually found near you
We read the 551 citations issued within 25 miles in the last 12 months — including the 45 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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Pointe Health & Wellness | 0.9 mi | ★★★★★ | 12 | 0 |
| Cypress Creek Rehabilitation And Healthcare Center | 2.5 mi | ★★★★★ | 4 | 0 |
| Copperfield Healthcare And Rehabilitation | 2.8 mi | ★★★★★ | 17 | 3 |
| Fallbrook Rehabilitation And Care Center | 3 mi | ★★★★★ | 17 | 4 |
| Park Manor Of Cyfair | 3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.