Above average — CMS composite of the measures below.
The next survey window likely opens 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 Ebony Lake Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with diabetes, hemiplegia, and moderate cognitive impairment, who was dependent for toileting and bed mobility, was found by CNAs to have new purple discoloration and dry, scratch-like areas on the trunk/back after a reported fall the previous day. An LVN assessed the area, documented the findings, and noted the resident’s statement that it resulted from the fall, but did not notify the physician, initiate a change in condition assessment, or ensure notification of the resident’s representative, believing the discoloration was part of the prior fall incident. The DON confirmed that no follow-up with the physician or change in condition/skin assessment was completed because the discoloration was considered related to the earlier fall, contrary to the facility’s policy requiring prompt notification of changes.
A resident with diabetes, hemiplegia, and moderately impaired cognition, assessed as dependent for ADLs and transfers, had a care plan that noted dependence on two staff for transfers but did not specify the need for a mechanical lift. Progress notes documented that CNAs found the resident on the floor after he rolled from the mattress during care. In interviews, an LVN, the MDS nurse, and the DON all stated the resident required a two-person mechanical lift transfer and that such requirements should be reflected in the care plan for CNA guidance, but the transfer type was missing despite established processes for timely, individualized care planning.
A resident with hemiplegia, hemiparesis, type 2 DM, and moderately impaired cognition had a care plan and MDS indicating dependence for toileting hygiene and a requirement for two-person assist with bed mobility. Despite this, one CNA performed bed mobility alone after being told by another CNA to wait, and the resident fell to the floor while attempting to grab the mattress as the sheet was pulled. An LVN later documented a scratch on the resident’s shoulder blade and, the following day, discoloration on the trunk/back after the resident reported pain, but did not contact the physician, considering it part of the prior fall. The DON stated staff must follow each resident’s plan of care for proper transfers and that failure to do so can result in injury, and facility policy required reporting and investigation of all incidents and accidents involving residents.
A resident with diabetes and hemiplegia, fully dependent on staff for toileting hygiene, received perineal care from two CNAs during which one CNA failed to perform required hand hygiene between glove changes. The CNA removed a soiled brief, changed gloves without washing or using hand sanitizer, cleaned the perineal area, then again changed gloves without hand hygiene, with both CNAs only washing their hands before and after the procedure. The CNA later acknowledged she should have sanitized or washed her hands between glove changes, and the DON confirmed facility expectations and CDC-based standards for hand hygiene during such care.
A resident with multiple neurologic and respiratory diagnoses and moderate cognitive impairment had a documented change in code status from full code to DNR, with a care plan and physician order reflecting DNR status. An OOH-DNR form was completed and signed by the resident’s representative and two witnesses, but the attending physician did not sign the form as required by the OOH-DNR instructions and the facility’s advance directive policy. Facility staff, including SS, the DON, and the Administrator, acknowledged the missing physician signature yet indicated the DNR would still be honored in-house, resulting in a deficiency related to improper completion of the OOH-DNR.
Two residents with complex medical conditions, including stroke, Parkinson’s disease, Alzheimer’s disease, toxic encephalopathy, diabetes, and heart disease, had no physician or NP notes entered in the electronic medical record over extended periods, despite nursing notes indicating that FNPs and NPs were in the facility, assessed the residents, made medication changes, and addressed high blood sugar and family requests. The DON and Administrator reported that providers were expected to document in the electronic system, typically via notes uploaded into the Miscellaneous tab, but they could not explain why no provider documentation appeared for these residents, contrary to the facility’s policy requiring complete, accurate, and timely clinical records.
Surveyors observed a medication cart on the 400 hallway left unlocked and unattended at the nurse’s station. A GVN responsible for the cart acknowledged that it contained resident medications and that he was expected to lock it whenever he walked away. The DON reported that multiple staff, including the DON and ADON, are responsible for ensuring carts are locked and confirmed the expectation that carts be secured when not in use. Facility policy states that medication carts must remain locked at all times when not in use.
Medication carts were not maintained in proper condition for 3 of 4 carts reviewed. A nurse cart contained a personal bag with toiletries and body spray, a med-aide cart contained a brown bottle of liquid medication with a faded label that could not be read, and another nurse cart was found unlocked with drawers accessible. Staff stated personal items did not belong in med carts, the unlabeled medication could not be identified, and carts should not be left unlocked.
Food Storage and Steam Table Sanitation Deficiency: A kitchen refrigerator contained a box of cabbage that was spoiled, had black mold, was not sealed properly, and lacked a use-by date, while all 3 steam table wells had white buildup. The DA G and DM acknowledged the improper storage and cleaning issues, and the facility policy required refrigerated ready-to-eat food to be date marked.
A resident with severe cognitive impairment and multiple chronic conditions, including HTN, Parkinson’s disease, Alzheimer’s disease, and end stage renal disease, received Amlodipine despite physician orders to hold the medication for BP below 100/60 or HR below 60. MAR review showed the medication was documented as given on three occasions when the diastolic BP was below 60, and both the RN and DON acknowledged the medication should have been held.
Menu Did Not Reflect Residents' Cultural Food Preferences: Residents reported dissatisfaction with the daily menu and asked for more Mexican-style foods. Review of the Mexican/Hispanic menu showed only 1 day in a 4-week cycle included Mexican entrees, while most other meals were standard items such as shepherd's pie, smoked ham, spaghetti, pizza, and fried fish. The DM and RD stated resident food preferences were reviewed, but the menu remained on a distributor-based rotation with limited cultural options.
Hand Hygiene Not Performed During Wound Care Prep: A wound care nurse disinfected scissors, removed gloves, and then put on new gloves without performing hand hygiene while preparing supplies for a resident with multiple pressure ulcers and significant comorbidities including ESRD and DM2. The DON stated staff should perform hand hygiene after every glove removal, and the facility policy states gloves do not replace hand hygiene.
A CMA left a medication cart computer screen unlocked, exposing a resident's picture and personal information, which was observed by surveyors. The CMA admitted to forgetting to lock the screen, and the DON confirmed that this action violated facility policy and HIPAA requirements for resident privacy and confidentiality.
A resident with multiple fractures and surgical staples did not have complete documentation in the medical record regarding the removal of her staples. Although orders were present and the procedure was reportedly performed, there was no record of who removed the staples, how many were removed, or how the resident tolerated the procedure, contrary to facility policy and professional standards.
A resident with hypertension and other complex conditions did not receive pharmaceutical services in accordance with physician orders, as staff failed to hold Cozaar when blood pressure was out of parameters and inaccurately documented medication administration on the MAR. Staff did not consistently notify nursing when medication was held or refused, and documentation did not reflect actual events, despite prior training and competency assessments.
A resident with hypertension and other serious conditions had a physician order for an antihypertensive medication to be held if blood pressure or pulse was below set parameters. On three occasions, medication aides either did not administer the medication due to low blood pressure or administered it and the resident spit it out, but all documented the medication as given on the MAR. None notified nursing staff as required, resulting in inaccurate and incomplete clinical records.
A facility failed to update a resident's care plan after their code status changed from DNR to Full Code. Despite the physician orders reflecting the new status, the care plan still indicated DNR, which was acknowledged as an oversight by the MDS Coordinator and DON. The facility's policy requires care plans to be revised upon status changes, but this was not followed, resulting in a discrepancy between the care plan and the resident's current needs.
A resident with severe cognitive impairment and respiratory needs did not receive proper care due to the facility's failure to change suction and oxygen supplies as required. Observations showed outdated and undated equipment, and staff interviews confirmed the supplies were not changed weekly as per protocol, risking infection. The facility lacked a physician order for changing these supplies, contributing to the deficiency.
A deficiency was observed in the hand hygiene practices of a kitchen staff member, Cook E, who failed to wash hands for the required 20 seconds after contamination events. This was noted during a kitchen tour, where Cook E washed hands for only 5 and 3 seconds on separate occasions. Interviews confirmed the facility's policy and the importance of proper hand hygiene to prevent cross-contamination and infection spread.
A facility failed to accurately document the administration of supplemental oxygen for a resident with dementia and heart failure. Despite observations of the resident receiving oxygen, the treatment administration record did not reflect this, leading to discrepancies in the medical records. Staff interviews confirmed the lack of documentation, and the facility did not provide a medication administration policy.
Failure to Notify Physician and Representative of Resident’s Change in Condition After Fall
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident, the resident’s physician, and the resident’s representative of a significant change in condition. The resident was an older male with type 2 diabetes mellitus and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, who was dependent on staff for toileting and required two staff for bed mobility and repositioning. His quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition. On the evening of 4/10/26, an LVN documented that CNAs reported discoloration on the resident’s left lower back near the armpit while changing him. The LVN assessed the resident and observed dry, scratch-like areas with purple discoloration in that area, and the resident stated that this occurred because he had fallen the previous day. During interview, the LVN stated that the resident had complained of pain to the right side of his trunk/back on 4/10/26, and upon assessment she saw a discoloration about 5 inches long on the left side of the trunk/back. She reported that the resident told her he had fallen the day before, and she did not call the physician, did not initiate a change in condition assessment, and did not treat this as a new change because she believed the discoloration was part of the prior fall incident from 4/9/26 and that the discoloration appeared the next day. The DON similarly stated that the LVN did not follow up with the physician regarding the discoloration because it was considered part of the earlier fall and that a change of condition or skin assessment was not done for the same reason. These actions and inactions were inconsistent with the facility’s “Notification of Changes” policy, which requires prompt informing of the resident, consultation with the resident’s physician, and notification of the resident’s representative when there is a change requiring notification.
Failure to Include Mechanical Lift Transfer in Resident Care Plan
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive care plan that included measurable objectives and time frames to meet a resident’s mental and psychosocial needs and transfer needs. Record review showed that a male resident with type 2 diabetes mellitus and hemiplegia/hemiparesis following a cerebral infarction, with a BIMS score of 12 indicating moderately impaired cognition, was assessed as dependent for toileting hygiene and transfers. The resident’s care plan, dated 12/24/24, documented an ADL self-care performance deficit related to limited mobility, hemiplegia, and hemiparesis, and stated that the resident was dependent on two staff for transfers, but it did not specify the use of a mechanical lift. The facility’s policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified needs. Progress notes dated 4/9/26 documented that CNAs called an LVN to the resident’s room and the resident was found on the floor on his left side after rolling from the mattress while CNAs were providing care; assessment noted a scratch to the left lower shoulder blade without pain, bruising, or skin tear. During interviews, an LVN, the MDS nurse, and the DON each stated that the resident required a two-person mechanical lift transfer and that such transfer requirements should be included in the care plan for CNAs to reference. The LVN and MDS nurse confirmed that the resident’s care plan did not indicate the need for a two-person mechanical lift transfer, and the MDS nurse and DON stated they did not know why the transfer type was not included, despite acknowledging that MDS nurses are responsible for creating and updating individualized care plans within specified time frames and upon changes in condition.
Failure to Follow Two-Person Assist Care Plan During Bed Mobility Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure a resident remained free from accidents and hazards and did not provide adequate supervision and assistance during bed mobility, contrary to the resident’s care plan. The resident was an older male with type 2 diabetes mellitus and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, with a BIMS score of 12 indicating moderately impaired cognition. His quarterly MDS and care plan documented that he was dependent on staff for toileting hygiene and required assistance from two staff members for bed mobility, including turning and repositioning in bed. Despite this, on the morning of 4/9/26, CNAs were providing care when the resident ended up on the floor; progress notes documented that upon entering the room, an LVN found the resident on his left side on the floor, with CNAs reporting that the resident grabbed the mattress and rolled over to the right side, landing on his right side. The LVN’s head-to-toe assessment noted a scratch on the left lower shoulder blade, with no pain, bruising, or skin tear at that time, and later x-rays showed no acute left rib fracture or pneumothorax. In an interview, the resident stated that one night he fell because only one CNA changed him when there was supposed to be two, and that when he tried to grab the mattress and the CNA pulled the sheet, he fell to the floor. He also stated that the CNA did not wait for the other CNA and that x-rays were ordered two days later. Another CNA reported that she knew the resident was a two-person assist, had told the other CNA to wait while she assisted another resident, and that the other CNA decided to perform the bed mobility alone. An LVN stated that the resident required a two-person assist for bed mobility and reported that on the day after the fall the resident complained of pain to the right side of his trunk/back, with observed discoloration about 5 inches long on the left side of his trunk/back; the LVN stated she did not call the doctor because she considered it part of the prior fall incident. The DON stated that staff should follow each resident’s plan of care for proper transfers and that failure to do so could result in injury to residents or staff. The facility’s incident and accident policy required staff to report, investigate, and review any accidents or incidents occurring or allegedly occurring on facility property involving residents.
Improper Hand Hygiene During Perineal Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper hand hygiene during perineal care for one resident. The resident was an older male with type 2 diabetes mellitus and hemiplegia/hemiparesis following a cerebral infarction, and was care planned and assessed as dependent on staff for toileting hygiene and bed mobility. During an observed perineal care procedure, two CNAs entered the resident’s room and placed supplies on the bedside table. CNA A washed her hands and donned a gown and gloves, then removed the resident’s soiled brief and discarded it. After removing her gloves, CNA A immediately donned a new pair of gloves without washing or sanitizing her hands. CNA A then cleaned the resident’s perineal area, removed those gloves, and again failed to wash or sanitize her hands before donning another pair of gloves. The observation further showed that CNA A and CNA B washed their hands only before and after the entire procedure, and not between glove changes or after contact with soiled items and the perineal area. In an interview, CNA A acknowledged she should have washed or sanitized her hands between glove changes and stated she forgot because she was nervous. The DON stated that staff should wash hands if gloves are visibly soiled or use hand sanitizer between glove changes, and that the DON and ADON are responsible for monitoring staff compliance with infection control. The facility’s infection prevention and control policy referenced maintaining a program consistent with accepted national standards, and CDC guidance cited in the report specifies that hand hygiene should occur before moving from a soiled body site to a clean body site on the same patient and immediately after glove removal.
Failure to Obtain Physician Signature on OOH-DNR Order
Penalty
Summary
The facility failed to ensure a resident’s right to formulate and implement an advance directive by not obtaining the physician’s signature on an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order. The resident was an older female with diagnoses including nontraumatic intracerebral hemorrhage in the cortical hemisphere, other toxic encephalopathy, pneumonia due to inhalation of food and vomit, and Wernicke’s encephalopathy. Her Quarterly MDS showed a BIMS score of 09, indicating moderate cognitive impairment, with unclear speech and intermittent ability to understand and be understood. The comprehensive care plan identified the resident as DNR, initiated and revised on the same date, and a progress note documented that the resident’s representative requested a change from full code to DNR. The order summary also reflected a DNR order. The OOH-DNR form for this resident, dated the same day as the DNR order, contained the signatures of the resident’s representative and two witnesses but lacked the attending physician’s signature, as required by the OOH-DNR instructions and the facility’s policy on residents’ rights regarding treatment and advance directives. During interviews, the social services staff member, the DON, and the Administrator each acknowledged that the physician had not signed the OOH-DNR at the time, yet stated that the DNR would be honored in-house if an event occurred. The OOH-DNR instructions specified that the attending physician must sign the form and document the existence of the order in the permanent medical record, and that the order must be signed and dated by two witnesses and, when applicable, by the physician in the designated section. The absence of the physician’s signature on the OOH-DNR constituted the deficiency.
Missing Physician/NP Documentation in Electronic Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents. For the first resident, an older male with multiple complex diagnoses including cerebral infarction with right-sided involvement, Parkinson’s disease, Alzheimer’s disease, end-stage renal disease on dialysis, and Type 2 diabetes mellitus, the electronic medical record lacked any physician or nurse practitioner documentation over an extended period. The resident’s MDS showed he was nonverbal, rarely/never understood or able to understand others, and was fully dependent for toileting, showering, and personal hygiene, with continuous bladder and bowel incontinence. Nursing progress notes documented that a family nurse practitioner (FNP) assessed the resident on several dates in January, February, and March and made medication changes and follow-up plans, but there were no corresponding physician or NP notes entered in the Progress Notes or Miscellaneous sections of the electronic record from 01/21/2026 through 03/24/2026. For the second resident, an older female with diagnoses including hypertension, Type 2 diabetes mellitus, heart disease, and other toxic encephalopathy, the facility similarly failed to maintain physician or NP documentation in the electronic record. Her MDS reflected a BIMS score of 9, indicating moderate cognitive impairment, with clear speech and usual ability to understand and be understood, and a need for substantial/maximal assistance with toileting and showering, along with frequent bladder and occasional bowel incontinence. A nursing progress note documented that an NP was in the facility, was notified of the resident’s high blood sugar and the family’s request to review and discontinue some medications, and that the NP acted on this request. However, there were no physician or NP notes in the Progress Notes or Miscellaneous sections for this resident from 02/21/2026 through 03/24/2026. Interviews with facility leadership confirmed that the absence of provider documentation in the electronic medical record was inconsistent with facility expectations and policy. The DON stated that physicians and NPs should have notes in the Progress Notes or Miscellaneous sections of the electronic chart, and that they typically wrote notes on paper which were then uploaded into the Miscellaneous tab. She acknowledged not knowing why the two residents’ charts lacked doctor or NP notes and stated that if such notes were not in the computer, the resident’s progress or status would not be shown. The Administrator similarly stated that there should be physician and NP notes in the electronic system and that providers were usually on their computers while in the facility, but she did not know how or why there were no notes for these two residents. The facility’s “Documentation in Medical Record” policy required that each resident’s record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation of assessments, observations, and services, completed at the time of service or by the end of the shift, and containing sufficient detail about the resident’s care and responses to care.
Unattended, Unlocked Medication Cart on 400 Hallway
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored and secured in accordance with professional standards for one of five medication carts, specifically the cart on the 400 hallway. During an observation at 6:07 PM, the 400 Hall nurse’s medication cart was found unlocked and unattended while positioned against the nurse’s station. When the surveyor notified GVN A, who was responsible for that cart, he then locked it. GVN A stated he was expected to lock the medication cart whenever he walked away from it and confirmed that the cart contained medications for residents on the 400 hallway. In an interview, GVN A acknowledged responsibility for the cart and recognized that if it was left unlocked, a resident could open a drawer and take medication not prescribed for them. In a separate interview, the DON stated that multiple staff, including the DON and ADON, were responsible for ensuring medication carts were locked and confirmed the expectation that staff lock the cart whenever they walk away from it. The DON stated that if the cart was left unlocked, a resident or visitor could grab medication from the cart and it could harm them. Review of the facility’s policy “Medication Carts and Supplies for Administering Meds,” dated 10/1/2019, showed that the medication cart is required to be locked at all times when not in use.
Medication carts contained personal items, unlabeled medication, and an unlocked cart
Penalty
Summary
Drugs and biologicals were not stored and labeled appropriately for 3 of 4 medication carts reviewed. The 300 Hall Nurse Cart belonging to LVN-E contained a white personalized bag with a toothbrush, toothpaste, dental floss, and body spray. The Blue Med-Aide Cart belonging to Medication Aide-D contained a brown prescription bottle about 3/4 full of liquid medication, but the label was so faded that the medication name, expiration date, and resident it belonged to could not be read. The 200 Hall Nurse Cart belonging to LVN-C was observed unlocked, with the lock popped out and all drawers except the narcotic drawer accessible. During interview, LVN-C stated she knew she was not supposed to leave the med-cart unlocked when she walked away, but said she had been busy with residents and was not sure why it happened that night. LVN-E stated personal belongings did not belong in medication carts because they could cause cross-contamination with medication. Medication Aide-D stated she was not sure where the bottle came from or which resident it belonged to because she could not read the label. ADON-B stated nurses were not supposed to leave personal belongings in medication carts, should check carts each shift for expired medications, and should not leave carts unlocked. The DON stated nurses routinely checked carts for expired medications and the pharmacist typically checked them at least monthly.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, distribute, and serve food in accordance with professional standards for food service safety in 1 of 2 kitchen refrigerators and 3 of 3 steam table wells reviewed. During the initial kitchen tour, a box in the refrigerator was observed containing eight heads of cabbage that were spoiled and had black mold, and the box did not have a use-by date. The cabbage was also not sealed properly and was not labeled and dated as required for stored food items. Observation of the steam table wells showed white buildup on the bottom of all 3 wells. In interview, the DA G stated the steam table wells were cleaned every day by staff on all shifts after every use, but did not know why they were in that condition. The DM stated the cabbage had not been stored correctly, should have had a protective barrier and an in-date label, and that she did not know why it did not have a date or when it was placed in the refrigerator. Record review of the facility's food storage policy and FDA Food Code guidance showed ready-to-eat refrigerated food held more than 24 hours must be clearly date marked.
Amlodipine Given Outside Ordered BP Parameters
Penalty
Summary
The facility failed to ensure that Resident #23 was free from significant medication errors when Amlodipine was administered outside of the physician-ordered blood pressure and pulse parameters. Resident #23 was a male admitted on 10/28/24 with diagnoses including type 2 diabetes, Parkinson’s disease, Alzheimer’s disease, hypertensive urgency, and end stage renal disease. His quarterly MDS reflected a BIMS of 00, indicating severe cognitive impairment. The physician’s order dated 11/25/25 directed Amlodipine 10 mg via G-tube daily for HTN and to hold the medication for BP less than 100/60 or HR less than 60. Review of the December 2025 MAR blood pressure and pulse summaries showed that Amlodipine was documented as given on 12/04/25 when the blood pressure was 130/53 with a pulse of 92, on 12/22/25 when the blood pressure was 135/51 with a pulse of 81, and on 12/23/25 when the blood pressure was 131/57 with a pulse of 100. During interview, RN F stated the medication should have been held because the diastolic blood pressure was less than 60 and said the entries were made in error. The DON also stated the medication should not have been given because the blood pressure was outside of parameters per the physician’s orders.
Menu Did Not Reflect Residents' Cultural Food Preferences
Penalty
Summary
The facility failed to ensure meals served reflected the cultural and ethnic needs of the resident population for 1 of 3 meals observed. During the Resident Council meeting, residents stated they were not happy with the daily food selection and wanted more foods they enjoyed from their Mexican culture. The Resident Council president stated he could speak for residents in the facility who had told him the menu did not offer enough Mexican-style foods and tended to serve food they were not accustomed to eating. Record review of the Mexican/Hispanic menu showed that only 1 day of the 4-week menu included Mexican-style entrees, while the remaining days included items such as shepherd's pie, smoked ham, chicken Dijon, tuna patty, spaghetti with meatballs, deli sandwich, sweet and sour chicken, pepperoni pizza, fried fish, BBQ pork, meatballs with buttered noodles, broccoli cheese soup, and chicken salad sandwich. The Dietary Manager stated the menus were on a 5-week rotation, that she was responsible for making changes when foods were not being eaten, and that she would look for other menus and add different kinds of Mexican food to the rotation. The Dietitian stated the DM received resident food preferences from quarterly assessments and would swap out items if residents did not eat them before changes could be made.
Hand Hygiene Not Performed During Wound Care Preparation
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one of six residents reviewed for infection control and transmission-based precautions. During wound care preparation for a resident with an original admission date of 12/29/25, diagnoses of hypotension, end stage renal disease, and type 2 diabetes, and an MDS BIMS score of 12, the wound care nurse disinfected scissors, removed her gloves, and did not perform hand hygiene before putting on new gloves. The resident had physician orders dated 01/05/2026 for daily treatment to the coccyx, right heel, and right ear for unstageable pressure ulcers and a stage 1 pressure ulcer. During interview, the wound care nurse stated she did not realize she had not performed hand hygiene after sanitizing the scissors and said she was nervous and forgot. She stated hand hygiene after glove removal was important to prevent cross contamination and because the scissors were dirty and had Clorox on them from the wipe used. The DON stated all staff should perform hand hygiene after every glove removal to prevent the spread of infection and stated that if the resident's wound came into contact with bacteria, it could become infected, worsen, or delay healing. The facility's hand hygiene policy stated that gloves do not replace hand hygiene and that hand hygiene should be performed immediately after removing gloves.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records for 12 residents reviewed for residents' rights. During an observation, a CMA left a medication cart computer screen unlocked and exposed a resident's picture, making resident-identifiable information visible. The CMA acknowledged forgetting to lock the computer screen, which was recognized as a HIPAA violation. The Director of Nursing confirmed that staff are expected to lock computer screens to prevent exposure of resident information. Review of facility policy indicated residents have the right to privacy and confidentiality of their information.
Incomplete Documentation of Staple Removal Procedure
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was admitted with multiple fractures, including those of the left ulna, humerus, and pubis, following a fall. The resident had surgical wounds with staples in the left upper arm and wrist. Medical orders were present to remove the staples, and documentation indicated that the removal was authorized and signed off in the electronic medical record. However, there was no documentation in the resident's medical record specifying when the staples were actually removed, who performed the procedure, how many staples were removed, whether any were left, or how the resident tolerated the procedure. Interviews with nursing staff revealed uncertainty about who removed the staples, and the responsible wound care nurse was no longer employed at the facility. The resident's responsible party reported witnessing the staple removal by a male nurse, but this was not reflected in the clinical documentation. The facility's policy required that all assessments, observations, and services provided be documented in a timely and complete manner, including details of procedures such as staple removal. The lack of documentation for this procedure meant the resident's clinical record was incomplete and did not meet accepted professional standards, as required by facility policy and regulatory expectations.
Failure to Follow Medication Administration Parameters and Documentation Procedures
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate administration and documentation of medications for a resident with multiple complex diagnoses, including acute kidney failure, secondary malignancies, and hypertension. The resident had a physician's order for Cozaar (Losartan Potassium) with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 120 or the diastolic blood pressure (DBP) was less than 60, or if the pulse was less than 60. Despite these clear parameters, medication administration records (MAR) indicated that the medication was signed as administered on three separate days when the resident's blood pressure readings were below the ordered thresholds. Interviews with the medication aides (MAs) responsible for administering the medication revealed that on each occasion, the staff either did not administer the medication due to the resident being out of parameters but still signed the MAR as if it had been given, or in one case, administered the medication despite the resident being out of parameters, after which the resident spit out the medication. The MAs did not consistently notify a nurse when the medication was held or refused, and documentation on the MAR did not accurately reflect the events. The staff cited reasons such as being rushed, forgetting to document, or assuming standard parameters, and acknowledged that their actions did not align with facility policy or physician orders. The Director of Nursing (DON) confirmed that the staff did not follow the required procedures for checking parameters, documenting accurately, and notifying nursing staff when medications were held or refused. The DON also verified that all three staff members had received training and competency assessments related to medication administration, including following parameters and proper documentation. However, the failure to adhere to these protocols resulted in inaccurate MAR documentation and a lack of appropriate communication regarding the resident's medication administration.
Inaccurate Medication Administration Documentation and Failure to Follow Parameters
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, specifically regarding the administration of a physician-ordered antihypertensive medication. The resident, an older female with diagnoses including acute kidney failure, secondary malignant neoplasms, and hypertension, had a physician's order for Cozaar (Losartan Potassium) with specific parameters to hold the medication if systolic blood pressure was below 120 or diastolic below 60, or if pulse was below 60. On three consecutive days, medication administration records (MAR) were signed off by medication aides as if the medication had been administered, despite the resident's blood pressure readings being outside the prescribed parameters for safe administration. Interviews with the medication aides responsible for those days revealed that two of them did not administer the medication because the resident's blood pressure was out of range, but they erroneously documented it as given on the MAR. The third aide administered the medication despite the blood pressure being out of parameters, and the resident subsequently spit out the medication due to nausea. This aide also documented the medication as administered and did not make a note about the incident or notify a nurse. All three aides failed to notify nursing staff when the medication was held or refused, as required by facility policy and physician orders. The Director of Nursing confirmed that the medication should not have been administered on any of the three days based on the resident's blood pressure readings and that the documentation on the MAR was inaccurate. The facility's policy required staff to check vital signs, hold medication if parameters were not met, and accurately document administration or refusal, including notifying the nurse when medication was held or refused. Despite prior training and competency assessments, the staff did not follow these procedures, resulting in incomplete and inaccurate clinical records for the resident.
Failure to Update Care Plan After Code Status Change
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident was not revised after the resident's code status was changed from Do Not Resuscitate (DNR) to Full Code. This oversight was identified during a review of the resident's records, which showed that the care plan still reflected a DNR status despite the physician orders indicating a Full Code status. The MDS Coordinator acknowledged that the care plan should have been updated to reflect the resident's current code status. The Director of Nursing (DON) confirmed that the care plan should have been updated when the change in code status occurred. The resident had previously been on hospice services with a DNR status, but after returning from the hospital, the resident and family requested a change to Full Code. The facility's policy on care plan revision upon status change outlines the procedure for updating care plans, which includes collaboration among the MDS Coordinator and the Interdisciplinary Team, documentation of discussions, and communication of care plan interventions to all staff involved in the resident's care. However, the care plan for this resident was missed, leading to a discrepancy between the care plan and the resident's current needs.
Failure to Maintain Respiratory Care Supplies
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in the maintenance and replacement of suction and oxygen supplies. The resident, a male with severe cognitive impairment and multiple diagnoses including COPD and congestive heart failure, required respiratory care as part of his comprehensive care plan. However, observations revealed that the suction canister, tubing, and Yankauer suction device in the resident's room were not dated or changed as per the facility's protocol, with the Yankauer device still in packaging dated over a week prior. Interviews with facility staff, including a registered nurse (RN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the supplies were supposed to be changed weekly or as needed if soiled. The RN admitted that the supplies should have been changed and acknowledged the risk of infection if they were not. The ADON expressed doubt about the accuracy of the dates on the supplies and noted that the respiratory therapist had not been present for several days. The DON reiterated the importance of changing disposable supplies to prevent infection. The facility's Infection Prevention and Control Program Policy outlined the requirement for single-use disposable equipment to be discarded after use and for sterile supplies to be inspected before use. Despite these policies, the facility did not have a physician order for changing the suction and oxygen supplies, which could lead to bacterial growth and infection. The lack of adherence to these protocols and the absence of a physician order for changing supplies contributed to the deficiency in providing safe respiratory care for the resident.
Deficiency in Hand Hygiene Observed in Kitchen Staff
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene, as observed with Cook E. During a kitchen tour, Cook E was seen washing her hands for only 5 seconds after picking up an item from the floor and for 3 seconds after taking food temperatures. This was contrary to the facility's policy and professional standards, which require handwashing for at least 20 seconds to prevent cross-contamination and the spread of infections. Interviews with Cook E and other staff members, including the Dietary Manager (DM), Assistant Director of Nursing (ADON), and Director of Nursing (DON), confirmed the importance of proper hand hygiene. Cook E acknowledged the requirement for 20-second handwashing but admitted to not following it due to nervousness. The facility's hand hygiene policy, dated 10/24/22, mandates thorough handwashing to prevent infection spread, aligning with FDA Food Code 2022 standards. Despite regular in-service training, the deficiency in hand hygiene was evident, posing a risk of cross-contamination and infection to residents.
Inaccurate Documentation of Oxygen Therapy
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the administration of supplemental oxygen. The resident, an elderly female with dementia and diastolic heart failure, had an active order for oxygen therapy as needed for hypoxia. However, the treatment administration record did not reflect the administration of oxygen during August and September, despite observations of the resident receiving oxygen on multiple occasions. Interviews with staff, including the MDS coordinator, LVN, ADON, and DON, confirmed discrepancies between the observed administration of oxygen and the documentation in the medical records. The MDS assessment inaccurately indicated that the resident had not received oxygen therapy in the past 14 days, contradicting the observations and staff statements. The LVN and ADON acknowledged the importance of documenting PRN treatments in the MAR to prevent errors and ensure accurate records for future treatment decisions. The DON also emphasized the need for accurate documentation to reflect the resident's actual use of oxygen. Despite requests, the facility did not provide a policy for medication administration, highlighting a gap in procedural adherence.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 102 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brownsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesa Hills Post Acute | 1.3 mi | ★★★★★ | 6 | 0 |
| Alta Vista Rehabilitation And Healthcare | 1.5 mi | ★★★★★ | 16 | 0 |
| Spanish Meadows | 1.6 mi | ★★★★★ | 16 | 0 |
| Fox Hollow Post Acute | 2.7 mi | ★★★★★ | 12 | 3 |
| Las Alturas Nursing & Transitional Care Brownsvill | 2.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.