Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eden Home during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter and EBP signage posted was receiving toileting-related care when a CNA was observed without PPE. The charge nurse and nurse educator stated the CNA should have worn a gown and gloves for the resident’s high-contact care, including hygiene and catheter-related care, consistent with the facility’s PPE policy.
Respiratory care was not provided as ordered for two residents and oxygen storage was not maintained correctly. One resident’s nasal cannulas and BiPAP mask were left uncovered instead of being stored in plastic bags when not in use, another resident’s oxygen concentrator was observed set at 4 LPM instead of the ordered 2 to 3 LPM, and the oxygen cylinder room had a full cylinder on the empty side and an empty cylinder on the full side. Staff, including RN and DON, confirmed the issues during interview.
Expired meds were found in a med room and a nursing cart, including eye drops and Mucinex, and an insulin lispro pen for a resident with DM was kept past the 28-day discard date. In another event, a med aide gave enalapril to a resident with HTN after checking a BP of 113/54 without first reporting the low diastolic reading to the charge nurse, despite staff stating out-of-range values should be reported for review.
A resident with cervical spine fusion, central cord syndrome, and pressure ulcers had wound care physician notes missing from the EHR, even though weekly wound assessments were documented and staff said the resident was seen by the wound MD. Surveyors also observed an open staff break room on hall 8000 where resident charts, including face sheets, orders, and hospice records, were stored on a shelf.
Call Light Not Kept Within Reach: A resident with moderate cognitive impairment, gait instability, and a fall risk care plan had her call light hanging from an oxygen concentrator where she could not reach it. Staff observed the call light out of reach during multiple checks, and an CNA later moved it to the quarter rail within reach. The DON and Administrator stated staff were responsible for ensuring call lights were in place.
A cognitively intact resident with MS, quadriplegia, dysarthria, and contractures preferred to eat in her room and used a laptop to communicate. Staff brought her to the dining room for lunch because there was not enough staff to feed residents in their rooms, despite her objection. The resident reported feeling embarrassed sitting in the dining area with her bib on for an extended period before the meal was served.
A resident’s bathroom was observed with feces on the toilet seat and feces left in the toilet. The resident, an 88-year-old female with muscle weakness, Parkinson’s disease, and depression, required assistance from one staff member for toileting due to impaired mobility and weakness. RN confirmed the feces was not cleaned or flushed after bowel care, and the DON stated the resident had the right to a clean and sanitary environment.
A resident’s Quarterly MDS did not accurately reflect an indwelling Foley catheter. The resident had an order for the catheter for urine retention, the care plan identified it for neurogenic bladder, and the resident stated she had a leg catheter in place. The MDS nurse said the omission was human error, and the DON confirmed the catheter was not coded on the MDS.
Incomplete Perineal Care During Incontinence and Catheter Care: A resident with an indwelling catheter and bowel incontinence received incontinent care from a CNA who cleaned the catheter, genital area, groin, rectum, and right buttock after a BM, but did not clean the left buttock before applying a clean brief. The CNA said she forgot, and both the CNA and DON stated the area should have been cleaned to help prevent infection and skin breakdown; the facility policy required cleansing the buttocks and anus when the perineum was grossly soiled.
Unit pantry food storage was out of compliance in the Bluebonnet Hall pantry. The refrigerator was observed at 42 degrees Fahrenheit and later confirmed at 45 degrees Fahrenheit by an RN, and an open apple juice container was half full with no label or date. The RN stated temperatures above 42 degrees Fahrenheit could cause food to spoil, and the DON was unsure why the refrigerator temperature was high.
Improper Dumpster Disposal: Surveyors observed that 1 of 1 dumpsters lacked a bottom plug. The FSM stated he was not aware of the missing plug and said he would call the city. The facility policy stated that food waste and rubbish are to be disposed of in an approved manner to prevent contamination of food, clean dishes, or clean working areas.
Infection control lapses were observed for two residents. One resident was on contact precautions for MRSA and ESBL, but an RN entered the room without gloves and a gown despite signage requiring both. Another resident had a G-tube and bacteremia, and an LVN changed gloves during tube care without sanitizing or washing hands first. The DON confirmed both staff actions were improper.
Missing Abuse, Neglect, Exploitation, and Dementia Training: The facility failed to ensure CNA-M completed required abuse, neglect, and exploitation training, and dementia training was also not completed. HR records showed no evidence of the required training, and the Staffing Coordinator stated she did not verify whether the agency CNA had completed the training before working on the floor. The facility policy required new employees to be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation.
Late and Missing MDS Transmissions: The facility failed to complete and transmit several MDS assessments on time for multiple residents. Four residents had discharge MDSs that were completed but not sent to CMS, while another resident’s admission MDS remained in progress because the MDS nurse said she was too busy with workload. The MDS staff and DON described staffing and workflow issues, and the DON acknowledged the assessments were the responsibility of the MDS team and Medical Records for transmission.
A resident with a history of stroke and hemiplegia, admitted for respite and receiving hospice care, developed a worsened sacral wound during their stay. Although staff documented the deterioration and discussed making notifications, neither the physician nor the responsible party were informed as required by facility policy. The responsible party only learned of the wound after the resident returned home, and the nurse practitioner confirmed that no notification was made.
A resident with significant cognitive and physical impairments, who required two-person mechanical lift transfers, was transferred by a CNA alone using a gait belt instead of the required equipment. The CNA did not check the care summary or consult with nursing staff, resulting in the resident sustaining a displaced humeral neck fracture. Staff interviews and record reviews confirmed the resident's transfer needs were clearly documented and known to staff.
A facility failed to obtain a DNR order for a resident upon admission, despite the resident's Living Will indicating a wish not to receive CPR. The resident's clinical assessment and care plan inaccurately reflected a full code status. Staff interviews revealed a communication breakdown, with the SW not informed of the resident's wishes. The DON highlighted the importance of obtaining a DNR order, while the resident's family member was unaware of the Living Will but willing to honor it.
A CNA failed to report a suspected abuse incident involving a resident with Alzheimer's disease within the required timeframe. The incident, where another CNA made an inappropriate gesture towards the resident, was observed but not reported immediately, leading to a delay in notifying the State Survey Agency. The observing CNA hesitated to report due to concerns about getting her colleague in trouble, despite having received training on timely reporting.
Two residents with mental health diagnoses had inaccuracies in their MDS assessments, leading to deficiencies in their care plans. One resident's Major Depressive Disorder was not reflected in her assessment despite being treated with Sertraline. Another resident's PTSD and Major Depressive Disorder were omitted from his MDS, despite documented history and medication use. Staff acknowledged the importance of accurate assessments for ensuring proper care.
The facility failed to implement comprehensive care plans for two residents with psychiatric needs. One resident with Major Depressive Disorder (MDD) was not accurately documented in the care plan, missing details about her diagnosis and treatment with Sertraline. Another resident with MDD and PTSD had a care plan that did not reflect his psychiatric services, despite being treated with medications like Buspirone and Sertraline. The facility's policy requires comprehensive care plans, which was not followed in these instances.
The facility failed to coordinate PASARR assessments for two residents diagnosed with Major Depressive Disorder (MDD). One resident, admitted with cerebral infarction and dementia, was not referred for PASARR after an MDD diagnosis. Another resident with PTSD and depression also lacked a PASARR referral despite receiving psychiatric treatment. Staff interviews confirmed the oversight and the importance of PASARR screenings for appropriate care.
A facility failed to complete a quarterly MDS assessment for a resident with Alzheimer's and other conditions, missing the required timeline. The last completed MDS had an ARD in July, and the next was due in October but remained incomplete by mid-November. The delay was due to the absence of a full-time MDS nurse and a part-time consultant, potentially affecting care plans.
A resident with a history of dysphagia and muscular dystrophy was served a ham sandwich that did not meet the prescribed mechanical soft diet requirements, leading to choking and death. Despite clear orders for ground meats, the facility's dietary staff believed thinly sliced ham was appropriate, resulting in a fatal incident.
A facility failed to secure medications properly, leaving a resident's medication unattended on a bedside table. The resident, with intact cognition, reported that a nurse left the medications there. Interviews indicated that the LVN did not leave medications at the bedside, and the MA was responsible for administering them. The DON expected MAs to ensure medications were taken and not left in rooms, as per facility policy.
Failure to Use PPE During EBP 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 for 1 of 5 residents reviewed for infection prevention measures. The deficiency involved a resident with chronic kidney disease and a history of urinary tract infections who was admitted with an indwelling urinary catheter and was assessed as needing catheter care. The resident’s physician orders required staff to cleanse the catheter, drain the collection bag, and secure the drainage line, and the care plan identified the resident as needing assistance with personal hygiene and having an indwelling catheter. During an observation, the resident was in the bathroom seated on the toilet while CNA A waited to assist with care. The resident’s room had Enhanced Barrier Precautions signage posted stating that staff must clean their hands and wear gloves and a gown for high-contact resident care activities, including hygiene, toileting, and urinary catheter care. CNA A was observed not wearing any PPE while the resident was receiving care and while CNA A was waiting to assist with cleansing and dressing. In interviews, the charge nurse stated the resident needed Enhanced Barrier Precautions related to the catheter and that CNA staff were expected to perform hand hygiene, don a gown and gloves, provide care, then doff PPE and perform hand hygiene before exiting the room. The nurse educator gave the same description of the facility’s EBP training for CNAs and stated CNA A should have worn gown and gloves while providing care for the resident. The facility’s PPE policy stated that staff who have contact with residents or their environments must wear PPE as appropriate during resident care activities and when exposure to blood, body fluids, or potentially infectious materials is likely, and that PPE is used as part of standard precautions regardless of infectious status.
Respiratory Care and Oxygen Storage Deficiencies
Penalty
Summary
Resident #91 had diagnoses including acute respiratory failure and COPD, and his care plan and physician orders required BiPAP use at night while sleeping, oxygen via nasal cannula at 3.5 liters per minute continuously, and that oxygen tubing and the BiPAP mask be bagged when not in use. During observation on 03/17/2026, the resident was not in the room, but the oxygen cannula at the bedside was not covered with a plastic bag, the BiPAP mask on the nightstand was not covered with a plastic bag, and another nasal cannula in the restroom was also not covered with a plastic bag. RN-G stated the cannulas and BiPAP mask should have been covered with plastic bags to prevent infection, and the DON stated the facility nurses should have covered them. Resident #117 had diagnoses including COPD, atherosclerotic heart disease, and generalized anxiety disorder, and her MDS showed a BIMS score of 11 with oxygen therapy coded. Her care plan and physician order directed oxygen at 2 to 3 liters per minute via nasal cannula as needed for oxygen saturation below 90%. On 03/17/2026 and again on 03/18/2026, observation showed the resident in bed wearing nasal cannula with the oxygen concentrator set at 4 liters per minute. During interview and observation, RN B stated the concentrator should have been set at 2 liters per minute, confirmed it was set at 4 liters per minute, and adjusted it to 2 liters per minute. RN B also reviewed the physician order and stated it was for 2 to 3 liters per minute. In the oxygen cylinder room, observation on 03/18/2026 found 15 oxygen tanks, with one empty cylinder on the full side and one full cylinder on the empty side. RN E confirmed the cylinders were mixed up and stated full cylinders should be on the full side and empty cylinders on the empty side. The DON stated the same during interview and said the facility did not have a policy for the oxygen cylinder room. The Administrator stated she was not aware the cylinders were mixed up and the oxygen policy was not provided prior to exit.
Expired Medications and Blood Pressure Monitoring Lapses
Penalty
Summary
Pharmaceutical services were not provided in a manner that ensured accurate acquiring, receiving, dispensing, and administering of drugs and biologicals in the 500-hall medication room and on the 500-hall A and B nursing carts. Surveyors found one box of Refresh Plus eye drop lubricant vials in the 500-hall medication room that had expired in 01/2026, and one bottle of Mucinex 600 mg guaifenesin extended-release in the 500-hall B nursing cart that had expired on 12/09/2025. RN-B acknowledged both expired medications should have been discarded and stated she did not know why they remained in the medication room and cart. Resident #52, a 78-year-old female with diagnoses including type 2 diabetes mellitus and muscle weakness, had an order for insulin lispro sliding scale injections before meals and at bedtime. The resident’s insulin lispro pen was observed in the 500-hall A nursing cart and was documented as having been opened on 02/09/2026. LVN-J stated the pen should have been discarded 28 days after opening, which would have been 03/09/2026, but it remained in the cart on 03/18/2026. She also stated she had used a new insulin lispro pen that day, but other nurses might use the older pen. Resident #155, a 79-year-old female with diagnoses including arthritis, type 2 diabetes mellitus, and hypertension, had an order for enalapril maleate 20 mg twice daily for blood pressure without a specific hold parameter. MA-I took the resident’s blood pressure as 113/54 with a pulse of 85 and administered the enalapril. MA-I later stated she should have reported the blood pressure to the charge nurse because the diastolic pressure was low. The DON stated medication aides should take blood pressure before giving blood pressure medications and report values out of normal range to the charge nurse, who should retake the blood pressure with a manual cuff.
Incomplete wound care records and unsecured resident charts
Penalty
Summary
The facility failed to maintain complete medical records for Resident #105 by not having the resident’s wound care physician visits and notes documented in the EHR before or after discharge. Resident #105 was a cognitively intact male with diagnoses including cervical spine fusion, central cord syndrome, muscle wasting and atrophy, and gait and mobility abnormalities. He was admitted with an unstageable sacral/buttocks pressure ulcer and later developed a new unstageable left heel pressure ulcer, with weekly wound care assessments documented in the record. Record review showed ten weekly wound care nurse assessments dated from 1/19/26 through 3/4/26, but all were created and signed on 3/10/26, the day after the resident discharged home with home health. On 3/19/26, the EHR did not contain any wound care physician progress notes or documentation that the wound care physician had seen the resident. On 3/20/26, one physician wound care progress note with an effective date of 2/19/26 was uploaded to the EHR. During interviews, LVN C and LVN D stated the resident was seen weekly by the wound care physician, while LVN D also stated the notes may not have been uploaded yet and later said the 2/19/26 note was the only one because the physician had not returned another week. The facility also failed to safeguard resident medical record information on hall 8000. Observation on 3/18/26 and again on 3/19/26 showed the staff break room was open and contained resident charts on a shelf, including face sheets, orders, miscellaneous records, and hospice charts. Staff confirmed the room was used as a break room and that resident charts were kept there. The DON stated she did not see an issue with the room being open and said residents and families could not go into the chart room, while the ADM stated she was not aware the room was open and that the charts contained vital resident information.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure Resident #117 had the call light within reach. Resident #117 was admitted with diagnoses including carcinoma in situ of the anus and anal canal, generalized anxiety disorder, muscle wasting and atrophy, multiple sites, unsteadiness on feet, other abnormalities of gait and mobility, need for assistance with personal care, and history of falling. Her quarterly MDS assessment showed a BIMS score of 11, indicating moderate cognitive impairment, and she required partial/moderate assistance for several ADLs and supervision or touching assistance for transfers. Her care plan identified fall risk and directed staff to keep the call light within easy reach and teach and encourage use of it. During observation, Resident #117 was lying in bed with the call light hanging through the handle of the oxygen concentrator at the left side of the head of the bed, where she could not reach it. She stated she used her button when she needed help and could not locate it when she felt for it near the quarter bed rail. A later observation showed the call light remained in the same unreachable location. CNA A stated the resident would not have been able to reach it there and then wrapped it around the quarter rail within reach. CNA A also stated the resident typically used the call light and had been confused that morning after a shower and hospice care. The DON and Administrator stated that everyone was responsible for ensuring call lights were in place, and the Administrator stated that without the call light within reach, the resident could try to get up herself and fall or not be able to call for help.
Resident’s Preference to Eat in Room Not Honored
Penalty
Summary
Resident #136 was not allowed to eat in her room, which was her stated preference. The resident had multiple sclerosis, dysarthria following cerebrovascular disease, anxiety, quadriplegia, cognitive communication deficit, dependence on a wheelchair, and contractures of the right elbow, right hand, and left hand. Her quarterly MDS reflected a BIMS of 15/15, indicating she was cognitively intact, and she used an electric wheelchair and a computer device to communicate by typing with her eyes. The grievance record stated that the resident was brought to the dining area about 1.5 hours before lunch with her bib already in place. Her family reported that she told staff she did not want to eat in the dining room, but staff told her it would not be possible because of the number of residents needing feeding assistance. The resident reported feeling embarrassed sitting in the dining area with her bib on for an extended period and stated she had to stare at a wall for about 1.5 hours before the meal was served because there was no TV available. A progress note documented that the patient was upset that staff brought her to the dining room for lunch to be fed and that there was not enough staff on the floor to feed everyone in rooms. The DON was notified and agreed with bringing the resident to the dining room. Interviews later confirmed that the resident preferred to stay in her room, used her laptop computer to communicate, and did not like coming out of her room. Staff also stated they did not have enough staff to feed her in her room and that she was fed in the dining room instead.
Dirty Toilet and Unflushed Feces in Resident Bathroom
Penalty
Summary
Resident #156’s bathroom was observed with brown particles on the toilet seat that appeared to be human feces, and a lump of feces was also observed inside the toilet. Resident #156 was an 88-year-old female admitted with diagnoses of muscle weakness, Parkinson’s disease, and depression. Her baseline care plan identified that she had a potential self-care deficit due to impaired mobility and weakness and required assistance from one staff member for toileting. During interview, Resident #156 stated she could not use her bathroom by herself and needed staff assistance. RN-G confirmed the brown particles on the toilet seat were feces and that feces remained in the toilet. RN-G stated staff did not clean the toilet seat and did not flush the toilet after assisting the resident with bowel movements. The DON later stated staff should have cleaned the toilet seat and flushed the toilet after helping the resident, and that the resident had the right to a clean and sanitary environment.
Inaccurate MDS Did Not Reflect Indwelling Catheter
Penalty
Summary
Resident #94’s assessment was not accurate because the Quarterly MDS did not reflect her indwelling catheter. The resident was admitted with neuromuscular dysfunction of the bladder, had a March 2026 order for an indwelling Foley catheter 16 French for urine retention every shift with a leg bag permitted while up during the day, and her care plan identified an indwelling catheter for neurogenic bladder. During interview, the resident stated she had a leg catheter on at the time of the survey. The MDS nurse stated the omission was human error and acknowledged the need to ensure staff code correctly and are aware of resident care, and the DON stated the MDS staff told her the indwelling catheter was not coded for the resident.
Incomplete Perineal Care During Incontinence and Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided for a resident who was incontinent of bladder and had an indwelling urinary catheter. Resident #64 was a 91-year-old male with diagnoses including spondylosis, weakness, and neuromuscular dysfunction of the bladder. His MDS assessment documented a BIMS score of 12 out of 15, urinary indwelling catheter use, and that he was always bowel incontinent. His care plan identified that he had an indwelling catheter and included monitoring for signs and symptoms of discomfort on urination and frequency. During observation, CNA-A provided incontinent and catheter care after the resident had a bowel movement. CNA-A cleaned the catheter, genital area, groin, rectum, and right buttock area, changed gloves, and then placed a clean brief on the resident without cleaning the left buttock area. During interview, CNA-A stated she was nervous and forgot to clean the left buttock area. The CNA stated the area should have been cleaned because the resident had a bowel movement and to prevent possible infection and skin breakdown. The DON also stated the left buttock area should have been cleaned to prevent possible infection and skin breakdown, and the facility policy required cleansing the buttocks and anus when the perineum was grossly soiled.
Unit Pantry Food Storage Deficiency
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in the Bluebonnet Hall unit pantry. During observation, the unit pantry refrigerator was found at 42 degrees Fahrenheit at 9:13 AM and again at 10:18 AM, and RN E later confirmed the refrigerator temperature was 45 degrees Fahrenheit. RN E stated that if the refrigerator unit was higher than 42 degrees Fahrenheit, it could cause food to spoil. The apple juice container in the Bluebonnet Hall unit pantry was half full and was not labeled or dated during both observations. RN E confirmed the apple juice had no label and was not dated and stated this could cause spoilage. RN E also stated the unit refrigerator was used for residents when they needed snacks or hydration, the temperature was checked daily, and staff using the food item were responsible for labeling and dating open containers. The DON stated she was not sure why the Bluebonnet Hall unit pantry refrigerator temperature was high and suggested residents or staff may have just opened it.
Improper Dumpster Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 1 dumpsters because the garbage container did not have a plug at the bottom. During observation on 3/17/2026 at 9:45 AM with the FSM, surveyors observed that the dumpster lacked a bottom plug. During interview at the same time, the FSM stated he was not aware the dumpster did not have a plug and said he would call the city. Record review of the facility's Sanitation and Infection Prevention, Solid Waste Disposal policy dated 5/95 stated that food waste and rubbish in the Food and Nutrition Services Department are to be disposed of in an approved manner to prevent contamination of food, clean dishes, or clean working areas.
Infection Control Lapses During Contact Precautions and G-Tube Care
Penalty
Summary
The facility failed to establish and maintain an infection control program for 2 residents reviewed for infection control practices. Resident #47 had diagnoses including a periprosthetic fracture around the internal prosthetic right hip joint, MRSA infection, and ESBL in the urine, and the care plan directed staff to maintain contact precautions when providing care. During observation, RN-G entered the resident’s room without putting on gloves and a gown even though a contact precaution sign on the door indicated gown and gloves were required before entry. RN-G later stated she forgot to wear the PPE, and the DON stated she should have worn gown and gloves before entering the room to prevent infection. Resident #153 had diagnoses including adjustment disorder with depressed mood, bacteremia, and a gastrostomy tube. The physician’s order included gastrostomy tube feedings and cleansing the G-tube site with wound cleanser, pat dry, and apply split sponge dressing every night shift. During observation, LVN-L administered medications via the gastrostomy tube, changed her gloves, and then cleaned the G-tube site and applied a new dressing without sanitizing or washing her hands between glove changes. LVN-L stated she changed her gloves without sanitizing or washing her hands because she was nervous and forgot, and the DON stated she should have sanitized or washed her hands before putting on new gloves.
Missing Abuse, Neglect, Exploitation, and Dementia Training
Penalty
Summary
The facility failed to ensure abuse, neglect, and exploitation training, as well as dementia training, were completed for 1 of 5 employees reviewed, CNA-M. Record review showed CNA-M had a hire date of 11/24/2024, and the training log from human resources contained no evidence that CNA-M received abuse, neglect, and exploitation training. During interview on 03/20/2026 at 12:04 PM, the Staffing Coordinator stated CNA-M was agency staff and was no longer working at the facility as of 01/19/2026, but acknowledged the facility should have verified whether CNA-M had completed the required training before allowing the CNA to work on the floor. The Staffing Coordinator stated it was her responsibility to confirm agency staff completed all required trainings and admitted she did not check whether CNA-M had completed abuse, neglect, and exploitation training. The facility policy titled "Abuse prevention," dated 03/16/2022, stated new employees would be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation.
Late and Missing MDS Transmissions
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete MDS data to the CMS system within 14 days after completion for 5 of 14 residents reviewed. Residents #62, #107, #123, and #132 each had discharge MDS assessments that were completed but not transmitted to CMS. Resident #62 was admitted with diagnoses including a right clavicle fracture, respiratory failure with hypoxia, metabolic encephalopathy, muscle wasting and atrophy, gait and mobility abnormalities, dehydration, malnutrition, and decreased white blood cell count. Resident #107 was admitted with diagnoses including UTI, muscle wasting and atrophy, gait and mobility abnormalities, muscle weakness, unsteadiness, chronic diastolic CHF, sleep apnea, overactive bladder, hypertension, and bone density disorders. Resident #123 was admitted with diagnoses including sepsis, hypothyroidism, hypercholesterolemia, insomnia, interstitial pulmonary disease, acute respiratory failure with hypoxia, right shoulder pain, osteoporosis, and physical debility. Resident #132 was admitted with diagnoses including multiple pelvic fractures, muscle wasting and atrophy, gait and mobility abnormalities, muscle weakness, type 2 diabetes, generalized anxiety disorder, and late-onset Alzheimer’s disease. During interview, the MDS Coordinator stated she did not know why the discharge MDS assessments for Residents #62 and #107 had not been transmitted and said they had been locked when the 5-day MDS assessments were completed because the residents were managed care and would not have transmitted the 5-day assessments. Another MDS Coordinator stated she was catching up on other MDS assessments and had not completed the discharge assessments for Residents #123 and #132. The DON stated the MDS Coordinators were responsible for completing the assessments, the facility had been down one MDS Coordinator for a long time, and Medical Records was responsible for transmitting the MDS assessments. The DON also stated that not transmitting MDS assessments could affect CMS compliance and payment. Resident #86’s admission MDS assessment remained in progress and had not been completed or transmitted. The resident was an 85-year-old female with diagnoses including senile degeneration of the brain, dementia, and type 2 diabetes mellitus. The MDS nurse stated she did not complete the assessment because she was very busy due to her workload and said she should have completed and transmitted it by the required timeframe. The DON stated the MDS nurse should have completed and transmitted the assessment and did not know why it was late.
Failure to Notify Physician and Responsible Party of Worsened Wound
Penalty
Summary
The facility failed to immediately notify a resident's physician and responsible party when there was a significant change in the resident's condition, specifically a worsened wound to the sacrum. The resident, an elderly male admitted for respite care with a history of stroke, cerebrovascular disease, and right-sided hemiplegia, was receiving hospice care at the time of admission. Upon admission, a nonblanchable redness was noted on the coccyx. On a subsequent assessment, the wound was found to have deteriorated and opened up. Certified nursing assistants observed and reported the change to an LVN, who documented the issue and indicated that notifications would be made. However, interviews and record reviews revealed that neither the resident's physician nor the responsible party were notified of the worsened wound. The charge nurse acknowledged being informed of the new or worsened sore but did not make the required notifications. The responsible party only became aware of the wound after the resident returned home, and the nurse practitioner confirmed that the physician and nurse practitioner were not notified. Facility policy required notification of the physician and responsible party upon identification of new or worsened wounds, but this protocol was not followed in this instance.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the prescribed transfer protocol for a resident who required maximum assistance of two staff members and the use of a mechanical lift. The resident, an elderly female with diagnoses including dementia, chronic kidney disease, muscle weakness, cognitive communication deficit, and abnormal gait, was dependent on staff for activities of daily living and required two-person mechanical lift transfers as documented in her care plan and medical records. On the date of the incident, the CNA transferred the resident alone using a gait belt instead of the required mechanical lift, without checking the resident's care summary or consulting with nursing staff regarding the appropriate transfer method. During the transfer from wheelchair to bed, the CNA heard a popping sound, and the resident subsequently complained of pain in her right arm. Assessment by the charge nurse and hospice nurse revealed swelling and pain in the right shoulder, and an X-ray confirmed a displaced fracture of the humeral neck. The resident's care plan, MDS assessments, and active orders all indicated the need for two-person mechanical lift transfers, and interviews with staff confirmed that this was the established protocol for the resident. The CNA admitted to not checking the care summary or asking the nurse about the correct transfer method, despite having received training on these procedures during onboarding. The incident was identified as Immediate Jeopardy due to the failure to provide adequate supervision and assistance devices, resulting in a serious injury to the resident. The event was corroborated by interviews with multiple staff members, review of medical records, and direct observation of the resident's condition following the incident. The deficiency was attributed to the CNA's inaction in verifying the resident's transfer requirements and not adhering to established safety protocols.
Failure to Honor Resident's Advance Directive for DNR
Penalty
Summary
The facility failed to honor a resident's right to formulate an advance directive and determine their choice regarding CPR. Specifically, the facility did not obtain a Do Not Resuscitate (DNR) order for a resident upon admission, despite the existence of a Living Will indicating the resident's wish not to receive cardiac resuscitation. The resident was admitted with diagnoses including Cerebral Infarction and unspecified Atrial Fibrillation, and the clinical assessment and baseline care plan inaccurately reflected a full code status. Interviews with facility staff revealed a breakdown in communication and procedure. The RN acknowledged that the resident's Living Will should have prompted a request for a DNR order. The SW and LVN/MDS Coordinator confirmed that the Living Will should have led to obtaining a DNR order, but the SW had not been informed of the resident's wishes. The DON emphasized the importance of obtaining a DNR order to honor the resident's wishes, but noted that sometimes family members might go against the resident's wishes. The resident's family member was unaware of the Living Will but expressed willingness to honor the resident's wishes once informed.
Delayed Reporting of Suspected Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of abuse involving a resident within the required timeframe. A Certified Nursing Assistant (CNA) observed another CNA making an inappropriate gesture towards a resident with Alzheimer's disease and unspecified dementia. The incident occurred during a morning shift, but the observing CNA did not report it immediately, as required by facility policy. Instead, the report was delayed until two days later, which resulted in the incident not being reported to the State Survey Agency within the mandated two-hour window for suspected abuse. The resident involved was an elderly male with a history of Alzheimer's disease and unspecified dementia. During the incident, the resident made a remark that prompted the inappropriate gesture from the CNA. The observing CNA did not report the incident immediately because she did not want to get her colleague in trouble, despite having received training on the importance of timely reporting. This delay in reporting could potentially place residents at risk for continued abuse and neglect.
Inaccurate MDS Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. Resident #48, who was diagnosed with Major Depressive Disorder (MDD), had this diagnosis omitted from her most recent quarterly Minimum Data Set (MDS) assessment. Despite being treated with Sertraline for depression, her MDS did not reflect her MDD diagnosis or her medication regimen. This oversight was confirmed during an interview with the LVN/MDS Coordinator, who acknowledged the importance of accurate MDS assessments to ensure residents receive necessary care and services. Similarly, Resident #73's MDS assessment failed to include his chronic diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder, despite his use of medications like Buspirone, Sertraline, and Depakote for these conditions. His care plan and psychiatric progress notes indicated a long history of these diagnoses, yet they were not reflected in the MDS. The LVN/MDS Coordinator and the Director of Nursing both emphasized the critical role of accurate MDS assessments and care plans in guiding staff to provide appropriate care based on residents' needs.
Failure to Implement Comprehensive Care Plans for Residents with Psychiatric Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which did not accurately reflect their psychiatric diagnoses and treatments. Resident #48, who was diagnosed with Major Depressive Disorder (MDD) and was receiving Sertraline and psychiatric services, had a care plan that did not include these critical details. Despite being treated for MDD, the care plan revised on 9/23/24 did not reflect her diagnosis or treatment, which was confirmed by the LVN/MDS Coordinator. This oversight was evident during an observation where the resident exhibited a flat affect, indicating the need for accurate documentation to ensure appropriate care. Similarly, Resident #73, diagnosed with MDD and PTSD, had a care plan that failed to document his receipt of psychiatric services, despite being treated with medications like Buspirone, Sertraline, and Depakote for these conditions. The resident's care plan, last revised on 4/18/24, did not reflect his ongoing psychiatric treatment, as confirmed by the LVN/MDS Coordinator. The Director of Nursing emphasized the importance of accurate MDS assessments and care plans to guide staff in providing necessary care. The facility's policy mandates comprehensive care plans that include measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Failure to Coordinate PASARR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for two residents diagnosed with Major Depressive Disorder (MDD). Resident #48, who was admitted with diagnoses including cerebral infarction and unspecified dementia, was not referred to the state-designated authority after being diagnosed with MDD. Despite receiving psychiatric services and medication for MDD, the necessary PASARR screening was not completed to ensure appropriate placement and care. Similarly, Resident #73, admitted with diagnoses of Post Traumatic Stress Disorder (PTSD) and depression, was not referred for a PASARR screening after being diagnosed with MDD and PTSD. The resident's care plan included medications for anxiety and depression, but the facility did not complete the required PASARR screening to reflect the mental illness diagnoses. Interviews with facility staff, including the LVN/MDS Coordinator and the Director of Nursing, confirmed the oversight and emphasized the importance of PASARR screenings to ensure residents receive appropriate care and services.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for a resident, which is required to be updated at least once every three months. The resident in question, an elderly female with Alzheimer's disease, paroxysmal atrial fibrillation, heart failure, muscle wasting, and hypertension, had her last completed quarterly MDS with an Assessment Reference Date (ARD) of July 11, 2024. The subsequent quarterly MDS, which should have been completed by October 10, 2024, was still in progress as of November 14, 2024. This delay was acknowledged by both the Director of Nursing (DON) and the MDS Consultant, who cited the absence of a full-time MDS nurse and the part-time status of the consultant as reasons for the backlog. The incomplete MDS assessment could lead to residents not receiving necessary, complete, or correct care due to the lack of current information for care plans. The facility's policy, dated May 5, 2022, mandates the use of the current version of the Resident Assessment Instrument (RAI) for conducting assessments and care planning within the timelines dictated by the RAI Manual. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that the MDS completion date must be no later than 14 days after the ARD, a requirement that was not met in this instance.
Failure to Follow Mechanical Soft Diet Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and provided adequate supervision to prevent accidents. Specifically, the facility did not follow the Speech Language Pathologist's (SLP) recommendations for a resident who required a mechanical soft diet with ground meats. Instead, the resident was served a ham sandwich with thinly sliced ham, which was not in accordance with the prescribed diet texture. This oversight led to the resident choking on the sandwich, becoming unresponsive, and ultimately dying after being transported to the hospital. The resident in question had a history of muscular dystrophy, dysphagia, and dementia, and was assessed to have intact cognition with a BIMS score of 13 out of 15. The resident's care plan and physician's orders clearly indicated the need for a mechanical soft diet with ground meats due to swallowing difficulties. Despite these orders, the facility's dietary staff, including the Assistant Food Service Manager and the Registered Dietician, believed that thinly sliced ham was appropriate for a mechanical soft diet, which contradicted the SLP's recommendations. On the day of the incident, the resident was served a ham sandwich that did not meet the mechanical soft diet requirements. The resident was later found gasping for air and unresponsive, with food debris in her mouth. Despite efforts by the staff to perform CPR and clear the airway, the resident was pronounced dead at the hospital due to choking and severe aspiration. Interviews with staff revealed a lack of understanding and adherence to the specific dietary needs of residents requiring mechanical soft diets, contributing to the tragic outcome.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and only accessible to authorized personnel, as required by State and Federal laws. During an observation, it was noted that a medication cup containing a round white pill and a capsule with red/orange powder was left unsecured and unattended on a resident's bedside table. The resident, who had a BIMS score indicating intact cognition, stated that the nurse had left the medications there and instructed her to take them. The resident had already taken some of the pills but was waiting to take the last two. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) did not leave medications at the resident's bedside and only administered injections and narcotics, while the Medication Aide (MA) was responsible for administering other medications. The Director of Nursing (DON) stated that the expectation was for MAs to ensure residents took their medications and that no medications were left in resident rooms. The facility's policy on medication administration required that all medications be administered to the resident, ensuring they were taken.
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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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Nursing homes near New Braunfels
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sundance Inn Health Center | 2.2 mi | ★★★★★ | 16 | 0 |
| Kirkwood Manor | 2.5 mi | ★★★★★ | 19 | 0 |
| Avir At New Braunfels | 2.9 mi | ★★★★★ | 38 | 2 |
| Legend Oaks Healthcare And Rehabilitation - New Br | 3.9 mi | ★★★★★ | 11 | 0 |
| Avir At Schertz | 12.2 mi | ★★★★★ | 41 | 2 |
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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.