Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elgin Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic PTSD, psychotic disorder, and impaired cognition did not have his specific PTSD triggers identified in the care plan. The care plan noted a history of incarceration, paranoia, and behaviors that could escalate with anxiety or perceived threat, but it did not list triggers such as loud noises or men trying to boss him. The resident said no one had asked about triggers, and the SW, ADON, and MDS Coordinator acknowledged the triggers should have been documented.
Failure to Report Resident-to-Resident Abuse Allegations: The facility did not report multiple resident-to-resident incidents to HHSC, including an event where a blind resident allegedly struck another resident in the face, an incident where a wheelchair bumped another resident and both residents pushed at each other with a small skin tear noted, and a hallway altercation where two residents kicked and struck each other. Staff and the DON/Administrator described the events as accidental, minimal, or lacking intent to harm, and no HHSC report was made.
Late meal service was observed when lunch trays were not sent out until well after the posted time, and residents were brought into the dining room and left waiting before food was served. A resident with COPD, DM, CKD, and moderate cognitive issues said lunch had been late for about a month, and another resident with COPD and a history of prostate cancer said the delay bothered him. The RD, DM, and Administrator all stated meals should be served close to the posted schedule.
Failure to Maintain Effective Pest Control Program: The facility did not keep flies out of resident rooms, the kitchen, or common areas. Flies were observed in the kitchen dry goods area, on dining tables, on a resident’s legs during assisted dining, around another resident’s head and over-bed table, and on the straw in a resident’s hydration cup. The DON, ADM, ICP, and MAIN acknowledged the fly problem and described routine pest control visits, but records showed only outside insect light traps and no inside treatment for flies.
Resident dignity was not maintained when a resident’s name was written in large letters on the outside of his shirt and visible to everyone. The resident, who had moderate cognitive impairment and multiple chronic conditions, said staff marked his clothing because items were missing, but he preferred the name inside the shirt and said it did not make him feel good. Interviews with the DON, ADM, ES, MA G, and LVN H showed staff knew names were generally supposed to be placed inside clothing, but they did not know why this resident’s name was on the outside.
Call lights were not kept within reach for three residents with cognitive and mobility needs. One resident with schizophrenia, bipolar disorder, HTN, DM2, and anxiety had the call light on the floor under the bed on two observations; another resident with dementia, Alzheimer’s disease, a fall history, and anxiety had the call light buried in a laundry basket under clothing and stuffed animals; and a third resident with Alzheimer’s disease, DM2, muscle wasting, unsteadiness, and a fall history had the call light placed on the far side of the bedside table while asleep in bed. The DON stated call lights should be within reach when residents are in bed.
Two residents had annual MDS assessments that incorrectly marked current tobacco use as no. Both residents stated they used smokeless tobacco, and one was observed with snuff in his bedside table. Neither resident had a smoking assessment completed, and their care plans did not reflect tobacco use. Interviews with the RN B, SW, and ADM confirmed tobacco use should be captured on the MDS and that the residents were not listed on the smoking residents list.
Care plans for two residents failed to include smokeless tobacco use, despite one resident having no cognitive impairment and the other having dementia with a BIMS of 06. RN and LVN staff stated tobacco use should be included in the interdisciplinary care plan, and the DON said both residents should have been assessed for tobacco use on admission; an audit had identified that both residents used smokeless tobacco.
Expired medications were found stored in the medication room, including Aspirin 81 mg, Aspirin 325 mg, and Bisacodyl 10 mg suppositories. The ADON, DON, ADM, LVN H, and MR F gave differing accounts of who was responsible for checking expiration dates, while the facility policy stated nurses were responsible for monitoring expiration dates and expired medications were not to be used.
Enhanced Barrier Precautions were not followed during wound care for a resident with a Stage IV heel pressure injury and moderate cognitive impairment. An RN/LVN performed hand hygiene and provided the treatment with gloves, but did not wear a gown even though the room had an EBP sign and PPE was available at the door. The DON, ICP, and other staff confirmed that gown and gloves were required for wound care under the facility’s EBP policy.
A resident with dementia, depression, anxiety, impulse disorder, and prior behavioral issues was struck in the face twice by another resident while seated in a wheelchair. Nursing staff assessed the resident, documented stable VS and low pain, and reassured the resident, but the incident report did not specify changes to the plan of care. The existing care plan focused on longstanding behavioral and sexual issues and was revised only to add a general intervention to monitor for concerns related to peer contact under an unrelated behavior problem. The ADON, DON, and ADM acknowledged that the care plan did not include a distinct problem or specific interventions related to the altercation or psychosocial monitoring, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
Two residents experienced misappropriation of their controlled medications when significant quantities of Amphetamine-Dextroamphetamine and Hydrocodone-Acetaminophen went missing. Medication count sheets and narcotic records were found to be tampered with, and the discrepancies were linked to a nurse who had access to the medication carts during both incidents. Despite the missing medications, both residents continued to receive their prescribed doses without interruption.
A resident did not receive scheduled hydrocodone for three days due to communication lapses and failure to follow medication administration policies. The resident experienced discomfort and potential withdrawal symptoms, and the facility's system for monitoring medication availability over the weekend was inadequate.
The facility failed to develop comprehensive care plans for residents, including one with significant weight loss and others with PTSD. A resident's refusal to be weighed was not addressed in his care plan, and PTSD triggers were not documented for two residents, potentially impacting their well-being.
The facility failed to provide trauma-informed care for three residents with PTSD, as their care plans lacked identified triggers and interventions. Despite staff acknowledging known triggers, such as loud noises for one resident, this information was not documented, potentially leading to re-traumatization.
The facility failed to provide palatable and attractive food, with residents reporting issues with texture, taste, and appearance. Observations revealed non-adherence to recipes, resulting in unappetizing meals. A test tray confirmed the poor quality, with items being overly seasoned and unappealing.
The facility failed to meet food safety standards, with issues in labeling, sealing, and discarding food items, as well as improper hand hygiene and lack of hair restraints by staff. These deficiencies could lead to food contamination and illness.
A facility failed to update the activity plan for a resident with Alzheimer's and dementia who was admitted to hospice care. The resident, who became bedfast, did not receive an activity assessment or revised care plan for in-room activities. Observations showed the resident was often left in a dark room without stimulation, and the Activity Director admitted to missing the update. The facility's policy requires regular visits for bedfast residents, which was not followed.
A resident with Alzheimer's and contractures in a LTC facility was not provided with appropriate treatment to prevent a decline in range of motion. Despite needing hand rolls in both hands, the resident was often found without one in her right hand. Staff were unclear about the necessity and responsibility for the hand roll placement, and the facility lacked a specific policy for contracture management.
A medication aide failed to sanitize hands between residents and improperly handled medication and drinking cups, risking cross-contamination. The DON confirmed the expectation for proper hand hygiene, aligning with the facility's policy on medication administration.
Failure to Identify PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to ensure a resident with a history of post-traumatic stress disorder (PTSD) received trauma-informed care that identified his specific triggers. The resident’s record showed diagnoses including chronic PTSD, impulse disorder, and psychotic disorder with hallucinations. His quarterly MDS reflected a BIMS score of 9, indicating moderately impaired cognition, and he was assessed as feeling down, depressed, or hopeless and as having delusions. The comprehensive care plan noted the resident was at risk for emotional and/or physical symptoms associated with distressing events and an increased inability to cope related to PTSD. It also documented a history of incarceration, delusions, paranoia, and longstanding mistrust of others, with behaviors that could include verbal aggression, racially derogatory statements, refusal of care, and escalating behaviors during increased anxiety or perceived threat. However, the care plan did not include a focus area identifying the resident’s possible PTSD triggers. During interview, the resident stated no one in the facility had asked him what might trigger a PTSD episode. He reported that loud noises, people talking very loudly, and men trying to boss him reminded him of being in jail and made him nervous and mad. The ADON, Social Worker, and MDS Coordinator each stated the resident’s PTSD triggers should have been identified and documented, and the Social Worker acknowledged she was not aware of the specific triggers and that the care plan was not specific enough.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that alleged resident-to-resident abuse or mistreatment was reported to HHSC in accordance with required timeframes for four incidents involving Resident #11, Resident #60, Resident #64, Resident #98, and Resident #2. The report states that the facility did not report these incidents even though they involved resident-to-resident altercations, physical contact, and, in one case, a small skin tear. Facility staff and leadership repeatedly determined that the events did not rise to the level of reportable abuse because they believed there was no intent to harm, no serious injury, or only minimal contact. Resident #64 was a 51-year-old male with legal blindness, traumatic brain injury, delusional disorder, impaired cognition, limited mobility, and a history of inappropriate and unsafe behaviors. Resident #98 was a 42-year-old female with multiple sclerosis, paraplegia, cachexia, and severe cognitive issues. The record described an incident in the dining room where Resident #64, while moving through the area without staff present, allegedly hit Resident #98 on the chin or face while using his hands to feel his way forward. Resident #98 stated that Resident #64 hit her and that it hurt, though no bruise or visible injury was found. The DON, FDON, Administrator, and other staff documented that Resident #64 had not intentionally attacked Resident #98 and that the contact was accidental, and the facility did not report the event to HHSC. Resident #2 was a 68-year-old male with dementia, alcoholic cirrhosis, and cognitive communication deficit, and Resident #64 was also involved in a separate dining room incident with him. The record states that Resident #64 propelled his wheelchair into Resident #2's wheelchair, after which both residents pushed at each other and Resident #2 was observed with a small skin tear to the left finger. Staff described the event as residents pushing away from each other rather than punching or deliberate aggression, and the FDON and Administrator said they did not report it because they believed there was no deliberate aggression and no reportable injury. The report also describes an incident involving Resident #11, a 79-year-old male with dementia, adjustment disorder, hemiplegia/hemiparesis, aphasia, and no speech, and Resident #60, a 79-year-old male with dementia, sequelae of cerebral infarction, and dysarthria/anarthria. CNA K and LVN I described a hallway altercation in which the residents kicked at each other and Resident #60 swung his fist and made contact with Resident #11, but staff documented minimal contact, no injuries, and no emotional distress. The Administrator stated that he did not consider the event to be abuse and therefore did not report it to HHSC.
Late Meal Service and Residents Waiting in Dining Room
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen. Survey observations on 06/14/2026 showed the first lunch trays coming out of the kitchen and being placed on the serving cart at 12:53 PM, with trays for the 300 hall beginning to be passed at 1:15 PM. Lunch trays were also observed beginning to be served to residents seated in the dining room at 1:00 PM, well after the facility’s posted lunch time of 11:30 AM. Resident #86 was a male with diagnoses including COPD, type 2 DM with diabetic CKD, and abnormalities of gait and mobility. His care plan identified a potential fluid deficit related to poor intake, and his MDS showed moderate cognitive issues. During interview, he stated it bothered him that lunch was served late and said it had been served late for about a month. Resident #56, who had COPD, a history of prostate cancer, and monoclonal gammopathy, also had moderate cognitive issues on MDS and a care plan addressing nutritional risk related to a no added salt diet. On 06/15/2026, lunch trays were still being checked at 12:47 PM to confirm meal tickets matched the food on the trays, and no trays had yet been passed to residents in the hallway. Resident #2 stated she was brought into the dining room and then had to sit and wait for no reason because lunch was late. Resident #56 stated lunch was one and a half hours late and that it bothered him because he expected punctuality and order. The RD stated meals should be served as close to the posted time as possible, and the DM stated meals should go out as soon as possible according to schedule, noting that if meals are late, snacks and medications are late. The Administrator stated meals should begin at the posted mealtimes and that he did not want residents to get hungry or have their day interfered with.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free of flies in resident rooms, the kitchen, and common areas. During observations, a fly was seen in the kitchen dry goods storage area, flies were seen on dining room tables, and flies were observed in the assisted dining room landing on Resident #80’s legs while she was seated for dining. Resident #80 had Alzheimer’s disease, contractures, and lack of coordination and could not complete an interview. Additional observations showed a fly flying around Resident #72’s head and landing on objects on her over-the-bed table in her room. Resident #72 had dementia, COPD, and chronic diastolic heart failure, and stated the flies really bothered her and made her feel awful. In another room, a fly landed on the end of the straw in Resident #84’s hydration cup. Resident #84 had asthma, anxiety disorder, and chronic kidney disease, and stated the flies bothered her because they bite and could land on her face and bite her. Staff interviews reflected that the DON, ADM, ICP, and MAIN were aware of flies in the facility and described routine pest control visits, monitoring during rounds, and outside treatment, but the ADM stated the pest control company was not treating inside the building for flies. The MAIN stated the company came monthly, with additional visits as needed, and that the facility had air curtains on the dining room doors, but flies were still getting inside. Review of the facility’s kitchen sanitation policy required a professional pest-control program, and invoice review showed insect light traps outside the building but no treatment inside the building for flies.
Resident Name Displayed on Clothing
Penalty
Summary
The facility failed to treat one resident with dignity when Resident #15’s name was written in large letters on the back of his shirt and was visible to everyone. Resident #15 was a [AGE]-year-old male admitted on [DATE] with diagnoses including anemia, muscle wasting, unsteadiness on feet, type 2 diabetes mellitus with diabetic kidney disease, cognitive communication deficit, hyperlipidemia, heart disease, and hypertension. His quarterly MDS assessment showed a BIMS score of 10, indicating moderate impairment. During observation in the dining room, Resident #15 was seen with his name written big on the back of his shirt. In interview, Resident #15 said staff put his name on the back of his shirt because his clothes were coming up missing, but he would prefer his name on the inside of his shirt. He said having his name on the outside did not make him feel good and described it as tacky. He also stated that his name on the back of his shirt was visible to everyone. Interviews with the DON, ADM, ES, MA G, and LVN H showed staff awareness that resident names were generally supposed to be placed inside clothing and that dignity involved privacy, respect, and resident preference. The DON and ADM both said they did not know why Resident #15’s name was written on the outside of his shirt. The facility’s Promoting/Maintaining Resident Dignity Policy stated that the facility protects and promotes resident rights and treats each resident with respect and dignity in a manner that maintains or enhances quality of life by recognizing each resident’s individuality.
Call lights not kept within reach of residents
Penalty
Summary
The facility failed to ensure that the call light system was positioned within reach for three residents who were reviewed for reasonable accommodation of needs. Resident #9 had diagnoses including schizophrenia, bipolar disorder, hypertension, type 2 diabetes mellitus, and anxiety disorder, and was documented as mildly cognitively impaired with supervision needed for toileting and transfers. Her care plan included keeping the call light within reach and ensuring a safe environment with a working and reachable call light, but on 06/14/2026 and again on 06/15/2026 the call light cord was observed on the floor under the bed while she was sitting in her recliner or on the edge of the bed. Resident #30 had diagnoses including hypertensive heart disease, unspecified dementia, Alzheimer’s disease, history of falling, and anxiety disorder, and was documented as mildly cognitively impaired with supervision needed for bed mobility and transfers and use of a wheelchair. Her care plan also directed that the call light be within reach and reachable. On 06/14/2026, the resident was observed asleep in bed while her call light was inside a laundry basket with stuffed animals and clothing placed on top of it. Resident #40 had diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, muscle wasting and atrophy, unsteadiness on feet, and history of falling, and was documented as cognitively intact but needing supervision with self-care and mobility. Her care plan included keeping the call light within reach. On 06/14/2026, she was observed lying in bed asleep with her call light on the far side of the bedside table away from her. During interviews, a CNA stated that if the call light was not within reach the resident could not reach it to call for help, and the DON stated that when residents were in bed, call lights should be on the bed where they could reach them.
MDS assessments did not accurately reflect residents’ tobacco use
Penalty
Summary
The facility failed to ensure that annual MDS assessments accurately reflected the smoking status of 2 residents. For Resident #36, the annual MDS marked current tobacco use as no, but the resident’s care plan did not reflect smoking status and no smoking assessment had been completed. During interview, Resident #36 stated he used smokeless tobacco daily, kept a can of wintergreen snuff in his bedside table, and said staff knew he had it. Observation also confirmed a can of wintergreen snuff in the resident’s bedside table. For Resident #68, the annual MDS also marked current tobacco use as no, while the care plan did not reflect smoking status and no smoking assessment had been completed. During interview, Resident #68 stated he was a smokeless tobacco user, used tobacco pouches, spit in a cup, and kept his snuff in his pocket. He said the tobacco helped with his anxiety and helped keep him calm, and he did not want the facility to take it away from him. Interviews with the RN B, SW, and ADM showed they were trained on the MDS process and stated tobacco use should be captured on admission, annual, and significant change assessments. They also stated the MDS was completed by the MDS coordinator after other departments completed their sections, and that the smoking status could have been missed or not reported on admission. The Smoking Residents list did not include either resident, and the facility policy stated residents are to be asked about tobacco use during admission and quarterly or comprehensive MDS assessments.
Care Plans Omitted Smokeless Tobacco Use for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents by omitting their smokeless tobacco use from the care plan. Resident #36 was a male admitted with diagnoses including cerebral palsy, muscle wasting and atrophy, and hypertensive heart disease, and his MDS showed a BIMS score of 15, indicating no cognitive impairment. Review of his comprehensive care plan revealed no tobacco use, goals, or interventions related to tobacco products. Resident #68 was a male admitted with diagnoses including unspecified dementia with mood disturbance, type 2 diabetes mellitus without complications, and muscle wasting and atrophy. His MDS showed a BIMS score of 06, indicating moderately impaired cognition. Review of his comprehensive care plan also revealed no tobacco use, goals, or interventions related to tobacco products. During interviews, RN B and LVN A stated care plans were interdisciplinary and agreed that a resident using smokeless tobacco should be included in the care plan. The DON stated both residents should have been assessed upon admission for tobacco use and said an audit the day before identified that both residents used smokeless tobacco. The Administrator stated the care plan should include everything needed to care for a resident and that smokeless tobacco use should be care planned.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to ensure pharmaceutical services met resident needs because expired medications were found stored in the medication room during an observation with the ADON. The expired items included one bottle of Aspirin 81 mg enteric coated tablets with an expiration date of 03/2026, six bottles of Aspirin 325 mg tablets with an expiration date of 05/2026, and ten boxes of Bisacodyl 10 mg suppositories with an expiration date of 02/2026. During interviews, the ADON, DON, ADM, LVN H, and MR F each described shared responsibility for checking the medication room for expired medications, with MR F identified as responsible for monitoring the room and nurses and medication aides also checking medications when removed. The facility policy stated expired medications were not to be used beyond the manufacturer or pharmacy expiration date, that nurses were responsible for monitoring expiration dates, and that a continuous monitoring system would be designated by the DON to identify and remove expired medications. The ADM stated he was not sure why expired medications remained in the medication room and described it as a system failure.
Enhanced Barrier Precautions Not Followed During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when Enhanced Barrier Precautions were not followed during wound care for a resident with a right heel Stage IV pressure injury. The resident was admitted with diagnoses including paroxysmal atrial fibrillation, unspecified dementia, and peripheral vascular disease. Her MDS reflected a BIMS score of 11, indicating moderate cognitive impairment, and her care plan identified the need for Enhanced Barrier Precautions because of her wound. The care plan and orders required gown and gloves for high-contact resident care activities, including wound care. During observation of wound care, TN E performed hand hygiene, put on gloves, and provided the resident’s wound care, but did not wear a gown while performing the treatment. The resident’s room had a sign indicating Enhanced Barrier Precautions and personal protective equipment was available hanging on the door. TN E later stated she had been trained on Enhanced Barrier Precautions and wound care, and said she forgot to put on the gown while providing care. She stated she was trained to wear a gown and gloves for residents with an open wound or indwelling medical device and acknowledged that not wearing the gown could have possibly spread infection to the resident. Interviews with the DON, ADM, ICP, MA G, and LVN H confirmed that staff were expected to wear gown and gloves for residents requiring Enhanced Barrier Precautions, including those with wounds, and that the ICP was responsible for monitoring compliance during rounds. The facility policy stated that residents with wounds were to be placed on Enhanced Barrier Precautions and that gowns and gloves were to be available near or outside the resident’s room. The policy also identified wound care as a high-contact resident care activity requiring gown and gloves.
Failure to Update Care Plan After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes that reflected a resident’s needs following a resident-to-resident altercation. A male resident with diagnoses including unspecified dementia, major depressive disorder, generalized anxiety disorder, impulse disorder, and cerebral infarction had a comprehensive MDS showing moderate cognitive impairment (BIMS score of 11) and no documented behaviors in Section E. His existing care plan, initiated in 2019 and last revised in March 2026, focused on behavior problems such as tearing diapers, chewing briefs, inserting fingers into the rectum and mouth, laughing when falling, sexual behaviors in public, inappropriate sexual comments, exposing genitals, entering others’ rooms uninvited, and a history of inappropriate touching of female residents. On a date in March 2026, an incident report documented that a CNA observed another resident hit this resident in the face twice while he was sitting in his wheelchair in the hallway next to the other resident. The CNA moved him to the dining room, and a nurse assessed him, finding no injuries and documenting vital signs, a low pain score, and the resident’s denial of pain, fear, or feeling unsafe. The nurse reassured him that the other resident would be kept separate and noted that he remained in the dining room watching TV with wheelchair brakes locked, with the notation that the plan of care was ongoing. The incident report did not include further details about changes or additions to the plan of care. Despite this altercation, the resident’s care plan revision only added an intervention under the pre-existing behavior problem, stating to continue to monitor for areas of concern related to contact with a peer. The ADON acknowledged that the problem statement used for the revision did not relate to the incident and that the care plan was not updated with a problem specific to the resident-to-resident altercation or psychosocial monitoring needs. The DON and the administrator both stated that care plans are used by floor staff to guide care and that the care plan for this resident did not reflect the interventions put in place after the altercation, nor did it include a problem related to monitoring for psychosocial harm. This was inconsistent with the facility’s Comprehensive Care Plans policy, which requires a comprehensive, person-centered care plan with measurable objectives and timeframes to address medical, nursing, mental, and psychosocial needs identified in the assessment.
Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure the right to be free from misappropriation of resident property for two residents, resulting in the diversion and loss of controlled medications. For one resident with multiple sclerosis, ADHD, PTSD, and anxiety disorder, approximately 25 tablets of Amphetamine-Dextroamphetamine were reported missing. The medication count sheets and narcotic substance records were found to be tampered with, including scratched-out and overwritten numbers, and the corresponding blister packs could not be located. Staff interviews and record reviews confirmed that the medication was present and accounted for at the end of one shift, but discrepancies were discovered after the subsequent shift, during which a specific nurse had access to the medication cart and documentation. A second incident involved another resident with chronic pain syndrome, osteoarthritis, and hemiplegia, for whom 57 tablets of Hydrocodone-Acetaminophen (Norco) were reported missing. The narcotic count sheet for this medication was also found to be altered, with evidence of white-out and overmarking to make the count appear correct. The pharmacy confirmed the delivery of the correct quantity of medication, but the facility discovered the discrepancy when a refill was requested earlier than scheduled. The missing medication and altered documentation were linked to the same nurse who had access to the medication cart during both incidents. In both cases, the residents did not miss any doses of their prescribed medications, and there were no reports of unrelieved pain or missed treatments. However, the facility's failure to prevent the misappropriation of controlled substances and the tampering of medication records constituted a violation of residents' rights and facility policy. The investigation did not identify eyewitnesses to the theft, but the documentation and timing of the discrepancies pointed to a single staff member who had access during the relevant periods.
Failure to Provide Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a resident received scheduled hydrocodone as ordered from 03/29/24 to 03/31/24. This failure was identified through observation, interview, and record review, and it placed the resident at risk of increased pain and decreased quality of life. The resident, a cognitively intact female with a history of chronic pain and rheumatoid arthritis, did not receive her scheduled hydrocodone doses for three days, despite it being part of her pain management regimen. The resident reported feeling poorly, experiencing irritation in her legs, and sweating during this period, although she did not initially communicate her discomfort to the nursing staff, assuming they were aware of the medication issue. The medication administration records indicated that the hydrocodone doses were marked as unavailable, and the progress notes reflected attempts to reorder the medication. However, the medication was not administered from the emergency kit after the initial dose on 03/28/24. Interviews with the nursing staff revealed a lack of communication and follow-up regarding the medication's unavailability. The charge nurse and medication aide did not ensure the medication was reordered in a timely manner, and the resident's pain assessments during this period did not indicate any reported pain, leading to further delays in addressing the issue. The facility's policies on pain management, medication administration, and ordering and receiving medications were not followed, resulting in the resident going without her prescribed pain medication for an extended period. The ADON and DON acknowledged the communication lapses and the failure to monitor medication availability over the weekend. The facility relied on staff to report missing medications verbally, but this system failed, leading to the resident's discomfort and potential withdrawal symptoms due to the lack of hydrocodone.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in meeting their individualized needs. Resident #54, who has a history of significant weight loss and multiple health conditions, regularly refused to be weighed, which was not addressed in his care plan. Despite documentation of his refusals and the importance of monitoring his weight, the care plan was not updated to reflect these issues, potentially impacting his nutritional status and overall health. Additionally, the facility did not adequately address the needs of residents with PTSD. Resident #58, who has a diagnosis of PTSD, did not have his condition or potential triggers documented in his care plan. This oversight could lead to re-traumatization or psychosocial harm, as his care plan only included medication management for depression and anxiety without specific interventions for PTSD. Similarly, Residents #61 and #63, both diagnosed with PTSD, had care plans that lacked identification of triggers and appropriate interventions. The care plans primarily focused on medication management without addressing the specific needs related to their PTSD. This lack of comprehensive planning could result in adverse effects on their mental and psychosocial well-being, as the facility's policy requires individualized interventions for trauma survivors.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for three residents diagnosed with Post-Traumatic Stress Disorder (PTSD). The care plans for these residents did not include identified triggers or interventions related to their PTSD, which is a requirement to prevent re-traumatization. Resident #58, a male with a history of military service and a traumatic childhood accident, was not aware of his PTSD diagnosis and had not been asked about potential triggers. Despite the Assistant Director of Nursing (ADON) acknowledging that loud noises were a known trigger for him, this information was not documented in his care plan. Resident #61, a female with chronic obstructive pulmonary disease, morbid obesity, and PTSD, also had a care plan that lacked specific PTSD triggers or interventions beyond medication. Although she was assessed to have mood indicators of depression and anxiety, her care plan did not address potential triggers for her PTSD. The MDS Coordinator confirmed that her care plan should have included more detailed information about her PTSD triggers. Resident #63, a female with dementia, bipolar disorder, and PTSD, had a care plan that included medication interventions and monitoring of behavior episodes but did not identify any specific PTSD triggers. Despite her history of paranoia and hallucinations, the care plan failed to document potential triggers that could exacerbate her condition. Interviews with facility staff, including the MDS Coordinators and Social Worker, revealed a consensus that PTSD triggers should be documented to ensure proper care and prevent negative outcomes, yet this was not reflected in the residents' care plans.
Deficiency in Food Quality and Preparation
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and at a safe and appetizing temperature. Multiple residents expressed dissatisfaction with the food's texture, quality, appearance, and taste. Resident #2, for instance, reported that the meat served was too hard to cut and that she consumed only a small portion of her meal due to its poor quality. Similarly, Resident #245 found the meal unappealing, with the gravy being too gelatinous and the mashed potatoes overly seasoned with garlic and pepper. Resident #4 also reported that the mushrooms in her meal were overcooked and slimy, making the entire dish unappetizing. The facility's failure to follow recipes when preparing meals contributed to the unpalatable food. During an observation, a staff member was seen not using measuring spoons to add seasonings, instead using an eating utensil to pour unmeasured amounts of seasoning into the food. This lack of adherence to recipes resulted in meals that did not meet the expected taste and nutritional standards. The Dietary Manager (DM) acknowledged the importance of following meal tickets and recipes to ensure food is appealing and meets residents' nutritional needs. The test tray sampled during the survey further highlighted the issues with food quality. The beef patty with gravy and mushrooms was described as gelatinous and unappealing, with the meat having a mushy texture. The mashed potatoes were inedible due to excessive seasoning, and the wheat roll was dry and hard. These observations, along with resident interviews, indicate a systemic issue with food preparation and presentation in the facility, potentially affecting residents' food intake and quality of life.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Several deficiencies were noted, including improper labeling and dating of dry storage food, inadequate sealing of dry storage items, and uncovered beverages left in the freezer. Additionally, damaged or dented canned food items were not separated into a designated area, and expired food, such as a container of jelly, was not discarded. These lapses in food storage and handling could lead to food contamination and foodborne illness. During the survey, it was observed that kitchen staff did not consistently practice proper hand hygiene and glove use. One staff member was seen putting gloved hands in pockets to retrieve alcohol wipes during food preparation and temperature checks, without washing hands between glove changes. Another staff member was observed without a hairnet or beard guard while assembling meals, which could lead to cross-contamination. The facility's policies require hair restraints and proper handwashing, but these were not followed, increasing the risk of contamination. Interviews with staff and the Administrator revealed a lack of awareness and adherence to food safety protocols. Staff members were unsure about the correct procedures for labeling, sealing, and discarding food items. The Administrator and Dietary Manager expressed expectations for proper food storage, labeling, and hygiene practices, but these were not consistently implemented. The failure to follow these protocols could result in contamination and potential illness for residents.
Failure to Update Activity Plan for Resident on Hospice
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs and preferences of a resident who experienced a change in condition. The resident, an elderly female with Alzheimer's disease, dementia, and contractures, was admitted to hospice care, which resulted in her no longer getting out of bed. Despite these changes, the facility did not conduct an activity assessment or update her care plan to include in-room activities, as required by their policy. Observations revealed that the resident was often left in a dark room with the TV off, and her representative expressed concerns about the lack of stimulation. Interviews with the Activity Director (AD) and the Administrator confirmed that the resident's activity plan was not updated following her change in condition. The AD acknowledged the oversight and admitted that the resident's care plan should have been revised to ensure she received adequate stimulation, especially since she was no longer able to participate in group activities. The facility's policy mandates that residents, particularly those who are bedfast, should be visited by the AD, Activity Assistant, or volunteers at least three times a week, which was not adhered to in this case.
Failure to Prevent Decline in Range of Motion for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with limited mobility, specifically Resident #43, who had contractures in her right hand. The resident, an elderly female with Alzheimer's disease, dementia, and contractures, was observed without a hand roll in her right hand, which was necessary to prevent further decline in her range of motion. Despite being assessed as having functional limitations in range of motion for her bilateral upper and lower extremities, there were no physician orders or interventions in place for her right-hand contracture. Observations and interviews revealed that Resident #43 was often found in bed without a hand roll in her right hand, although one was present in her left hand. The resident's responsible party expressed concern about her long fingernails digging into her hand due to the contracture. Staff members, including CNAs and an LVN, were unsure about the necessity of the hand roll for the right hand and who was responsible for monitoring its placement. The Director of Nursing (DON) acknowledged the oversight and mentioned updating the task list to include hand rolls and nail checks, although the staff had not yet been informed. The physical therapist confirmed that Resident #43 should have hand rolls in both hands at all times to manage her contractures. The resident had been on physical therapy for contracture management but was discharged to restorative care for hand rolls after being admitted to hospice. The facility lacked a specific policy for contracture management, which contributed to the oversight in the resident's care plan and the failure to prevent a decline in her range of motion.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a medication pass, as observed with one of the medication aides (MA C). MA C did not sanitize her hands between residents and handled drinking and medication cups improperly by placing her fingers inside the cups. This occurred during the administration of medication to two residents, Resident #146 and Resident #85, which could potentially lead to cross-contamination and infections. During the observation, MA C was seen leaving one resident's room without sanitizing her hands and then proceeded to another room, where she continued to handle cups inappropriately. In an interview, MA C acknowledged the failure to sanitize hands and the improper handling of the cups. The Director of Nursing (DON) confirmed that the expectation was for medication aides to practice good hand hygiene and avoid touching the inside of cups to prevent cross-contamination. The facility's policy on medication administration emphasized the importance of handwashing and sanitization between handling medications and residents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 255 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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elgin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakcrest Nursing And Rehabilitation Center | 13.8 mi | ★★★★★ | 2 | 0 |
| Pflugerville Nursing And Rehabilitation Center | 15.4 mi | ★★★★★ | 4 | 0 |
| Falcon Ridge Rehabilitation | 15.5 mi | ★★★★★ | 9 | 0 |
| Spjst Rest Home 1 | 15.8 mi | ★★★★★ | 7 | 0 |
| Five Points Of Pflugerville | 16.1 mi | ★★★★★ | 17 | 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 October 2026) and official state health department websites.