Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Falcon Point Post Acute during CMS and state inspections, most recent first.
Two residents experienced medication administration errors when nursing staff failed to follow physician-ordered hold parameters for antihypertensive medications and did not accurately administer and document an ordered anticonvulsant. For one resident with severe cognitive impairment and multiple comorbidities, hydralazine and telmisartan were repeatedly given despite SBP and pulse readings that met the ordered hold criteria, with no documentation of physician notification or rationale in the record. For another resident with a G-tube and seizure disorder, an RN was observed administering several crushed medications via the tube, but the ordered Lacosamide dose—initialed as given on the MAR—was not observed being administered, and the RN later gave an unclear account of when additional medications were provided. These actions conflicted with facility policy requiring medications to be administered as prescribed, within scheduled time frames, and accurately documented.
Surveyors found that lunch items on a test tray, including fish tenders, potatoes, hushpuppies, and coleslaw, were not held or served at temperatures consistent with the facility’s policy requiring hot foods to be at least 135°F and cold foods no more than 41°F. The DM calibrated a thermometer in ice water and then measured each item, obtaining temperatures below the required hot-holding range and above the required cold-holding range. The DM and Administrator confirmed that food is checked on the steam table before service, trays are transported on metal racks without hot plates, and it can take 10–15 minutes for trays to reach hallways, with no reported resident complaints about food temperature.
Staff failed to follow the facility’s Enhanced Barrier Precautions policy during a high-contact transfer of a resident on EBP. A resident with severe cognitive impairment, multiple comorbidities, and total dependence for transfers had an EBP sign posted, yet one CNA entered the room without PPE and another wore only gloves while assisting with a mechanical lift transfer from bed to wheelchair. Both CNAs later stated they had received PPE in-services but forgot to don the required gown and gloves, contrary to facility policy and administrative expectations.
A resident with Down Syndrome, serious mental illness, developmental delay, and total dependence for ADLs was identified as PASRR positive, but the facility did not have the PASARR Level II assessment in the record and did not show that Level II recommendations were incorporated into her assessment, care plan, or transitions of care. Her MDS documented severe communication deficits, and her care plan referenced PASRR status and therapy needs, yet no Level II documentation was produced when requested. Additionally, after an IDT meeting identified needs for PT, OT, ST, a specialized mattress, wheelchair services, and a positioning wedge, the facility failed to submit a complete and accurate NFSS request within required timeframes, with NFSS forms for therapies and equipment not fully signed until months later and the approved positioning wedge lacking a corresponding timely NFSS submission.
The facility failed to keep a resident’s environment free from accident hazards when an electrical bed remote had multiple areas of exposed inner wiring along its cord, with only tape applied over the damage. The resident, an elderly female with moderate cognitive impairment, multiple comorbidities including DM2, morbid obesity, unsteadiness on feet, cellulitis, a pacemaker, and lumbar spinal stenosis, was totally dependent on staff for ADLs. She reported the wires had been exposed since she received the bed. Nursing staff stated the wires should not have been exposed and reported they had informed the Maintenance Director about the problem on more than one occasion, including after a family complaint, yet the condition persisted with only makeshift taping. The facility’s maintenance policy assigned responsibility to the Maintenance Director but did not address maintenance standards for resident equipment.
A resident with multiple comorbidities, including post-stroke hemiparesis, mobility deficits, and dependence on staff for ADLs, was observed receiving improper incontinent and perineal care. A CNA, despite prior in-service training, failed to clean the penis, scrotum, and full buttock area, did not change gloves during the entire episode of care, and applied zinc oxide ointment and a clean brief while still wearing contaminated gloves. This care did not follow the facility’s perineal care policy, which requires thorough cleansing of the male perineal and rectal areas with appropriate glove use to help prevent UTIs and skin issues.
A resident with COPD, dementia, severe visual impairment, and a history of falls was transferred to a new room where she later sustained an unwitnessed fall with a bleeding head injury. After she was found on the floor and sent to the hospital, blood from the incident remained on a pillow, the carpet, and the wall in the room. The resident’s representative later observed a bloody pillow in the wheelchair, fecal matter on the other bed, and belongings from a previous resident still in drawers, indicating the room had not been properly cleaned before or after the transfer. Surveyors and housekeeping confirmed a dark spot on the carpet and a smudge on the wall were likely blood, and facility leadership acknowledged that the blood-stained items and surfaces should have been cleaned or disposed of under the facility’s infection control policy, but this was not done.
A resident with dementia, severe visual impairment, COPD, and a recent history of falls was transferred to a new room that had not been properly cleaned or prepared. The room contained a bloody pillow in the resident’s wheelchair, fecal matter on the other bed, clothing and belongings labeled to previous residents, a large stored geriatric wheelchair, an oxygen machine, extensive wall and baseboard scuffing with exposed drywall, dried liquid on the wall, and a dark reddish/purple carpet stain. Staff interviews showed that required deep cleaning and removal of prior residents’ items were not completed before the transfer, despite facility policy requiring a safe, functional, sanitary, and comfortable physical environment.
A resident with multiple neurological and psychiatric diagnoses was identified as PASRR positive and required specialized services, but after initially agreeing, refused all recommended therapies. Facility staff were unclear about the correct process for handling the refusal and did not submit the required NFSS request in the LTC portal within the mandated timeframe, resulting in noncompliance with PASRR coordination requirements.
The facility failed to maintain a safe, clean, and homelike environment, with deficiencies in linen availability, maintenance, and housekeeping. Residents reported a lack of towels for showers and unclean bed linens, while maintenance issues like unsecured wall sockets and exposed sheetrock were not promptly addressed. Staff interviews revealed systemic issues with laundry and housekeeping services, impacting residents' quality of life.
The facility failed to conduct an annual Employee Misconduct Registry (EMR) check for the DON, as required by their abuse prevention program. The HR Coordinator admitted to missing the annual check, and the Executive Director was unaware of the requirement, leading to potential non-compliance and risks to residents.
The facility failed to remove expired medications from the medication room, as five expired heparin flush syringes were found. Staff interviews revealed confusion about responsibility for checking expired medications, with the DON indicating the night nurse and ADON were responsible. The ADON stated she checked the rooms multiple times a week, but the expired medications were not removed, indicating a lapse in the process.
The facility failed to maintain an effective infection control program, leading to deficiencies involving three residents. A resident with a Foley catheter and lesions did not have infection control signage on her door for two days. Another resident's oxygen tubing was improperly handled, and staff failed to don full PPE while providing care to a resident with a gastrostomy tube. These oversights were acknowledged by staff, highlighting lapses in infection control protocols.
A resident's call light was found out of reach, preventing them from calling for help. Despite the facility's policy requiring call lights to be accessible, staff interviews revealed a lack of awareness and accountability for the call light's placement. The resident, with cognitive deficits, was unable to locate the call light, highlighting a failure in ensuring necessary accommodations for resident needs.
A resident with multiple health conditions, including acute cystitis and hemiplegia, did not receive appropriate incontinent care, as her brief was not changed for several hours, and cleaning was inadequate. This failure to adhere to the facility's policy of providing care every two hours and ensuring thorough cleaning could lead to urinary tract infections.
A facility failed to adhere to infection control practices for a resident requiring respiratory care. The resident's oxygen tubing was not placed in a bag when not in use and was observed on the floor. An RN removed the tubing without gloves and did not bag it, contrary to the facility's policy. The resident, with a history of respiratory failure, was care planned for oxygen use. The infection control nurse confirmed the correct procedure, highlighting the oversight in infection control.
Two residents experienced a breach of privacy during incontinent care when CNAs failed to close blinds and pull privacy curtains, leaving them exposed. One resident, with moderate cognitive impairment, was in a private room, while the other, with severe cognitive impairment, was in a shared room. Staff acknowledged the oversight as a dignity issue.
The facility failed to provide timely incontinent care for three residents with cognitive impairments and incontinence issues. Residents were left in wet briefs for extended periods, leading to discomfort and potential skin breakdown. Staff interviews revealed that aides did not adhere to the facility's policy of making rounds every two hours, resulting in the observed deficiencies.
Failure to Follow Hold Parameters and Accurate Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to blood pressure medications and an anticonvulsant medication. For one male resident with hypertension, dementia, Alzheimer’s disease, depression, hypothyroidism, urinary tract infection, and cognitive communication deficits, the physician ordered hydralazine 25 mg three times daily and telmisartan 40 mg once daily with explicit hold parameters. Hydralazine was to be held if systolic blood pressure (SBP) was less than 130 or pulse was greater than 85, and telmisartan was to be held if SBP was less than 130 or pulse was less than 60. Review of the Medication Administration Records (MARs) for February and March showed multiple instances where these medications were administered and not documented as held despite SBP and pulse readings that met the ordered hold parameters. In February, the resident’s SBP readings were repeatedly below 130 at various administration times, and pulse readings were above 85 on several dates, yet hydralazine was not documented as held. Similarly, telmisartan was not documented as held on multiple days when SBP was below 130 and when pulse readings were below 60. In March, the same pattern continued: hydralazine and telmisartan were administered without being held even when SBP and pulse values fell within the parameters requiring the medications to be withheld. The clinical record and nurses’ notes for these months contained no documentation that the physician was notified of the consistently out-of-parameter blood pressure and pulse readings, and no documented reasons were provided for not holding the medications as ordered. During interviews, a LVN stated that if there was an order to hold blood pressure medications within certain parameters and it was not followed, the resident’s blood pressure could get higher or lower and the resident could get sicker. She acknowledged that in this resident’s case, she did not document any physician notification and stated that in nursing, if it is not documented, it is considered not done, taking responsibility for the lack of documentation. The DON confirmed that nurses were expected to review parameters before administering blood pressure medications and acknowledged that if medications were given when readings were out of parameter, it could cause the blood pressure to be higher or lower. The DON also stated that medication reviews were generally triggered by changes in condition, such as falls, and that nurses should notify the physician when blood pressure readings were consistently outside the ordered parameters. A second deficiency involved another resident, a female with a gastrostomy tube, GERD, aphasia following cerebrovascular disease, hemiplegia and hemiparesis, convulsions, essential hypertension, cognitive communication deficit, and other lack of coordination. This resident was NPO and received nutrition and medications via a G-tube, with orders to check tube placement and residuals and to flush the tube before and after medications. The physician’s order included Lacosamide 150 mg via PEG-tube every 12 hours to treat partial-onset seizures. During a medication administration observation, an RN checked the resident’s blood pressure, prepared and crushed three medications, diluted them with water, checked G-tube residual, and administered the medications through the G-tube. Lacosamide was ordered and initialed as given on the MAR for that morning, but the surveyor did not observe it being administered during the pass. In a subsequent interview, the RN stated she later realized she had to get three more medications, including iron and a vitamin, and claimed she returned and gave them after passing medications on another side, but she did not recall the exact time. The DON stated that medications ordered every 12 hours should be given at 9:00 a.m. and 9:00 p.m., and that if the RN had administered the medication, she should have informed the surveyor. The DON also noted that he could not defend the administration because the surveyor did not observe the medication being given, even though it was initialed as administered on the MAR. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time, and required that the individual administering the medication initial the MAR after giving each medication before administering the next, as well as documenting and reporting medication errors.
Improper Holding and Service Temperatures for Lunch Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices when evaluating lunch meal service in the kitchen. On the specified date and time, the Dietary Manager (DM) delivered a regular lunch test tray containing fish tenders, hushpuppies, potato wedges, and coleslaw. The DM then left the tray to obtain a thermometer, alcohol wipes, and a glass of ice water, returning several minutes later. She calibrated the first thermometer in ice water, which read 32.9°F, then left again and returned with a second thermometer that read 32.5°F in ice water. Using this thermometer, she measured each food item, placing the thermometer in ice water between items and wiping it before each new measurement. The recorded temperatures were 113.5°F for the fish tenders, 100.5°F for the potatoes, 98.5°F for the hushpuppies, and 56.1°F for the coleslaw. The DM stated that the fish tenders and potatoes should have been 135°F, the hushpuppies 130°F, and the coleslaw 40°F, and that the thermometer should have read 32°F in ice water. She reported that kitchen staff check food temperatures on the steam table before trays go out, that the first cart leaves the kitchen within 10 minutes, and that trays are delivered on metal racks to the hallways for aides to serve to residents. She also confirmed the facility did not use hot plates. A dietary aide reported that residents did not complain about food and that it could take 10 to 15 minutes to get trays from the kitchen to the hallway. The Administrator stated he had not heard complaints of cold food and confirmed that warming plates were not used. Review of the facility’s undated food temperature policy showed that hot foods should be maintained at a minimum of 135°F and cold foods at a maximum of 41°F, which did not align with the observed temperatures of the test tray items.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident on EBP and two CNAs providing care. The resident was an adult female with Down syndrome, severe cognitive impairment (BIMS score of 3/15), generalized muscle weakness, gait and mobility abnormalities, type 2 diabetes mellitus with unspecified complications, and a documented ADL self-care deficit requiring total dependence with two-person transfers between bed and wheelchair. On the observation date, an EBP sign was posted on the resident’s door, indicating that enhanced barrier precautions were required during high-contact care activities such as transferring. Surveyors observed that one CNA entered the resident’s room with a mechanical lift and did not don any PPE before entering, and a second CNA entered to assist with the transfer and donned only clean gloves without a gown, despite the transfer being a high-contact care activity under the facility’s EBP policy. The resident was then transferred from bed to wheelchair via mechanical lift without both CNAs wearing the required gown and gloves. In subsequent interviews, both CNAs acknowledged they had received in-services on PPE use to prevent infection but stated they had forgotten to wear the required PPE during the transfer. The Administrator stated that his expectation was that staff don PPE before entering the rooms of residents with EBP signage to perform any care, consistent with the facility’s written EBP policy, which requires gown and glove use for high-contact activities such as transferring.
Failure to Integrate PASARR Level II Findings and Timely Submit Specialized Services Request
Penalty
Summary
The deficiency involves the facility’s failure to incorporate PASARR Level II recommendations and evaluation findings into a resident’s assessment, care planning, and transitions of care, and failure to timely and accurately submit a request for nursing facility specialized services (NFSS). The resident was an adult female with Down Syndrome, Type 2 Diabetes Mellitus, cognitive communication deficit, disorganized schizophrenia, bipolar disorder, and a history of developmental delay and seizures. Her care plan identified her as PASRR positive related to ID/DD and noted communication problems related to Down Syndrome, with interventions such as anticipating and meeting needs and referring her to speech therapy. Her Quarterly MDS documented that she was rarely or never understood, did not complete the BIMS, and was totally dependent on staff for all ADLs. However, there was no Level II PASARR assessment uploaded in her medical record, and the facility did not demonstrate that Level II recommendations were integrated into her comprehensive assessment or care plan. Record review showed that the resident had been admitted to the hospital with developmental delay and seizures and then transferred to the facility. A PASARR Level I dated 01/16/2025 scored 0, indicating a negative Level I screen at that time. The baseline care plan coded her as understanding staff but not able to easily communicate with staff and included physical, occupational, and speech therapy to improve functional status. Despite her PASRR-positive status later identified in the care plan, the facility’s records lacked the Level II PASARR documentation and did not show that the Level II determination and evaluation report were used to guide her ongoing assessment, care planning, or transitions of care. When surveyors requested the Level II assessment from the Administrator, no documents were provided by the time of exit. The facility also failed to submit a complete and accurate NFSS request within required timeframes. An IDT meeting on 03/24/2025 identified needs for a support mattress, PT, OT, ST, wheelchair service, and a positioning wedge. The state received an NFSS request on 04/25/2025 for PT, OT, and ST, and records indicated the resident was approved for a positioning wedge on 03/25/2025 but that the NFSS request for that item was not submitted. NFSS forms for therapy and equipment showed therapist, physician, and Administrator signatures dated in late June, July, and August 2025, and another NFSS form for a mattress was fully signed on 08/29/2025. The Director of Rehabilitation reported learning of the resident’s PASARR services from the MDS department but could not recall who informed her, and the MDS staff member responsible earlier in the timeline was unavailable for interview. The facility’s policy on post-admission notification of significant change did not address submission deadlines, and the Administrator stated he was not aware that the NFSS documents were not submitted in a timely manner.
Exposed Electrical Bed Remote Wiring Not Corrected
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents, as evidenced by damaged electrical bed equipment for one resident. The resident was an elderly female with multiple medical diagnoses including type 2 diabetes mellitus, morbid obesity, unsteadiness on feet, cellulitis, presence of a cardiac pacemaker, and lumbar spinal stenosis. Her MDS showed moderate cognitive impairment, and she was totally dependent on staff for ADLs such as showering, toileting, footwear, and hygiene. Her care plan included monitoring for congestive heart failure symptoms and pacemaker-related issues. Despite these needs, her electrical bed remote had exposed inner wiring (red, green, and blue wires) separated from the outer grey sheath at both the remote end and the outlet end, with an additional cut in the middle of the cord exposing the same inner wires. During observation and interview, the resident demonstrated the exposed wiring on her bed remote, noting that the wires had been exposed since she received the bed and that the remote had only recently been wrapped with black electrical tape. She reported that the Maintenance Director had told her the remote was on backorder. The Maintenance Director acknowledged receiving a report about the exposed wire and stated he wrapped it with electrical tape, describing the bed as low voltage and conceding that the manufacturer likely would not consider the condition acceptable. An LVN, upon viewing the cord, stated the wires should not have been exposed. Another LVN reported notifying the Maintenance Director about the exposed wiring approximately two weeks earlier and again after the resident’s family complained, after which someone wrapped the exposed wiring with scotch tape. The facility’s maintenance policy placed day-to-day maintenance operations under the Maintenance Director but did not specify how resident equipment should be maintained.
Improper Incontinent and Perineal Care for Male Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate incontinent care and perineal hygiene to prevent UTIs and restore continence for a male resident who was incontinent of bladder. The resident was an adult male with multiple medical diagnoses including reduced mobility, mild protein-calorie malnutrition, sequelae of cerebral infarction with left-sided hemiplegia/hemiparesis, secondary hypertension, hyperlipidemia, lack of coordination, cognitive communication deficit, dependence on supplemental oxygen, need for assistance with personal care, generalized muscle weakness, and gait and mobility abnormalities. His admission MDS showed a BIMS score of 15/15, indicating intact cognition, and his care plan documented an ADL self-care deficit with total dependence on staff for personal hygiene and toileting, including interventions for timely brief changes to prevent skin breakdown. During an observed episode of incontinent care, a CNA washed her hands and donned clean gloves, then unfastened the resident’s soiled brief and used wet wipes to clean the groin but did not clean the penis or scrotum. After repositioning the resident on his side, the CNA cleaned between the buttocks several times but did not clean the surrounding buttock area and did not change gloves at any point during the care. Without changing gloves, she opened a jar of zinc oxide ointment, applied it to the buttocks and groin, then placed a clean brief on the resident before removing the soiled gloves and washing her hands. In a subsequent interview, the CNA stated she believed she had done a good job, acknowledged she forgot to change gloves because she was confused when the resident’s wife handed her the ointment, and confirmed she had been in-serviced on incontinent care and knew that not changing gloves and not properly cleaning the buttocks and scrotum could cause more skin breakdown, odors, and UTIs. The facility’s written perineal care policy required thorough cleaning of the penis, scrotum, perineal area, and rectal area, with appropriate rinsing and drying, which was not followed in this instance.
Failure to Clean and Disinfect Blood-Contaminated Room After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program when managing blood contamination in a resident room following a fall with head injury. The resident was an older woman with COPD, dementia with mild behavior disturbance, macular degeneration with severe visual impairment, difficulty walking, respiratory failure, and a cognitive communication deficit. Her care plan documented impaired visual function and severe visual impairment, and she had a documented history of multiple falls in December, including unwitnessed and witnessed falls, with the last fall on 12/31 resulting in injury. Her BIMS score had declined from 15 (normal cognition) to 6 (severe cognitive impairment) shortly before the incident. She was moved from one room (Room A) to another (Room B) shortly before the fall. On 12/31, nursing documentation showed that the resident experienced a change in condition related to a fall, with vital signs recorded and increased confusion and memory loss noted. Later that day, an LVN documented finding the resident on the floor in Room B after an unwitnessed fall, with bruising and active bleeding to the forehead. Pressure was applied, vital signs were obtained, the NP and family were notified, and the resident was transferred to the hospital. The LVN later stated that when she found the resident, her head was bleeding, she was sitting in the middle of the floor, and her oxygen tank was next to her; the LVN hypothesized that the resident could have hit her head on the floor or the wall. The ADONs and DON later acknowledged that any blood left behind from the fall should have been cleaned and disinfected and that leaving blood exposed was an infection control issue. Subsequent observations and interviews revealed that blood and other contamination remained in Room B and that the room had not been properly cleaned either before the resident’s transfer into the room or after the fall. The resident’s RP reported that when she returned to collect belongings after the resident’s hospital transfer, she found a bloody pillow in the resident’s wheelchair, clothing items in drawers from a previous resident, and fecal matter on the bottom of the other bed, and stated that the room did not appear to have been cleaned prior to the room change. Surveyor observation of Room B found a dark reddish/purple circular spot on the carpet near the closet and a dark red smudge on the wall. When housekeeping staff sprayed and wiped the carpet spot, a reddish-brown tint appeared on the cloth, and the housekeeper stated it could be blood and then affirmed it likely was blood. Photographic evidence submitted by the RP showed a pillow with bright red blood on the pillowcase and pillow, identified by the RP as belonging to the resident. Facility staff, including the Maintenance Director, ADONs, and DON, acknowledged that the substances on the pillow, floor, and wall were blood and that the room should have been deep cleaned and blood properly removed in accordance with infection control policy, but this had not occurred. The facility’s written infection control policy required maintaining a safe, sanitary, and comfortable environment and preventing, detecting, investigating, and controlling infections, which was not followed in this instance. Additional interviews highlighted process failures related to room readiness and cleaning oversight. The Maintenance Director stated he was informed of new admissions or room transfers via a room readiness group text and that housekeeping was expected to deep clean rooms, including disinfecting mattresses and hard surfaces, before a new resident moved in, with him verifying room readiness. He acknowledged that Room B should have been reviewed for cleanliness. Housekeeping staff described that a deep clean included cleaning the television, remote, disinfecting the mattress, and overall cleaning, and one housekeeper stated that no one checked rooms after she completed cleaning them. Another staff member responsible for floors stated he was supposed to clean the floor in Room B but was pulled to other halls and did not complete the task. ADONs and the DON confirmed that housekeeping was supposed to clean rooms after residents left and that blood-stained items should have been cleaned or disposed of, but in this case, blood remained on the pillow, carpet, and wall in Room B after the resident’s fall and transfer, constituting a failure to implement the facility’s infection control policy and practices.
Failure to Provide Clean, Sanitary, and Prepared Room Before Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, functional, sanitary, and comfortable environment in a resident room that was reassigned to a cognitively and visually impaired resident. The resident, an older woman with COPD, dementia with behavioral disturbance, macular degeneration causing severe visual impairment, difficulty walking, respiratory failure, and a cognitive communication deficit, was initially admitted earlier in the month and most recently readmitted on 12/20/25. Her care plan documented impaired visual function and severe visual impairment, and she had a recent history of multiple falls, including both witnessed and unwitnessed events, one of which resulted in injury. Her cognitive status declined from a BIMS score of 15 (normal cognition) on the MDS to a BIMS score of 6 (severe cognitive impairment) on an updated assessment completed on 12/27/25. On 12/30/25, the resident was moved from Room A to Room B on the skilled hallway. Room B had previously been occupied and contained items and environmental conditions that were not addressed before the transfer. The resident’s responsible party later reported finding a bloody pillow in the resident’s wheelchair, clothing items in the drawers belonging to a previous resident, and fecal matter on the bottom of the other bed, stating that the room did not appear to have been cleaned and looked like it had been used as storage. Photographic evidence submitted by the responsible party showed a pillow with bright red blood on the pillowcase and pillow, positioned across the handlebars of a wheelchair in Room B, with an oxygen machine visible in the background. Surveyor observation of Room B showed two beds, a dresser pushed into a corner, and a large electric geriatric wheelchair with foot holders and other wheelchair parts stored in the far corner. The walls and baseboards were pale yellow with extensive black and grey scuff marks, including deep scuffs exposing white drywall, and dried liquid droplets on the wall next to one bed. An oxygen machine dated 12-29-25 was on the nightstand of one bed. The closet contained a trash bag full of clothes and multiple garments labeled with a previous resident’s name and room number, and a dark reddish/purple circular stain was present on the carpet near the front of the room. Staff interviews revealed that the room should have been deep cleaned and cleared of previous residents’ belongings before the transfer, that housekeeping and maintenance processes were not completed as intended, and that clothing and a large motorized wheelchair from previous residents remained in the room. The facility’s policy on Physical Environment stated the purpose was to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, which was not met in this instance.
Failure to Coordinate PASRR Assessments and Submit NFSS Request
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for a resident identified as PASRR positive for developmental disability. After an initial interdisciplinary team (IDT) meeting, the facility did not submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within the required 20-day timeframe. The resident, who had multiple diagnoses including encephalitis, demyelinating disease, bipolar disorder, functional quadriplegia, and major depressive disorder, was determined to need several specialized services such as customized wheelchair and therapy assessments. However, the resident refused all recommended services after initially agreeing to them, and the staff were uncertain about the correct procedure to follow in this situation. Interviews with facility staff revealed confusion regarding responsibilities for submitting the NFSS form and uncertainty about the process when a resident refuses services after initially consenting. The MDS Coordinator and Director of Rehabilitation (DOR) were identified as responsible for the submission, but the form was not submitted as required. The facility's PASRR policy requires screening and evaluation for mental disorders or intellectual disabilities prior to admission and provision of appropriate services, but this process was not completed in accordance with regulations for the resident in question.
Deficiencies in Cleanliness and Maintenance in LTC Facility
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. The survey revealed that the facility did not maintain clean bed and bath linens in good condition for multiple residents, and there were issues with the availability of towels and bed linens. Residents reported not having enough towels for showers, and some had to purchase their own to ensure they could bathe. Additionally, there were reports of bed linens not being changed regularly due to a lack of available sheets, and some residents did not have pillowcases on their pillows. The facility also failed to address maintenance issues, such as an unsecured wall socket and discoloration on walls in several rooms. Observations noted missing paint and exposed sheetrock in various resident rooms, which were not addressed in a timely manner. The Facility Maintenance Director was unaware of these issues until they were pointed out during the survey, indicating a lack of communication and follow-up on maintenance requests. Furthermore, housekeeping practices were inadequate, with reports of rooms not being vacuumed properly, leading to dust accumulation and exacerbating residents' allergies. Interviews with residents and staff highlighted systemic issues with the facility's laundry and housekeeping services. Residents expressed dissatisfaction with the cleanliness of their living environment and the availability of necessary linens and towels. Staff interviews revealed that there were often not enough linens available, and some staff members were accused of hiding towels to avoid performing their duties. The facility's management acknowledged these issues and noted that some staff had been disciplined for their actions, but the deficiencies persisted, impacting the residents' quality of life.
Failure to Conduct Annual Background Checks for Abuse Prevention
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents. Specifically, the facility did not conduct an annual Employee Misconduct Registry (EMR) check for the Director of Nursing (DON) between July 28, 2023, and January 9, 2025. This oversight was identified during a record review and interview process, which revealed that the facility's abuse prevention program required conducting employee background checks to ensure that no individual with a history of abuse, neglect, or exploitation was employed. The HR Coordinator acknowledged that the DON's last background check was completed on July 28, 2023, and the next check was only conducted on January 9, 2025, after the issue was brought to the facility's attention. The HR Coordinator admitted that annual checks are her responsibility and that the oversight was unintentional. The Executive Director was uncertain about the requirement for annual background checks, indicating a lack of awareness of state requirements, which could lead to non-compliance and potential risks to residents.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired medications from the medication storage room. During an observation, five expired heparin flush syringes with an expiration date of 07/2024 were found in the medication room on the long-term care hall. Interviews with staff revealed a lack of clarity regarding responsibility for checking and removing expired medications. RN E was unsure who was responsible for this task, while the DON indicated that the night nurse and ADON were responsible for checking the medication room for expired medications. The ADON stated that she checked the medication rooms two to three times a week and that expired medications should be placed in a biohazard bin for pharmacy drug destruction. However, the presence of expired heparin flushes suggests a lapse in this process. The facility's policy on discarding and destroying medications, revised in November 2022, outlines procedures for disposing of medications that cannot be returned to the pharmacy, but the policy was not effectively implemented in this instance. An attempted interview with the night nurse responsible for the long-term care hall was unsuccessful, leaving a gap in understanding the oversight in the medication management process.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in several deficiencies. One significant issue involved Resident #195, who was admitted with an indwelling Foley catheter and lesions on her body. Despite these conditions, infection control signage was not placed on her door until two days after her admission. The Infection Control Nurse acknowledged the oversight, stating that signage should have been placed to prevent cross-contamination, as the resident had conditions such as a urinary tract infection and draining lesions. Another deficiency was observed with Resident #63, who required oxygen therapy. The resident's oxygen tubing was found on the floor and not stored in a bag when not in use, which is against infection control protocols. Additionally, RN F failed to don gloves when handling the tubing and did not place it in a bag before disposal. This oversight was acknowledged by RN F, who admitted to not being aware of the resident's oxygen needs and failing to follow proper infection control procedures. The facility also failed to ensure that staff donned full PPE when providing care to Resident #68, who had a gastrostomy tube and was incontinent. CNAs I and J did not wear gowns while providing incontinent care, despite the presence of infection control signage on the resident's door. Both CNAs admitted to forgetting to don full PPE, which was a requirement to prevent cross-contamination and infection spread. The Infection Control Nurse reiterated the importance of wearing PPE for residents with medical devices to reduce infection risks.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents to call for help when needed. During an observation, a resident was found sitting in bed with the call light cord hung on the corner of the headboard, out of reach. When asked about the call light's location, the resident, who had cognitive deficits and was unable to complete a mental status interview, appeared confused and unable to locate it. A surveyor had to activate the call light, which prompted a CNA to enter the room and reposition the call light on the resident's chest. Interviews with facility staff, including CNAs, an LVN, the Executive Director, and the DON, revealed a lack of awareness and accountability regarding the call light's placement. The CNA who responded to the call light was not familiar with the resident's hall and was unsure how the call light became out of reach. The LVN acknowledged the importance of having the call light within reach and speculated that it might have been moved during care. The Executive Director and DON both emphasized the necessity of ensuring call lights are accessible to residents at all times to facilitate communication with staff. The facility's policy on answering call lights, revised in September 2022, mandates that call lights be plugged in, functioning, and accessible to residents when in bed. Despite this policy, the deficiency occurred, potentially affecting any resident's ability to call for assistance. The report highlights the importance of adhering to established procedures to ensure residents' needs are met promptly and safely.
Inadequate Incontinent Care for Resident
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to potential risks of urinary tract infections. The resident, a female with a history of heart disease, depression, prediabetes, acute cystitis, hemiplegia, hemiparesis, and aphasia, was observed to have a heavily soiled brief with urine and feces. The care plan for the resident required checking for incontinence every two hours and maintaining good hygiene practices to prevent infections. However, during an observation, it was noted that the resident's brief was not changed for several hours, and the cleaning was not thorough, leaving residual feces in the vaginal area. Interviews with the CNA and RN involved revealed that the last incontinent care was provided several hours before the observation, contrary to the facility's policy of providing care every two hours. The Director of Nursing confirmed that the staff should be providing incontinent care every two hours. The facility's policy on female incontinence care, which includes thorough cleaning from front to back, was not adhered to, contributing to the deficiency in care for the resident.
Inadequate Infection Control in Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, leading to a deficiency in infection control practices. Specifically, the facility did not ensure that the resident's oxygen tubing was placed inside a bag when not in use, and the tubing was observed on the floor, which was not addressed by changing it. On one occasion, a registered nurse (RN) removed the tubing without wearing gloves and did not place it in a bag, which is against the infection control policy. The resident involved was an elderly female with a history of respiratory failure with hypoxia, among other conditions, and was care planned for oxygen use as needed. The facility's infection control policy, revised in October 2018, requires that oxygen tubing be placed in a bag when not in use to prevent infections. The RN admitted to not being aware of the resident's oxygen needs and acknowledged the failure to follow proper infection control procedures. The facility's infection control nurse confirmed the correct procedure for handling oxygen tubing, which includes using gloves and placing the tubing in a bag before disposal. This oversight in infection control could potentially compromise the health of residents by increasing the risk of infection.
Privacy Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure the privacy of two residents during personal care, specifically during incontinent care. For the first resident, a CNA did not close the blinds or pull the privacy curtain around the bed, leaving the resident exposed to anyone who might open the door or pass by the window. This resident, who was in a private room, had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL) due to conditions such as diabetes and heart disease. The CNA acknowledged forgetting to close the blinds and curtain, recognizing it as a dignity issue. For the second resident, another CNA did not pull the privacy curtain around the bed during incontinent care, leaving the foot of the bed open. This resident, who had severe cognitive impairment and required extensive assistance with ADL, was positioned by the door and had a roommate, increasing the risk of exposure. The CNA admitted to realizing the oversight after starting care, acknowledging that anyone entering the room could see the resident, which was also identified as a dignity issue. Interviews with staff, including the DON and RN, confirmed that privacy measures such as closing curtains, blinds, and doors were necessary to maintain resident dignity.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining nutrition, grooming, and personal and oral hygiene. This deficiency was observed in three residents who required extensive assistance and were incontinent of bowel and bladder. The facility staff did not provide timely incontinent care, which could lead to discomfort, skin breakdown, and urinary tract infections. Resident #1, a female with moderate cognitive impairment and multiple health conditions, reported being left in a wet incontinent brief for over four hours. The brief was saturated with urine, and the resident expressed discomfort. The Certified Nursing Assistant (CNA) responsible for her care admitted to not checking on her due to being busy with other residents. The Director of Nursing (DON) and the Administrator confirmed that aides should make rounds every two hours, and failure to do so could result in skin breakdown and infection. Resident #2, with severe cognitive impairment and other health issues, was also left in a wet incontinent brief for an extended period. The resident's family member and staff interviews revealed that the resident was not checked on or changed for several hours. Similarly, Resident #3, with moderate cognitive impairment, was found sitting in a wheelchair with wet pants and an ammonia odor, indicating prolonged exposure to urine. Staff interviews confirmed that the resident had not been changed for over four hours, which could lead to skin breakdown. The facility's policy required aides to make rounds every two hours, but this was not adhered to, resulting in the observed deficiencies.
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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 Katy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Katy, Llc | 0.9 mi | ★★★★★ | 4 | 0 |
| Sterling Oaks Rehabilitation | 1.8 mi | ★★★★★ | 13 | 0 |
| Mason Creek Transitional Care Of Katy | 2.3 mi | ★★★★★ | 1 | 0 |
| Oakmont Healthcare And Rehabilitation Center Of Ka | 2.6 mi | ★★★★★ | 2 | 1 |
| Heritage Park Of Katy Nursing And Rehabilitation | 2.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.