Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Five Points At Lake Highlands Nursing And Rehab during CMS and state inspections, most recent first.
Failure to Provide Nail Care and Hygiene Assistance: A resident with severe cognitive impairment, diabetes, dementia, and MS was dependent for ADLs and required staff help with personal hygiene and oral care. Observation found long fingernails and brown matter under a thumb nail, and the resident requested trimming and cleaning. CNA and nursing staff acknowledged nail care responsibilities, and the facility policy stated nail care is usually done during the bath.
Care plan missing dementia diagnosis: A resident with dementia, CKD, HF, COPD, and osteoporosis had a quarterly MDS showing mild to moderate cognitive impairment and an active dementia diagnosis, but the comprehensive care plan had not been revised to include any dementia focus area, goals, or interventions. The MDS Coordinator, an LVN, and the DON each described care plan review/update responsibilities, but the dementia diagnosis remained absent from the plan.
Failure to Provide Nail and Grooming Care: Multiple residents with cognitive impairment, diabetes, dementia, MS, stroke-related deficits, and dependence for ADLs were observed with long, dirty, or untrimmed fingernails, and one resident also had untrimmed facial hair. Staff interviews confirmed that CNAs and nurses were responsible for nail care, that it should be provided on shower days and as needed, and that residents had not received the expected grooming assistance.
A cook prepared pureed potato salad for residents on a pureed diet without following the standardized recipe. Water was added instead of the specified liquid, thickener was added, and the food was portioned by estimate with a spatula rather than the expected #8 scoop. The DON stated that water can dilute flavor and nutritive value, and the cook acknowledged she did not review the recipe and did not use the required portioning method.
Late Lunch Service on Hall A1: Residents on hall A1 were seated for lunch at the posted 12:30 p.m. mealtime, but trays arrived about 45 to 55 minutes late and were distributed after the other halls had been served first. CNAs reported the delay happened daily, and the Dietary Mgr stated the expectation was for residents to receive trays within 40 minutes after the scheduled mealtime.
Improper Food Storage and Expired Item Left in Kitchen: Surveyors observed nectar-thick water past its use-by date left in the walk-in refrigerator and frozen food items stored in open cardboard boxes in the walk-in freezer. A Dietary Aide and the Dietary Manager stated that kitchen staff were responsible for keeping food covered and discarding expired items, and the facility policy required open packages to be stored in closed containers or sealed bags and expired products to be discarded.
Care Plan Did Not Address Scopolamine Patch Monitoring: A resident with severe cognitive impairment and sialorrhea had a physician-ordered Scopolamine patch, but the care plan did not include documentation to ensure the patch stayed in place. Staff observed the patch stuck to the resident's shirt and later found him without the patch while he was drooling heavily and wearing a shirt soaked with saliva. Interviews showed staff were unclear about who was responsible for monitoring the patch and updating the care plan.
Improper Tracheostomy Care and Hand Hygiene: An RN failed to perform hand hygiene when moving between dirty and clean steps during trach care and inserted a new inner cannula without sterile technique for a resident with trach status and acute respiratory failure with hypoxia. The resident’s care plan and MD orders required trach care every shift and as needed, and the DON confirmed trach care was to be aseptic/sterile technique.
A CMA left a resident’s morning meds in a cup on the bedside table instead of administering them and visually observing ingestion. The resident had severely impaired cognition and multiple diagnoses including AFib, DM, depression, thyroid disorder, seizure disorder, and anxiety. The resident was confused during the observation, and the CMA confirmed she had left the meds unattended in the room. The DON stated staff were expected to watch residents take meds and that meds must never be left unattended.
Unlabeled Insulin in Medication Cart: An insulin bottle of Lispro in a Hall C2 med cart was found without an open date during observation with an LVN. The LVN stated she had used the insulin for a resident’s breakfast and lunch doses, and the DON stated insulin should be labeled with the open date and is good for 28 days after opening.
Infection control failures occurred during incontinent care for two residents. One CNA provided peri-care and brief care for a resident with intact cognition but did not change gloves or perform hand hygiene when moving from dirty to clean tasks. For another resident on EBP for an indwelling foley and feeding tube, two CNAs entered without PPE, did not wear gowns, and one CNA continued incontinent care without changing gloves or performing hand hygiene between dirty and clean tasks. Interviews confirmed the staff knew the required infection control practices but did not follow them.
A resident with severe cognitive impairment and multiple comorbidities, identified as high risk for elopement, was able to exit the secured unit by forcing open a window that lacked an alarm and had a compromised locking mechanism. Staff last observed the resident in a common area, but during routine care activities, the resident left undetected. The resident was later found by emergency services with injuries, including a compression fracture, highlighting a failure in supervision and environmental safety measures.
A resident with Alzheimer's disease, who was on anticoagulant therapy, was accidentally hit by a door opened by an LVN. The LVN did not document the incident, complete an incident report, or notify the resident's representative or physician about the event or the resident's broken dentures. The family discovered bruises and the broken dentures upon discharge and reported not being informed of these issues. Staff interviews confirmed the lack of required notification and documentation.
A resident's room was found to have multiple extension cords running across the floor and exposed wires on a bed adjuster, creating tripping and electrical hazards. The resident required substantial assistance with ADLs and was at risk for falls. Facility staff acknowledged these hazards during interviews, and the facility's policy requires a safe and dignified environment.
A resident who required total assistance for ADLs due to reduced mobility did not receive scheduled showers for over five weeks, with records showing only sporadic bed baths and one shower after the resident complained. Staff interviews revealed inconsistent CNA assignments and a lack of oversight in ensuring showers were provided and documented, despite facility policy and the resident's care plan requiring regular bathing.
A resident admitted for respite care while on hospice did not receive scheduled hospice aide services due to the facility's failure to obtain required hospice documentation and lack of coordination with the hospice agency. Staff were unclear about the hospice plan of care and did not designate a team member to coordinate with hospice representatives, resulting in missed services during the resident's stay.
A resident with cognitive impairment and mental health diagnoses was left without a privacy curtain in her shared room for several weeks, requiring her to use the bathroom to change clothes due to lack of privacy. Staff interviews confirmed awareness of the missing curtain, but no action had been taken to restore it, resulting in a failure to maintain the resident's dignity as required by facility policy.
A resident with severe cognitive impairment and multiple medical conditions, who required maximum assistance with personal hygiene, was found with overgrown and dirty fingernails. Staff interviews confirmed that both CNAs and nurses were responsible for nail care, and facility policy required regular nail management, but the resident's nails had not been cleaned or trimmed as needed.
A CMA failed to disinfect a blood pressure cuff between use on two residents during a medication pass, contrary to facility infection control policy. Staff interviews confirmed that equipment should be sanitized between each resident, and the facility's policy requires cleaning of non-invasive equipment between uses to prevent cross-contamination.
A resident with multiple medical and behavioral health conditions was discharged without adequate preparation or documentation to a setting that could not meet her needs. The facility did not ensure the discharge destination was appropriate, failed to provide necessary referrals or ombudsman information, and did not document the representative's refusal of alternate placement, resulting in the resident being placed in an unsafe environment and ultimately requiring intervention by authorities.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A medication cart was found unlocked and unattended, with various medications accessible while a resident was present in the hallway. The medication technician responsible for the cart was not in direct proximity, contrary to facility policy requiring medication carts to be locked and attended by authorized staff.
A resident with significant respiratory needs was found in a room with a missing air conditioning vent cover, visible black substance in the ceiling opening, and a broken built-in dresser with missing drawers and doors. The room was warm with poor air circulation, and the resident reported difficulty sleeping and breathing due to the heat. Staff interviews confirmed the environmental issues and lack of timely repairs.
A resident with multiple medical conditions and a high risk for falls did not have a floor mat in place as required by his care plan while in bed. Staff interviews revealed the mat was removed for cleaning or to prevent tripping, and the assigned CNA was unaware of the intervention due to unfamiliarity with the resident's care plan. This resulted in the facility not following the specified fall prevention measures.
A resident with hemiplegia and hemiparesis who required staff assistance for bathing did not receive scheduled showers, and there was missing documentation for several shower days. The resident reported not being bathed for a week and expressed discomfort, while staff interviews confirmed the importance of documentation and monitoring, but records were incomplete.
The facility did not consistently perform daily inventory checks on an emergency response cart, resulting in incomplete documentation and unchecked critical items such as a backboard and medical supplies. Staff interviews confirmed lapses in the required nightly checks, and the facility lacked a policy for CPR, potentially impacting emergency response readiness.
A resident with severe cognitive impairment and a history of falls sustained multiple bruises and a laceration, which were not reported or investigated by the facility staff as required by policy. Despite several staff members noticing the injuries, they failed to notify the abuse and neglect coordinator, leading to a deficiency in care standards.
A facility failed to document blood pressure monitoring for a resident before administering Propranolol, as required by physician orders. The resident, with a history of hypertension and other conditions, received the medication without consistent blood pressure checks, risking inappropriate dosing. Staff interviews revealed a lack of documentation and communication, with the MAR lacking a section for recording blood pressure readings.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene by a CNA during incontinence care and the lack of enhanced barrier precautions for two residents with wounds and indwelling medical devices. These deficiencies increased the risk of infection transmission.
The facility failed to store, prepare, distribute, and serve food according to professional standards, as observed during a kitchen survey. Expired and unsealed food items were found in the dry storage, refrigerator, and freezer areas, posing a risk of cross-contamination and airborne illnesses to residents. Despite staff training, these deficiencies indicate a lack of adherence to food safety protocols.
A facility failed to maintain a safe and homelike environment for a resident with severe cognitive impairment and multiple medical conditions, as evidenced by a broken windowsill in her room that was not repaired in a timely manner. Despite the presence of a maintenance log system, the issue was not addressed until the resident and her roommate were moved to another room for repairs. Staff interviews revealed a lack of awareness and urgency in addressing the deficiency, highlighting a failure to adhere to the facility's policy on maintaining a safe and comfortable environment.
The facility failed to complete necessary PASARR Level 2 evaluations for several residents with mental illness, potentially risking their access to specialized services. Despite having serious mental health diagnoses, some residents were not properly assessed, and staff were unaware of these oversights. The facility's policy on PASARR maintenance was not followed, leading to deficiencies in resident care.
A resident with severe cognitive impairment and incontinence was not provided thorough incontinence care, leaving her at risk for infection. The CNA initially failed to clean the resident properly, and despite seeking help, did not follow proper hand hygiene protocols. The facility's personal care policy was not adhered to, compromising the resident's dignity and health.
A resident with severe cognitive impairment did not receive thorough incontinence care, as CNA D failed to clean the peri-area completely after a bowel movement. The CNA also neglected proper hand hygiene and glove use, increasing the risk of infection. Interviews confirmed non-compliance with facility protocols for perineal care.
A resident on a mechanical soft diet was served pot roast that was not ground as required, leading to an inability to consume the meal. Despite the resident's alertness and communication of his needs, the Dietary Manager and nursing staff were unaware of the specific dietary requirements, resulting in a failure to adhere to the facility's policy on mechanical soft diets.
A facility failed to include a smoking care plan for a resident with dementia, malnutrition, asthma, and COPD, who required supervision when smoking. Despite the resident's need for assistance with ADLs, the care plan lacked measures for smoking, confirmed by interviews with the resident and administrator.
A facility failed to label a Humalog insulin pen with an open date, risking the administration of ineffective medication. During an observation, an insulin pen was found without an open date, contrary to the facility's policy and professional standards. Interviews with the DON and ADON confirmed that insulin should be dated upon opening to ensure effectiveness, as it expires 28 days after being opened.
The facility failed to maintain a clean and safe environment, particularly on Hall 300, where equipment and resident rooms were found to be dirty and in disrepair. Observations revealed that the sit-to-stand lift and several residents' wheelchairs were covered in dust and debris, and Resident #2's room had multiple cleanliness issues, including a large unrepaired hole in the wall. Interviews with staff and residents highlighted a lack of a consistent cleaning schedule and unclear responsibilities, contributing to the deficiency.
A facility failed to secure residents' medication blister packs, leaving them unattended on a medication cart, which could lead to a breach of privacy. An LPN left the cart to assist a resident, exposing sensitive information. Despite recent HIPAA training, staff did not consistently follow procedures to secure such information.
A facility failed to maintain proper infection control when a piston syringe used for catheter flushing was left unwrapped on a resident's dresser. The resident, who had chronic urinary infections and required catheter care, was at risk due to this oversight. Staff interviews revealed a lack of accountability and adherence to infection control protocols, as the syringe should have been disposed of immediately after use.
A resident with cognitive impairment and high elopement risk left a facility unsupervised due to a door lacking an audible alarm. Despite being ambulatory with a wheelchair, the resident exited without triggering alarms, leading to a police search. Staff interviews indicated the resident often sat by exits but had not previously attempted to leave.
The facility failed to provide timely dental care for four residents, leading to prolonged dental issues and pain. Despite reporting their issues to the social worker, residents experienced significant delays in receiving dental services due to infrequent visits from a mobile dental service.
The facility failed to provide adequate supervision and safety measures for residents who smoke, specifically for two residents with intact cognition who were observed smoking without supervision. Despite being a non-smoking facility, 19 residents were known to smoke, and there was no smoking policy or designated staff to supervise smoking activities. Residents were not consistently signing out when leaving to smoke, and there was no documentation of education about smoking risks, leading to a deficiency in ensuring a safe environment.
The facility failed to implement a smoking policy, leading to unsupervised smoking by residents despite being a non-smoking facility. Two residents were observed smoking without staff supervision, keeping smoking materials in their rooms, and not adhering to any set schedule. Interviews revealed the facility had no formal smoking policy, placing residents at risk for injury and creating an unsafe environment.
A facility failed to ensure proper care for a resident with a feeding tube, as an LVN did not check for residual volume before administering medication. This oversight could lead to complications such as aspiration or vomiting. The resident, with severe cognitive impairment and requiring extensive assistance, was at risk due to this failure.
A LTC facility reported an 11% medication error rate involving two residents. An LVN administered Levemir instead of Lantus to one resident and incorrect doses of Vitamin B-12 and Folic acid to another. The facility's policy on medication administration was not followed, leading to these errors.
A facility failed to maintain an effective infection control program, as a CNA did not perform proper hand hygiene during incontinent care, and linens and trash were improperly managed in a resident's room, leading to a foul smell. The CNA admitted to not using available handwashing options, and the DON confirmed the expectations for hand hygiene and proper disposal of soiled items.
Failure to Provide Nail Care and Hygiene Assistance
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received necessary assistance to maintain nutrition, grooming, and personal and oral hygiene. Resident #1 was a female with diagnoses including hypertension, type 2 diabetes mellitus, non-Alzheimer's dementia, and multiple sclerosis. Her annual MDS dated 02/21/26 showed a BIMS score of 7/15, indicating severe cognitive impairment, and she was dependent with ADLs. Her care plan dated 03/04/26 identified an ADL self-care performance deficit and directed that she required assistance from one staff member with personal hygiene and oral care. On 05/26/26, observation showed Resident #1 seated in a wheelchair in the TV area with both hands severely contracted and supportive devices in place. Her fingernails were long, and there was brown matter under the left thumb nail. When asked, she said she wanted her fingernails trimmed and cleaned. Later that morning, CNA A physically assessed the nails and stated they needed trimming and that the left thumb needed cleaning. CNA A stated nail care was performed by CNAs on shower days and that nurses and CNAs were responsible for keeping residents' nails clean and trimmed. LVN B stated CNAs handled nail care unless residents were diabetic, in which case LVNs were responsible. The DON stated nail care was expected during shower days and that nurses had to trim the nails for diabetic residents. The facility policy stated nail care includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath.
Care plan missing dementia diagnosis
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plan for Resident #55 to include dementia. Resident #55 was an [AGE] year-old female admitted to the facility with diagnoses including dementia, acute kidney failure, heart failure, chronic obstructive pulmonary disease, and age-related osteoporosis. Her quarterly MDS assessment dated 03/09/26 showed a BIMS score of 12, indicating mild to moderate cognitive impairment, and Section I listed Non-Alzheimer's Dementia as an active diagnosis. Review of Resident #55's comprehensive care plan showed it was last reviewed on 01/09/2026 and did not contain a focus area, goals, or interventions for dementia. During interviews, the MDS Coordinator stated the care plan should be updated every 3 months and reviewed for diagnoses, goals, and interventions, but he did not know why the dementia diagnosis was missing. An LVN stated she was unaware of the resident's dementia diagnosis and that nurses were not responsible for updating care plans. The DON stated nurses were responsible for updating care plans for acute changes and was unsure why the care plan failed to address the dementia diagnosis.
Failure to Provide Nail and Personal Grooming Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living to maintain good grooming and personal hygiene for multiple residents who were dependent on staff for care. During observation and record review, residents were found with long, dirty, or untrimmed fingernails, and one resident also had untrimmed facial hair. The deficiency involved Resident #2, Resident #12, Resident #24, Resident #91, Resident #126, Resident #144, and Resident #156. Resident #2’s record showed diabetes mellitus, cerebral infarction, moderate cognitive impairment, and dependence on staff for personal hygiene. On observation, Resident #2 had long fingernails on both hands with discoloration and dark residue under the nails. Resident #12’s record showed dementia, muscle wasting, severe cognitive impairment, and extensive assistance needs for transfer and personal hygiene. On observation, Resident #12 was lying in bed with long, discolored fingernails on both hands. In interview, an LVN stated nurses and CNAs were responsible for clipping residents’ fingernails and that residents with diabetes required nurse involvement for trimming nails. Resident #24’s record showed schizophrenia, drug-induced subacute dyskinesia, severe cognitive impairment, and a history of aggression toward staff. On observation and interview, Resident #24 had long fingernails and toenails and stated she wanted them trimmed. Resident #91’s record showed dementia, blindness in both eyes, severe cognitive impairment, and dependence on staff for toileting hygiene. On observation and interview, Resident #91 had long fingernails on the left hand and stated she wanted them trimmed. Resident #126’s record showed hypertension, diabetes mellitus, hyperlipidemia, contractures, multiple sclerosis, severe cognitive impairment, and dependence on staff for personal hygiene. On observation and interview, Resident #126 had multiple chin hairs and long, jagged fingernails on both hands and stated she wanted her fingernails and facial hair trimmed. Resident #144’s record showed dementia and need for assistance with personal care, and on observation he had long fingernails on both hands and stated he wanted them trimmed. Resident #156’s record showed hemiplegia and hemiparesis following cerebral infarction, aphasia, type 2 diabetes mellitus, severe cognitive impairment, and need for assistance with toileting hygiene and showers. On observation, Resident #156 had long, dirty fingernails on both hands and stated they were too long and he wanted them trimmed. Staff interviews reflected that CNAs and nurses were responsible for nail care, that nail care should occur on shower days and as needed, and that long, dirty fingernails could lead to skin tears, infection, and loss of dignity.
Pureed Meal Prepared Outside Standardized Recipe
Penalty
Summary
Food prepared for residents on a pureed diet was not made according to the facility’s standardized recipe for pureed potato salad served at lunch. The recipe called for the potato salad to be placed in a blender or food processor and, if needed, to have liquid such as reserved juice, reserved liquid, or milk added to assist with pureeing; it specifically stated that water should not be used. The diet roster showed that Residents #11, #29, #72, #87, #129, and #133 were on a pureed texture diet for the lunch meal. During observation, Cook A prepared the pureed potato salad by adding an unmeasured amount of water from a steel pot next to the pureeing machine before pureeing the food, and no standardized recipe was referenced during preparation. Cook A then added about 1 tablespoon of thickener, pureed the mixture, and used a spatula to portion the food into six plastic cups, estimating each portion at about one-half cup rather than using the expected #8 scoop. The Dietary Manager stated that water should not be used because it can dilute flavor and nutritive value, and that the expectation was to use a standardized scoop for portioning. Cook A stated she did not review the standardized recipe and acknowledged that using water and not following the recipe could decrease the nutritional content of the meal.
Late Lunch Service on Hall A1
Penalty
Summary
The facility failed to provide lunch according to the designated meal service schedule for 1 of 5 halls reviewed, specifically hall A1. The posted meal service times showed breakfast at 7:30 a.m., lunch at 12:30 p.m., and dinner at 5:30 p.m., but during observations on 03/29/2026 and 03/30/2026, residents in the A1 dining room were seated for lunch at 12:30 p.m. while food trays did not arrive until 1:25 p.m. and 1:20 p.m., respectively. Residents remained waiting in the dining room until the trays were delivered and distributed. During interviews, CNA K stated lunch trays arrived daily 45 to 60 minutes after the scheduled 12:30 p.m. lunch time and that hall A1 was served last after the other halls. CNA L stated the trays were late because C1 was served first, followed by C2, B2, A2, and A1 last. CNA J stated lunch arrived on A1 Hall about 45 minutes after the scheduled time and that the serving time depended on who was in the kitchen. The Dietary Manager stated trays were walked to the hall dining rooms after preparation, nurses and CNAs distributed them, and the expectation was for residents to receive trays within 40 minutes after the scheduled mealtime.
Improper Food Storage and Expired Item Left in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in its only kitchen. On 03/29/2026 at 9:11 AM, surveyors observed approximately one-half pitcher labeled as nectar-thick water with a use-by date of 03/26/26 left in the walk-in refrigerator. On 03/29/2026 at 9:15 AM, surveyors observed multiple frozen sweet roll dough items and frozen beef steak fritters stored in open cardboard boxes and left exposed to frigid air in the walk-in freezer. During interviews, a Dietary Aide stated that everyone in the kitchen was responsible for covering food items, that dietary aides were usually responsible for making thickened water for service, and that thickened water should be discarded after the expiration date. The Dietary Manager stated that all food items were expected to be covered at all times, that leaving frozen food items exposed by not completely closing the cardboard box was not acceptable, and that expired food should be promptly discarded once it reached its expiration date. A review of the facility policy titled, Food Storage and Supplies, stated that open packages of food are to be stored in closed containers with covers or sealed bags and dated when opened, and that any product with a stamped expiration date will be discarded once that date passes.
Care Plan Did Not Address Scopolamine Patch Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #87 that included the services needed to attain or maintain his highest practicable physical, mental, and psychosocial well-being. Resident #87 was a male with diagnoses including non-Alzheimer's dementia, hypertension, chronic kidney disease, and lack of coordination. His MDS showed a BIMS score of 0, indicating severe cognitive impairment and that he was rarely or never understood. He required partial to moderate assistance with ADLs and was incontinent of bowel and bladder. The resident had a physician order for a Scopolamine Base Patch 72 Hour 1.5 MG to manage sialorrhea, and the MAR showed the patch was administered on 3/29/2026 in the morning. However, the care plan dated 1/6/2026 did not include documentation to ensure the patch remained in place. During observation on 3/29/2026, the resident was seen in the activity room drooling, with his red shirt soaked from chest to waist and a towel on his lap. When the LVN inspected him, the patch was found stuck to his shirt. On 3/30/2026, the resident was again observed without the patch behind either ear and with his shirt wet with drool. Interviews showed staff were unclear about responsibility for care plan updates and monitoring the patch. The charge RN stated she did not know why the patch was missing and was not sure whether the previous nurse had been informed. A CNA stated she was supposed to check for the patch when changing the resident's shirt and to notify the charge nurse if it was off or missing. The MDS coordinator administrator, ADON, and DON each described different processes for updating care plans, and the DON stated she was made aware of the concern only on the day of the interview. The DON also stated the resident's unmanaged drooling could result in skin issues from the wet shirt and affected his dignity.
Improper Tracheostomy Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper tracheostomy care was provided for Resident #89, a [AGE]-year-old female admitted with acute respiratory failure with hypoxia and tracheostomy status. Her MDS reflected she required tracheostomy care during the 14-day look-back period, her care plan identified tracheostomy care with a goal of no signs or symptoms of infection, and the physician’s orders directed tracheostomy care every shift and as needed. During an observation of tracheostomy care, RN D washed hands and donned a gown and clean gloves, but then removed the tracheostomy stoma dressing, changed gloves without performing hand hygiene, and later donned sterile gloves without hand hygiene. RN D suctioned the trach, wiped the stoma site, and placed a drainage sponge around the tracheostomy tube while wearing the same gloves. RN D then changed gloves again without hand hygiene and inserted a new disposable inner cannula into the trach without using sterile technique. In interview, RN D stated hand hygiene was supposed to be performed before and after trach care and that the procedure was supposed to be sterile to reduce cross contamination. The DON stated hand hygiene was required when moving from a dirty procedure to a clean procedure and that trach care was to be aseptic/sterile technique. The facility policy required cleansing hands after suctioning, putting on clean gloves, and cleansing hands again after removing soiled dressing and inner cannula.
Medication Left Unattended at Bedside
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident when a CMA left a cup of medications on the resident’s bedside table instead of administering them and observing the resident take them. Resident #112 was admitted with diagnoses including atrial fibrillation, hypertension, diabetes mellitus, depression, thyroid disorder, seizure disorder, and anxiety disorder, and the BIMs score of 07 indicated severely impaired cognition. The resident’s March 2026 physician orders included morning medications such as levothyroxine, potassium chloride, sertraline, apixaban, divalproex sodium, buspirone, and gabapentin. During observation, the resident’s room contained a medication cup on the bedside table with multiple tablets and a capsule, and the resident stated the medications were in the cup and she would take them. The resident was confused and talking about worms under her skin, fingernails, and cover. The CMA confirmed she had dispensed the medications that morning, left them on the bedside table, and left the room without watching the resident take them. The CMA stated medications were to be administered to residents and that she should stay with the resident to make sure the resident took the medication. The DON stated staff were expected to visually observe residents taking medications unless specifically ordered otherwise, and that medications must never be left unattended in a resident’s room.
Unlabeled Insulin in Medication Cart
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with currently accepted professional principles when an insulin bottle of Lispro injection 100 unit/ml in the Hall C2 medication cart was found with no open date. During observation on 03/30/26 at 1:47 PM, the medication cart for Hall C2 was checked with LVN J, and the top drawer containing insulin included a bottle of Lispro insulin without an open date. LVN J stated she had used that insulin bottle and administered insulin doses to Resident #2 at breakfast and lunch time. During interview on 03/31/26 at 1:05 PM, the DON stated nurses were expected to label and date all insulin in the cart with the open date, and that Lispro insulin is good for 28 days after opening. The DON also stated daily charge nurses were supposed to check for expired medications in the medication carts and pharmacists checked the carts monthly. Record review of the facility policy titled Medication Storage in the Facility 2025 stated outdated, contaminated, or deteriorated medications are to be immediately removed from stock, disposed of according to medication destruction procedures, and reordered from the pharmacy if a current order exists.
Infection Control Failures During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two residents observed during incontinent care. For one resident, who had a quarterly MDS showing a BIMS score of 14 and required maximal assistance with toileting hygiene, CNA C and CNA V entered the room to provide incontinence care. Both staff washed their hands and donned gloves, but during the care CNA C moved from dirty to clean tasks without changing gloves or performing hand hygiene, including after cleaning the resident and before fastening the clean brief. For another resident, whose quarterly MDS showed a BIMS score of 03 and diagnoses included cerebral infarction, end stage renal disease on dialysis, severe sepsis, and acute embolism and thrombosis of the right internal jugular vein, the care plan identified enhanced barrier precautions for high-contact activities such as toileting/incontinent care. During observation, CNA P and CNA Q entered the room without any PPE, despite signage and a PPE cart being present. They washed hands, donned gloves, and provided incontinent care without gowns. CNA Q cleaned the resident’s front area, including the foley catheter tube, then removed dirty gloves and washed hands before putting on clean gloves. CNA Q then continued care and finished applying the clean brief without changing gloves or performing hand hygiene between dirty and clean tasks. Interviews with CNA C, CNA P, and CNA Q confirmed they knew the expected infection control practices, including changing gloves and performing hand hygiene when moving from dirty to clean tasks and wearing gowns for enhanced barrier precautions, but stated they forgot or were nervous. The DON stated staff were to sanitize hands before and after care, change gloves between tasks, and wear gowns before touching residents with a port of entry. The facility policy stated hand hygiene is the primary means of preventing transmission of infection and is required after removing gloves or aprons.
Failure to Prevent Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for a resident at risk for elopement. The resident, a male with severe cognitive impairment, non-Alzheimer's dementia, anxiety, hypertensive heart disease, osteoarthritis, psychotic disorder, and intervertebral disc degeneration, was identified as high risk for elopement and placed in a secured unit. Despite this, the resident was able to exit the facility unsupervised by forcing open a window in a room near the TV area, which was found to have a compromised locking mechanism and no alarm at the time of the incident. On the night of the incident, staff last observed the resident in the TV room. During routine activities and medication administration, the resident was not directly supervised and was able to leave the secured unit undetected. Staff initiated a search and discovered a broken window with evidence of forced exit, including a sheared bolt and disturbed bushes outside. The resident was later found by emergency services in a nearby area, having sustained superficial abrasions and a compression fracture of the lumbar spine. Interviews with staff revealed that the window in question did not have an alarm prior to the incident and that the resident had not previously exhibited elopement behavior, though he was known to wander and was physically strong. The facility's elopement prevention policy required regular checks of exit devices, but the absence of an alarm and the compromised window allowed the resident to elope. Staff were occupied with other residents during the time of the incident, and the lack of direct supervision contributed to the resident's ability to leave the facility undetected.
Failure to Notify Physician and Family of Resident Incident and Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative and physician following a significant change in the resident's physical status. Specifically, a nurse entered the resident's room and accidentally hit the resident with the door. The nurse did not complete an incident report, document assessments, or initiate required ongoing monitoring for delayed injury. Additionally, the nurse did not notify the resident's responsible representative or physician about the incident or about the resident's broken dentures, which were discovered during the resident's stay. The resident involved was an elderly female with Alzheimer's disease, admitted for a short respite stay and was on anticoagulant medication, increasing her risk for bruising and injury. The resident was ambulatory, had wandering behaviors, and required a secured unit. During her stay, she was noted to have removed her upper dentures frequently, and staff later discovered the dentures were broken. The nurse reported the broken dentures to the Assistant Director of Nursing (ADON) but did not notify the family or physician at the time. When the resident's family arrived to pick her up, they observed bruises on her arms and forehead and noticed the broken dentures. They reported not being informed about the incident with the door, the lab work, or the broken dentures. Interviews with facility staff confirmed that the nurse did not document or report the incident or the broken dentures as required by facility policy, which mandates immediate notification and documentation of such events.
Failure to Maintain Safe and Hazard-Free Resident Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident who required substantial assistance with activities of daily living and was at risk for falls. Observations revealed that the resident's room contained a large extension cord running across the floor from the television to an outlet, despite there being an available outlet on the same wall as the television. Additionally, another extension cord was connected to two fans, and the bed adjuster on top of the resident's bed had exposed wires. During interviews, the Maintenance Supervisor acknowledged the presence of the extension cords and stated that they posed a tripping hazard and should not have been used. He also noted that the exposed wires on the bed adjuster, while a low shock risk, should not be exposed. The Administrator was not aware of these hazards until informed and agreed that such conditions could lead to fire or falls. The facility's policy requires maintaining an environment that promotes quality of life and protects resident rights, but these conditions were not met in this instance.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident who was dependent for activities of daily living (ADLs) received scheduled showers as required by her care plan. The resident, who had a history of cerebral infarction with reduced mobility and required total assistance for ADLs, did not receive any of her scheduled showers for over five weeks, except for one shower after she complained to leadership. Shower and bath records for November and December showed only sporadic documentation of bed baths and one shower, with some dates lacking any indication of care provided. The resident reported that staff told her they did not have time to provide showers and that the shower bed was broken. Interviews with staff revealed inconsistent practices regarding the assignment of CNAs to resident halls and a lack of oversight in ensuring that scheduled showers were provided and properly documented. Nurses and the ADON acknowledged that the resident should have received showers or bed baths at least three times a week, and that failure to do so could result in negative outcomes. However, there was no evidence that the required showers were consistently provided or that refusals were properly documented, as required by facility policy and the resident's care plan.
Failure to Coordinate Hospice Services and Obtain Required Documentation
Penalty
Summary
The facility failed to obtain essential hospice documentation and coordinate care for a resident admitted for a respite stay while receiving hospice services. Specifically, the facility did not secure the hospice election form, hospice plan of care, or physician certification and recertification of terminal illness from the hospice agency. Additionally, there was no designated member of the facility's interdisciplinary team responsible for coordinating with hospice representatives to ensure the resident's care was managed appropriately. During the resident's respite stay, the facility did not coordinate with Hospice Agency J to ensure the continuation of hospice aide services, resulting in the resident not receiving scheduled hospice aide visits for several days. Interviews revealed that staff were unclear about the hospice services to be provided, and there was confusion regarding the hospice aide's schedule and responsibilities. The facility staff relied on their usual procedures with other hospice agencies, but this was a new agency, and necessary communication and documentation were lacking. The resident involved was an elderly female with Alzheimer's disease, admitted for a short-term respite stay. She was ambulatory, required minimal assistance, and had a history of short-term memory impairment and wandering behaviors. Despite being scheduled for showers and some assistance, the lack of coordination between the facility and hospice agency led to missed hospice aide services, as neither party ensured the aide visits occurred or communicated effectively about the resident's care plan.
Failure to Provide Privacy Curtain Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a female resident with major depressive disorder, anxiety, and moderate cognitive impairment was found to be without a privacy curtain in her shared room for approximately four weeks. The resident reported having to use the bathroom to change clothes due to concerns about privacy, as anyone could enter the room while she was changing. Observation confirmed the absence of a privacy curtain, and the resident expressed discomfort with the situation. Staff interviews revealed that the LVN assigned to the hall was aware of the missing curtain but did not know why it was absent. The ADON and Administrator were not previously aware of the issue and speculated that laundry may have removed the curtain for cleaning. The resident's roommate had a privacy curtain, but this did not provide privacy for the affected resident. Facility policy requires that residents be treated with dignity and respect, including the provision of a private environment.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. The resident, an elderly male with severe cognitive impairment and multiple medical diagnoses including dehydration, coronary artery disease, and benign prostatic hyperplasia, required maximum assistance with personal hygiene according to his care plan. Despite this, observations on the specified date revealed that the resident's fingernails were overgrown, discolored, and had brown matter underneath. The resident expressed a desire to have his fingernails trimmed and cleaned. Record review showed that his last bed bath was two days prior and his last shower was several days before the observation. Interviews with staff, including a CNA, LVN, and the ADON, confirmed that both CNAs and nurses were responsible for nail care, with nurses specifically handling nail care for diabetic residents. Staff acknowledged that nail care should be performed on shower days and as needed, and that dirty, long nails could pose an infection risk. The facility's policy required regular nail management to promote cleanliness and prevent infection, typically during bathing. However, the resident's nail care needs were not met as required by his care plan and facility policy.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program as required, specifically in the disinfection of reusable resident care equipment. During a medication pass, a Certified Medication Aide (CMA) used a blood pressure cuff on two different residents without disinfecting it between uses. Observations showed that the CMA took the blood pressure cuff from the medication cart, used it on one resident, returned it to the cart without sanitizing, and then used the same cuff on another resident without cleaning it in between. The CMA stated in an interview that she cleaned the cuff at the start of her shift and twice during her shift, but also claimed to sanitize it between residents, which was not observed. The facility's policy requires non-invasive resident care equipment to be cleaned daily or as needed between use by nursing assistants, and immediately if visibly soiled. Interviews with the Regional Nurse and the Assistant Director of Nursing (ADON) confirmed that staff are trained and expected to disinfect reusable equipment between residents, in accordance with the facility's infection control policy. Both acknowledged that failure to do so poses a risk of cross-contamination. Record review of the facility's infection control policy further supported the requirement for cleaning equipment between resident use. The deficiency was identified through direct observation, staff interviews, and review of facility policy.
Failure to Ensure Safe and Documented Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a resident's safe and orderly transfer or discharge. The resident, who had a complex medical history including dementia, schizoaffective disorder, morbid obesity, and multiple physical health conditions, was discharged following an incident involving bodily harm to another resident. Despite the resident's significant care needs and cognitive impairments, there was no evidence that the facility ensured the discharge destination could meet her needs or that the resident and her representative were adequately prepared for the transition. Record reviews revealed that the resident was discharged home with medications and some instructions, but without home health services or documented referrals for psychiatric observation. The discharge summary indicated that the resident's representative was unable to care for her due to work obligations and physical limitations, and the resident ultimately did not go to the representative's home but to another family member's residence. There was no documentation that the representative declined alternate placement, received ombudsman contact information, or was provided with a written or verbal notice of intent to leave the facility. Staff interviews confirmed that the discharge was not safe, as the representative could not properly care for the resident, who required 24-hour licensed nursing care. The facility's own discharge policy required assessment of the discharge destination's ability to meet the resident's needs, involvement of the resident or representative in planning, and documentation of referrals and responses. These steps were not followed or documented in this case. The lack of preparation and failure to ensure a safe discharge destination resulted in the resident being placed in an inappropriate setting, leading to further intervention by authorities and eventual transfer to a psychiatric hospital.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart was observed unlocked, unattended, and not under the direct observation of authorized staff. The lock was in the out position, allowing anyone to open the drawers and access various multi-dose bottles of over-the-counter medications, as well as residents' routine and PRN medications and medication blister packs. During this time, a resident was seen ambulating back and forth in the hallway near the unattended cart. The medication technician responsible for the cart was not present at the cart and was observed returning from approximately twenty-five feet away. During an interview, the medication technician acknowledged that she should not have left the medication cart unlocked and unattended, stating that she was aware of the policy and had received training during new hire orientation. The facility's policy requires that medication carts remain locked when not in use or not attended by authorized personnel, and only licensed nurses, pharmacy staff, and those lawfully authorized are permitted access to the carts.
Failure to Maintain Safe and Comfortable Resident Environment Due to Missing Vent Cover and Damaged Furniture
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in one of five rooms observed. In the identified room, the metal vent cover was missing from the air conditioning opening in the ceiling, and a large amount of black substance was observed attached to the metal tubing inside the opening. Warm air was blowing out of the opening, and the room was warm with no air circulating. Additionally, the built-in dresser in the room was missing four drawers and two doors, leaving resident clothing exposed and metal brackets accessible, which could be hazardous. The resident occupying the room had a history of acute and chronic respiratory failure with hypercapnia, COPD with acute exacerbation, and essential hypertension. The resident required continuous oxygen and reported difficulty sleeping and breathing at night due to the room being too hot. During observation, the resident was using oxygen while in a wheelchair and stated the need for oxygen 24 hours a day. The care plan for the resident included interventions to monitor respiratory status and ensure adequate oxygenation. Interviews with facility staff revealed that the maintenance assistant, who was new to long-term care, was checking room temperatures due to high outdoor temperatures. The assistant noted that the vent cover had fallen off and acknowledged that the lack of a cover allowed warm air to enter the room, making it warmer. The administrator was unaware of the missing vent cover but was aware of the dresser's condition, stating it could not be repaired before the resident moved in. Facility policy on air conditioning failures was reviewed, but the observed deficiencies in the room environment were not addressed prior to the survey.
Failure to Implement Fall Prevention Intervention as Outlined in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident identified as high risk for falls. The resident, a male with diagnoses including unspecified Parkinsonism, involuntary abnormal movements, cognitive communication problems, and prostate cancer, was dependent on staff for activities of daily living and had a history of falls. His care plan, revised in April, specified the use of a floor mat as a fall prevention intervention. On the date of the incident, the resident was observed in bed without the required floor mat in place, despite being awake and attempting to climb out of bed. Staff interviews revealed that the floor mat was not present because it may have been removed for cleaning or to prevent tripping hazards, and the assigned CNA was unaware of the resident's need for a floor mat due to lack of familiarity with his care plan. Further interviews with nursing staff and facility leadership confirmed that the floor mat was a required intervention for fall prevention and should have been in place whenever the resident was in bed. The facility's policy on fall prevention emphasized the importance of implementing individualized interventions and educating staff about safety measures. The failure to ensure the floor mat was in place as specified in the care plan resulted in noncompliance with the requirement to provide comprehensive care planning and implementation for the resident's needs.
Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a stroke, who required staff assistance for bathing, was not provided showers as scheduled. Record reviews showed missing documentation for several scheduled shower days, and there was no evidence in nursing notes that the resident refused showers. The resident reported not receiving a shower for a week and expressed discomfort and dissatisfaction with the lack of bathing. Staff interviews confirmed the importance of documenting showers and monitoring that residents receive them, but documentation was missing for the relevant dates. The facility's policy outlined the goals and procedures for bathing but did not specify requirements for documenting showers or refusals. The ADON and DON acknowledged the need for proper documentation and monitoring, and the administrator stated that care should be provided as scheduled and documented. The lack of documentation and missed showers for the resident led to the deficiency, as the necessary services to maintain personal hygiene were not consistently provided or recorded.
Failure to Ensure Daily Emergency Cart Checks and CPR Readiness
Penalty
Summary
The facility failed to ensure that personnel provided basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel, as required by physician orders and the resident's advance directives. Specifically, the facility did not complete daily inventory checks on Emergency Response Cart 1 for a period of time, and the inventory log was found to be incomplete on one occasion, with several critical items such as a backboard, blood pressure cuff, stethoscope, and other supplies not checked off. Interviews with nursing staff and administration confirmed that the night shift was responsible for these checks, but the process was not consistently followed, and the charge nurses were expected to monitor compliance. Staff acknowledged the importance of these checks to ensure all necessary items were available in an emergency. Further review revealed that the facility did not have a policy for Cardiopulmonary Resuscitation (CPR), and the Central Supply Reference Guide required all emergency carts to be checked for expired items. The lack of daily checks and incomplete documentation could result in missing or expired emergency supplies, potentially delaying emergency response care. The deficiency was identified through observation, interview, and record review, and involved Emergency Response Cart 1 on the C hallway.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures to prevent and report abuse, neglect, and exploitation of residents, as evidenced by the case of a resident who sustained injuries of unknown origin. The resident, who had a history of Huntington's disease, dementia, and repeated falls, was found with a large bruise on her right and left eyes and a laceration on her right eyebrow. Despite these injuries, the facility staff did not report them to the abuse and neglect coordinator, which is a requirement under the facility's policy. The resident's medical records indicated that she had severe cognitive impairment and required substantial assistance for daily activities. On a particular day, the resident was minimally responsive and was sent to the ER for further treatment. A skin assessment revealed multiple bruises and abrasions, but these were not reported or investigated as required. Interviews with staff members revealed that several of them noticed the injuries but failed to report them to the appropriate authorities, citing various reasons such as assuming the injuries were old or not suspicious. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the failure to report and investigate the injuries. They noted that the injuries could have been related to the resident's condition, but emphasized that any injury of unknown origin should have been reported and investigated. The facility's policy clearly states that all potential abuse or neglect incidents must be reported and investigated, but this protocol was not followed in this case, leading to a deficiency in the facility's care standards.
Failure to Document Blood Pressure Monitoring for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not adhering to physician orders regarding the administration of Propranolol, a beta blocker medication. The medication was prescribed to be administered only if the resident's blood pressure was above 110/60. However, there was no documented evidence in the clinical record to indicate that the resident's blood pressure was taken to validate the need for the medication. This oversight occurred for a period from December 1, 2024, through January 18, 2025, with the exception of a few instances in December. The resident involved was an elderly female with a history of hypertension, Huntington's disease, dementia with mood disturbance, and repeated falls. Her care plan did not include a focus area for hypertension or related interventions, despite her being at risk for falls due to her medical conditions. The resident's blood pressure readings were not consistently documented, with only a few readings recorded in December and none in January up to the 18th. Interviews with facility staff revealed that there was a lack of proper documentation and communication regarding the blood pressure monitoring required before administering the medication. The Assistant Director of Nursing (ADON) and a Medication Aide (MA) acknowledged the importance of taking and documenting blood pressure readings but noted that the Medication Administration Record (MAR) did not have a designated area for recording these readings. The MA stated that she took the resident's blood pressure and recorded it on paper during her shift but destroyed the notes at the end of the day, leading to a lack of permanent documentation in the resident's records.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. One significant issue involved a Certified Nursing Assistant (CNA) who did not perform proper hand hygiene while providing incontinence care to a resident with severe cognitive impairment. The CNA failed to clean the resident's peri-area thoroughly, did not change gloves or perform hand hygiene between tasks, and handled soiled materials without gloves, increasing the risk of infection transmission. Additionally, the facility did not implement enhanced barrier precautions for two residents who were at increased risk of infection due to their medical conditions. One resident, who had multiple wounds and a peripherally inserted central catheter (PICC), did not have the necessary precautions in place, such as gown and glove use during high-contact care activities. The staff did not wear gowns while administering medications and performing wound care, contrary to the guidelines for residents with wounds or indwelling medical devices. Another resident with pressure ulcers and a PermaCath for dialysis also lacked enhanced barrier precautions. Staff did not wear gowns during care activities, including repositioning and dressing changes, despite the resident's risk factors. The facility's infection preventionist acknowledged the oversight and the potential for infection transmission due to the lack of appropriate precautions.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed that food items in the dry storage, refrigerator, and freezer areas were not labeled and dated according to guidelines. Additionally, open items were not sealed properly in plastic bags, and expired items were not removed from these storage areas. These practices could potentially affect residents who receive meals and snacks from the main kitchen, placing them at risk for cross-contamination and airborne illnesses. During the initial tour of the kitchen, several expired items were found, including thickened unflavored water, thickened orange juice, thickened cranberry cocktail, and thickened sweet tea. Other items such as spaghetti noodles, baking soda, squeezable honey, and creamy peanut butter were found unsealed. In the freezer, a container of thickened cranberry cocktail was also expired. In the refrigerator, a container of mixed fruit and a tray of ketchup cups were not properly sealed. These findings indicate a lack of adherence to food safety protocols, which require items to be sealed, labeled, and dated to prevent spoilage and contamination. Interviews with the Dietary Manager, a staff member, and the Dietary Aide revealed that all staff were responsible for ensuring that items in the kitchen were not expired and were properly sealed. Despite receiving in-service training on food preparation and storage, staff were unaware of the expired and unsealed items. The facility's policy on food storage and supplies emphasizes the importance of maintaining storage areas in an orderly manner to preserve food condition, but the observed practices did not align with these guidelines. The failure to follow these procedures could lead to the risk of airborne illnesses if contaminated food is ingested.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for Resident #98, as evidenced by a broken windowsill in her room that was not repaired in a timely manner. The windowsill was broken in the middle, leaving exposed adhesive and particle board, with loose wood debris present. This condition was observed by staff, including an LVN who noted that the windowsill had been in this state since he began working at the facility in October 2024. Despite the presence of a maintenance log system, there were no entries related to the windowsill, indicating a lack of communication and follow-up on the issue. Resident #98, a female with severe cognitive impairment and multiple medical conditions, including kidney failure, pneumonia, and anoxic brain damage, was affected by this deficiency. She was non-verbal, fed by a feeding tube, and required oxygen through a tracheostomy. The broken windowsill was located in her room, where she spent significant time due to her medical needs. The Social Worker and Maintenance Staff were made aware of the issue on December 8, 2024, but it was not addressed until the following day when the resident and her roommate were moved to another room for repairs. Interviews with facility staff revealed a lack of awareness and urgency in addressing the broken windowsill. The Maintenance Supervisor and Social Worker both acknowledged the issue but were unsure of when it was first reported or the potential safety risks it posed. The facility's policy on resident rights emphasizes the importance of maintaining a safe and comfortable environment, yet this incident highlights a failure to adhere to these standards, potentially impacting the quality of life for Resident #98.
Failure to Complete PASARR Evaluations for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that all residents with mental illness received the appropriate Pre-Admission Screening and Resident Review (PASARR) evaluations. Specifically, seven out of ten residents reviewed did not have the necessary PASARR Level 2 evaluations completed. This deficiency was identified through interviews and record reviews, which revealed that several residents with serious mental illnesses were not properly assessed, potentially placing them at risk of not receiving the specialized services they require. Resident #104, for instance, had a PASARR Level 1 screening that incorrectly indicated no serious mental illness, despite having diagnoses such as schizophrenia and psychotic disorder. The Director of Nursing (DON) and MDS Nurse were unaware of the reason for this discrepancy, and the resident's care plan included services for schizophrenia, highlighting the need for a Level 2 evaluation. Similarly, Resident #82 was identified as having a mental illness in the PASARR Level 1 screening, but there was no record of a referral to the Local Mental Health Authority (LMHA) for a Level 2 screening, as confirmed by the facility's social worker and MDS Nurse. Other residents, such as Resident #5 and Resident #14, did not have any PASARR evaluations completed, despite having diagnoses that warranted such assessments. Interviews with the MDS Nurse and DON revealed a lack of awareness and oversight regarding the completion of these evaluations. The facility's policy on PASARR maintenance was not adhered to, resulting in residents being at risk of not receiving the necessary care and management for their mental health conditions.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident who was unable to perform activities of daily living independently. The resident, a female with severe cognitive impairment and diagnoses including non-Alzheimer's dementia, muscle weakness, and lack of coordination, was observed in bed with a soiled blanket and brief. Despite being dependent on staff for personal hygiene, the resident did not receive timely assistance. A Certified Nursing Assistant (CNA) initially attempted to clean the resident but did not thoroughly remove all bowel movement from the peri-area, leaving the resident at risk for infection. The CNA left the room to seek additional help, returning with another CNA to complete the cleaning process. However, the CNA did not perform hand hygiene after changing gloves and tore a glove while applying fresh linen, further compromising the care process. Interviews with the CNA and the Director of Nursing (DON) revealed that the CNA had vision problems, which may have contributed to the inadequate cleaning. The facility's policy on personal care emphasizes maintaining resident dignity and preventing infections, but these standards were not met in this instance.
Inadequate Incontinence Care and Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident with severe cognitive impairment and dependency on staff for personal hygiene. During an observation, CNA D did not thoroughly clean the resident's peri-area after a bowel movement, leaving the area soiled. Despite using toilet paper and wipes, CNA D did not remove all the bowel movement from the resident's peri-area before placing a new brief on the resident. This incomplete cleaning was noted by the surveyor, prompting CNA D to seek assistance from another CNA. CNA D also failed to adhere to proper hand hygiene protocols during the incontinence care process. He changed gloves multiple times without performing hand hygiene, which is crucial to prevent the spread of infection. Additionally, CNA D wore torn gloves and handled soiled linen and trash without gloves, further increasing the risk of contamination and infection. Interviews with the facility's infection preventionist and DON confirmed that the staff did not follow the required procedures for glove use and hand hygiene. The facility's policy outlined specific steps for providing perineal care, including washing and rinsing the genital and rectal areas from front to back, which were not fully adhered to by CNA D. The failure to thoroughly clean the resident and maintain proper hygiene practices placed the resident at risk for infection.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident on a mechanical soft diet. The resident, who had difficulty swallowing and required a mechanically altered diet, was served pot roast that was not ground as required by his dietary needs. Despite the resident's alertness and ability to communicate his needs, he was unable to eat the meat due to its inappropriate texture, which was observed to be in large chunks rather than finely chopped or ground. Interviews with the Dietary Manager and nursing staff revealed a lack of awareness and communication regarding the resident's specific dietary requirements. The Dietary Manager acknowledged the importance of serving the correct texture to prevent choking or aspiration but was unaware of the resident's inability to consume the pot roast. The ADON and DON also confirmed the oversight, with the DON admitting unfamiliarity with the facility's policy on mechanical soft diets. The facility's policy specified that the mechanical soft diet should include minced and moist meat with specific particle size requirements, which were not met in this instance.
Failure to Address Smoking in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to address the resident's smoking habits. The resident, a male with Non-Alzheimer's Dementia, Malnutrition, Asthma, and Chronic Obstructive Pulmonary Disease, required moderate assistance with activities of daily living and supervision when smoking. Despite these needs, the resident's comprehensive care plan did not include any measures or objectives related to smoking, as revealed in a review of the care plan dated 10/15/24. Interviews conducted with the resident and the facility's administrator confirmed the absence of a smoking care plan. The resident did not provide details about his smoking habit, while the administrator acknowledged the oversight and emphasized the importance of including smoking in the care plan to ensure staff and other providers are aware of the resident's needs. The facility's policy mandates the development of a comprehensive care plan that includes measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Label Insulin Pen with Open Date
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles, specifically concerning the labeling of an insulin pen. During an observation of the medication cart, it was found that a Humalog insulin pen was open without an open date. This oversight was confirmed by LVN A, who acknowledged that insulin expires 28 days after opening and that without proper labeling, the medication could lose potency and become ineffective. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that there was an expectation for unit managers to check for expired medications weekly and for pharmacists to conduct monthly checks. Both the DON and ADON C stated that insulin should be dated upon opening to prevent the administration of expired medication, which could be ineffective. The facility's policy on medication storage, revised in 2012, also reflected the requirement for insulins to be labeled with expiration dates after opening.
Deficiency in Maintaining a Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for residents, particularly on Hall 300. Observations revealed that the sit-to-stand mechanical lift was covered in layers of dust and debris, indicating a lack of regular cleaning by the housekeeping and nursing departments. Additionally, Resident #2's room was found to have multiple cleanliness issues, including stains on the G-tube machine, bed frame, and light fixture, as well as a large unrepaired hole in the wall. This resident, who is nonverbal and severely cognitively impaired, relies entirely on staff for all activities of daily living. Several residents' wheelchairs, including those of Residents #5, #6, #7, and #8, were observed to be dirty, with layers of dust and debris on various parts of the wheelchairs. Interviews with residents and staff revealed that there was no consistent schedule or system in place for cleaning wheelchairs, leading to neglect in their maintenance. Resident #5, who has no cognitive impairment, expressed dissatisfaction with the cleanliness of his wheelchair, which he had previously reported to the administration without resolution. Similarly, Resident #6, who has mild cognitive impairment, reported that his family member had to clean his wheelchair due to the facility's inaction. Interviews with various staff members, including CNAs, LVNs, and the Maintenance Director, highlighted a lack of clarity and responsibility regarding the cleaning of equipment and maintenance of the facility. The Maintenance Director was unaware of the hole in Resident #2's room and acknowledged the absence of a designated person or system for ensuring wheelchair cleanliness. The Director of Rehabilitation and Housekeeping Supervisor also confirmed the absence of a structured cleaning schedule, contributing to the overall deficiency in maintaining a safe and clean environment for residents.
Failure to Secure Residents' Medication Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as observed during a survey. Specifically, the facility did not ensure that medication blister packs for four residents were secured, leading to a potential breach of privacy. The blister packs, which contained sensitive information such as the residents' names, medication details, and diagnoses, were left unattended on top of a medication cart outside a resident's room with the door closed. The incident occurred when LVN A left the medication cart unattended to assist a resident who appeared to be falling out of bed. During this time, the blister packs were exposed, allowing anyone passing by to potentially view the private information. LVN A acknowledged the mistake, stating that the blister packs should have been secured in the medication cart until they could be properly disposed of in a shredder box. Interviews with other staff members, including LVN B, ADON C, the DON, and the Administrator, revealed a lack of consistent adherence to HIPAA guidelines regarding the handling of empty blister packs. The facility's policy required that such items be kept inside the medication cart and locked if unattended. Despite recent HIPAA training, the staff did not consistently follow these procedures, resulting in the observed deficiency.
Infection Control Deficiency Due to Improper Syringe Disposal
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a piston syringe used for flushing a urinary catheter. During an observation, a piston syringe was found unwrapped and left on a dresser in a resident's room, surrounded by personal belongings, including a toothbrush and snacks. This oversight was noted during a survey, and the staff present could not identify who left the syringe there, indicating a lapse in adherence to infection control protocols. The resident involved was an elderly female with a history of respiratory failure, stage 4 ulcers, and total dependence on assistance for activities of daily living. She was also oxygen-dependent and had a suprapubic catheter due to chronic urinary infections. The resident's medical records indicated that her catheter was to be flushed with normal saline as needed, but there was no documentation of this procedure being performed in the treatment administration records. Interviews with various staff members, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurses (LVNs), and the Director of Nursing (DON), revealed a lack of clarity and accountability regarding the proper disposal of the syringe. The staff acknowledged that leaving the syringe in the resident's room posed a risk of infection, especially given the resident's existing chronic infections. The facility's infection control policy required the immediate disposal of syringes after use, but this protocol was not followed, leading to the deficiency noted by the surveyors.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically for a resident who left the facility unsupervised. The resident, who had a history of heart failure, schizophrenia, cognitive impairment, and end-stage renal disease, was assessed as having a high risk for elopement. Despite this, the resident was able to leave the facility without supervision, as there was a door near the secure unit that did not have an audible alarm. The resident was last seen sitting by one of the exits of the secured unit before 10:00 p.m. and was later found at a hospital emergency room the following day. The facility's records indicated that the resident was ambulatory using a wheelchair as a walker and had a history of sitting by exit doors without attempting to leave. However, on this occasion, the resident managed to exit the facility, leading to a search involving the police and the use of search dogs. Interviews with staff revealed that the resident often talked about checking on her family but had not previously attempted to leave the facility. The staff was unaware of any alarms being triggered, and the facility's alarm system was reportedly checked and found to be functioning properly. The incident highlighted a lapse in supervision and security measures, as the resident was able to leave the facility without setting off any alarms.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to assist residents in obtaining routine and 24-hour emergency dental care for four residents from December 2023 through May 17, 2024. Resident #3, a woman with multiple serious health conditions including chronic osteomyelitis and type 2 diabetes, reported a dental issue to the social worker in December 2023 but was not scheduled to be seen by the dentist until May 25, 2024. Despite persistently asking for dental care, her issue remained unaddressed for several months. Resident #4, who has multiple sclerosis and other severe health issues, reported that she did not receive regular oral care and had not seen a dentist in a long time. Observations confirmed plaque buildup on her lower teeth. Although her care plan indicated she required total assistance with personal hygiene, her request for more frequent teeth brushing was not consistently met. Resident #7, a man with schizophrenia and other mental health conditions, reported ongoing dental pain that was not resolved despite multiple visits to the dentist. He informed the social worker about his dental issues, but his pain persisted. Similarly, Resident #8, a woman with ataxia and other health issues, reported a cavity and experienced a long wait for a dental appointment, only to be told the dentist was done for the day. She had been waiting for dental care for about five months. Interviews with staff revealed that dental issues were referred to the social worker, who scheduled appointments with a mobile dental service that visited the facility infrequently, leading to delays in care.
Lack of Supervision and Smoking Policy for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents who smoke, specifically for two residents reviewed for accidents, hazards, and supervision. Resident #81, a male with diagnoses including dementia, alcohol dependence, and tobacco use, was observed smoking without supervision at the back entrance of the facility. Despite being aware that the facility was non-smoking, Resident #81 kept cigarettes and a lighter in his possession and was not informed of any consequences for smoking. The care plan for Resident #81 did not address smoking, and there was no staff supervision when residents smoked outside. Similarly, Resident #11, a male with diagnoses including type 2 diabetes and muscle weakness, was found to have cigarettes and a lighter in his bedside nightstand. He smoked multiple times a day without a set schedule and without supervision. The facility's Director of Nursing (DON) and Administrator acknowledged that the facility was non-smoking, yet 19 residents, including Resident #11, were known to smoke. The facility did not have a smoking policy, and residents were not required to sign out when they went to smoke, leading to a lack of supervision and control over smoking activities. Interviews with staff, including the DON and an LVN, revealed that there was no designated staff to supervise smoking activities, and residents were not consistently signing out when leaving to smoke. The facility did not have a smoking policy despite having residents who smoked, and there was no documentation of education provided to residents about the risks of smoking. The lack of supervision and absence of a smoking policy contributed to the deficiency in ensuring a safe environment for residents who smoke.
Lack of Smoking Policy and Supervision in Non-Smoking Facility
Penalty
Summary
The facility failed to establish and implement a smoking policy in accordance with applicable Federal, State, and local laws and regulations, which affected the safety of residents who smoked. Specifically, the facility did not have a policy addressing the signing in and out of residents on a Release of Responsibility for Leave of Absence form for smoking purposes. This deficiency was observed in two residents, both of whom were able to smoke without supervision and without adhering to any set schedule or designated smoking area. Resident #81, a male with diagnoses including dementia, alcohol dependence, and tobacco use, was observed smoking outside the back entrance of the facility without staff supervision. Despite the facility being designated as non-smoking, Resident #81 kept cigarettes and a lighter in his room and was not informed of any consequences for smoking. Similarly, Resident #11, who had type 2 diabetes and required assistance with daily living activities, also smoked without a set schedule and kept smoking materials in his room. Both residents were aware of the facility's non-smoking status but continued to smoke without intervention from staff. Interviews with staff, including the DON and the Administrator, revealed that the facility did not have a formal smoking policy, despite having 19 residents who smoked. The facility relied on residents signing out when they went to smoke, but there was no designated staff to ensure compliance. The lack of supervision and formal policy placed residents at risk for injury and created an unsafe smoking environment. The facility's approach was to inform residents of the non-smoking policy upon admission and offer nicotine patches, but there was no documentation of education or follow-up to ensure residents adhered to the policy.
Failure to Check Residual Volume Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications. Specifically, a Licensed Vocational Nurse (LVN) did not check for residual volume before administering medication through the resident's feeding tube. This oversight could lead to potential complications such as aspiration or vomiting. The resident in question, a female with severe cognitive impairment, required extensive assistance with activities of daily living and had a feeding tube due to her medical conditions, including gastrostomy status, dysphasia, and cerebral palsy. During an observation, the LVN was seen administering several medications through the feeding tube without checking for residual volume, which is a necessary step to ensure the resident is not being overfed. The LVN admitted to forgetting this step and acknowledged the importance of checking residuals to prevent overfeeding and its associated risks. The Director of Nursing (DON) confirmed that the LVN was supposed to check the residuals before medication administration to avoid potential complications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 11% error rate based on three out of 27 opportunities. This involved two residents who were affected by medication administration errors. One resident, a 71-year-old female with diagnoses including reduced mobility and morbid obesity, was administered Levemir instead of the prescribed Lantus insulin. The error was observed during a medication pass, where the LVN administered Levemir 18 units instead of the prescribed Lantus 18 units. The resident's medication administration record indicated the correct medication was Insulin Glargine, but the LVN failed to administer it as ordered. Another resident, with severe cognitive impairment and requiring extensive assistance, was administered incorrect doses of Vitamin B-12 and Folic acid. The LVN administered Vitamin B-12 1000 mcg instead of the prescribed 500 mcg and Folic acid 800 mcg instead of 1 mg. These errors were observed during a medication pass, where the LVN did not adhere to the prescribed dosages. The facility's policy on medication administration emphasizes adherence to the 10 rights of medication administration, which were not followed in these instances.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by two main deficiencies observed during the survey. Firstly, a Certified Nursing Assistant (CNA) failed to perform proper hand hygiene while providing incontinent care to a resident. The CNA did not complete hand hygiene after changing gloves during the care process, citing the absence of hand sanitizer in the room and the restriction against carrying it in pockets. The CNA acknowledged the oversight and admitted that handwashing with soap and water was an option that was not utilized. Secondly, the facility did not ensure that linens and trash were properly managed in a resident's room and bathroom. Linens and a used brief were found on the floor, contributing to a foul smell in the room. The CNA responsible for the care admitted to forgetting to bring trash bags, which led to the improper disposal of soiled items. The Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene with every glove change and that linens and soiled briefs should not be left in rooms to prevent odors and potential infection risks.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,147 citations issued within 25 miles in the last 12 months — including the 44 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| C C Young Memorial Home | 1.1 mi | ★★★★★ | 6 | 0 |
| Pure Health Transitional Care At Texas Health Pres | 1.3 mi | ★★★★★ | 0 | 0 |
| Villages Of Lake Highlands | 1.5 mi | ★★★★★ | 4 | 2 |
| The Meadows Health And Rehabilitation Center | 2 mi | ★★★★★ | 8 | 0 |
| Walnut Place | 2.2 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.