Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Nursing And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to ensure prompt resolution of resident grievances related to laundry for 6 of 11 anonymous residents reviewed. Residents reported missing clothing, laundry delivered to the wrong rooms, and items never being replaced, and they said the issue was not resolved. The LS, AD, DON, and ADM acknowledged the ongoing laundry concerns, but the DON stated no resolutions were documented and the ADM said the concerns were handled with in-services rather than a grievance process. Resident Advisory Council minutes repeatedly noted missing clothes and laundry mix-ups without documentation of responses, actions, or rationale.
Incomplete shift-to-shift narcotic counts were found on 4 of 4 med carts reviewed, with multiple blank signature/count spaces on the Controlled Drugs - Count Record. Staff interviews confirmed that the narcotic count and signatures were meant to verify controlled meds were accounted for and that the nurse accepting the cart was taking responsibility for the count. The facility policy required a physical inventory of controlled meds at each shift change and documentation on an audit or accountability record.
Baseline care plan missing anticoagulant information: A resident admitted with atrial fibrillation was prescribed Eliquis 5 mg BID, but the baseline care plan did not include anticoagulant-related interventions, monitoring, or medication information. Admission documentation also failed to identify the anticoagulant, even though staff stated the baseline care plan should reflect the resident’s meds and status and include monitoring for bruising, bleeding, and abnormal lab findings.
A resident with chronic pain and chest pain, cognitively intact and care planned for pain management, experienced repeated lapses in scheduled oxycodone-acetaminophen due to the facility’s failure to ensure timely refills and accurate monitoring of remaining doses. MARs documented multiple missed doses over two separate periods, often marked as unavailable or not given, with temporary use of alternative analgesics such as acetaminophen-codeine and tramadol. The MD described a lengthy Schedule II refill process requiring early requests, while the DON and ADONs stated they relied on nursing staff to request refills and suggested staff misjudged how long the remaining supply would last given the QID dosing. Nursing staff acknowledged that lapses in scheduled opioids could negatively affect residents and that alternative orders should be obtained during gaps, yet the resident still experienced documented interruptions in her opioid regimen.
A cognitively impaired, independently ambulatory resident with metabolic encephalopathy, dementia, and C. diff isolation status repeatedly expressed a desire to leave, demonstrated pacing and exit‑seeking, and had an attempted elopement that an LVN did not report because the resident was stopped before exiting. The following night, with the 400‑hallway exit door alarm and lock not functioning properly, the resident left the building unnoticed and walked to a nearby hotel to obtain a room, stating he felt held hostage due to isolation. Facility records documented the resident’s low mini‑mental score, inability to make informed decisions, prior unreported exit‑seeking behavior, and the malfunctioning exit door that allowed the elopement, leading to a deficiency for failure to maintain a hazard‑free environment and provide adequate supervision to prevent accidents.
A facility failed to ensure accurate and timely documentation in a resident's medical record, including incorrect times for when a baseline care plan was provided and when family and physician were notified of a fall. Nursing staff also entered progress notes after the resident's discharge without adjusting the times to reflect when care was actually provided, resulting in discrepancies in the EHR.
The facility failed to ensure proper pharmaceutical services, affecting three residents and two medication carts. Medications, including insulin and Naproxen, were found with improper open or expiration dates, contrary to the facility's policy. Staff interviews highlighted concerns about medication effectiveness due to these deficiencies.
The facility failed to properly store and label medications, with unsecured drugs found on residents' bedside tables and loose pills in medication carts. Medications lacked open and expiration dates, risking drug efficacy and safety. Staff interviews highlighted potential negative outcomes, such as missed doses and administration of expired medications.
The facility failed to properly store, label, and date food items in the Nourishment Room, as observed during a survey. Opened containers of orange juice, yogurt smoothies, and chocolate milk in the refrigerator, along with items in the freezer, lacked labels and dates. Staff interviews confirmed that dietary staff were responsible for maintaining proper labeling, and acknowledged the risk of food-borne illness from expired food. The facility's policy required food to be covered and labeled with a date, which was not followed.
A confidentiality breach occurred when a CNA assignment sheet with sensitive resident information was left unattended in a public area of Hall 100. The sheet, containing details such as diagnoses, dietary needs, and advanced directives for 16 residents, was accessible to residents and visitors for two hours without staff presence. Interviews with staff confirmed the importance of maintaining privacy, as outlined in the facility's policy on resident rights.
A facility failed to develop a comprehensive baseline care plan for a resident within 48 hours of admission, omitting critical information about the resident's Type 2 diabetes and spinal fracture. Despite receiving insulin treatment and requiring skilled care for a spinal injury, these conditions were not included in the care plan, potentially impacting the resident's care. Staff interviews revealed that the admission assessment, which should inform the care plan, was incomplete, highlighting a lapse in adherence to facility policy.
A resident in an LTC facility was found to have her nasal cannula improperly stored on the floor, with white specks of discoloration and an outdated hydration bottle. Staff interviews revealed that the facility lacked a specific policy for storing respiratory equipment, leading to improper handling and increased infection risk.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two staff members not performing hand hygiene during resident care. An MA did not wash hands before administering eye drops, and a CNA did not change gloves or wash hands after perineal care. Both acknowledged the risk of contamination and infection spread.
A facility failed to ensure accurate documentation of a resident's advance directive, resulting in conflicting code status records. The resident, who was severely cognitively impaired, had a Full Code status in her medical orders and face sheet, while a DNR form was present in her health record. Staff interviews revealed that the nursing staff is responsible for maintaining accurate records, but no policy exists to ensure this accuracy. The discrepancy could lead to the resident's end-of-life wishes being dishonored.
A resident with Alzheimer's disease engaged in inappropriate behavior towards the ABOM, who responded with verbal abuse. The resident, who was cognitively impaired, approached the ABOM in her office, leading to the incident. The facility's failure to protect the resident from verbal abuse was identified as a deficiency.
Failure to Resolve Resident Laundry Grievances
Penalty
Summary
The facility failed to ensure residents had the right to voice grievances and that prompt efforts were made to resolve those grievances for 6 of 11 anonymous residents reviewed for resident rights. Multiple anonymous residents stated that laundry was a big issue, with clothes going missing, being delivered to the wrong rooms, or never being replaced, and they stated they did not feel the issue was resolved. Facility leadership acknowledged the laundry problems during interviews, with the LS attributing the issues to an inability to keep stable staff and stating residents could get upset as a result. The AD stated that missing clothes could upset residents and leave them without clothing, while the DON stated staff were in-serviced and complaints were reviewed, but no resolutions were documented because the issue was usually resolved by finding the item. The DON also stated residents could feel like the grievance was invalid or that the facility did not care. The ADM stated the concerns were resolved with in-services but that no grievance was done. Resident Advisory Council minutes from multiple meetings documented ongoing concerns about missing clothing and laundry being placed in other residents’ rooms, but the records did not show responses, actions, or rationale taken regarding those concerns.
Incomplete Shift-to-Shift Narcotic Counts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet each resident’s needs by not ensuring accurate shift-to-shift controlled drug counts were completed on 4 of 4 medication carts reviewed. Observation of the facility’s narcotic count books on 5/19/26 showed multiple blank spaces on the Controlled Drugs - Count Record for May 2026: Hall 100 had 11 blanks, Hall 200 had 2 blanks, Hall 300 had 1 blank, and Hall 400 had 3 blanks. The bottom section of the Controlled Drugs - Audit Record stated that signing acknowledged the nurse had counted the controlled drugs and verified the quantity matched the accountability record, and that discrepancies must be noted and the DON notified. During interviews on 5/21/26, the Adm., DON, RN A, RN B, MA C, the ADON/RN, and LVN D all stated that the shift-to-shift narcotic count and signatures were used to verify that controlled medications were accounted for and that the nurse accepting the cart was taking responsibility for the count. The facility’s policy, Controlled Medications - Administration, revised 4/6/26, required a physical inventory of all controlled medications at each shift change by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech, or equivalent, documented on an audit record or accountability record.
Baseline Care Plan Missing Anticoagulant Information
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #84 that included the instructions needed to provide effective and person-centered care. Resident #84 was a [AGE]-year-old female admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, mild protein-calorie malnutrition, chronic combined systolic and diastolic heart failure, and atrial fibrillation. Her baseline care plan, initiated on 05/15/2026, did not include any interventions, monitoring, or care plan focus related to anticoagulant therapy, and no additional care plan addressing anticoagulant use had been developed. Record review showed Resident #84 was prescribed Eliquis 5 mg by mouth twice daily for atrial fibrillation on the hospital medication list dated 05/14/2026, and the active physician orders as of 05/19/2026 also included Eliquis 5 mg twice daily for anticoagulant use. The admission documentation completed on 05/15/2026 did not select the anticoagulant medication on the question asking whether the resident was prescribed medications including anticoagulants. During interviews, facility staff stated the baseline care plan should be completed within 24 hours or the next business day and should reflect the resident’s medications and status, and the MDS LVN stated anticoagulant therapy was important to include so staff could monitor bruising, bleeding, and abnormal laboratory findings.
Failure to Ensure Timely Refill and Continuous Administration of Opioid Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely refills and uninterrupted administration of an opioid pain medication for one resident. The resident was an adult female with chronic pain syndrome and angina pectoris, cognitively intact with a BIMS score of 15, and care planned for pain management with a noted potential for uncontrolled pain. Her care plan directed staff to anticipate her need for pain relief and respond immediately to any complaint of pain. The facility’s own policy required that Schedule II controlled substances be reordered when a 3–5-day supply remained. Medication Administration Records (MARs) showed multiple missed doses of the resident’s scheduled oxycodone-acetaminophen 5-325 mg. In November, she missed 10 doses over three days, with several entries marked as “unavailable” or “see nursing notes.” During this lapse, a new order for acetaminophen-codeine 300-60 mg every 4 hours as needed for pain was obtained, and the resident received that medication several times until the order ended. In January, the MAR again showed 11 missed doses of oxycodone-acetaminophen over several days, many marked as “unavailable,” “not given,” or “see nursing notes.” During this second lapse, a new order for tramadol 50 mg four times daily was written to be used until the oxycodone arrived, and the resident received tramadol as documented on the MAR. Interviews revealed that the resident and her family member were aware of and reported multiple lapses in her pain medication refills, with the resident stating that staff and the physician’s office blamed each other and the pharmacy. The MD acknowledged that the oxycodone refill process was lengthy and required the facility to request refills when two days of medication remained, but stated there was no reason the medication should have lapsed. The ADONs and DON stated they relied on nursing staff to request refills when 1–5 days of medication remained and suggested nurses may not have accounted for the four-times-daily dosing when estimating remaining supply. Nursing staff interviewed recognized that lapses in regularly scheduled opioid medications could negatively affect residents and stated that alternative orders should be obtained until refills were received. Despite these understandings and existing policies, the resident experienced repeated lapses in her scheduled opioid pain medication.
Elopement of Cognitively Impaired Resident Through Malfunctioning Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment as free from accident hazards as possible and to provide adequate supervision and assistance to prevent an elopement. The resident was an older adult male admitted with multiple serious diagnoses, including metabolic encephalopathy, protein-calorie malnutrition, hypertension, acute pulmonary edema, acute kidney failure, intestinal obstruction, enterocolitis due to C. difficile, and a cognitive communication deficit. His initial care plan identified altered neurological status, impaired cognitive function/dementia or impaired thought processes, and risk for falls, with interventions such as cueing, reorientation, monitoring for cognitive changes, and ensuring safe ambulation. At the time of the incident, the resident was on contact isolation for C. difficile and was independently ambulatory, and a Medicare 5‑day MDS documented that he scored 5/15 on a mini‑mental exam and was not capable of making informed decisions. On the night of the elopement, the resident was last seen by staff during rounds at approximately 12:20 a.m. and was later found by local police at a nearby hotel about 0.4 miles from the facility, after he had left the building without staff knowledge. It was documented that the resident had walked to the hotel, where he attempted to obtain a room because he felt he was being held “hostage” due to being kept in isolation. Nursing documentation and an elopement evaluation sheet recorded that the resident exhibited cognitive impairment, pacing, exit‑seeking, and restlessness at the time of the event. The nurse’s notes also recorded the resident’s statement that he did not want to be in the facility and believed he was being held hostage, and that he was returned to his room by police, where a skin assessment showed no new injuries. Prior to the elopement, there were indications of exit‑seeking behavior that were not acted upon in accordance with the facility’s elopement prevention expectations. An LVN reported that on the night before the elopement, the resident had tried to elope but was stopped at the door at the end of the hallway; the LVN described the resident as confused, repeatedly stating he did not want to be in the nursing home and trying to get out. The LVN later stated he did not inform anyone of this attempted elopement because the resident had not actually left the facility and he believed reporting was unnecessary. Speech therapy staff also reported that the resident was anxious, non‑compliant with the BIMS assessment, repeatedly stated he did not want to be there, and on a subsequent day was fully dressed with boots on and stated he was going home. A family member reported that the resident’s dementia was worsening, that he had recently lost his wallet and could not use his phone, and that he was very upset about being in isolation and not allowed to leave his room, all of which were consistent with the exit‑seeking and elopement behavior that ultimately occurred. The facility’s own documentation acknowledged that staff reported the 400‑hallway exit door alarm and lock did not function properly at the time of the elopement, and that the door remained unlocked despite several attempts by nurses to reset the lock. The administrator stated that three nurses could not get the 400‑hallway door to lock. Although maintenance logs showed that door locks and alarms were checked on weekdays and the maintenance supervisor stated the 400‑hallway lock had been working the day before, on the night of the incident the malfunctioning door allowed the resident to exit the building unsupervised. The combination of the resident’s known cognitive impairment and exit‑seeking behavior, the lack of reporting and escalation of a prior attempted elopement, and the failure of the 400‑hallway door locking/alarm system resulted in the resident leaving the facility unnoticed and traveling to a nearby hotel, constituting the identified accident‑prevention deficiency.
Removal Plan
- Administrator assessed all exit doors for proper function.
- Staff were posted at all exit doors until the locking/alarm system was repaired by the vendor.
- Maintenance checked all doors for proper function.
- Facility door security vendor assessed and repaired malfunctioning doors/locks (including reworking mag lock wires, reinstalling strike plate, replacing timers and a keypad, and reworking timers).
- The delayed egress/locking mechanism activation time was reduced so the locking mechanism would activate sooner.
- Signs were posted on all exit doors with instructions on how to reset the alarm once the door was open.
- Large red 'Emergency Exit Only' signs were placed on all exit doors.
- Elopement in-service training was initiated/completed for staff (Elopement Response and Prevention – Code Orange).
- Elopement drills were conducted per protocol across shifts.
- Elopement risk assessments were completed on all residents.
- Daily monitoring/rounds were implemented to check for visitors or staff allowing residents to exit unsupervised (Missing Resident/Elopement Monitoring documentation completed daily).
Failure to Accurately Document Medical Records and Notification Times
Penalty
Summary
The facility failed to maintain accurate and timely medical records for a resident, as required by professional standards. Specifically, documentation errors were identified in the resident's electronic health record (EHR), including incorrect times recorded for when the resident and his family received copies of the baseline care plan, and for when the family and physician were notified of a fall. Additionally, progress notes entered by a registered nurse after the resident's discharge reflected times that did not correspond to when the assessments actually occurred, as the nurse documented information after the fact without adjusting the time entries. The resident involved was an elderly male admitted with multiple diagnoses, including hemiplegia, cerebral infarction, and mobility issues, and was at risk for falls. He experienced a fall during his stay, and the documentation of notifications to his family and physician was inaccurately timed. The resident was later transferred to the hospital for an altered mental state, and subsequent nursing notes were entered into the EHR after his discharge, with times that did not reflect when the care was actually provided. Interviews with facility staff confirmed that the inaccurate documentation was due to a lack of awareness regarding the expectation to enter assessments at the point of care and to adjust times when documenting retrospectively. Staff acknowledged that inaccurate medical records could negatively impact resident care, and the facility's policy required all documentation to be complete, accurate, and properly dated and timed.
Deficiency in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administration of drugs and biologicals for three residents and two medication carts. Specifically, Resident #39's Lispro and Resident #230's Lantus Solostar Pen were found with open dates of 02/17/2025 and 02/08/2025, respectively. Additionally, Resident #65's Insulin Lispro had an open date of 02/19/2025, and a bottle of Naproxen 220mg was found with an expiration date of 02/2025. These findings were observed during a survey on 03/24/25, indicating a failure to store and label medications in accordance with professional principles, which could potentially lead to medication errors. Interviews with facility staff, including LVN B, LVN D, and the DON, revealed concerns about the effectiveness of medications without proper open or expiration dates. The facility's policy, revised in 07/2012, requires medications that need an open date to be clearly dated when opened. The lack of adherence to this policy was evident in the observations made during the survey, highlighting a deficiency in the facility's pharmaceutical services that could impact the effectiveness of medications administered to residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled according to professional principles. Observations revealed that medications were left unsecured on bedside tables of several residents, including a nasal spray bottle for one resident and a tube of Neosporin ointment for another. Additionally, loose pills were found in the medication cart drawers for multiple halls, indicating a lack of proper storage and organization. The medication carts for Halls 100, 200, 300, and 400 were found to have various deficiencies. For instance, the cart for Hall 200 contained 25.5 unidentifiable loose pills, while the cart for Hall 400 had 1.5 loose pills. Furthermore, medications such as Stiolto Aer and Trelegy Ellipta for certain residents lacked open dates, and bottles of Melatonin and Aspirin did not have expiration dates. These lapses in labeling and storage could lead to issues such as drug diversion, lack of drug efficacy, and adverse reactions. Interviews with staff, including LVNs and the DON, highlighted the potential negative outcomes of these deficiencies, such as missed doses, administration of expired medications, and the risk of residents taking incorrect or additional doses. The facility's policies on medication storage and administration were not adhered to, as evidenced by the presence of loose pills and unlabeled medications, which could compromise the safety and effectiveness of the medication administration process.
Failure to Properly Store and Label Food in Nourishment Room
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the Nourishment Room, as observed during a survey. Specifically, the facility did not ensure that freezer and refrigerated items were properly stored, labeled, and dated. Observations revealed multiple items in the refrigerator, such as opened containers of orange juice, yogurt smoothie drinks, and chocolate milk, all lacking labels and dates. Similarly, the freezer contained items like opened Outshine bars, a half-gone gallon of ice cream, and loose popsicles, none of which were labeled or dated. Interviews with staff, including a dietary staff member, the Director of Nursing (DON), and the Dietary Manager (DM), confirmed that the responsibility for maintaining the cleanliness and proper labeling of items in the Nourishment Room lay with the dietary staff. The staff acknowledged that failing to label and date food items could lead to residents consuming expired food, potentially resulting in food-borne illnesses. A review of the facility's policy from 2012 indicated that food must be covered and labeled with a date when stored, which was not adhered to in this instance.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical records in one of the hallways monitored for personal privacy. A CNA assignment sheet containing sensitive information about 16 residents was left unattended on a table in a family area of Hall 100 for a period of two hours. This sheet included details such as primary diagnoses, dietary needs, advanced directives, continence status, and vital signs. The area was accessible to residents and visitors, and no staff were present during multiple observations. Interviews with staff, including a CNA, an LVN, and the DON, confirmed that resident information should be kept private and covered to prevent unauthorized access. The staff acknowledged that leaving such information exposed could lead to a violation of residents' rights and potentially result in the information being stolen or shared inappropriately. The facility's policy on resident rights emphasizes the importance of maintaining privacy and confidentiality of personal and medical records.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #228 within 48 hours of admission, as required. The baseline care plan did not include critical information regarding the resident's Type 2 diabetes and spinal fracture. This omission was identified through observations, interviews, and record reviews. Resident #228, an elderly female, was admitted with multiple diagnoses, including a spinal fracture and Type 2 diabetes, and was receiving insulin treatment. However, these conditions were not reflected in her baseline care plan or admission assessment, which could lead to inadequate care. Interviews with facility staff, including the Director of Nursing (DON) and registered nurses, revealed that the admission assessment, which should populate the baseline care plan, was incomplete. The DON and other staff acknowledged the importance of including all necessary information in the care plan to ensure proper care and patient safety. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission, including essential healthcare information, but this was not adhered to in the case of Resident #228.
Improper Storage of Nasal Cannula in LTC Facility
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, specifically in the storage and maintenance of the nasal cannula used for oxygen therapy. The resident, an elderly female with a history of pleural effusion, diabetes, pneumonia, and anxiety, was observed to have her nasal cannula improperly stored on the floor behind her oxygen concentrator. This was noted during multiple observations over two days, with the nasal cannula showing white specks of discoloration from use and lacking a date label. The hydration bottle attached to the oxygen concentrator was also outdated, with a date of 3-7-2025. Interviews with staff, including a CNA, LVN, and the DON, revealed that the facility's protocol required staff to make rounds every two hours to check on residents' oxygen equipment. Staff were expected to ensure that the nasal cannula was worn correctly or stored properly in a plastic bag off the floor when not in use. However, the facility lacked a specific policy on the storage of respiratory equipment, relying instead on general guidelines for oxygen administration. The staff acknowledged that a nasal cannula on the floor should be replaced immediately to prevent infection risk. The deficiency was identified through observations and interviews, highlighting a gap in the facility's infection control practices related to respiratory equipment. The DON confirmed that the facility did not have a specific policy for storing nasal cannulas and tubing, which contributed to the improper handling and storage of the resident's oxygen equipment. This oversight placed the resident at risk for infection, as confirmed by staff interviews.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two staff members, MA E and CNA K, during resident care. MA E did not perform hand hygiene before donning gloves to administer medicated eye drops to a resident. This oversight was observed during a morning medication administration, and MA E acknowledged that not performing hand hygiene could lead to contamination. The Director of Nursing (DON) also confirmed that failing to perform hand hygiene before medication administration could result in cross-contamination, as the nurse's hands might be dirty and come into contact with the resident's face. Similarly, CNA K did not perform hand hygiene or change gloves after providing perineal care to another resident. Instead, CNA K proceeded to place a clean brief on the resident without changing gloves, which could lead to the spread of bacteria and potential infection. This was confirmed during an interview with CNA K, who acknowledged the risk of spreading bacteria by not changing gloves and performing hand hygiene between dirty and clean areas. The facility's policy on infection control emphasizes the importance of hand hygiene before and after direct resident contact and after contact with a resident's mucous membranes and body fluids.
Failure to Ensure Accurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive, as evidenced by the case of a resident who had conflicting code status documentation. The resident, who was severely cognitively impaired, had a Full Code status listed in her active medical orders and on her face sheet, while a Do Not Resuscitate (DNR) form was present in her health record, signed by family, witnesses, and a physician. This discrepancy in documentation could lead to the resident's end-of-life wishes being dishonored. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), and Director of Nursing (DON), revealed that the nursing staff is responsible for ensuring the accuracy of code status in the electronic health record. However, there was no policy in place regarding the accuracy of records. The staff acknowledged the potential negative outcomes of performing CPR on a resident with a DNR, such as causing physical harm or distress to the family. The facility's policy on physician's orders, dated 2015, requires a licensed nurse to review monthly consolidated orders to ensure accuracy, but this did not prevent the error in the resident's code status documentation.
Verbal Abuse Incident Involving Resident with Alzheimer's
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse, as evidenced by an incident involving a resident with Alzheimer's disease. The resident, who was cognitively impaired and had a history of wandering, approached the Assistant Business Office Manager (ABOM) in her office and engaged in sexually inappropriate behavior. The ABOM responded by yelling at the resident to leave her office, using explicit language. This interaction was witnessed by two staff members, including the Director of Nursing (DON) and a Social Worker (SW). The resident involved in the incident was an elderly male with multiple medical conditions, including Alzheimer's disease, psychotic disorder with delusions, and major depressive disorder. His cognitive impairment was documented in his quarterly MDS resident assessments, which showed a decline in his cognitive awareness and decision-making abilities. On the day of the incident, the resident exhibited inappropriate sexual behavior towards the ABOM, which led to her verbal outburst. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse, including verbal abuse. Despite this policy, the ABOM's response to the resident's behavior was deemed verbally abusive. The facility's failure to protect the resident from verbal abuse was identified as a deficiency, as it placed the resident at risk of mental anguish or emotional distress.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 81 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kirkland Court Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 8 | 3 |
| Amarillo Center For Skilled Care | 1.2 mi | ★★★★★ | 8 | 0 |
| Heritage Convalescent Center | 1.8 mi | ★★★★★ | 9 | 0 |
| Windflower Health Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Amarillo Medical Lodge | 1.9 mi | ★★★★★ | 4 | 0 |
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